The NHS wants to give people better ways to see their personal health information online. We know that people want to be able to access their health records. It can help you see test results faster and it also lets you read and review notes from your appointments in your own time. The NHS plan is that from 4th October 2023 if you are over 16 years of age and have an online account through the NHS App, or another online primary care service, you will be able to see all future notes and health records from your GP.

We have decided, based on the information that we have from NHS England, our clinical system provider (EMIS), our Integrated Care Board, our Data Protection Officer and listening to advice from The British Medical Association and our Local Medical Committee, that there remains uncertainty surrounding the safety and security of this service and therefore we will not be offering automatic prospective access to consultation text and documents without prior review by a clinician. As Data Controllers, we seek to reassure you that implementing the service in a controlled way is important for the safety and security of all our patients. We will continue to keep our protocols and systems under review.

If you already have access to certain parts of your medical information through the NHS App, or similar service you should see no change to the information that you can see. If you experience a change in the information that you can see through the NHS App, or similar service, please let us know by emailing charlton.reception@nhs.net or phoning Reception on 01952 620138.

If you do not already have access to your medical records via the NHS app, please follow the instructions below.

To request Full Online Access to your records, please complete the application form which can be found HERE. The application form is also available to collect from Reception.

Please bring your completed form to Reception where a member of the team will verify your identity. A code will be added to your records "Patient Registration Data Verified" and your request will be forwarded to a clinician for review. We will endeavour to review all requests within 28 days but this may take longer depending on the number of applications we receive. We will contact you once your request has been reviewed and advise you accordingly.

Important Information about software issue that prevents documents from being visible to patients. 

We understand that some of our patients may have encountered difficulties viewing certain documents (e.g. letters from the hospital) due to a software problem. We sincerely apologise for any inconvenience this may have caused. We are pleased to inform you that this issue has been resolved for new documents being added onto the system. It may take up to a month for older documents to become visible. 

Your GP team will have been able to access the letters so your care will not have been affected during this time.

Acute Medication

• Temporary and limited medication for a short-term condition
• Prescribed for something new until reviewed as appropriate for continued (repeat) prescribing 
• Cannot be ordered through an app

Repeat Medication

• Ongoing medication for a chronic illness or long-term condition.
• You can order repeat medications through your phone app.

Consultations

• Following any interaction with a member of the Practice Team, details of that interaction/conversation will be recorded in your record. Some administrative conversations may also be recorded.
• Only consultations recorded after the 1st November will be visible to you.
• Consultations are primarily designed to communicate in the most effective way, to the next clinician reading them, what is required for your continued care.
• Every clinician is an independent practitioner with different backgrounds, specialities, experiences and ongoing professional training. As such there is no one correct way to record a consultation and each clinician will do so in the way they see as best for the patients care.
• When reading a consultation, it may not all make sense to you, but it will to other clinicians and staff viewing your records for your care.
• Sometimes the details of a consultation may present risk to the patient or a third party and in these cases, we may choose to hide this from the online access.
• PLEASE NOTE: We cannot amend the content of a past consultation, even based on a patient's request to do so. If a Factual error has been made, this can be documented separately in the record. A differing opinion to that of a clinician does not constitute an error.

Problem Headings

• Within a consultation, details of a diagnosis or illness are recorded as a 'problem'.
• Recording problems allows us to ensure you receive the best ongoing care for that problem though processes such as annual reviews.
• PLEASE NOTE: A problem heading is used for administrative purposes and can be used to cover a wide range of conditions, some of which are not serious.

Lab Results

• The results of tests such as Blood tests, Xrays or ECGs will be visible after the update.
• Without a clinical understanding of these results and the context around them including other relevant factors, it is easy to be confused or worried about them, especially if you see them before a clinician has had a chance to review them and speak to you.
• We will contact you to discuss ABNORMAL results. We do not routinely contact patients to advise of normal results.
• Contacting us to discuss your results will not speed up the process and creates additional work for the practice which can delay care for others. Please wait for us to contact you.
• Our reception team are not trained to interpret results but may be asked by a clinician to pass on information to a patient regarding them.

Documents

• Letters we receive from outside organisations regarding your care will be visible to you.
• Letters we send to you or on your behalf (e.g. referrals) will be visible to you.

Allergies

• Any allergies we have recorded for you will be visible regardless of when they were inputted onto your record.

Please contact the surgery immediately at charlton.online@nhs.net or on 01952 620138 if:

• You see information that is not about you or is factually inaccurate
• If you feel under pressure (coerced) to give access to someone else. If someone else currently has access to your online medical records, please consider the impact of all the above on your personal situation.

You can view some commonly used abbreviations HERE, which may help you understand your records.

Upon reviewing your records, you may feel that certain notes made by our clinicians are incorrect and you may wish to request that they are amended/removed.

The General Data Protection Regulations (GDPR) and the Data Protection Act 2018 state that an individual has the 'right to be forgotten', which is sometimes called the 'right to erasure', however medical records are slightly different in that they hold special category data. The GP's (or other clinician's) opinion at the time will not alter, therefore we cannot remove information simply at the patient's request.

