COMPLETE
PATIENT
OPT OUT
PACK
Summary Care Record
The Hampshire Health Record
Care.data
EMIS Data Sharing
Page 2
Page 4
Page 7
Page 9
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 1 of 9
Issue Number: 06
SUMMARY CARE RECORD (SCR)
The Summary Care Record has been created to help emergency doctors and nurses help you
when you contact them when the surgery is closed. Initially, it will contain just your medications
and allergies. Later on as the SCR develops, other staff who work in the NHS will be able to
access it along with information from hospitals, out of hours services, and specialists letters that
may be added as well. Your information will be extracted from practices such as ours and held
on central NHS databases.
As with all new systems there are pros and cons to think about. When you speak to an
emergency doctor you might overlook something that is important and if they have access to
your medical record it might avoid mistakes or problems, although even then, you should be
asked to give your consent each time a member of NHS Staff wishes to access your record,
unless you are medically unable to do so.
On the other hand, you may have strong views about sharing your personal information and
wish to keep your information at the level of this practice. Connecting for Health (CfH), the
government agency responsible for the SCR have agreed with doctors’ leaders that new
patients registering with this practice should be able to decide whether or not their information is
uploaded to the Central NHS Computer System.
If you DO NOT want a SCR please fill out the Opt Out form and send it to your GP practice
(completed forms must be returned to your GP practice. Forms sent anywhere other than your
GP practice will not be actioned).
Please note that NHS healthcare staff caring for you may not be aware of your current
medications, allergies you suffer from and any bad reactions to medicines you have had, in
order to treat you safely in an emergency.
Your records will stay as they are now with information being shared by letter, email, fax or
phone.
Opting out of the SCR will automatically opt you out of Adjusted Clinical Groups – ACG Tool for
risk stratification
For further information visit the HSCIC Website http://systems.hscic.gov.uk/scr
If you have any questions, or if you want to discuss your choices, please:
• phone the Summary Care Record Information Line on 0300 123 3020;
• contact your local Patient Advice Liaison Service (PALS)
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 2 of 9
Issue Number: 06
OPT-OUT FORM
MY SUMMARY CARE RECORD
Under section 10 of the data protection act, I request that my personal data is not added to the
NHS Summary Care Record service database.
I understand the consequences of taking this action and have carefully considered the
implications of not having a summary care record
A. Please complete in BLOCK CAPITALS
B. If you are filling out this form on behalf of another person or child, their GP practice will
consider this request. Please ensure you fill out their details in section A and your details
in section B
A. Title Surname / Family name .....................................Forename(s) .........................
Address
..............................................................................................................................................
Postcode .......................... Phone No ........................Date of birth .................................
NHS number (if known) ................................................ Signature ....................................
B. Your name .........................................................Your signature
Relationship to patient ................................................ Date ...............................................
FOR NHS USE ONLY
#9Ndo
Actioned by practice yes/no .................................................... Date ...........................................
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 3 of 9
Issue Number: 06
The Hampshire Health Record (HHR)
Access to the Hampshire Health Record is limited to NHS staff who are involved in
patient care. They must ask your permission before they look at your electronic record.
A clinical committee reviews the security arrangements and ensures that any risks are identified
and managed safely. This committee is made up of health care professionals and patient
representatives. Every time someone looks at your record, their identity and the time and date
are recorded for security purposes. They may be asked to justify their action and will be
disciplined or even dismissed if rules on confidentiality are broken. You may request details of
the information within your record and the identity of persons who have accessed it by
contacting us at 023 8029 6276.
The information contained in the HHR is valuable in helping the health service with research into
illnesses and treatments to improve patient care. All analyses of this sort are carried out on
records which have had all personal identification removed. It is not possible for you or anyone
else to be identified from these analyses and approval of the clinical committee is required
before any analyses are undertaken.
Opting out of the HHR will automatically opt you out of Adjusted Clinical Groups – ACG Tool for
risk stratification.
Further information
If you have any questions, please contact telephone the Hampshire Health Record
on 0300 123 1519
or by email at: info@hantshealthrecord.nhs.uk
or write to:
Hampshire Health Record
NHS Hampshire
OMEGA House
112 Southampton Road
Eastleigh
SO50 5PB
Further information is also available via the website at: www.hantshealthrecord.nhs.uk
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 4 of 9
Issue Number: 06
REQUEST TO OPT OUT (HHR)
Please complete this form, amending any details as necessary and return It. Along with
the appropriate identification to:
NHS Hampshire
Omega House
112 Southampton Road
Eastleigh
SO50 5PB
1. Check the following details are correct and amend or complete as necessary:
Please Tick:
Dr
Mr
Mrs
Ms
Miss
First Name(s): (in full)
Last Name:
Home Address:
Date of Birth:
(HHR opt out form cont)
Doctor’s Name (if known):
Surgery Name & Address:
PLEASE
This is a local project and you will only be included in the Hampshire
NOTE:
Health Record if your GP Practice is located within Hampshire.
