All patients have been allocated a named GP who is responsible for their overall care and takes responsibility for the coordination of all services required.

Patients have the right to express a preferred GP if that GP is available.

Read/Download our Complaints Procedure

Information on how to make a complaint to Oldham ICB can be sought from its webpage https://gmintegratedcare.org.uk/have-your-say/contact-us/

Complaints,
Oldham – NHS GM,
Civic Centre
West Street
Oldham, OL1 1UT

Email:
[email protected]

Call:

07966 746 117

Complete our Complaints form

Read/Download our Covid-19 and your information

Dear patient,

NHS Digital has been directed to collect, process, analyse and disseminate general practice data to support the purposes set out in the GP Data for Planning and Research Direction 2021.  This is a national initiative and from July 1^st, 2021, patient data will be extracted from  GP systems on a daily basis; data will be encrypted in transit and pseudonymised.

As this is a statutory obligation, practices are legally obliged to share this data, unless patients have opted out of having their data shared.  If you as patient want to opt out of your data being shared, apart from information used for your direct care,  you have the option of registering a Type 1 Opt-out or a National Data Opt-out, or both.

Please find information by following the link below:

Make your choice about sharing data from your health records – NHS (www.nhs.uk)

If you complete the form online please inform your GP surgery as we need to add a code onto your records to register that you have opted out.

Information about you and the care you receive is shared in a secure system by healthcare staff to support your treatment and care.  Information such as your postcode and NHS number but not your name will be used to link your records in a secure system so your identity is protected.  This information can then be used by others such as researchers and those planning health services.

If you do not want information that identifies you to be shared outside the practice you must let us know so we can make a note on your medical record.  Please contact the surgery if you wish to opt out of the data sharing programme

Care Data Programme

ShareforYou

Protecting Your Data

Introduction

This privacy notice explains in detail why we use your personal data which we, the GP practice, (Data Controller), collects and processes about you.  A Data Controller determines how the data will be processed and used with the GP practice and with others who we share this data with.  We are legally responsible for ensuring that all personal data that we hold and use is done so in a way that meets the data protection principles under the General Data Protection Regulation (GDPR) and Data Protection Act 2018.  This notice also explains how we handle that data and keep it safe.

Caldicott Guardian

The GP Practice also has a Caldicott Guardian. A Caldicott Guardian is a senior person within a health or social care organisation, preferably a health professional, who makes sure that the personal information about those who use its services is used legally, ethically and appropriately, and that confidentiality is maintained.  The Caldicott Guardian for the GP practice is:

Dr H Hunjan

Data Protection Officer (DPO)

Under GDPR all public bodies must nominate a Data Protection Officer.  The DPO is responsible for advising on compliance, training and awareness and is the main point of contact with the Information Commissioner’s Office (ICO).  The DPO for the practice is:

Jane Hill – [email protected] West Pennine LMC c/o Cottage Lane Surgery, Cottage lane, Gamesley, Glossop SK13 6EQ

We will continually review and update this privacy notice to reflect changes in our services and to comply with changes in the Law.  When such changes occur, we will revise the last updated date as documented in the version status in the header of this document.

What we do?

We are here to provide care and treatment to you as our patients.  In order to do this, the GP practice keeps personal demographic data about you such as your name, address, date of birth, telephone numbers, email address, NHS Number etc and your health and care information.  Information is needed so we can provide you with the best possible health and care.  We also use your data to:

• Confirm your identity to provide these services and those of your family / carers
• Understand your needs to provide the services that you request
• Obtain your opinion on our services (with consent)
• Prevent and detect fraud and corruption in the use of public funds
• Make sure we meet our statutory obligations, including those related to diversity and equalities
• Adhere to a legal requirement that will allow us to use or provide information (e.g. a formal Court Order or legislation)

Definition of Data Types

We use the following types of information / data:

Personal Data
This contains details that identify individuals even from one data item or a combination of data items. The following are demographic data items that are considered identifiable such as name, address, NHS Number, full postcode, date of birth. Under GDPR, this now includes location data and online identifiers.

Special categories of data (previously known as sensitive data)
This is personal data consisting of information as to: race, ethnic origin, political opinions, health, religious beliefs, trade union membership, sexual life and previous criminal convictions. Under GDPR, this now includes biometric data and genetic data.

Personal Confidential Data (PCD)
This term came from the Caldicott review undertaken in 2013 and describes personal information about identified or identifiable individuals, which should be kept private or secret. It includes personal data and special categories of data but it is adapted to include dead as well as living people and ‘confidential’ includes both information ‘given in confidence’ and ‘that which is owed a duty of confidence’.

Pseudonymised Data or Coded Data
Individual-level information where individuals can be distinguished by using a coded reference, which does not reveal their ‘real world’ identity. When data has been pseudonymised it still retains a level of detail in the replaced data by use of a key / code or pseudonym that should allow tracking back of the data to its original state.