In line with the General Medical Council's (GMC) guidance, Doctors have an obligation to:

• Keep clear, accurate and legibile records
• Make records at the time the events happen, or as soon as possible afterwards

Source: https://www.gmc-uk.org/-/media/documents/good-medical-practice---english-20200128_pdf-51527435.pdf

The NHS constitution states that as a patient, "You have the right to have any factual inaccuracies in your health record corrected, however there are limited exceptions to this right, there is no obligation to amend something in a health record that is a professional opinion", i.e the GP's opinion at the time.

Source: https://www.gov.uk/government/publications/supplements-to-the-nhs-constitution-for-england/the-handbook-to-the-nhs-constitution-for-england#patients-and-the-public-your-rights-and-the-nhs-pledges-to-you

This also applies to data that forms part of your medical record, for example letters and forms issued by other Healthcare Organisations involved in your care that have supplied copies to us as your General Practice/registered GP. Data on your record is only to be used in relation to direct care purposes, and if considered to be used for anything else, it would need to have the relevant lawful basis and other data protection principles applied.

Should you request any corrections or redactions we will review your request and if we decide we are not able to comply we will inform you of this decision. We will also ensure we add details of your request to your record and the reasons why we have not been able to comply. Please make any such requests to the Practice by completing the following form : FORM

Whilst we endeavour to respond in a timely manner to any queries abotu your records, please bear in mind that we must prioritise our workload and deal with patients that are unwell and need us. Please do not use appointments purely to request something is removed from or changed within your notes. As above, please contact us in writing and we will liase with the clinical team and respond within an appropriate time frame-as with most administrative requests this can be up to 28 days.

Did you know? From Summer 2021, everyone's health and social care records in Shropshire, Telford and Wrekin will be available on the new integrated care record 'One Health and Care'. 

Completely confidential and secure, it's designed to help doctors, nurses and other registered health and social care professionals directly involved in your care to make better, safer decisions. The information that they will be able to see includes:

• Your name, date of birth, sex, address, telephone number, NHS number
• The name of your GP Practice and GP
• Medications, allergies, ongoing and historic conditions, immunisations and diagnoses
• Test results, hospital referrals, admissions, discharges and clinics attended
• Social and mental health information and care plans

Sensitive information such as attendance at sexual health clinics, fertility treatment records and records relating to gender reassignment will not be included.

During Summer 2021, all GP practices within Shropshire, Telford and Wrekin will have access to One Health and Care along with the following organisations:

• Shropshire Community Health NHS Trust
• Midlands Partnership NHS Foundation Trust
• Shropshire Council (Social care)
• Telford and Wrekin Council (Social care)
• Shrewsbury and Telford Hospital NHS Trust
• Robert Jones & Agnes Hunt Orthopaedic Hospital

Raising an Objection

If you are happy for your records to be available on One Health and Care to health and social care professionals, you do not need to do anything. Alternatively, if you wish to object, you can contact your GP practice and they can record your objection for you or you can download the opt out form Opt out of sharing your health records - NHS (www.nhs.uk) and return to your GP practice.

For more information, contact:

W: onehealthandcare.com

E: onehealthandcare@nhs.net

What is the national use opt out?

NHS Digital have rolled out a national data opt-out that allows patients to choose how their confidential patient information can be used. This is due to plans to use patient data for purposes beyond their individual care and treatment - specifically for research and planning across the NHS. If patients do not want their data to be used in this way, they can opt out. NHS Digital recently confirmd that the deadline to opt out has been extended to 30 September 2021.

Is the national opt-out linked to One Health and Care - Integrated Care record?

The national data opt-out is not linked to the Integrated Care record.

Raising an Objection

National data opt-outs can be set by patient themselves. There is no need to contact a GP practice. The easiest way is to download the NHS app and do it through that, but all of the ways that a patient can opt-out are outlined by clicking the below link:

Setting or changing a national data opt-out choice - NHS Digital

There is a new Central NHS Computer System called the Summary Care Record (SCR). It is an electronic record whcih contains information about the medicines you take, allergies you suffer from and any bad reactions to medicines you have had.

Why do I need a Summary Care Record?

Storing information in one place makes it easier for healthcare staff to treat you in an emergency, or when your GP practice is closed.

This information could make a difference to how a doctor decides to care for you, for example which medicines they choose to prescribe for you.

Who can see it?

Only health care staff involved in your care can see your Summary Care Record.

How do I know if I have one?

Over half of the population of England now have a Summary Care Record. You can find out whether Summary Care Records have come to your area by asking your GP.

Do I have to have one?

No, it is not compulsory. If you choose to opt out of the scheme, then you will need to complete a form and bring it along to the surgery. You can use the form at the foot of this page.

More Information

For further information visit the NHS Care Records Website.

Information about you and the care you receive is shared in a secure system, by healthcare staff to support your treatment and care.

It is important that we, the NHS can you use this information to plan and improve services for all patients. We would like to link information from all the different places where you recieve care, such as your GP, hospital and community service to help us provide a full picture. This will allow us to compare the care you received in one area against the care you received in abother, so we can see what has worked best.

Information such as your postcode and NHS number, but not your name, will be used to link your records in secure system so your identity is protected. Information which does not reveal your identity can then be used by others, such as researchers and those planning health services to make sure we provide the best care possible for everyone.

You have a choice if you are happy for your information to be used in this way you do not have to do anything. If you have any concerns or wish to prevent this from happening, please speak to practice staff or download the opt out form below, complete it and return it to the practice.

We need to make sure that you know this is happening and the choices you have.

You can find out more on the NHS England Care Data Website