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DATA PROTECTION POLICY STATEMENT

 

Issue No: 1

Issue Date: 25th May 2018

 

  1. Introduction

 

  1. Background to the General Data Protection Regulation (‘GDPR’)

The General Data Protection Regulation 2016 replaces the EU Data Protection Directive of 1995 and supersedes the laws of individual Member States that were developed in compliance with the Data Protection Directive 95/46/EC. Its purpose is to protect the “rights and freedoms” of natural persons (i.e. living individuals) and to ensure that personal data is not processed without their knowledge, and, wherever possible, that it is processed with their consent.

 

  1. Definitions used by the organisation (drawn from the GDPR)

Material scope (Article 2) – the GDPR applies to the processing of personal data wholly or partly by automated means (i.e. by computer) and to the processing other than by automated means of personal data (i.e. paper records) that form part of a filing system or are intended to form part of a filing system.

 

Territorial scope (Article 3) – the GDPR will apply to all controllers that are established in the EU (European Union) who process the personal data of data subjects, in the context of that establishment. It will also apply to controllers outside of the EU that process personal data in order to offer goods and services, or monitor the behavior of data subjects who are resident in the EU.

 

  1. Article 4 definitions

Establishment – the main establishment of the controller in the EU will be the place in which the controller makes the main decisions as to the purpose and means of its data processing activities. The main establishment of a processor in the EU will be its administrative centre. If a controller is based outside the EU, it will have to appoint a representative in the jurisdiction in which the controller operates to act on behalf of the controller and deal with supervisory authorities.

 

Personal data – any information relating to an identified or identifiable natural person ('data subject'); an identifiable natural person is one who can be identified, directly or indirectly, in particular by reference to an identifier such as a name, an identification number, location data, an online identifier or to one or more factors specific to the physical, physiological, genetic, mental, economic, cultural or social identity of that natural person.

 

Special categories of personal data – personal data revealing racial or ethnic origin, political opinions, religious or philosophical beliefs, or trade-union membership, and the processing of genetic data, biometric data for the purpose of uniquely identifying a natural person, data concerning health or data concerning a natural person's sex life or sexual orientation.

 

Data controller – the natural or legal person, public authority, agency or other body which, alone or jointly with others, determines the purposes and means of the processing of personal data; where the purposes and means of such processing are determined by Union or Member State law, the controller or the specific criteria for its nomination may be provided for by Union or Member State law.

 

Data subject – any living individual who is the subject of personal data held by an organisation.

 

 

Processing – any operation or set of operations which is performed on personal data or on sets of personal data, whether or not by automated means, such as collection, recording, organisation, structuring, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, restriction, erasure or destruction.

 

Profiling – is any form of automated processing of personal data intended to evaluate certain personal aspects relating to a natural person, or to analyse or predict that person’s performance at work, economic situation, location, health, personal preferences, reliability, or behavior. This definition is linked to the right of the data subject to object to profiling and a right to be informed about the existence of profiling, of measures based on profiling and the envisaged effects of profiling on the individual.

 

Personal data breach – a breach of security leading to the accidental, or unlawful, destruction, loss, alteration, unauthorised disclosure of, or access to, personal data transmitted, stored or otherwise processed. There is an obligation on the controller to report personal data breaches to the supervisory authority and where the breach is likely to adversely affect the personal data or privacy of the data subject.

 

Data subject consent - means any freely given, specific, informed and unambiguous indication of the data subject's wishes by which he or she, by a statement or by a clear affirmative action, signifies agreement to the processing of personal data.

 

Child – the GDPR defines a child as anyone under the age of 16 years [A1] old. The processing of personal data of a child is only lawful if parental or custodian consent has been obtained. The controller shall make reasonable efforts to verify in such cases that consent is given or authorised by the holder of parental responsibility over the child.

 

Third party – a natural or legal person, public authority, agency or body other than the data subject, controller, processor and persons who, under the direct authority of the controller or processor, are authorised to process personal data.

 

Filing system – any structured set of personal data which are accessible according to specific criteria, whether centralised, decentralised or dispersed on a functional or geographical basis.