Anonymised Data
This is data about individuals but with all identifying details removed. Data can be considered anonymised when it does not allow identification of the individuals to whom it relates, and it is not possible that any individual could be identified from the data by any further processing of that data or by processing it together with other information which is available or likely to be available.

Aggregated Data
This is statistical information about multiple individuals that has been combined to show general trends or values without identifying individuals within the data.

Our data processing activities

The law on data protection under the GDPR sets out a number of different reasons for which personal data can be processed for.  The law states that we have to inform you what the legal basis is for processing personal data and also if we process special category of data such as health data what the condition is for processing.

The types of processing we carry out in the GP practice and the legal bases and conditions we use to do this are outlined below:

Provision of Direct Care and administrative purposes within the GP practice

Direct care means a clinical, social or public health activity concerned with the prevention, investigation and treatment of illness and the alleviation of suffering of individuals. This is carried out by one or more registered and regulated health or social care professionals and their team with whom the individual has a legitimate relationship with. In addition, this also covers administrative purposes which are in the patient’s reasonable expectations.

To explain this, a patient has a legitimate relationship with a GP in order for them to be treated and the GP practice staff process the data in order to keep up to date records and to send referral letters etc.

Other local administrative purposes include waiting list management, performance against national targets, activity monitoring, local clinical audit and production of datasets to submit for national collections.

This processing covers the majority of our tasks to deliver health and care services to you.  When we use the above legal basis and condition to process your data for direct care, consent under GDPR is not needed.  However, we must still satisfy the common law duty of confidentiality and we rely on implied consent. For example, where a patient agrees to a referral from one healthcare professional to another and where the patient agrees this implies their consent.

Medicines Management and Optimisation

Oldham CCG pharmacists work with GP practices to provide advice on medicines and prescribing queries, process repeat prescription requests and review prescribing of medicines to ensure that it is safe and cost-effective. This may require the use of identifiable information.

In cases where identifiable data is required, this is done with practice agreement and in the case of repeat prescription processing with patient consent. No data is removed from the practice’s clinical system and no changes are made to patient’s records without permission from the GP. Patient records are viewed [insert how they are viewed e.g. remotely via secure laptops from the CCG’s premises, in the GP practice, in care homes or patient homes].

Where specialist support is required (e.g. to order a drug that comes in solid form in gas or liquid form) Oldham CCG medicines optimisation pharmacists will order this on behalf of a GP to support your care. Identifiable data is used for this purpose.

Identifiable data is also used by our pharmacists in order to review and authorise (if appropriate) requests for high cost drugs which are not routinely funded. In cases where identifiable data is used, this is done with the consent of the patients.

Purposes other than direct care (secondary use)

This is information which is used for non-healthcare purposes. Generally this could be for research purposes, audits, service management, safeguarding, commissioning, complaints and patient and public involvement.

When your personal information is used for secondary use this should, where appropriate, be limited and de-identified so that the secondary uses process is confidential.

Safeguarding

Information is provided to care providers to ensure that adult and children’s safeguarding matters are managed appropriately. Access to personal data and health information will be shared in some limited circumstances where it’s legally required for the safety of the individuals concerned. For the purposes of safeguarding children and vulnerable adults, personal and healthcare data is disclosed under  the provisions of the Children Acts 1989 and 2006 and Care Act 2014.

Risk Stratification

Risk stratification entails applying computer based algorithms, or calculations to identify those patients who are most at risk from certain medical conditions and who will benefit from clinical care to help prevent or better treat their condition. To identify those patients individually from the patient community would be a lengthy and time-consuming process which would by its nature potentially not identify individuals quickly and increase the time to improve care.  A GP / health professional reviews this information before a decision is made.

The use of personal and health data for risk stratification has been approved by the Secretary of State, through the Confidentiality Advisory Group of the Health Research Authority (known as Section 251 approval). This approval allows your GP or staff within your GP Practice who are responsible for providing your care, to see information that identifies you, but CCG staff will only be able to see information in a format that does not reveal your identity.

NHS England encourages GPs to use risk stratification tools as part of their local strategies for supporting patients with long-term conditions and to help and prevent avoidable admissions.

Knowledge of the risk profile of our population helps to commission appropriate preventative services and to promote quality improvement.

Risk stratification tools use various combinations of historic information about patients, for example, age, gender, diagnoses and patterns of hospital attendance and admission and primary care data collected in GP practice systems.

Our data processor for Risk Stratification purposes is NW DSCRO and CCG’s BI Teams.

If you do not wish information about you to be included in our risk stratification programme, please contact the GP Practice. We can add a code to your records that will stop your information from being used for this purpose. Please see the section below regarding objections for using data for secondary uses.

National Clinical Audits

The GP practice contributes to national clinical audits and will send the data which are required by NHS Digital when the law allows. This may include demographic data such as data of birth and information about your health which is recorded in coded form, for example, the clinical code for diabetes or high blood pressure.