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 5 of 9
Issue Number: 06
2. In order to ensure only you can Opt your records out, proof of identification is required.
Please enclose a PHOTOCOPY of TWO or MORE of the following showing your:
First name
Last name
Address
Date of birth.
Examples are:
Current UK
Driving
Licence
Personal ID
Current signed
passport
or
ID Card
Birth Certificate
Address ID
Recent utility bill (Within the last 3
plus one Months)
of the
following Local Authority Council Tax Bill
Bank/Building Society Statement of
personal account
If this information is not provided we cannot process this application any further.
3. Declaration: To be completed by the applicant. Please note that any attempt to
mislead may result in prosecution.
I ……………………………………………………………….. certify that the information
given on this application form is true. I understand that it is necessary for the Hampshire
Health Record to confirm my identity, and that it may be necessary to make further
checks in order to ensure the correct information is provided.
…………………………………………………………………
………………………..
Signature
FOR NHS USE ONLY
Date
#93C1 (see Data Registration Template)
Actioned by practice yes/no .................................................... Date ...........................................
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 6 of 9
Issue Number: 06
Care.data
What is care.data?
Care.data is a system whereby information about you can be retrieved from care computer
systems and is shared, securely, by healthcare staff to support your treatment and care. It is
important that we, the NHS, can use this information to plan and improve services for all
patients. It helps us to compare the care you received in one area against the care you
received in another, so we can see what has worked best. 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.
If you do not want information that identifies you to be shared through the care.data system
for planning health services and research you can object.
Information comes not just from your GP surgery so you have two types of information
sharing that you can object to:
• You can object to information containing data that identifies you from leaving your GP
practice. This type of objection will prevent the identifiable information held in your GP record
from being sent to the secure data environment held nationally. It will also prevent those who
have gained special legal approval from using your health information for research.
• You can also object to any information containing data that identifies you from leaving the
national secure database. This includes information from all places you receive NHS care,
such as hospitals. If you do not object, information that identifies you will only leave the
secure database in limited circumstances where there is special legal approval, for example
for medical research. If you object, confidential information will not leave the secure database
and be used in this way, except in very rare circumstances for example in the event of a civil
emergency.
For more details please contact the care.data health line on 0300 456 3531 or talk to your GP
practice.
For more information:
www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/care-data.aspx
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 7 of 9
Issue Number: 06
Care.data: Opt-Out Form
If you would like more information about the care.data programme and/or you need
some assistance with making your decision please contact the national patient data
sharing helpline on 0300 456 3531
Please tick one or both options below:
I do NOT want my personal confidential data to be released by my GP surgery for the
care.data programme.
(Staff: HSCIC1)
I do NOT want my personal confidential data from hospitals and other care providers
to be released by the Health & Social Care Information Centre (HSCIC) for the care.data
programme.
(Staff: HSCIC2)
Section A: it is important that you complete this section accurately and please use BLOCK CAPITALS
Title
Forename(s)
Surname
Address
Phone No.
Date of Birth
NHS Number (if known)
Patient’s signature
Date
If you are filling out this form on behalf of another person or child, their GP practice will check that
you have the authority to do so. Please ensure you fill out their details in section A and your details
in section B.
Section B:
Your name
Relationship to patient
Your signature
Date
***Please return this completed form to your GP surgery (or the patient’s registered GP surgery if
you are completing this form for somebody else)***
For GP practice use only:
9Nu0 Keyword HSCIC1 added Y/N
9Nu4 Keyword HSCIC2 added Y/N
Initials
Date
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 8 of 9
Issue Number: 06
EMIS Data Sharing
EMIS Data Sharing is a real time surveillance system based from >3000 EMIS UK general
practices. It forms a critical part of the UK emergency response to pandemic flu, natural
chemical disasters. It collects, analyses/reports diseases rates vaccine uptake. Only data
aggregated by age/sex is collected (i.e. counts of patients with diseases). No individual patient
data is extracted; there is no risk to patient confidentiality. It is run as a collaboration between
the University of Nottingham, EMIS Clinrisk Ltd. It is approved by the BMA, MREC, NUG and
RCGP.
I wish to opt out from EMIS Data Sharing
Section A: it is important that you complete this section accurately and please use BLOCK CAPITALS
Title
Forename(s)
Surname
Address
Phone No.
Date of Birth
NHS Number (if known)
Patient’s signature
Date
If you are filling out this form on behalf of another person or child, their GP practice will check that
you have the authority to do so. Please ensure you fill out their details in section A and your details
in section B.
Section B:
Your name
Relationship to patient
Your signature
Date
For GP practice use only:
Procedure: Registration  Sharing Consent  EMIS Sharing  Patient does not wish to share the detailed record.
Staff Initials:
Date:
Template
Waterside & Blackfield Health Centres
Complete Patient Opt Out Pack
Owner: IM&T Manager
Date: 11/05/15
Page 9 of 9
Issue Number: 06