We will always respect your privacy, dignity and your religious and cultural beliefs particularly when intimate examinations are advisable – these will only be carried out with your express agreement and you will be offered a chaperone to attend the examination if you so wish.

You may also request a chaperone when making the appointment or on arrival at the surgery (please let the receptionist know) or at any time during the consultation.

Consent to treatment is the principle that a person must give their permission before they receive any type of medical treatment or examination.

This must be done on the basis of a preliminary explanation by a clinician.

Consent is required from a patient regardless of the intervention – from a physical examination to organ donation.

The principle of consent is an important part of medical ethics and the international human rights law.

It can be given:

• Verbally – for example, by saying they are happy to have an X-ray.
• In writing – for example, by signing a consent form for surgery.

Patients may passively allow treatment to take place – for example, by holding out an arm to show they are happy to have a blood test. However, since the capacity to consent has not been tested, and the benefits and risks have not been explained, this is not the same as consent (see below).

“Capacity” means the ability to use and understand information to make a decision, and communicate any decision made.

Defining consent

For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision. These terms are explained below:

• Voluntary – the decision to either consent or not to consent to treatment must be made by the person themselves, and must not be influenced by pressure from medical staff, friends or family.
• Informed – the person must be given all of the information in terms of what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments and what will happen if treatment does not go ahead.
• Capacity – the person must be capable of giving consent, which means they understand the information given to them, and they can use it to make an informed decision.

If an adult has the capacity to make a voluntary and informed decision to consent to or refuse a particular treatment, their decision must be respected. This still stands even if refusing treatment would result in their death, or the death of their unborn child.

If a person does not have the capacity to make a decision about their treatment, the healthcare professionals treating them can go ahead and give treatment if they believe it is in the person’s best interests. However, the clinicians must take reasonable steps to seek advice from the patient’s friends or relatives before making these decisions.

How to give consent

Consent should be given to the healthcare professional directly responsible for the person’s current treatment, such as the nurse arranging a blood test, the GP prescribing new medication or the surgeon planning an operation.

If someone is going to have a major medical procedure, such as an operation, their consent should ideally be obtained well in advance, so they have plenty of time to examine any information about the procedure and ask questions. If they change their mind at any point before the procedure, the person is entitled to withdraw their previous consent.

If they are able to, consent is usually given by patients themselves. However, someone with parental responsibility may need to give consent for a child to have treatment. Read more about the rules of consent applying to children and young people.

If someone with little or no chance of recovery requires treatment for the sole purpose of keeping them alive, and the person is unable to make a decision themselves, an agreement about continuing or stopping treatment will need to be reached between the healthcare professionals responsible for their care and the person’s relatives and friends.

When consent is not necessary

There are a few exceptions when treatment can go ahead without consent.

For example, it may not be necessary to obtain consent if:

• Treatment is needed in an emergency, and the person is unable to give consent because they lack the capacity to do so.
• When, during an operation, it becomes obvious that the person immediately requires an additional procedure to treat a life-threatening problem that was not included in their original consent.
• A person with a severe mental health condition – such as schizophrenia, bipolar disorder or dementia – lacks the capacity to consent to the treatment of their mental health. However, in these cases, treatment for unrelated physical conditions still requires consent, which the patient may be able to provide, despite their mental illness.

We need to hold personal information about you on our computer systems and in paper records to help us to look after your health needs, and your doctor is responsible for their accuracy and safe-keeping. Please help to keep your record up to date by informing us of any changes to your circumstances.

Doctors and staff in the practice have access to your medical records to enable them to do their jobs. From time to time information may be shared with others involved in your care if it is necessary. Anyone with access to your record is properly trained in confidentiality issues and is governed by both legal and contractual duty to keep your details private.

All information about you is held securely and appropriate safeguards are in place to prevent accidental loss.

In some circumstances we may be required by law to release your details to statutory or other official bodies, for example if a court order is presented, or in the case of public health issues. In other circumstance you may be required to give written consent before information is released – such as for medical reports for insurance, solicitors etc.

To ensure your privacy, we will not disclose information over the telephone or fax unless we are sure that we are talking to you. Information will not be disclosed to family, friends or spouses unless we have prior written consent, and we do not, leave messages with others.

You have a right to see your records if you wish. Please ask at reception if you would like further details about our patient information leaflet. An appointment may be required. In some circumstances a fee may be payable.

There is wheelchair access through the back door. Care Navs will get to the door as soon as they can but please be aware that they could be held up with a patient or on the phone.