 

 

  1. Policy statement

 

  1. The Board of Directors and management of Harley Street Spine, head office which is located at Highgate Private Hospital, are committed to compliance with all relevant EU and Member State laws in respect of personal data, and the protection of the “rights and freedoms” of individuals whose information Harley Street Spine collects and processes in accordance with the General Data Protection Regulation (GDPR).

  2. Compliance with the GDPR is described by this policy and other relevant policies such as the Standard Operating Procedure (SOP) and Service Level Agreements (SLAs) along[PR2]  with connected processes and procedures.

  3. The GDPR and this policy apply to all of Harley Street Spine’s personal and sensitive data processing functions, including those performed on patients’, employees’, suppliers’ and partners’ personal data, and any other personal data the organisation processes from any source.  

  4. Harley Street Spine has established objectives for data protection and privacy[PR3]  as detailed in this policy. 

  5. Data Protection Officer is responsible for reviewing the register of processing annually in the light of any changes to Total Orthopaedic’s activities (as determined by changes to the data inventory register and the management review) and to any additional requirements identified by means of data protection impact assessments. This register needs to be available on the supervisory authority’s request.

  6. This policy applies to all processors of Harley Street Spine such as outsourced processors. Any breach of the GDPR may be a criminal offence, in which case the matter will be reported as soon as possible to the appropriate authorities.

  7. Partners and any third parties working with or for Harley Street Spine, and who have or may have access to personal data, will be expected to have read, understood and to comply with this policy. No third party may access personal data held by Harley Street Spine without having first signing a copy of this policy which imposes on the third-party obligations no less onerous than those to which Harley Street Spine is committed, and which gives Harley Street Spine the right to audit compliance with the agreement.

 

  1. Responsibilities and roles under the General Data Protection Regulation

 

Harley Street Spine and associated Consultants are Data Controllers under the GDPR.

  1. Top Management and all those in managerial or supervisory roles throughout Harley Street Spine are responsible for developing and encouraging good information handling practices within Harley Street Spine; responsibilities are set out in Service Level Agreements (SLAs).

  2. Data Protection Officer, a role specified in the GDPR, should be a member of the senior management team, is accountable to Board of Directors of Harley Street Spine for the management of personal data within Harley Street Spine and for ensuring that compliance with data protection legislation and good practice can be demonstrated. This accountability includes:

    1. development and implementation of the GDPR as required by this policy; and

    2. security and risk management in relation to compliance with the policy.

 

  1. Data Protection Officer, who the Board of Directors considers to be suitably qualified and experienced, has been appointed to take responsibility for Harley Street Spine’s compliance with this policy on a day-to-day basis and, in particular, has direct responsibility for ensuring that Harley Street Spine complies with the GDPR, as do Directors in respect of data processing that takes place within their area of responsibility. 

  2. The Data Protection Officer has specific responsibilities in respect of procedures such as the Subject Access Request Procedure (as documented in the SLAs) and are the first point of call for any stakeholder seeking clarification on any aspect of data protection compliance.

  3. Compliance with data protection legislation is the responsibility of all staff within Harley Street Spine who process personal data.

  4. Harley Street Spine’s Training Policy (as documented in the SLAs) sets out specific training and awareness requirements in relation to all internal and external staff of Harley Street Spine generally.

  5. Internal and external staff of Harley Street Spine are responsible for ensuring that any personal data about them and supplied by them to Harley Street Spine is accurate and up-to-date.

 

  1. Data protection principles

 

All processing of personal data must be conducted in accordance with the data protection principles as set out in Article 5 of the GDPR. Harley Street Spine’s policies and procedures are designed to ensure compliance with the principles.

 

  1. Personal data must be processed lawfully, fairly and transparently

Lawful – identify a lawful basis before you can process personal data. These are often referred to as the “conditions for processing”, for example consent.

 

Fairly[A4]  – in order for processing to be fair, the data controller has to make certain information available to the data subjects as practicable. This applies whether the personal data was obtained directly from the data subjects or from other sources. 

 

The GDPR has increased requirements about what information should be available to data subjects, which is covered in the ‘Transparency’ requirement.

 

Transparently – the GDPR includes rules on giving privacy information to data subjects in Articles 12, 13 and 14. These are detailed and specific, placing an emphasis on making privacy notices understandable and accessible. Information must be communicated to the data subject in an intelligible form using clear and plain language.