Research

All NHS organisations (including Health & Social Care in Northern Ireland) are expected to participate and support health and care research. The Health Research Authority and government departments in Northern Ireland, Scotland and Wales set standards for NHS organisations to make sure they protect your privacy and comply with the law when they are involved in research. Our research ethics committees review research studies to make sure that the research uses of data about you are in the public interest, and meet ethical standards.

Health and care research may be exploring prevention, diagnosis or treatment of disease, which includes health and social factors in any disease area. Research may be sponsored by companies developing new medicines or medical devices, NHS organisations, universities or medical research charities. The research sponsor decides what information will be collected for the study and how it will be used.

Health and care research should serve the public interest, which means that research sponsors have to demonstrate that their research serves the interests of society as a whole. They do this by following the UK Policy Framework for Health and Social Care Research. They also have to have a legal basis for any use of personally-identifiable information.

How patient information may be used for research

When you agree to take part in a research study, the sponsor will collect the minimum personally-identifiable information needed for the purposes of the research project. Information about you will be used in the ways needed to conduct and analyse the research study. NHS organisations may keep a copy of the information collected about you. Depending on the needs of the study, the information that is passed to the research sponsor may include personal data that could identify you. You can find out more about the use of patient information for the study you are taking part in from the research team or the study sponsor. You can find out who the study sponsor is from the information you were given when you agreed to take part in the study.

For some research studies, you may be asked to provide information about your health to the research team, for example in a questionnaire. Sometimes information about you will be collected for research at the same time as for your clinical care, for example when a blood test is taken. In other cases, information may be copied from your health records. Information from your health records may be linked to information from other places such as central NHS records, or information about you collected by other organisations. You will be told about this when you agree to take part in the study.

Even though consent is not the legal basis for processing personal data for research, the common law duty of confidentiality is not changing, so consent is still needed for people outside the care team to access and use confidential patient information for research, unless you have support under the Health Service (Control of Patient Information Regulations) 2002 (‘section 251 support’) applying via the Confidentiality Advisory Group in England and Wales or similar arrangements elsewhere in the UK

Your choices about health and care research

If you are asked about taking part in research, usually someone in the care team looking after you will contact you. People in your care team may look at your health records to check whether you are suitable to take part in a research study, before asking you whether you are interested or sending you a letter on behalf of the researcher.

In some hospitals and GP practices, you may have the opportunity to sign up to a register to hear about suitable research studies that you could take part in. If you agree to this, then research nurses, researchers or administrative staff authorised by the organisation may look at your health records to see if you are suitable for any research studies.

It’s important for you to be aware that if you are taking part in research, or information about you is used for research, your rights to access, change or move information about you are limited. This is because researchers need to manage your information in specific ways in order for the research to be reliable and accurate. If you withdraw from a study, the sponsor will keep the information about you that it has already obtained. They may also keep information from research indefinitely.

If you would like to find out more about why and how patient data is used in research, please visit the Understanding Patient Data website.

https://understandingpatientdata.org.uk/what-you-need-know

In England you can register your choice to opt out via the “Your Data Matters” webpage on the link below:

https://www.nhs.uk/your-nhs-data-matters/

If you do choose to opt out you can still agree to take part in any research study you want to, without affecting your ability to opt out of other research. You can also change your choice about opting out at any time.

To find out more about GDPR and using personal data for research, please visit the Health Research Authority website on the link below:

https://www.hra.nhs.uk/hra-guidance-general-data-protection-regulation/

Complaints

If you contact the GP Practice about a complaint, we require your explicit consent to process this complaint for you.  You will be informed of how and with whom your data will be shared by us, including if you have or you are a representative you wish the GP practice to deal with on your behalf.

Purposes requiring consent

There are also other areas of processing undertaken where consent is required from you. Under GDPR, consent must be freely given, specific, you must be informed and a record must be made that you have given your consent, to confirm you have understood.

Patient and Public Involvement

If you have asked us to keep you regularly informed and up to date about the work of the GP Practice or if you are actively involved in our engagement and consultation activities or patient participation groups, we will collect and process personal confidential data which you share with us.

We obtain your consent for this purpose. Where you submit your details to us for involvement purposes, we will only use your information for this purpose. You can opt out at any time by contacting us using our contact details at the end of this document.

Using anonymous or coded information

This type of data may be used to help assess the needs of the general population and make informed decisions about the provision of future services. Information can also be used to conduct health research and development and monitor NHS performance where the law allows this. Where information is used for statistical purposes, stringent measures are taken to ensure individual patients cannot be identified. Anonymous statistical information may also be passed to organisations with a legitimate interest, including universities, community safety units and research institutions.

National Data Opt Out

Whenever you use a health or care service, such as attending the practice, important information about you is collected in a patient record for that service. Collecting this information helps to ensure you get the best possible care and treatment.

The information collected about you when you use these services can also be used and provided to other organisations for purposes beyond your individual care, for instance to help with:

• improving the quality and standards of care provided
• research into the development of new treatments
• preventing illness and diseases
• monitoring safety
• planning services

This may only take place when there is a clear legal basis to use this information. All these uses help to provide better health and care for you, your family and future generations. Confidential patient information about your health and care is only used like this where allowed by law.