Hearing Difficulties

If you are experiencing hearing difficulties when being called in to see the doctor or nurse, please do let us know in order for us to set up an alert on your medical records and personally collect you from the waiting room.

Alternatively, we do have the facility of a portable induction loop. If you would like to use this, please ask at reception for assistance.

All GP practices are required to declare the mean earnings (e.g. average pay) for GPs working to deliver NHS services to patients at each practice.

The average pay for GPs working in Spencer Street Surgery in the last financial year was £84,964 before tax and National Insurance. This is for 2 full time GPs, 8 part time GPs and 1 long term locum GP who worked in the practice for more than six months

PATIENTS

If you wish to apply for access to your medical record, this can be done by:
Signing up for The NHS APP and requesting access to your full medical record – please contact reception for further details.

OR

Complete a Subject Access Request (SAR) Application form and submit to the Practice.

Subject Access Request Application Form

Once the Subject Access Request Application form has been completed, application is as follows:

E-Mail request is preferred – please e-mail your request to: cuccg.spencerstadmin@nhs.net  and your request will be dealt with within 28 days. We will send your records back in an electronic format free of charge

Hand your request in at the desk – we will provide a copy of your records without charge which can be collected at the reception desk.

SOLICITORS

REQUESTS SHOULD BE MADE ELECTRONICALLY WHERE POSSIBLE

We have a duty under GDPR to make the records available to the requestor or the data subject FREE OF CHARGE.
Patient / Representative should make an application via email to cuccg.spencerstadmin@nhs.net

Under GDPR your SAR request must “specify the information or processing activities to which the request relates.” as per Recital 63. We would then provide that targeted SAR according to Article 15(3), i.e. no fee necessary. In some circumstances a request for full medical records may be deemed excessive and therefore a fee may be chargeable if the reason for request relates to a certain period in time or a certain condition.

You could utilise Article 9(2)(f) which we believe to be the correct lawful basis for processing this sort of request under GDPR.
If the case relates to employment or an insurance contract, then we believe that you should use the Access to Medical Reports Act (AMRA).

If none of the above are suitable you could simply request a non GDPR, non AMRA but properly consented report. A fee would apply.

Finally, we also assume you have made the data subject aware of the guidance on the ICO web site regarding the issue of 3rd parties requesting SARs from GPs. This says that another option is for us give the copied records to the data subject directly, and they then decide what data to share with you.

On the issue of consent, we are aware that many patients do not fully understand what is meant when they agree to all their records being disclosed to a third party. We are not party to your full consenting arrangements nor any other options they may have been given. GDPR requires their consent to have been freely, actively and demonstrably given and we believe our patient should have been advised of this. To ensure that they are fully aware we will contact the patient directly to ensure they do understand they are releasing their records and to give them the option of holding the records themselves so they can share information with you as they see fit.

Your patient record is held securely and confidentially on the electronic system at your GP practice. If you require treatment in another NHS healthcare setting such as an Emergency Department or Minor Injury Unit, those treating you would be better able to give you appropriate care if some of the information from the GP practice were available to them.

This information can now be shared electronically via: The Summary Care Record, used nationally across England

The information will be used only by authorised health care professionals directly involved in your care. Your permission will be asked before the information is accessed, unless the clinician is unable to ask you and there is a clinical reason for access.

If you would like to opt out, please ask reception for our opt out form.

A parent or guardian can request to opt out children under 16 but ultimately it is the GP’s decision whether to create the records or not, because of their duty of care to the child. If you are the parent or guardian of a child under 16 and feel that they are able to understand, then you should make this information available to them.

Who Has Access?

Across all health care settings, including urgent care, community care and outpatient departments in England.

Information Source

GP record

Content

• Your current medications
• Any allergies you have
• Any bad reactions you have had to medicines
• Additional information (upon request to your GP)

For more information visit:

www.digital.nhs.uk

GPs in Training

Our practice is approved to train fully qualified doctors who wish to specialise in general practice.

Our GP registrar will have had 2-4 years of experience as a qualified hospital doctor working in various specialities. They consult patients on their own, under the mentorship of our trainers, Dr Saw & Dr Wright.

Occasionally we ask permission to video a consultation. You will always be asked in advance and are given the option not to take part, and this will not affect your care in any way. No recording will be taken without your consent and the camera will be switched off on request. These videos are used only for educational purposes with the doctor doing the consultation and are destroyed after use.

Dr Ali & Dr Ogunlewe are currently the GP registrars at the practice.

Medical Students

Medical students are sometimes attached to the practice for 2 – 3 weeks as part of their training.

If you do not wish a student to be present during your consultation, please inform the receptionist.

The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons.

Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety.

In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.