Harley Street Spine’s Privacy Notice is available on the website and upon request.

 

The specific information that must be provided to the data subject must, as a minimum, include:

  1. the identity and the contact details of the controller and, if any, of the controller's representative;

  2. the contact details of the Data Protection Officer;

  3. the purposes of the processing for which the personal data are intended as well as the legal basis for the processing;

  4. the period for which the personal data will be stored;

  5. the existence of the rights to request access, rectification, erasure or to object to the processing, and the conditions (or lack of) relating to exercising these rights, such as whether the lawfulness of previous processing will be affected;

  6. the categories of personal data concerned;

  7. the recipients or categories of recipients of the personal data, where applicable;

  8. where applicable, that the controller intends to transfer personal data to a recipient in a third country and the level of protection afforded to the data;

  9. any further information necessary to guarantee fair processing.

 

  1. Personal data can only be collected for specific, explicit and legitimate purposes

Data obtained for specified purposes must not be used for a purpose that differs from those formally notified to the supervisory authority as part of Harley Street Spine’s GDPR register of processing.

 

  1. Personal data must be adequate, relevant and limited to what is necessary for processing[A5] 

    1. The Data Protection Officer is responsible for ensuring that Harley Street Spine does not collect information that is not strictly necessary for the purpose for which it is obtained.

    2. All data collection forms (electronic or paper-based) must link to a privacy statement and be approved by the Data Protection Officer.

    3. The Data Protection Officer will ensure that, on an annual basis all data collection methods are reviewed to ensure that collected data continues to be adequate, relevant and not excessive.

 

  1. Personal data must be accurate and kept up to date with every effort to erase or rectify without delay

    1. Data that is stored by the data controller must be reviewed and updated as necessary. No data should be kept unless it is reasonable to assume that it is accurate.

    2. The Data Protection Officer is responsible for ensuring that all staff are trained in the importance of collecting accurate data and maintaining it.

    3. It is also the responsibility of the data subject to ensure that data held by Harley Street Spine is accurate and up to date. Completion of a registration or application form by a data subject will include a statement that the data contained therein is accurate at the date of submission.

    4. Staff should be required to notify Harley Street Spine of any changes in circumstance to enable personal records to be updated accordingly. Instructions for updating records are contained. It is the responsibility of Harley Street Spine to ensure that any notification regarding change of circumstances is recorded and acted upon.

    5. The Data Protection Officer is responsible for ensuring that appropriate procedures and policies are in place to keep personal data accurate and up to date, taking into account the volume of data collected, the speed with which it might change and any other relevant factors.

    6. On at least an annual basis, the Data Protection Officer will review the retention dates of all the personal data processed by Harley Street Spine and will identify any data that is no longer required in the context of the registered purpose.

    7. The Data Protection Officer is responsible for responding to requests for rectification from data subjects within one month. This[A6]  can be extended to a further two months for complex requests. If Harley Street Spine decides not to comply with the request, the Data Protection Officer must respond to the data subject to explain its reasoning and inform them of their right to complain to the supervisory authority and seek judicial remedy.

    8. The Data Protection Officer is responsible for making appropriate arrangements that, where third-party organisations may have been passed inaccurate or out-of-date personal data, to inform them that the information is inaccurate and/or out of date and is not to be used to inform decisions about the individuals concerned; and for passing any correction to the personal data to the third party where this is required.

 

  1. Personal data must be kept in a form such that the data subject can be identified only as long as is necessary for processing.

    1. Where personal data is retained beyond the processing date, it will be archived in an encrypted format[PR7]  in order to protect the identity of the data subject in the event of a data breach.

    2. Personal data will be retained for eight years and, once its retention date is passed, it must be securely archived as set out in this procedure.

    3. The Data Protection Officer must specifically approve in writing any data retention that exceeds this and must ensure that the justification is clearly identified and in line with the requirements of the data protection legislation.

 

  1. Personal data must be processed in a manner that ensures the appropriate security[A8] [A9] 

The Data Protection Officer will carry out a risk assessment [A10] taking into account all the circumstances of Harley Street Spine’s controlling or processing operations.