Most of the time, anonymised data is used for research and planning so that you cannot be identified in which case your confidential patient information isn’t needed.

You have a choice about whether you want your confidential patient information to be used in this way. If you are happy with this use of information you do not need to do anything. If you do choose to opt-out your confidential patient information will still be used to support your individual care.

To find out more or to register your choice to opt out, please visit:

www.nhs.uk/your-nhs-data-matters

On this web page you will:

• See what is meant by confidential patient information
• Find examples of when confidential patient information is used for individual care and examples of when it is used for purposes beyond individual care
• Find out more about the benefits of sharing data
• Understand more about who uses the data
• Find out how your data is protected
• Be able to access the system to view, set or change your opt-out setting
• Find the contact telephone number if you want to know any more or to set/change your opt-out by phone
• See the situations where the opt-out will not apply

You can also find out more about how patient information is used at:

https://www.hra.nhs.uk/information-about-patients/ (which covers health and care research);

and,

https://understandingpatientdata.org.uk/what-you-need-know (which covers how and why patient information is used, the safeguards and how decisions are made)

You can change your mind about your choice at any time.

Data being used or shared for purposes beyond individual care does not include your data being shared with insurance companies or used for marketing purposes and data would only be used in this way with your specific agreement.

Health and care organisations have until 2020 to put systems and processes in place so they can apply your national data opt-out choice. Our organisation is able to apply your national data opt-out choice to any confidential patient information we may use or share with other organisations for purposes beyond your individual care.  “

How we protect your personal data

We will use the information in a manner that conforms to the General Data Protection Regulations (GDPR) and Data Protection Act 2018.   The information you provide will be subject to rigorous measures and procedures to make sure it can’t be seen, accessed or disclosed to any inappropriate persons.   We have an Information Governance Framework that explains the approach within the GP practice, our commitments and responsibilities to your privacy and cover a range of information and technology security areas.

Access to your personal confidential data is password protected on secure systems and securely locked in filing cabinet when on paper.

Our IT Services provider, Greater Manchester Shared Service, regularly monitor our system for potential vulnerabilities and attacks and look to always ensure security is strengthened.

All our staff have received up to date data security and protection training.  They are obliged in their employment contracts to uphold confidentiality, and may face disciplinary procedures if they do not do so. We have incident reporting and management processes in place for reporting any data breaches or incidents.  We learn from such events to help prevent further issues and inform patients of breaches when required.

How long do we keep your personal data?

Whenever we collect or process your data, we will only keep it for as long as is necessary for the purpose it was collected.  For a GP practice, we comply with the Records Management NHS Code of Practice which states that we keep records for 10 years after date of death.  Following this time, the records are securely destroyed if stored on paper, deleted on the electronic health record system or archived for research purposes where this applies.

Destruction

This will only happen following a review of the information at the end of its retention period. Where data has been identified for disposal we have the following responsibilities:

• to ensure that information held in manual form is destroyed using a cross cut shredder or contracted to a reputable confidential waste company that complies with European Standard EN15713 and obtain certificates of destruction.
• to ensure that electronic storage media used to hold or process information are destroyed or overwritten to national standards.

Who we share your data with?

As stated above, where your data is being processed for direct care this will be shared with other care providers who are providing direct care to you such as:

• NHS Trusts / Foundation Trusts
• GP’s
• Independent Contractors such as dentists, opticians, pharmacists
• Private Sector Providers
• Voluntary Sector Providers
• Ambulance Trusts
• Social Care Services
• Out of hours providers
• Walk in centres
• Clinics

We work with third parties and suppliers (data processors) to be able for us to provide a service to you. These include:

NHS Greater Manchester Shared Services – to provide our IT services

Medi2data – to provide Third Party Medical Reports

Health Innovation Manchester – https://healthinnovationmanchester.com/the-gm-care-record-privacy/

There may be occasions whereby these organisations have potential access to your personal data, for example, if they are fixing an IT fault on the system.  To protect your data, we have contracts and / or Information Sharing Agreements in place stipulating the data protection compliance they must have and re-enforce their responsibilities as a data processor to ensure you data is securely protected at all times.

We will not disclose your information to any 3^rd party without your consent unless:

• there are exceptional circumstances (life or death situations)
• where the law requires information to be passed on as stated above
• required for fraud management – we may share information about fraudulent activity in our premises or systems. This may include sharing data about individuals with law enforcement bodies.
• It is required to be disclosed to the police or other enforcement, regulatory or government body for prevention and / or detection of crime

Where is your data processed?

Your data is processed with the GP surgery who are UK based.  Your personal data is not sent outside of the UK for processing.

Where information sharing is required with a country outside of the EU you will be informed of this and we will have a relevant Information Sharing Agreement in place. We will not disclose any health information without an appropriate lawful principle, unless there are exceptional circumstances such as when the health or safety of others is at risk, where the law requires it, or to carry out a statutory functions i.e. reporting to external bodies to meet legal obligations

What are your rights over your personal data?

