• Why the NHS is introducing this service.
• How the service will improve your health care.
• How the service will work, your options when using the service and what to do next.

Improving the way we care for you in England

The NHS in England is introducing the NHS Care Records Service. This is to improve the safety and quality of patient care. It will give health care staff faster, easier access to reliable information about you to help with your treatment.

Today, all the places where you receive care keep records about you. They can usually only share information from your records by letter, e-mail, fax or phone. At times, this can be slow and sometimes things get lost on the way. Now there will be quicker ways to get important information to NHS staff treating you, including in an emergency.

How will this benefit me?

Over time, NHS organisations will keep your health care records on computers that link up your notes, allowing them to get access to information in a safe and secure way. This change will take place over several years and will bring a number of improvements.

• Health care staff will be able to get a more complete picture of your health care.
• Health care staff will have quicker access to your records so they can provide more effective care.
• You will have access to a summary of your health care records, whenever you want it, through Healthspace (a secure internet site).

What kind of information is in my health records today?

Your health care records normally include the following.

• Your name, address, date of birth and NHS number.
• Details of any medicines, allergies, test results and x-rays.
• Details of your health conditions, such as asthma or diabetes.
• Notes about treatments or operations you have had.
• Proposed plans or reminders for your care.

They sometimes include other information you may have shared (for example, about your family or work), but only if this is relevant to your health care. With the new service, your records will begin with basic information and will be built up over time.

How are my health care records used?

Like paper records, your new electronic records will be used as follows.

• With your name included, to provide you with care and check the quality of that care
• With your name and other identifying details removed (to protect your confidentiality), to: improve;
  - find out what the NHS does well or needs to improve
  - compare treatments to see what works best
  - carry out research;
  - manage NHS services and finances.

In very limited circumstances allowed by law, information identifying you can be used without your permission. (For example, a doctor must tell your local authority if you have food poisoning).

What will change with the new service?

Your Summary Care Record

You will have a Summary Care Record, which will be available to people providing you with care anywhere in England. At first, your Summary Care Record will contain basic information such as details of allergies, current prescriptions and bad reactions to medicines. After that, each time you use any NHS health services, details about any current health problems, summaries of your care the professionals treating you may be added to your Summary Care Record. As new information is added to your Summary Care Record, you can discuss what is being added and how sensitive information is handled.
The NHS will begin to create Summary Care Records from 2007. It will be several years before everyone can have one. You will be told about this by your Primary Care Trust or GP surgery before your Summary Care Record is ready so that you have time to consider your options. If you wan to put limits on access to your information, you will have to speak to a health care professional about this.

Detailed records

You will also have detailed records. NHS organisations which normally work together in a local area - such as hospitals, clinics and GPs - are gradually being linked electronically. So instead of having separate records in all the different places where you receive care, staff caring for you will have access to the information they need. The local NHS will tell you when this happens. Depending on where you receive care, you may have more than one linked record.

Who will see my NHS Care Records?

Unless you choose to limit the health information that can be seen, health care professionals treating you across England will be able to see your Summary Care Record. Only those treating you in your local area will have access to your detailed records. Not everyone involved in your care will be able to see all of your records. The amount of information they can see will depend on their job. Staff who do not need to see information about your treatment will not be able to view it.

Sometimes your care team includes care professionals (such as social workers). These professionals may have access to parts of your records. You will be told if this happens.

How is my confidentiality protected?

By law, everyone working for or on behalf of the NHS must respect your confidentiality and keep all information about you secure. In every place where you’re treated by the NHS, there are people responsible for protecting your confidentiality. These people are often known as Caldicott G.

The NHS publishes a Care Record Guarantee for England. This says how the NHS Care Records Service will collect, store and allow access to your electronic records, and your options to take part in the service. If you would like a copy, there is information on how to get one at the end of this leaflet. The NHS Care Records Service will use the strongest national and international security measures available for handling your information.

These measures make sure that your information is stored safely, stays private and can only be seen by appropriate people.

How will access to my records be controlled?

When the new system is fully up and running, the following will apply to anyone who gets access to your records.

• They must be involved in your care.
• They must have a smartcard, protected by a chip and a passcode.
• They will only see information appropriate to their role (for example, a receptionist may only see the information needed to process your appointment, not your full clinical records).
• They will automatically have their details recorded - who they are and what they did. You can ask to see this.

Until these controls are fully in place across England, your local NHS organisations will have their own measures to protect your confidentiality. Your local NHS can give you more details.

Will I have access to my own electronic records?

Yes. You have a right to see your records, whether they are paper or electronic. You need to apply directly to the NHS organisations where you have received treatment. You may have to pay a small charge. However, once you have a Summary Care Record, you will be able to view it online, at any time, by visiting www.nhs.uk/healthspace. You will be able to make sure the record is accurate.

In the future you will be able to add a note on your wishes (for example, if you have communication needs or need wheelchair access). To use Healthspace to see your Summary Care Record, you will need to register first.

People from Scotland, Wales and Northern Ireland

If you live outside England but receive care here, you will have a separate NHS Care Record covering your treatment in England. When you return home, information about your care will be sent back, as it is now, by letter, e-mail, phone or fax.

What you will need to do?

You do not need to do anything until your Primary Care Trust or GP surgery writes to you to tell you that the Summary Care Record is coming to your area.
Once your PCT or GP surgery have written to you to tell you that the Summary Care Record is coming to your area:

1) Your records will automatically become part of the new NHS Care Records Service over the next few years, unless you object. When you are told the Summary Care Record is coming to your area, if you are happy about this, you don’t need to do anything.

2) If you have concerns, you can get more information in several ways:

• Get a copy of the leaflets, ‘Your health information, confidentiality and the NHS Care Records Service’ (available February 2007) and ‘The NHS Care Record Guarantee for England’ from the website (www.nhscarerecords.nhs.uk). When the Summary Care Record is about to come to your area, you will also be able to get the leaflets from your GP surgery.
• Contact your local Patient Advice and Liaison Service (PALS). Ask your local NHS for details or visit www.pals.nhs.uk
• You will be able to contact the NHS Care Records Service Information Line by phone to discuss your concerns.

3) You will be able to limit the information that health care professionals can have access to in your NHS Care Records. You can ask that certain information not be included, or that the entire Summary Care Record appears as a blank. You can also ask not to have a Summary Care Record created at all. Limiting information in any of these ways would mean that you won’t be able to take advantage of the full benefits of the new service.

If you are thinking of doing this, you should first find out more (see above). If you then want to see what is in your Summary Care Record, or if you don’t want a Summary Care Record, ask someone in your GP surgery to discuss this with you. They can make a note of your decision for the future, when your records start to be linked. If you change your mind at any time, tell your surgery.

You don’t need to do this until your PCT or GP surgery tells you that the Summary Care Record is coming to your area.

For more information please visit the NHS Care Records Service website.

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