 

In determining appropriateness, the Data Protection Officer  should also consider the extent of possible damage or loss that might be caused to individuals if a security breach occurs, the effect of any security breach on Harley Street Spine itself, and any likely reputational damage including the possible loss of customer trust.

 

When assessing appropriate technical measures, the Data Protection Officer will consider the following:

  • Password protection;

  • Automatic locking of idle terminals;

  • Removal of access rights for USB and other memory media;

  • Virus checking software and firewalls;

  • Role-based access rights including those assigned to temporary staff;

  • Encryption of devices that leave the organisations premises such as laptops;

  • Security of local and wide area networks;

  • Privacy enhancing technologies such as pseudonymisation and anonymisation;

  • Identifying appropriate international security standards relevant to Harley Street Spine.

 

When assessing appropriate organisational measures the Data Protection Officer will consider the following:

  • The appropriate training levels throughout Harley Street Spine;

  • Measures that consider the reliability of employees (such as references etc.);

  • The inclusion of data protection in employment contracts;

  • Identification of disciplinary action measures for data breaches;

  • Monitoring of staff for compliance with relevant security standards;

  • Physical access controls to electronic and paper based records;

  • Adoption of a clear desk policy;

  • Storing of paper based data in lockable fire-proof cabinets;

  • Restricting the use of portable electronic devices outside of the workplace;

  • Restricting the use of employee’s own personal devices [A11] being used in the workplace;

  • Adopting clear rules about passwords;

  • Making regular backups of personal data and storing the media off-site;

  • The imposition of contractual obligations on the importing organisations to take appropriate security measures when transferring data outside the EEA.

 

These controls have been selected on the basis of identified risks to personal data, and the potential for damage or distress to individuals whose data is being processed.

 

  1. The controller must be able to demonstrate compliance with the GDPR’s other principles (accountability)

 

The GDPR includes provisions that promote accountability and governance. These complement the GDPR’s transparency requirements. The accountability principle in Article 5(2) requires you to demonstrate that you comply with the principles and states explicitly that this is your responsibility.

 

Harley Street Spine will demonstrate compliance with the data protection principles by implementing data protection policies, adhering to codes of conduct, implementing technical and organisational measures, as well as adopting techniques such as data protection by design, DPIAs, breach notification procedures and incident response plans.

 

  1. Data subjects’ rights

 

  1. Data subjects have the following rights regarding data processing, and the data that is recorded about them:

    1. To make subject access requests regarding the nature of information held and to whom it has been disclosed.

    2. To prevent processing likely to cause damage or distress.

    3. To prevent processing for purposes of direct marketing.

    4. To be informed about the mechanics of automated decision-taking process that will significantly affect them.

    5. To not have significant decisions that will affect them taken solely by automated process.

    6. To sue for compensation if they suffer damage by any contravention of the GDPR.

    7. To take action to rectify, block, erased, including the right to be forgotten, or destroy inaccurate data.

    8. To request the supervisory authority to assess whether any provision of the GDPR has been contravened.

    9. To have personal data provided to them in a structured, commonly used and machine-readable format, and the right to have that data transmitted to another controller.

    10. To object to any automated profiling that is occurring without consent.

 

  1. Harley Street Spine ensures that data subjects may exercise these rights:

    1. Data subjects may make data access requests.  Harley Street Spine will ensure that its response to the data access request complies with the requirements of the GDPR.

    2. Data subjects have the right to complain to Harley Street Spine related to the processing of their personal data, the handling of a request from a data subject and appeals from a data subject on how complaints have been handled.

 

  1. Consent

 

  1. Harley Street Spine understands ‘consent’ to mean that it has been explicitly and freely given, and a specific, informed and unambiguous indication of the data subject’s wishes that, by statement or by a clear affirmative action, signifies agreement to the processing of personal data relating to him or her. The data subject can withdraw their consent at any time[A12] .

  2. Harley Street Spine understands ‘consent’ to mean that the data subject has been fully informed of the intended processing and has signified their agreement, while in a fit state of mind to do so and without pressure being exerted upon them. Consent obtained under duress or on the basis of misleading information will not be a valid basis for processing.

