We aim to provide you with the highest quality of health care. To do this, we must keep records about you, your health and the care we provided to you or plan to provide to you.
This is our Trust's commitment to use records about you in ways that respect your rights and promote your health and wellbeing.
What do you use my records for?
The people who care for you use records to:
- Provide a good basis for all health decisions made by you and care professionals;
- Allow you to work with those providing care;
- Make sure your care is safe and effective;
- Work effectively with others providing you with care.
Others may also need to use records about you to:
- Check the quality of care (such as clinical audit);
- Protect the health of the general public;
- Keep track of NHS spending;
- Manage the health service;
- Help investigate any concerns or complaints you or your family have about your health care;
- Teach health care workers; and
- Help with research
What rights do I have in relation to my Health Records?
You have the right:
- To confidentiality under the Data Protection Act 1998, the Human Rights Act 1998 and the common law duty of confidence. (The Disability Discrimination Act 1995 and the Race Relations Amendment Act 2000 may also apply);
- To ask for a copy of all records about your health care (you may have to pay a fee).
We have a duty to:
- Maintain full and accurate records of the care we provide to you;
- Keep records about you confidential, secure and accurate; and
- Provide information in a format that is accessible to you (for example, in large type if you are partially sighted).
It is good practice for people in Basildon and Thurrock University Hospitals NHS Foundation Trust who provide your care to:
- Discuss and agree with you what they are going to record about you;
- Give you a copy of letters they are writing about you;
- Show you what they recorded about you, if you ask.
Our 10 commitments to you:
1. When we receive a request from you in writing, we must normally give you access to everything we have recorded about you. We may not give you confidential information about other people or information that a health professional considers likely to cause serious harm to your physical or mental health or that of someone else. This applies to paper and electronic records. However, if you ask us to, we will let other people see health records about you.
Wherever possible, we will make your health records available to you for a minimal charge, as allowed by law. We will provide other ways for you to apply to see your records, if you cannot do so in writing.
We have a duty to provide information in a format that is accessible to you (for example, in large type if you are partially sighted).
2. When we provide health care, we will share health records about you with the people providing care or checking its quality. They must keep the information confidential, whether shared using the computer system or in any other way (such as on paper). We will aim to share only as much information as people need to know to play their part in your health care.
3. We will not share information (particularly with other government agencies) that identifies you for any reason, unless;
- You ask us to do so;
- We ask and you give us specific permission;
- We have to do this by law;
- We have special permission for health or research purposes; or
- We have special permission because the interests of the public are thought to be of greater importance than your confidentiality.
If we share information without your permission, we will make sure that we follow the NHS Confidentiality Code of Practice and other national guidelines on best practice.
4. Under current law, no-one else can make decisions about sharing health information about you on your behalf. At the moment, the only exceptions to this are parents or legal guardians or people with powers under mental health law or an independent body called the NHS Health Research Authority, who may approve the sharing of information.
When we might use or share information that names you without asking you:
i. Sometimes we have a legal duty to give information about people. Examples include:
- Births of children;
- Reporting some infectious diseases;
- Reporting gunshot wounds to the police; or
- Because a court orders us to do so;
- In response to a Section 47 enquiry when relevant information is shared with social care or the police (when concerns have arisen in regard to safeguarding children) to protect children.
ii. Sometimes special permission will be given to view your information without your consent.
This may be for:
- medical research,
- keeping registers of cancer patients
- checking quality of care (such as clinical audit)
- protecting the health of the general public
- keeping track of NHS spending
- teaching health care workers
- helping to investigate any concerns or complaints you or your family have about the health care.
This permission is given by the independent NHS Health Research Authority,
iii. Special permission may also be given when the interests of the public are thought to be of greater importance than your confidentiality. This is very rare, but some situations where this might happen include:
- when a serious crime has been committed;
- when there are serious risks to the public or NHS staff; or
- to protect children.
This permission is given by the senior clinician in charge of protecting your privacy in each health or care organisation, called the Caldicott Guardian.
However, if you are not able to make decisions about sharing information, a senior health care professional involved in your care may consider it to be in your best interests to share information. This judgment should take account of the views of relatives and carers and any views you have already recorded.
5. Sometimes your health care will be provided by members of a care team, which might include people from other services, such as social care or education. We will tell you if this is the case. When it could be best for your care for us to share health information with organisations outside the NHS, we will agree this with you beforehand. If you don't agree, we will discuss with you the possible effect this may have on your care and alternatives available to you.
6. Usually you can choose to limit how we share the information in your electronic care records which identifies you. In helping you decide, we will discuss with you how this may affect our ability to provide you with care or treatment and any alternatives available to you.
7. We will deal fairly and efficiently with your questions, concerns and complaints about how we use information about you. Basildon and Thurrock University Hospitals NHS Foundation Trust have a 'Patient Advice and Liaison Service' (PALS) which can answer questions, point people toward sources of advice and support, and advise on how to make a complaint. We have a clear complaints procedure. We will use what we learn from your concerns and complaints to improve our services.
8. We will take appropriate steps to make sure information about you is accurate. You will be given opportunities to check records about you and point out any mistakes. We would normally correct factual mistakes. If you are not happy with an opinion or comment that has been recorded, we will add your comments to the record. If you are suffering distress or harm as a result of information being held in your record, you can apply to have the information changed or deleted.
9. We will make sure, through contract terms and staff training, that everyone who works in or on behalf of the NHS understands their duty of confidentiality, what it means in practice and how it applies to all parts of their work. Organisations under contract to the NHS must follow the same policies and controls as the NHS does. We will enforce this duty at all times.
10. We have a duty to take appropriate steps to ensure that records we hold about you – both paper and electronic – are kept confidential and secure and only make them available to people who have a right to see them.
Things you can do in return
1. Help us to make sure that we have identified you correctly.
2. Tell us if any information in your records is wrong.
3. Allow us to share as much information about you as we need to provide you with health care.
4. If you decided not to allow us to share records of your care with others, tell us if you change your mind. Preventing us from sharing information may make diagnosis difficult and treatment dangerous, and could prevent research. And, in extreme circumstances, we might not be able to offer you the most appropriate treatment.
5. Only let others – insurers, mortgage lenders, employers, solicitors – look at your records if you are sure it is necessary. Think carefully about who you give permission to and why. Try to restrict their access to what they need to know and no more.
6. At some time, we might ask your permission to use records from which you could be identified for important research. Please give us permission unless you feel strongly that you do not want us to use your information in this way.
7. Tell us if any of your personal information changes, such as, your name, address, telephone number, GP or emergency contact.
More information is available from:
The Office of the Information Commissioner
Telephone: 0303 123 1113
Confidentiality Code of Practice
NHS Health Research Authority
Basildon and Thurrock University Hospitals NHS Foundation Trust
Patient Advice and Liaison Service (PALS)
Telephone: 01268 394440