Your Medical Records

Doctors have always had the discretion to allow patients to see their health records and to share information where appropriate with the carers of children and incapacitated adults. Additionally in recent years Acts of Parliament have given certain statutory rights of access to records. None of the legislation prevents doctors from informally showing patients their records or, bearing in mind duties of confidentiality, discussing relevant health issues with carers.

The implementation of data protection legislation in early 2000 changed patients' statutory rights of access to their health records. The purpose of this guidance is to set out in some detail the legal requirements on doctors as holders of health records. This summary highlights the main points.

What records are covered?

All manual and computerised health records about living people are accessible under the Data Protection Act 1998.

Does it matter when the records were made?

No, access must be given equally to all records regardless of when they were made.

Does the Act cover all of the UK?

Yes.

Who can apply for access?

Competent patients may apply for access to their own records, or may authorise a third party, such as their lawyer, to do so on their behalf. Parents may have access to their child's records if this is in the child's best interests and not contrary to a competent child's wishes. People appointed by a court to manage the affairs of mentally incapacitated adults may have access to information necessary to fulfil their function.

Are there any exemptions?

Yes, the main exemptions are that information must not be disclosed if it:

• is likely to cause serious physical or mental harm to the patient or another person; or
• relates to a third party who has not given consent for disclosure (where that third party is not a health professional who has cared for the patient).

Must copies of the records be given if requested?

Yes, patients are entitled to a copy of their records, for example a photocopy of paper records or print out of computerised records.

Is it necessary for patients to make a formal application for access to see their records?

No, nothing in the law prevents doctors from informally showing patients their records or, bearing in mind duties of confidentiality, discussing relevant health issues with carers.

Can a fee be charged?

Yes, and the fee varies depending on the type of record and whether the patient wants copies of the records or just to see them.

To provide access and copies:

• Records held totally on computer: £11
• Records held in part on computer and in part manually: a reasonable fee of up to £50
• Records held totally manually: a reasonable fee of up to £50

To allow patients to read their records (where no copy is required):

• Records held totally on computer: £11
• Records held in part on computer and in part manually: £11
• Records held totally manually: £11 unless the records have been added to in the last 40 days when no charge can be made

If you are applying to access your health record you will need to

• Complete this form  
• Provide two types of identification as well as proof of current address. Photocopies should initially be provided, but original copies must be available when collecting your information
• An initial administration fee of £11.00 will be charged. This must be paid by cash or cheque. Please make all cheques payable to Dr Monella and Partners
• There may be an additional charge payable when you collect your results as detailed above.

What about access to the records of deceased patients?

The Data Protection Act 1998 only covers the records of living patients. If a person has a claim arising from the death of an individual, he or she has a right of access to information in the deceased's records necessary to fulfil that claim. These rights are set out in the Access to Health Records Act 1990 or Access to Health Records (Northern Ireland) Order 1993. The provisions and fees are slightly different from those in the Data Protection Act.

If you wish to access your medical records please contact reception for an application form.

Guidance on confidentiality and on sharing information with relatives and carers is available from the BMA's Medical Ethics Department.
© British Medical Association 2004

---

Freedom of Information

The Freedom of Information (FOI) Act was passed on 30 November 2000. It gives a general right of access to all types of recorded information held by public authorities, with full access granted in January 2005. The Act sets out exemptions to that right and places certain obligations on public authorities.

FOI replaced the Open Government Code of Practice, which has been in operation since 1994.

For information about the Freedom of Information Act model publication scheme click here.

Data Protection and FOI – how do the two interact?

The Data Protection Act 1998 came into force on 1 March 2000. It provides living individuals with a right of access to personal information held about them. The right applies to all information held in computerised form and also to non-computerised information held in filing systems structured so that specific information about particular individuals can retrieved readily.

Individuals already have the right to access information about themselves (personal data), which is held on computer and in some paper files under the Data Protection Act 1998.

The right also applies to those archives that meet these criteria. However, the right is subject to exemptions, which will affect whether information is provided. Requests will be dealt with on a case by case basis.

The Freedom of Information Act and the Data Protection Act are the responsibility of the Lord Chancellor’s Department. A few of its strategic objectives being:

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

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 the public under the terms of the FOI Act.

Date updated: 16/09/2011

Making a Complaint

If you have a complaint or concern about the service you have received from the doctors or any of the staff working in this practice, please let us know. We operate a practice complaints procedure with conforms with NHS recommendations and national criteria.

We hope that most problems can be sorted out easily and quickly, often at the time they arise and with the person concerned. If your problem cannot be sorted out in this way and you wish to make a complaint, we would like you to let us know as soon as possible, ideally, within a matter of days or at most a few weeks - this will enable us to establish what happened more easily. If it is not possible to do that, please let us have details of your complaint:

• Within 6 months of the incident that caused the problem or
• Within 6 months of discovering that you have a problem, provided this is within 12 months of the incident.