  3. There must be some active communication between the parties to demonstrate active consent[A13]  and this is done at the first point of contact with a data subject in the form of a Consent Form and stored on TO DGL database. Consent cannot be inferred from non-response to a communication. The Controller must be able to demonstrate that consent was obtained for the processing operation.[A14] 

  4. For sensitive data, explicit written consent [A15] of data subjects must be obtained unless an alternative legitimate basis for processing exists and this will be done at the first point of  contact with a data subject in the form of a Consent Form and stored on TO DGL database.

  5. In most instances, consent to process personal and sensitive data is obtained routinely by Harley Street Spine using standard consent documents at the time of first contact ie when a new patient books in for a consultation.  

 

  1. Security of data

 

  1. All staff are responsible for ensuring that any personal data that Harley Street Spine holds and for which they are responsible, is kept securely and is not under any conditions disclosed to any third party unless that third party has been specifically authorised by Harley Street Spine to receive that information and has entered into a confidentiality agreement.   

  2. All personal data should be accessible only to those who need to use it. All personal data should be treated with the highest security and must be kept:

  • in a lockable room with controlled access; and/or

  • in a locked drawer or filing cabinet; and/or

  • if computerised, password protected in line with company requirements as stated in the SOP

  • stored on (removable) computer media which are encrypted.

 

  1. Care must be taken to ensure that PC screens and terminals are not visible except to authorised Staff of Harley Street Spine.

  2. Manual records may not be left where they can be accessed by unauthorised personnel and may not be removed from business premises without explicit authorisation. As soon as manual records are no longer required for day-to-day client support, they must be shredded and disposed of as ‘confidential waste’. 

  3. Personal data may only be deleted or disposed securely. Manual records that have reached their retention date are to be shredded and disposed of as ‘confidential waste[A16] ’. Hard drives of redundant PCs are to be removed and immediately destroyed before disposal.

  4. Processing of personal data ‘off-site’ presents a potentially greater risk of loss, theft or damage to personal data. Staff must be specifically authorised to process data off-site by a their individual consultant.

 

  1. Disclosure of data

 

  1. Harley Street Spine must ensure that personal data is not disclosed to unauthorised third parties which includes family members, friends, government bodies, and in certain circumstances, the Police. All Staff should exercise caution when asked to disclose personal data held on another individual to a third party. It is important to bear in mind whether or not disclosure of the information is relevant to, and necessary for, the conduct of Harley Street Spine’s business.

  2. All third party requests to provide data must be supported by appropriate paperwork and all such disclosures must be specifically authorised by the Data Protection Officer.

 

  1. Retention and disposal of data

 

  1. Harley Street Spine shall not keep personal data in a form that permits identification of data subjects for longer a period than is necessary, in relation to the purposes for which the data was originally collected.

  2. Harley Street Spine may store data for longer periods if the personal data will be processed solely for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes, subject to the implementation of appropriate technical and organisational measures to safeguard the rights and freedoms of the data subject. 

  3. Personal data must be disposed of securely in accordance with the sixth principle of the GDPR – processed in an appropriate manner to maintain security, thereby protecting the “rights and freedoms” of data subjects.

 

  1. Data transfers

 

  1. All exports of data from within the European Economic Area (EEA) [A17] to non-European Economic Area countries (referred to in the GDPR as ‘third countries’) are unlawful unless there is an appropriate “level of protection for the fundamental rights of the data subjects[A18] ”.[A19] 

 

The transfer of personal data outside of the EEA is prohibited unless one or more of the specified safeguards, or exceptions, apply:

  1. An adequacy decision

The European Commission can and does assess third countries, a territory and/or specific sectors within third countries to assess whether there is an appropriate level of protection for the rights and freedoms of natural persons. In these instances no authorisation is required.

Countries that are members of the European Economic Area (EEA) but not of the EU are accepted as having met the conditions for an adequacy decision.

A list of countries that currently satisfy the adequacy requirements of the Commission are published in the http://ec.europa.eu/justice/data-protection/international-transfers/adequacy/index_en.htm

  1. Privacy Shield

If Harley Street Spine wishes to transfer personal data from the EU to an organisation in the United States it should check that the organisation is signed up with the Privacy Shield framework at the U.S. Department of Commerce. The obligation applying to companies under the Privacy Shield are contained in the “Privacy Principles”. The US DOC is responsible for managing and administering the Privacy Shield and ensuring that companies live up to their commitments. In order to be able to certify, companies must have a privacy policy in line with the Privacy Principles e.g. use, store and further transfer the personal data according to a strong set of data protection rules and safeguards. The protection given to the personal data applies regardless of whether the personal data is related to an EU resident or not. Organisations must renew their “membership” to the Privacy Shield on an annual basis. If they do not, they can no longer receive and use personal data from the EU under that framework.

