THE SURGERY

FREEDOM OF INFORMATION
 &
ACCESS TO MEDICAL REPORTS AND PATIENT RECORDS

From January 2005, the introduction of the Freedom of Information Act gives everyone the right to obtain information from Public bodies which includes general practitioners who within the National health service.

Members of the Public may also request information under: - 
•	The Data Protection Act 1998 (DPA), which gives everyone access rights to their own personal information. The right applies to all information held electronically and also on paper records or filing systems about particular individuals which can be retrieved readily. The DPA covers both private & Public organisations.
•	The Environmental Information Regulations 2004 (EIR), which gives everyone the right to environmental information held by Public organisations.
•	The Access to Health Records Act 1990 – rights of access to deceased patient health records by specified persons.
•	The Medical reports Act 1988 – the right for individuals to have access to reports relating to themselves, provided by medical practitioners for employment or insurance purposes.

The objective of the Freedom of Information and Data protection act is to:
•	To improve people’s knowledge and understanding of their rights and responsibilities
•	Seeking to encourage an increase in openness in the public sector
•	Monitoring the Code of Practice on Access to government information
•	Developing a data protection policy which properly balances personal information privacy with the need for public and private organisations to process personal information.

The FOI Act does not give individuals access to their personal information, though if a request is made the Data Protection Act gives the individual  this right.  If the individual chooses to make this information public it could be used alongside non-personal information gained by public under the terms of the Freedom of Information act.

The Surgery may consult with third parties before disclosing information that could affect their rights and interests.  However according to the FOI act, the practice must take the final decision on disclosure.

The Surgery will record all FOI Act requests and our responses and will monitor performance in handling requests and complaints.
The Surgery will ensure that all staff are aware of their obligations under the FOI Act.

How to access information under Freedom of Information Act

The request must be made in writing to the Practice Manager.  The Surgery has 20 days to respond to the request for information.  There are types of information which cannot be given to the public, eg. Information about law enforcement, national security or personal information about others.  In most cases it is unlikely there will be a fee payable.  If reprographic costs are incurred, however, you will be advised of the fee payable.
The FOI Act does not require us to provide information that we do not already gather.  If we are unable to provide you with the information you request, we will advise you why.  If you are not satisfied with our response please contact us and tell us why.  If we are unable to resolve the matter and you remain dissatisfied, you may ask the Northern Ireland Commissioner to decide if your request has been dealt with correctly.  However the Commissioner will require you to make contact with use in the first instance.

Third party information may also be accessed under the FOI act. Under the Access to Health Records 1993 (NI order), this legislation where a patient has died, their personal representative or executor or administrator or anyone having a claim resulting from the death has a right to apply for access to the deceased’s health record for any entries made after 1994 unless:
•	The deceased person had indicated that they did not wish information to be disclosed, or
•	The record contains information that the deceased person expected to remain confidential

Forward Request to:  Practice Manager
			    The Surgery
                                     1 Church Street
                                     Newtownards
                                     BT23 4FH
                                     Tel: 028 91816333

How to access your Health Records- ‘Subject Access Requests’ (SARS)

If you require access or copies of your Health Records the request must be submitted in writing to the Practice Manager (using the attached form).
Please provide as much detail as possible as to the reason for requiring access to this information.

When making your request for access it is helpful that you provide details of these periods and parts of your health records you require.  A member of staff may contact you on receipt of your request to clarify details.

The practice is not obliged to comply with your access request unless they have sufficient information to identify you and to locate the information held about you.
Once the practice has all the required information and relevant fee, your request should be completed within 28 days, in exceptional circumstances where it is not possible to comply within this period you will be informed of the delay and given a timescale for when your request is likely to be met.

The Data protection Act does not give third parties rights of access to personal information for research purposes.

All requests for Access to Medical records will be recorded in the health record itself and The Surgery will monitor all requests.

Inspection of health records will be supervised by a member of Surgery staff.

Privacy Notice

We use a processor, iGPR Technologies Limited (“iGPR”), to assist us with responding to report requests relating to your patient data, such as subject access requests that you submit to us (or that someone acting on your behalf submits to us) and report requests that insurers submit to us under the Access to Medical Records Act 1988 in relation to a life insurance policy that you hold or that you are applying for. iGPR manages the reporting process for us by reviewing and responding to requests in accordance with our instructions and all applicable laws, including UK data protection laws. The instructions we issue to iGPR include general instructions on responding to requests and specific instructions on issues that will require further consultation with the GP responsible for your care.

PLEASE NOTE ONLY 1 COPY OF NOTES WILL BE PROVIDED FREE OF CHARGE.  IF ANY FURTHER COPIES ARE REQUIRED, THERE WILL BE A CHARGE FOR ADMINISTRATION AND GP TIME. 

Children and Young people

The law regards young people aged 16 or 17 to be adults in respect of their rights to confidentiality.
In Northern Ireland a young person under the age of 16 should demonstrate that they have the capacity to make these decisions.  Where a child is considered to be capable, then their consent should be sought before access is given to a third party.  Access can be denied if the Health professional considers that the child does not have capacity to give consent/decline decisions.

