Patient Record

Accessing your GP-held records via the NHS app, NHS website or myGP app

As your GP practice, we have been asked to provide you with access to your full medical record going forward via the NHS app (and NHS website) or other app such as myGP if you have a suitable NHS login

Your GP medical record contains consultation notes based on conversations between you, your GP and their team: medicines prescribed to you; all test results including hospital investigations; allergies; vaccines; and your medical conditions along with documents that may have been sent from local hospitals, clinics or other agencies, eg the police. There is likely to be sensitive and personal information within your medical record.

We are supportive of providing you with access to your record, but we wish to do this safely and make you aware that this is happening so that you can opt out, if you so wish. You may wish to speak with us first to understand what it is that you will see, and the risks which may be involved in having such confidential data either on your smartphone with the NHS app installed or online if other people might have access to that information through your devices. If you are in a difficult or pressured relationship for example, you may prefer your records to remain accessible only to those treating you, with them not appearing on your smartphone or online. Government has been clear that if a patient does not wish to have access, then we do not have to provide it. This is one reason why we have asked if you wish to opt out, or have it switched off for the time being.

For those who would like access, we are happy to explain the different levels you might like. Everyone can have access to their medication history and allergies, for example, and will be able to order their repeat prescriptions. It’s also possible to request access to what we call your ‘coded record’ where you can see a list of medical problems and results. You can also request access to the ‘full’ record where you will be able to see everything, including the notes which have been written by doctors, nurses and others involved in your care, at the GP surgery, and elsewhere.

It’s important to remember that these documents may, at times, contain information that could be upsetting, especially if they contain news of a serious condition. It can also be a cause for worry seeing results online when it isn’t clear what the results might mean, and no one is available to ask, as can be the case during the evening or at weekends, for example. 

Sometimes people with a mental health condition might prefer not to see documents that remind them of difficult times in their life. Letters from mental health teams sometimes go into detail about past events, and great care would be needed in deciding whether you would want to see these letters. It is possible for individual items to be hidden at your request and your GP would be happy to talk about any concerns you may have.

Great care is also needed in case private details might cause harm at home, should people in a difficult or pressured relationship be forced to show their medical record to an abusive partner. Anyone in such a position should make this clear to us at the practice, so we can take steps to keep you safe. This might mean removing access through the NHS app for the time being, or through a careful process where we hide sensitive things. We would talk this through with you.

Requesting access – what do I need to do?

The easiest way to get access is to create an NHS login through the NHS app. Although you can also access your GP records via the internet on a computer, the first bit is easiest if done through a smartphone. If you don’t have one, you may have a family member or friend you trust who can help you. You can also ask your practice receptionist, but you’ll need some proof of who you are, eg a passport, driving licence or household bill.

If you use the NHS app, you’ll have to set up an account using a unique e-mail address and then ‘authenticate’ yourself to the NHS system to prove you are who you say you are. This will involve confirming your name, date of birth and contact details. The NHS login has several levels of authentication and to gain access to your records you’ll need the highest level of authentication. This generally involves you recording a short video of yourself to prove you are a real person as well as uploading a copy of a suitable identification document. Your GP practice can bypass this step if you are struggling, but we’d ask you to try to sign up to the NHS app yourself.

Once you have suitably authenticated yourself and created your NHS login you can view your records, being mindful of the risks associated with access and the importance of not sharing passwords or having them stored in your smartphone if you think other people might want to see them without your permission. If you have any concerns, you should explain these to your GP practice team who can guide you.

If you are happy with this and would like to continue to have prospective access, there is no further action required from you. If you change your mind at any time, please contact the practice.

Increasingly, patient medical data is shared e.g. between GP surgeries and District Nursing, in order to give clinicians access to the most up to date information when attending patients.