 

Assessment of adequacy by the data controller

In making an assessment of adequacy, the UK based exporting controller should take account of the following factors:

  • the nature of the information being transferred;

  • the country or territory of the origin, and final destination, of the information;

  • how the information will be used and for how long;

  • the laws and practices of the country of the transferee, including relevant codes of practice and international obligations; and

  • the security measures that are to be taken as regards the data in the overseas location[A20] .

 

  1. Exceptions

In the absence of an adequacy decision, Privacy Shield membership, binding corporate rules and/or model contract clauses, a transfer of personal data to a third country or international organisation shall only take place on one of the following conditions:

  • the data subject has explicitly consented to the proposed transfer, after having been informed of the possible risks of such transfers for the data subject due to the absence of an adequacy decision and appropriate safeguards;

  • the transfer is necessary for the performance of a contract between the data subject and the controller or the implementation of pre-contractual measures taken at the data subject's request;

  • the transfer is necessary for the conclusion or performance of a contract concluded in the interest of the data subject between the controller and another natural or legal person;

  • the transfer is necessary for important reasons of public interest;

  • the transfer is necessary for the establishment, exercise or defence of legal claims; and/or

  • the transfer is necessary in order to protect the vital interests of the data subject or of other persons, where the data subject is physically or legally incapable of giving consent.

 

 

  1. Data inventory

 

  1. Harley Street Spine has established a data inventory and data flow process as part of its approach to address risks and opportunities throughout its GDPR compliance project. Harley Street Spine’s data inventory and data flow determines:

  • business processes that use personal data;

  • source of personal data;

    • volume of data subjects;

    • description of each item of personal data;

    • processing activity;

    • maintains the inventory of data categories of personal data processed;

    • documents the purpose(s) for which each category of personal data is used;

    • recipients, and potential recipients, of the personal data;

    • the role of the Harley Street Spine throughout the data flow;

    • key systems and repositories;

    • any data transfers[A21] ; and

    • all retention and disposal requirements.

 

  1. Harley Street Spine is aware of any risks associated with the processing of particular types of personal data.

    1. Harley Street Spine assesses the level of risk to individuals associated with the processing of their personal data. Data protection impact assessments (DPIAs) are carried out in relation to the processing of personal data by Harley Street Spine, and in relation to processing undertaken by other organisations on behalf of Harley Street Spine.

    2. Harley Street Spine shall manage any risks identified by the risk assessment in order to reduce the likelihood of a non-conformance with this policy.

    3. Where a type of processing, in particular using new technologies and taking into account the nature, scope, context and purposes of the processing is likely to result in a high risk to the rights and freedoms of natural persons, Harley Street Spine shall, prior to the processing, carry out a DPIA of the impact of the envisaged processing operations on the protection of personal data. A single DPIA may address a set of similar processing operations that present similar high risks.

    4. Where, as a result of a DPIA it is clear that Harley Street Spine is about to commence processing of personal data that could cause damage and/or distress to the data subjects, the decision as to whether or not Harley Street Spine may proceed must be escalated for review to the Data Protection Officer

    5. The Data Protection Officer shall, if there are significant concerns, either as to the potential damage or distress, or the quantity of data concerned, escalate the matter to the supervisory authority.

    6. Appropriate controls will be selected and applied to reduce the level of risk associated with processing individual data to an acceptable level and requirements of the GDPR.

 

Document Owner and Approval

 

The Data Protection Officer is the owner of this document and is responsible for ensuring that this policy document is reviewed in line with the review requirements stated above.

 

This policy was approved by the Board of Directors on 25th May 2018 and is issued on a version controlled basis under the signature of the Data Protection Consultant Representative.

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Issue

Description of Change

Approval

Date of Issue

1

Initial issue

Mr H Nwaboku

25th May 2018

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