You have the following rights over your data we hold:

• Subject Access Rights – you can request access to and or copies of personal data we hold about you, free of charge (subject to exemptions) and provided to you within 1 calendar month. We request that you provide us with adequate information in writing to process your request such as full name, address, date of birth, NHS number and details of your request and documents to verify your identity so we can process the request efficiently.  On processing a request, there may be occasions when information may be withheld if the organisation believes that releasing the information to you could cause serious harm to your physical or mental health. Information may also be withheld if another person (i.e. third party) is identified in the record, and they do not want their information disclosed to you. However, if the other person was acting in their professional capacity in caring for you, in normal circumstances they could not prevent you from having access to that information.

To request a copy or request access to information we hold about you and / or to request information to be corrected if it is inaccurate, please contact the Practice Manager

Email: [email protected]

Postal Address:

Hopwood House Medical Practice. The Vineyards, Lees Road Oldham OL4 1JN              

• Right to rectification – The correction of personal data when incorrect, out of date or incomplete which must be acted upon within 1 calendar month of receipt of such request. Please ensure the GP practice has the correct contact details for you.
• Right to withdraw consent – If we have your explicit consent for any processing we do, you have the right to withdraw that consent at any time
• Right to Erasure (‘be forgotten’)
  If we obtain consent for any processing we do, you have the right to have that data deleted / erased. Please note this does not apply to health records.
• Right to Data Portability
  If we obtain consent for any processing we do, you have the right to have data provided to you in a commonly used and machine readable format such as excel spreadsheet, csv file.
• Right to object to processing – you have the right to object to processing however please note if we can demonstrate compelling legitimate grounds which outweighs the interest of you then processing can continue. If we didn’t process any information about you and your health care if would be very difficult for us to care and treat you.
• Right to restriction of processing
  This right enables individuals to suspend the processing of personal information, for example, if you want to establish its accuracy or the reason for processing it.

Objections to processing for secondary purposes (other than direct care)

The NHS Constitution states “You have the right to request that your confidential information is not used beyond your own care and treatment and to have your objections considered”.    The possible consequences (i.e. lack of joined up care, delay in treatment if information has to be sourced from elsewhere, medication complications which all lead to the possibility of difficulties in providing the best level of care and treatment) will be fully explained to you to allow you to make an informed decision.

If you wish to opt out of your data being processed and / or shared onwards with other organisations for purposes not related to your direct care, please contact the surgery at: [email protected]

Complaints / Contacting the Regulator

If you feel that your data has not been handled correctly or you are unhappy with our response to any requests you have made to us regarding the use of your personal data, please contact our Data Protection Officer / Practice Manager at the following contact details:

Email: [email protected]

Postal Address:

Hopwood House Medical Practice. The Vineyards, Lees Road Oldham OL4 1JN              

If you are not happy with our responses and wish to take your complaint to an independent body, you have the right to lodge a complaint with the Information Commissioner’s Office.

You can contact them by calling 0303 123 1133
Or go online to www.ico.org.uk/concerns

Further Information / Contact Us

We hope that the Privacy Notice has been helpful in setting out the way we handle your personal data and your rights to control it.  Should you have any questions / or would like further information, please visit the websites below and / or contact either our Caldicott Guardian / Data Protection Officer / Practice Manager at the following contact details:

Email: [email protected]

Postal Address:

Hopwood House Medical Practice. The Vineyards, Lees Road Oldham OL4 1JN              

Links

If you would like to find out more information on the wider health and care system approach to using personal information or other useful information, please click and / or search for the following on the internet:

• Information Commissioners Office
• Information Governance Alliance
• NHS Digital National Data Opt Out Programme
• NHS Constitution
• NHS Care Record Guarantee
• NHS Digital Guide to Confidentiality in Health and Social Care
• Health Research Authority
  • Health Research Authority Confidentiality Advisory Group (CAG)

All GPs are required to declare the mean earnings for GPs working to deliver NHS services to patients at each practice.

Read/Download our GP Fair Processing Notice

NHS Oldham Clinical Commissioning Group (CCG) closed at the end of June 2022 and its functions have been taken over by NHS Greater Manchester Integrated Care (‘NHS GM’).

This new organisation is the statutory body in charge of NHS money and is responsible for making sure services are in place to put plans into action. You can find out more here: gmintegratedcare.org.uk.

If you need help accessing local NHS services or wish to make a complaint, you can contact NHS GM Customer Services by emailing [email protected] or calling 07966 746117. Or you can write to: Customer Services, NHS Greater Manchester Integrated Care, 4th Floor, Piccadilly Place, Manchester M1 3BN.

Please note, NHS GM is unable to investigate complaints about general practice. These should be directed either to ourselves directly or to NHS England.

If you’re making, or thinking about making, a complaint, someone from the independent NHS Complaints Advocacy Service can help you. Cloverleaf Advocacy provides this service in Oldham. The service is accessible to all Oldham residents and is completely free.