Complaints should be addressed to the Practice Manager or any of the doctors. Alternatively, you may ask for an appointment with the Practice Manager in order to discuss your concerns. He will explain the complaints procedure to you and will make sure that your concerns are dealt with promptly. It will be a great help if you are as specific as possible about your complaint.

What we will do

We will acknowledge your complaint within two working days and aim to have looked into your complaint within ten working days of the date when you raised the complaint with us. We shall then be in a position to offer you an explanation, or a meeting with the person(s) involved. When we look into your complaint, we shall aim to:

• Find out what happened and what went wrong
• Make it possible for you to discuss the problem with those concerned, if you would like this
• Make sure you receive an apology, where this is appropriate
• Identify what we can do to make sure the problem does not happen again

Complaining on behalf of someone else

Please note that we keep strictly to the rules of medical confidentiality. If you are complaining on behalf of someone else, we have to know that you have his or her permission to do so. A note signed by the person concerned will be needed, unless they are incapable (because of illness) of providing this.

DOWNLOAD A COMMENTS / SUGGESTIONS / COMPLAINT FORM HERE

Complaining to NHS England

We hope that, if you have a problem, you will use our practice complaints procedure. We believe this will give us the best chance of putting right whatever has gone wrong and an opportunity to improve our practice. This does not affect your right to approach NHS England and speak to the Complaints Manager on 0300 311 22 33 for further advice or email england.contactus@nhs.net.

You may also like to contact Surrey ICAS - Surrey Independent Complaints Advocacy Service. Patients can contact them by telephone on 01753 552227

Date updated: 16/09/2011

We will:

• Ensure our patients have 24-hour access to medical advice.
• Aim for you to have access to a suitably qualified medical professional within 48 hours of your initial contact during surgery hours, or in an urgent case, the same day.
• Work in partnership with you to achieve the best medical care possible.
• Involve you and listen to your opinions and views in all aspects of your medical care.
• The prevention of disease, illness and injury is a primary concern.
• The medical staff will advise and inform you of the steps you can take to promote good health and a healthy lifestyle.
  

We ask that you:

• Let us know if you intend to cancel an appointment or are running late.
• Treat staff with courtesy and respect.
• Inform the practice staff of any alterations in your circumstances, such as change of surname, address or telephone number. Please ensure that we have your correct telephone number, even if it is ex-directory.

Date updated: 16/09/2011

Medwyn Surgery is an accredited NHS training practice for undergraduate medical students and postgraduate doctors (Specialist Training GP Registrars).

GP registrars are fully qualified doctors who have completed hospital training and wish to pursue a career in general practice. They spend up to twelve months at Medwyn to improve their consulting skills and widen their experience in primary healthcare. The GP registrars hold daily surgeries like the other doctors at the practice and are mentored by a GP trainer. Dr Chris Monella, Dr Stewart Tomlinson and Dr Raj Sekhon are all approved trainers for the Kent, Surrey and Sussex Postgraduate Deanery.

Occasionally, medical students from St George's Hospital in London will be attached to Medwyn Surgery. During their time at the practice they will observe consultations with the doctor or nurse. This is an essential part of training the next generation of doctors who could be responsible for your future care. Reception staff will always ask if you agree to a medical student oberving your consultation. If you would prefer not to have a student present during your consultation please let us know.

Information for doctors

Medwyn Surgery has been a training practice for the Kent, Surrey and Sussex Deanery since 2001. Dr Chris Monella is responsible for doctors training on Epsom VTS scheme and Dr Stewart Tomlinson and Dr Raj Sekhon are responsible for doctors training on the East Surrey VTS Scheme. Further information about both vocational training schemes is shown below:

East Surrey VTS

Epsom VTS

If you wish to consider becoming a registrar at Medwyn Surgery why not view our training profile. Please feel free to contact any of our trainers to discuss your training at Medwyn on 01306 883816.

Other useful website resources for GP training include:

Kent Surrey and Sussex Deanery

Postgraduate Medical Education and Training Board

Royal College of General Practitioners

National Institute of Clinical Excellence

Department of Health

Date updated: 16/09/2011

Under the Freedom of Information Act 2000 we are obliged to make a range of general information about the practice readily available.  If you would like a copy of this information please contact the Practice Manager.

Under the Data Protection Act 1998 you are entitled to access your clinical records or any other personal information held about you. If you wish to do this please contact the Practice Manager who can explain the procedure involved.

Date updated: 16/09/2011