Information Governance Management
Complex Commercial Third Party (CTP) Organisations Providing Health
Care or Support Services to, or on behalf of, National Health
Establishments
Guidance
Requirement 15 ( Ref: 401)
Does the CTP ensure that the NHS Number is used routinely on all
communications and active patient records?
CTPS should ensure a verified NHS number is routinely collected for every
active patient and it is used routinely on records or on clinical communications
generated by the CTP.
NHS Number strategy
Where a CTP receives information about a patient in order to provide that patient
with treatment, care or services they must ensure that an NHS Number is both
recorded and verified with the NHS organisation. To meet this requirement the CTP
must have procedures in place that set out how pre-recorded NHS Numbers will be
checked and how NHS Numbers will be collected if they are not already recorded.
The CTP should take advice from the NHS organisation(s) with which it contracts on
the most appropriate method of collecting and checking NHS Numbers. The CTP
should regularly review validated and un-validated numbers with the aim of achieving
100% of validated numbers within the patient records it holds.
Responsibility for monitoring NHS Number collection and validation can, if necessary,
be allocated to an appropriate staff member and be contained within their job
description. The CTP or nominated person, should ensure that procedures are
followed and that any other staff members are aware of the importance of collecting,
recording and verifying NHS Numbers.
Improvement plans
 Level 1
The CTP should review its current arrangements and document a procedure for
collecting, checking and using NHS numbers, taking advice from the NHS
organisation with which it contracts.
 Level 2
The CTP should implement its procedure for collecting, checking and using NHS
Numbers and ensure the NHS number is collected and verified for all new patients
and that it is routinely used in clinical communications. All relevant staff should be
made aware of and comply with the procedure.
 Level 3
The CTP should be able to demonstrate commitment to working towards 100%
verification of NHS numbers for the active patient records it holds.