Cloverleaf can help you to raise a formal complaint about an NHS funded service.  An advocate will also be able to attend meetings with you and review any information you’re given during the complaints process. You can seek advice from an NHS complaints advocate at any stage of the process.

The GP’s receive many requests for reports from government organisations or other third parties.

The GP’s do not have a contractual obligation to complete any of these forms and they all attract a fee which takes into consideration their professional time and an administrative charge.

NHS work must always take priority.  Please be patient as you will have to wait for reports/letters/forms etc.

Summary

• Hormonal treatments for gender incongruence carry a lot of potential risks, and require expert monitoring which is outside of the competence of NHS GPs.
• As NHS GPs, we would consider engaging with NHS gender identity clinics where a shared care protocol is being followed and appropriate assessments have been carried out.
• The practice will not be able to prescribe hormone treatments for gender incongruence outside of an NHS shared care protocol. This includes requests from private providers, and patient-directed requests for “bridging” prescriptions.
• Patients should be advised to avoid procuring hormone medication from online sources without qualified specialist advice.
• Patients seeking treatment from private medical providers are entitled to do so at their own judgement, but the practice would not be prepared to take over a prescribing role on behalf of a private clinic.

Background

As a GP practice we are committed providing the best possible primary care for our patients. Patients who are transgender and experiencing gender difficulties (gender incongruence, also referred to as gender dysphoria) often have problems which GPs are best placed to help, treat, support, and signpost or refer to specialist services. At the practice we pride ourselves in being able to help many patients with multiple aspects of their mental and physical health, to support their general wellbeing.

Sadly, in the UK the gender identity services (GIDS at Tavistock NHS Trust in London, and various regional adult NHS Gender Identity Clinic services) are vastly under-resourced for the demand that is put upon them. Often the waiting lists are several years in length. Gender identity clinics are very important for coordinating the detailed psychological assessments that are required before making decisions such as medical (hormones) or surgical therapies to treat gender incongruence. As a result, GPs are facing increasing difficulties addressing patient requests for “bridging” prescriptions while they wait for formal assessment in the gender identity clinics, particularly for those patients who have self-started medication, including medication which they have procured over the internet.

It is easy to understand the frustration that patients can feel in this situation, but it is important to ensure we are practising medicine in a safe and fair way.

All hormone medications used to treat gender incongruence are being used outside of their UK license and are subject to complex monitoring requirements that are directed by specialist gender physicians and endocrinologists. Some of these medications have irreversible unwanted effects, and may adversely affect physical characteristics, impair future fertility, and can also pose risks such as risks of breast cancers and major blood clots.

As General Medical Council (GMC) registered doctors, we are bound to follow the rules of GMC Good Medical Practice. Article 14 of GMC GMP states “You must recognise and work within the limits of your competence”, and the GMC guidance on prescribing medications outside of their UK license states that this must only be done if the GP is able to accept personal responsibility for the medication, is competent in all areas of its use, and is able to council patients thoroughly about risks and side effects. In the GMC document “Trans healthcare: Ethical Guidance 2019” they have defined an “experienced gender specialist” as a doctor who has “evidence of relevant training and at least two years’ experience working in a specialised gender dysphoria practice such as an NHS Gender Identity Clinic”.

The Royal College of General Practitioners (RCGP) has published a statement about GP competences to prescribe hormones for gender incongruence including the topic of “bridging” prescriptions (https://www.rcgp.org.uk/policy/rcgp-policy-areas/transgender-care). This statement included the following: “GPs are expert generalists. The provision of detailed advice about gender identity issues and associated treatments does not fall within the remit of a GPs education and training, therefore GPs often feel it its outside their area of competence to advise patients with gender dysphoria. … GPs are ultimately responsible for their prescribing and should not be pressured into prescribing where they feel it is unsafe or involves unacceptable risks.” The RCGP has repeatedly recommended the UK Government and NHS England provide more funding for gender services to reduce waiting lists.

The national gender service at The Tavistock and Portman NHS Trust states that “Gender identity clinics do not endorse GPs prescribing hormone therapy or bridging prescriptions for self-started, internet-sourced hormones, until a gender identity clinic has made a full assessment of the patient”.

Practice approach to prescribing treatments for Gender Incongruence

As GPs, we would be pleased to discuss possible treatments and support with individual patients. There is a lot that GPs can offer patients with gender incongruence, this support may include aspects of mental and physical health, and we can help signpost or refer individuals to a lot of helpful services. If a patient is wishing to seek medical (hormones) or surgical gender treatments, we can have a preliminary discussion with them, and refer relevant NHS gender identity clinic services.

Once a patient has been seen by an NHS gender identity clinic, the GPs at the practice will be happy to discuss and engage with NHS gender identity clinics about the possibility of starting hormone treatments. Providing a satisfactory and safe “Shared Care Protocol” has been produced by the specialist clinic, we would be willing to discuss prescribing these treatments on behalf of the specialist, following the strict monitoring requirements set out by the specialist, with the safety-net of further NHS gender specialist review should side-effects occur, or abnormalities be found on monitoring.