Individuals with parental responsibility for an under 18 year old will have a right to request access to those medical notes.  Access may be granted if access is not contrary to the wishes of the competent child.  Not all parents have Parental Responsibility.  A person with parental responsibility is either:
•	Birth mother
•	Birth father (if married to the mother at the time of the childs birth or subsequently) if both are on the birth certificate, or
•	An individual given parental responsibility by a court

Parental responsibility is not lost on divorce.  If parents have never been married on the mother has automatic parental responsibility, however the father may subsequently ‘acquire’ it.

If the child is considered ‘Gillick’ competent by the Health professional, the child should be asked for his/her consent before disclosure is given to someone with parental responsibility.

If the child is not ‘Gillick’ competent and there is more than on person with parental responsibility, each may exercise their right to access, and there is no obligation to inform the other parent, however this may not be practical and both parents should be made aware of access requests unless there is a good reason not to do so.

In some cases, the DPA permits the practice to withhold information held in your health record.
These rare cases are:
•	Where it has been judged that supplying you with the information is likely to cause serious harm to the physical or mental health condition of you, or any other person
•	Where providing you with access would disclose information relating to or provided by a third person who had not consented to the disclosure, this exemption does not apply where that third person is a health professional involved in your care.

Patient representatives

A patient can give written authorisation for a person (eg solicitor or relative) to make an application on their behalf.  The Practice may withhold access if it is of the view that the patent authorising the access has not understood the meaning of the authorisation.

Access to Deceased Medical Records

Where the patient has died, the patient’s personal representative or any person who may have a claim arising out of the patient’s death may make an application.  Access may be denied to any part of the medical record, which in the Gp’s opinion would disclose information which is not relevant to any claim which may arise out of the patient’s death.

Requests made by telephone

No patient information may be disclosed to members of the public by telephone.  However it is sometimes necessary to give patient information to another NHS employee over the telephone.  Before doing so, the identity f the person requesting the information must be confirmed.

Requests made by the Police

In all cases the Practice can release confidential information if the patient has given his/her consent (in writing) and understands the consequences of making that decision.  There is, however, no obligation to disclose information to the police unless there is a court order or this is required under statute eg Road Traffic Act.
The Practice does, however, have a power under the DPA and Crime Disorder Act to release confidential health records without consent for the purposes of the prevention or detection of crime or the apprehension or prosecution of offenders.  The release of such information must be necessary for the administration of justice and is only lawful if this is necessary.

Only information, which is strictly relevant to a specific police investigation, should be considered for release and only then if the police investigation would be seriously prejudiced or delayed without it.  The Police should be asked to provide written reasons why this information is relevant and essential for them to conclude their investigations.

If you have any complaints about any aspect of your application to obtain access to your health records, you should first discuss this with the Health professional concerned.  If this proves unsuccessful, you can make a complaint through the NHS complaints procedure, alternatively you can contact the Information Commissioners Officer, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF. Tel: 01625 545700 or www.ico.gov.uk/

THE SURGERY

APPLICATION FOR ACCESS TO MEDICAL RECORDS
(SARS)
Data Protection Act 1998 Subject Access Request

Details of the Record to be Accessed:

Patient Surname	NHS Number
	
Forename(s)	Address

Date of Birth		
Details of the Person who wishes to access the records, if different to above:
Surname		
Forename(s)		
Address	

Telephone Number (Mobile)*		
Relationship to Patient		
Email *		
*Must be completed

Declaration: I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the Data Protection Act 1998.
Tick which ever of the following statements apply.

o	I am the patient.

o	I have been asked to act by the patient and attach the patient’s written authorisation.

o	I am acting in Loco Parentis and the patient is under age sixteen, and is incapable of understanding the request / has consented to me making this request.
(*delete as appropriate).

o	I am the deceased patient’s Personal Representative and attach confirmation of my appointment.

o	I have a claim arising from the patient’s death and wish to access information relevant to my claim on the grounds that….(please supply your reasons below).

YOUR SIGNATURE……………………..DATE………………………..

Details of my Application 
				(please tick as appropriate)

Patient to complete:

I am applying for a summary print out of my notes		
I am applying for copies of my medical record		
I have instructed someone else to apply on my behalf		

Notes:
Under the Data Protection Act 1998 you do not have to give a reason for applying for access to your health records but this will help us with your request.

Optional - Please use this space below to inform us of certain periods and parts of your health record you may require, or provide more information as requested above.

This may include specific dates, consultant name and location, and parts of the records you require e.g. written diagnosis and reports. Note: defining the specific records you need may result in lower fee charges and a quicker response.

I would like a copy of all records

I would like a copy of records between specific dates only (please give date range) below

		
I would like copy records relating to a specific condition / specific incident only (please provide the reason you are requesting these copy records. Thank you)

		

PLEASE NOTE ONLY 1 COPY OF NOTES WILL BE PROVIDED FREE OF CHARGE. SHOULD FURTHER ADDITIONAL COPIES BE REQUIRED, THERE WILL BE A CHARGE FOR ADMINISTRATION. 

From Jan 25 – this service has been outsourced to IGPR, a Managed service to assist us with responding to Insurance report requests and Subject Access requests. (Access to medical records Act 1988). IGPR is now the Data Processor acting on instructions from your practice, The Data Controller.

This means that your request will be forwarded electronically to IGPR and you will receive notification from them when your copy notes are ready.  They will send these to you via a link either by email or Text message for you to access. 

The Practice will no longer print out records for collection.

Please forward your request to: THE ADMINISTRATION TEAM
                                                   	 The Surgery
                                                  	 1 Church Street, Newtownards, BT23 4FH