The Caldicott role in General Practice

Information Governance Policy TeamNHS Connecting for Health

Key Learning PointsThe background to Caldicott and how it has

evolved into NHS Information GovernanceWho should be the Caldicott or confidentiality

lead?The role of the Caldicott LeadThe IM&T Directed Enhanced Service and IG

Toolkit assessmentThe National Programme for ITSupport and guidance Recommended further training

Background

1997 Caldicott Committee reported Caldicott Report Recommendations

Appointment of NHS Caldicott Guardians (HSC1999_012 Caldicott Guardians)

Appointment of Social Care Caldicott Guardians (LAC(2002)2_Caldicott Guardians)

The new GMS contract has sought to extend the Caldicott role into General Practice

Caldicott Principles

1. Justify the purpose for using confidential information

2. Only use it when absolutely necessary

3. Use the minimum required

4. Access should be on a strict need-to-know basis

5. Everyone must understand their responsibilities

6. Everyone must understand and comply with the law

The Caldicott Lead is responsible for:

Agreeing and reviewing policies and ensuring the Practice satisfies the highest practical confidentiality standards

Acting as the ‘conscience’ of the Practice and advising on lawful and ethical processing of information

Resolving local Practice issues and ensuring a record of issues is kept

Tapping into the broader Information Governance function across the PCT

The Caldicott Lead may also be responsible for: Demonstrating to third parties that the Practice

meets appropriate Information Governance standards, e.g. for the IM&T DES or the NHS CFH Statement of Compliance

The IG Toolkit assessment: Mandated for General Practices involved in

the IM&T Directed Enhanced Service A subset of standards for the Statement of

Compliance applications for an N3 connection www.connectingforhealth.nhs.uk/soc

IM&T DES Fact sheet Directed Enhanced Service (DES) was developed to facilitate the use of

information management and technology (IM&T), supporting the delivery of the National Programme for IT.

A key objective of this DES is to support practices in achieving accredited data quality standards that are acceptable for sharing in the NHS Care Records Service.

The actual accreditation is a three-part process:6. Practice submission 7. Quantitative analysis of data taken from the practice 8. Visits to provide necessary qualitative analysis

Information Governance compliance and engagement with the IG Toolkit is required under component 1 of IM&T DES process

See www.primis.nhs.uk/data-accreditation/ for more information

The Information Governance Toolkit#1

The NHS IG Toolkit sets out a range of standards encompassing the entire IG agenda for General Practices

Basis for the Practice to assure information handling in accordance with the law, guidance and best practice.

Includes guidance and resource materials, a clear framework for assurance and controls, and an on-line tool for efficient performance assessment reporting

The Information Governance Toolkit#2

14 requirements for General Practice Clear responsibility for IG standards A documented IG Policy Secure and confidential transfer of patient records Robust procedures for informing patients about how

their information is used and their choices Appropriate training for all staff

www.igt.connectingforhealth.nhs.uk

The Information Governance Toolkit#3

Who can view the Practices assessment(s)?

The Practice can view their own assessment only

The NHS CFH IG Policy Team can view all Practice assessments

Work in progress - Tracking Database

The National Programme for IT Modern information technology (IT) products which will give staff

the information they need at the touch of a button, meaning better care for patients.

NHS Connecting for Health are an agency of the Department of Health responsible for delivering NPfIT.

Programme of work includes:• NHS Care Records Service• Choose and Book• Electronic Prescription Service (EPS)• National Networks for the NHS (N3)• Picture Archiving and Communications Systems (PACS)• IT Supporting GPs• NHSmail

www.connectingforhealth.nhs.uk

Support and Guidance for Caldicott Leads

Local PCT

NHS Connecting for Health

IG Policy Team

The UK Council of Caldicott Guardians

Further guidance and useful links

www.connectingforhealth.nhs.uk/infogov/caldicottThe UK Council of Caldicott Guardian

Tel: 01392 251289

email: exeter.helpdesk@nhs.net

IG Helpdesk

www.igt.connectingforhealth.nhs.uk

Information Governance Toolkit Website

www.connectingforhealth.nhs.uk/infogovNHS Connecting for Health IG Policy website

Further guidance and useful links

DH: Records Management NHS Code of PracticeRecords Management NHS Code of Practice

DH: Security Management NHS Code of PracticeSecurity Management NHS Code of Practice

DH: Confidentiality NHS Code of Practice Confidentiality NHS Code of Practice

www.connectingforhealth.nhs.uk/infogov/resources/new_guidanceThe Caldicott Guardian Manual 2006

…continued

Further guidance and useful links

www.opsi.gov.uk/acts/acts2000/20000036.htm

The Freedom of Information Act 2000

www.ico.gov.uk/ The Information Commissioner: for guidance on data protection

www.dh.gov.uk/en/HomeDepartment of Health website

www.foi.gov.uk/ The Department for Constitutional Affairs: for guidance on

freedom of information

www.opsi.gov.uk/acts/acts1998/19980029.htmThe Data Protection Act 1998

Recommended further training for Caldicott Leads

Other relevant NHS Connecting for Health ‘IG Training Tool’ modules

External academic courses for Caldicott Guardians (GP specific) in either Confidentiality, FOI, DPA or Caldicott Guardianship. (these may incur a fee)

Attend national conferences which offer further training to assist in the day to day fulfilment of the Caldicott Guardian role.

Please send your completed evaluation form to igtrainingtool@nhs.net

Click here for form:-

Assessment select one answer for each question. Further instructions will appear if you are successful or not.

1. Which of the following are one of the 16 recommendations made by the Caldicott Committee to improve security and confidentiality of patient identifiable information?

• The establishment and appointment of a Freedom of Information Lead in each NHS organisation

• The establishment and appointment of the Caldicott Guardian role in each NHS organisation

• The establishment of a Caldicott Guardian Committee in each NHS organisation?

2. Which of the following is one of the 6 Caldicott Principles? Justify the purpose for accepting confidential information Justify the purpose for transferring information outside of

the EEA (European Economic Area) Justify the purpose for using confidential information

Assessment

1. Which of these statements could be identified as part of the Caldicott Lead’s role in General Practice? Acting as the ‘conscience’ of the Practice and advising on

lawful and ethical processing of information The Caldicott Lead is responsible for agreeing and reviewing

policies governing the protection of all NHS information of any form.

The Caldicott Lead is responsible for helping the organisation resolve local issues impacting on the Corporate and Financial agenda

2. What involvement should the Practice have with the IG Toolkit Assessment Tool when carrying out the IM&T DES process?

• The Practice should complete a full assessment and have an external auditor sign off the assessment

• The Practice should engage and prove engagement with the IG Toolkit assessment tool for purposes of the IM&T DES.

• The Practice should only complete the requirements they feel are applicable to them and submit this to the PCT for sign off.

Assessment

1. What does the abbreviation QMAS stand for?• Quantitative Management and Analysis System• Quarterly Management Analysis System• Quality Management and Analysis System

2. Which of the following support and guidance documents do NOT exist?

• The Caldicott Guardian Manual 2006• The Caldicott Information: NHS Code of Practice• The UK Council of Caldicott Guardians