In Greater Manchester, our local adult gender identity clinic is Indigo (https://indigogenderservice.uk/). Indigo is an NHS commissioned gender identity clinic which uses established and approved “Shared Care Protocols” agreed with the health board in Greater Manchester (the Greater Manchester Medicines Management Group, GMMMG: https://gmmmg.nhs.uk/).

However, prescribing hormones outside of a rigorous “Shared Care Protocol” would be outside of our competence as GPs. This applies to where patients may be sourcing treatment themselves from the internet, from private providers (who often do not provide a rigorous NHS-level standard of care, and frequently are not accessible by GPs for support), and requests for unsupervised “bridging” prescriptions. It is outside of our expertise and competence to prescribe hormones for gender incongruence where proper assessments and care agreements have not taken place.

Further notes on self-sourced medication or private prescription services

The practice does not recommend patients to seek prescriptions online without specialist assessment, for the safety reasons listed above.

For patients seeking assessments from private providers, any person is entitled to seek private healthcare on their own initiative, and at their own risk and cost. The practice cannot recommend private providers to patients. For the reasons listed above, we would not be prepared to take over prescribing roles on behalf of a private provider. This is also reflected in NHS England advice about the NHS-Private interface, which sets out rules on the separation of private and NHS treatment. Specifically, “the NHS cannot pay for or subsidise your private hospital treatment” and “there must be as clear a separation as possible between your private treatment and your NHS treatment”. More information can be found on the NHS website: https://www.nhs.uk/common-health-questions/nhs-services-and-treatments/if-i-pay-for-private-treatment-how-will-my-nhs-care-be-affected.

Diazepam for Fear of Flying, and other requests (including scans and dental appointments)

Hopwood House Medical Practice – Practice Policy

Background

Benzodiazepines (including diazepam, lorazepam, temazepam, clonazepam) are medicines that have been in use since the 1960s for a wide range of conditions, such as alcohol withdrawal, epilepsy, and muscle spasms. They are strongly sedating drugs that have negative effects on memory, coordination, concentration, and reaction times. They are addictive and withdrawal can lead to seizures, hallucinations, agitation, and confusion.

Unfortunately, benzodiazepines have widely become drugs of abuse, and as a result they are controlled in the UK as Class C, Schedule 4 drugs. This means there are restrictions on when and how much can be prescribed under the Controlled Substances Act, and inappropriate use, supply or possession of these medications is illegal in the UK under the Misuse of Drugs Act.

Many people approach their GP practice asking for diazepam to help with fear of flying, or to sleep during a flight. There are several good reasons why prescribing diazepam is not recommended, and as a result we will no longer prescribe diazepam for patients who wish to use this for a fear of flying.

Reasons

1. The national prescribing guidelines followed by GPs (the British National Formulary – BNF) states that all benzodiazepines are ‘contraindicated’ (not allowed) in treatment of phobias (fear conditions, such as fear of flying). It also states that the use of benzodiazepines to treat short-term anxiety is ‘inappropriate’. Benzodiazepines are only licensed for short-term use in a generalised anxiety crisis – but if this is the case for you, you should seek proper care and support for your mental health, and it would not be advisable to go on a flight. Your GP would be taking a significant legal risk by prescribing against these national guidelines.
2. Diazepam is a sedative, so it makes you sleepier. If an emergency occurred during the flight, this could impair your ability to concentrate, follow instructions, or react to the situation. This could seriously affect the safety of you and the people around you. Such incidents are rare but they do occur, and it can be fatal if you are unable to evacuate the plane properly (an example event is flight BA28M, where 55 people sadly died while the plane burned while sat on Manchester Airport runway, and the official AAIB incident report specifically commented on evacuation delays contributing to the deaths). No-one else on board a plane will evacuate for you – the cabin crew are there to guide an evacuation, but you need to be responsible for yourself. As a result, many airlines consider sedative medications as a reason why someone would not be allowed on a plane, in a similar way that someone who has consumed excessive alcohol may be removed from a plane.
3. Sedative drugs can make you fall asleep; however, the sleep is an unnatural non-REM sleep. Your movements during this type of sleep are reduced and this can place you at an even higher risk of developing blood clots in the legs (deep vein thrombosis – a DVT) or lungs (pulmonary embolism – a PE). These blood clots are very dangerous and can even be fatal. This risk further increases if your flight is over 4 hours long.
4. Going on an aeroplane normally involves your blood oxygen levels decreasing from around 98% to as low as 90%, due to the air pressure decrease at cruising altitudes. Normally your body compensates for this by altering the rate and depth of your breathing. However, benzodiazepines work to depress your breathing and this can put you at risk of hypoxia (excessively low blood oxygen), especially if you have lung problems already, which can be very dangerous.
5. Most people feel sleepy when they take diazepam, but a small proportion of people experience the opposite effect and can become aggressive. This is called a paradoxical effect, and it can be unexpectedly inconsistent, even if diazepam has been used in the past. Alongside aggression and agitation, this response can cause disinhibition and make you behave in ways you normally wouldn’t. This could also impact on your safety and the safety of your fellow passengers or could lead you to get in trouble with the law. Recently, a passenger in this situation was detained by the aircrew, arrested after an emergency landing, given jail time, and was also fined for the costs of redirecting the plane.
6. In several countries, diazepam and similar drugs are illegal (Greece, Japan, and many Middle Eastern countries including the UAE are just some examples). They would be confiscated, and you might find yourself in trouble with the police for being in control of an illegal substance, even if it has been prescribed by a doctor in the UK. This has led to people spending time in a jail a foreign country.
7. Diazepam has a long half-life, which means it stays in your system for a significant time. If your job requires you to submit random drug testing, you may fail these tests.
8. There is a possible link between occasional use of benzodiazepines and earlier onset of dementia in later life.