The systems we operate require that any sharing of medical information is consented to by patients beforehand. Patients must consent to sharing of the data held by a health provider out to other health providers and must also consent to which of the other providers can access their data.

e.g. it may be necessary to share data held in GP practices with district nurses but the local podiatry department would not need to see it to undertake their work. In this case, patients would allow the surgery to share their data, they would allow the district nurses to access it but they would not allow access by the podiatry department. In this way access to patient data is under patients' control and can be shared on a 'need to know' basis.

Your Summary Care Record is a short summary of your GP medical records. It tells other health and care staff who care for you about the medicines you take and your allergies.

All patients registered with a GP have a Summary Care Record, unless they have chosen not to have one. The information held in your Summary Care Record gives health and care professionals, away from your usual GP practice, access to information to provide you with safer care, reduce the risk of prescribing errors and improve your patient experience.

Your Summary Care Record contains basic information about allergies and medications and any reactions that you have had to medication in the past.

Some patients, including many with long term health conditions, have previously agreed to have Additional Information shared as part of their Summary Care Record. This additional information includes information about significant medical history (past and present), reasons for medications, care plan information and immunisations.

Before accessing a Summary Care Record healthcare staff will always ask your permission to view it, unless it is a medical emergency and you are unable to give permission and only staff with the right levels of security clearance can access the system, so your information is secure. You can ask an organisation to show you a record of who has looked at your SCR - this is called a Subject Access Request.

The purpose of SCR is to improve the care that you receive, however, if you don't want to have an SCR you have the option to opt out. If this is your preference please inform your GP or fill in an SCR patient consent preferences form and return it to your GP practice.

Regardless of your past decisions about your Summary Care Record consent preferences, you can change your mind at any time. You can choose any of the following options:

1. To have a Summary Care Record with Additional Information shared. This means that any authorised, registered and regulated health and care professionals will be able to see a enriched Summary Care Record if they need to provide you with direct care.
2. To have a Summary Care Record with core information only. This means that any authorised, registered and regulated health and care professionals will be able to see information about allergies and medications only in your Summary Care Record if they need to provide you with direct care.
3. To opt-out of having a Summary Care Record altogether. This means that you do not want any information shared with other authorised, registered and regulated health and care professionals involved in your direct care, including in an emergency.

Whenever you use a health or care service, such as attending Accident & Emergency or using Community Care services, important information about you is collected in a patient record for that service. Collecting this information helps to ensure you get the best possible care and treatment.

The information collected about you when you use these services can also be used and provided to other organisations for purposes beyond your individual care, for instance to help with:

• improving the quality and standards of care provided
• research into the development of new treatment
• preventing illness and diseases
• monitoring safety
• planning services

This may only take place when there is a clear legal basis to use this information. All these uses help to provide better health and care for you, your family and future generations. Confidential patient information about your health and care is only used like this where allowed by law.

Most of the time, anonymised data is used for research and planning so that you cannot be identified in which case your confidential patient information isn’t needed.

You have a choice about whether you want your confidential patient information to be used in this way. If you are happy with this use of information you do not need to do anything. If you do choose to opt out your confidential patient information will still be used to support your individual care.

To find out more or to register your choice to opt out, please visit www.nhs.uk/your-nhs-data-matters.  On this web page you will:

• See what is meant by confidential patient information
• Find examples of when confidential patient information is used for individual care and examples of when it is used for purposes beyond individual care
• Find out more about the benefits of sharing data
• Understand more about who uses the data
• Find out how your data is protected
• Be able to access the system to view, set or change your opt-out setting
• Find the contact telephone number if you want to know any more or to set/change your opt-out by phone
• See the situations where the opt-out will not apply

You can also find out more about how patient information is used at:

https://www.hra.nhs.uk/information-about-patients/ (which covers health and care research); and

https://understandingpatientdata.org.uk/what-you-need-know (which covers how and why patient information is used, the safeguards and how decisions are made)

You can change your mind about your choice at any time.

Data being used or shared for purposes beyond individual care does not include your data being shared with insurance companies or used for marketing purposes and data would only be used in this way with your specific agreement.