What you can do

A fear of flying is frightening and can be debilitating. However, there are much better and effective ways of tackling the problem. We recommend you tackle your problem with a Fear of Flying Course, which are aviation-industry approved and are run by several airlines. These courses are far more effective than diazepam and have none of the undesirable effects. Also, the positive effects of the courses continue after the courses have been completed.

Easy Jet :                       www.fearlessflyer.easyjet.com                                      Tel: 0203 813 1644

British Airways:             http://flyingwithconfidence.com/courses/venues           Tel: 01252 793 250

Virgin Atlantic:              https://flyingwithoutfear.co.uk/collections                    Tel: 01423 714 900

Fly And Be Calm is an instant download audio course which includes instructions, a fear removal tool and two hypnotic tracks. You can find this at: https://flyandbecalm.co.uk/

Alternatively, you could contact your local psychology therapy provider to consider having Cognitive Behavioural Therapy (CBT). Details of the local Healthy Minds service for Oldham can be found here: https://www.penninecare.nhs.uk/healthymindsoldham

Ultimately, if you still feel unable to fly, then it may be appropriate to consider alternative routes of transport.

If you still wish to consider diazepam for fear of flying, we suggest consulting with a private GP or a private travel clinic, who may be able to help you further. These services are private and not offered by the NHS. The private clinics may then liaise with the airlines directly to arrange a medically-trained escort for a passenger who is taking sedative medications, which can be expensive.

Other situations – scans, dental appointments etc.

We do not provide sedative medications such as diazepam for use in other situations, such as for dental/hospital procedures or scans. The Royal College of Radiologists sets out clear guidance for sedation in hospital radiology departments (https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr182_safe_sedation.pdf) which states “Sedation and analgesia should be administered by a competent and well-trained sedation and oversight provided by a sedation committee within the institution”.

The Intercollegiate Advisory Committee for Sedation in Dentistry has a similar guideline (https://www.saad.org.uk/IACSD%202020.pdf) which states “The monitoring and discharge requirements for oral sedation are the same as for intravenous sedation. Oral sedation must only be administered in the place where the dental treatment is provided and must only be carried out by practitioners who are already competent in intravenous sedation.”

As a result, responsibility for this type of treatment lies with your dentist or hospital staff, and not your GP. If you feel this is required, we suggest consulting with your dentist or the hospital teams in good time before any scans or treatments occur.

Publication Scheme

Trainees

We are an HEE approved Teaching & Training Practice. We are pleased to be a training practice for postgraduate doctors who have worked in hospitals and are gaining experience of General Practice.

This enables patients to see a wider range of clinicians whilst allowing the surgery to benefit from the fresh ideas and approaches brought by young enthusiastic doctors.

You can of course still elect to see your chosen regular doctor but sometimes this may require you to plan your appointment.

We are a member practice of Oldham Clinical Commissioning Group, which will be the organisation responsible for deciding how around £312m of taxpayers’ money is spent on Oldham people from April 2013. You can find out more about Oldham CCG at www.oldhamccg.nhs.uk.

Sometimes information about you, as a patient, will be used within the NHS to help us improve the care and services you receive. Information about patients can help us to:

• Protect your health, for example by assessing trends in illness
• Provide training and teaching for our staff
• Manage and plan the NHS for your benefit, for example by making sure services continue to meet your needs
• Prepare statistics on how well we are performing and how busy we are, which in turn ensures we can meet your needs.
  As a member practice we wholeheartedly support these aims. Therefore, we need to share information about the care we provide to you, as our patients, with Oldham Clinical Commissioning Group Governing Body. This is a committee of clinicians and practice staff that are responsible for making decisions about local health services.

By sharing this information we can identify areas for improvement, by comparing what we do with other practices. We will be able to identify individuals who may be at a particularly high risk of being admitted to hospital, so we can support them and help prevent this happening.

We would like to reassure you this information will be shared in a safe and secure way and will be used in the strictest confidence. If you have any concerns, or any questions about how the data is being used, you should contact J Berry Hopwood House 0161 628 3628.