This Privacy Notice explains why your GP practice collects information about you, how that information may be used and how we keep it confidential.
Reviews of and Changes to this Privacy Notice
This Privacy Notice is regularly reviewed and updated by the CCG Data Protection Officer/DPO support service to member practices. The member practice will also have their own named Data Protection Officer, and may also have their own personal data flows with organisations other than those referred within this notice.
- April 2019: template published (benchmarked against best practice guidance).
- May 2019: Local Health and Care Record (LHCR) included.
- June 2019: CCG disclaimer and member practice website links included.
- August 2019: member practice website links updated.
- January 2020: changes to references to national opt-outs
- February 2020: changes to references to Data Flow Maps and Information Asset Registers, changes to narrative on Risk Stratification.
- March 2020: update to include reference to offer of video consultations in light of developing COVID-19 pandemic.
Clinical Commissioning Group (CCG) Disclaimer
The Privacy Notice published below is for use by CCG member practices to explain to patients why the practice collects information about them, how that information may be used and how it is kept confidential. Members practice can signpost to this Privacy Notice from their own website.
However, as member practices are data controllers in their own right, they may use patient identifiable and/or confidential data for further purposes in addition to those described within this notice. Where relevant these details are to be published on the practice website.
The Privacy Notice published below has been benchmarked against national guidance and information governance best practice. The CCG’s Data Protection Officer endorses this notice and therefore recommends that it is signposted to from member practice websites. However the CCG’s Data Protection Officer cannot approve its use by individual practice as this is for their appointed Data Protection Officer.
If this Privacy Notice has been reached through signposting from a practice website, then a patient can take this to mean that the practice Data Protection Officer has approved its adoption for use by the practice.
If your practice has any local flows relevant to it only it will publish details on its website.
Member practices in Buckinghamshire
Why we need information about you
All Health and Social Care organisations that provide you with care are required by law to maintain records about you, your health and any treatment or care you have received. The information that makes up your record is also essential to help these organisations provide you with the best possible care.
This practice collects and holds data for the purpose of providing healthcare services to our patients and running our organisation, which includes monitoring the quality of care and planning the care that we provide.
To do this we may collect information about you which helps us
- respond to your queries,
- provide you with the most appropriate care,
- Or arrange specialist services on your behalf.
We may keep your information in written form and/or in digital/electronic form. The records will include basic details about you, such as your name and address. They may also contain sensitive information about your health such as outcomes of assessments. All information about you is treated confidentially and only shared as described in this Privacy Notice.
Details we collect about you
We hold different types of information about you
Basic personal information:
- Contact details such as your address and next of kin
- Any record of contact the surgery has had with you, such as past appointments, clinic visits, emergency appointments, etc.
Sensitive personal information also called Special Category data:
- Information about allergies and adverse reactions
- Details about your treatment and care
- Results of investigations, such as laboratory tests, x-rays, etc.
- Record of medicines prescribed
- GP notes and reports
- Relevant information from other health and social care professionals, relatives or those who care for you
- Information about care and treatment that you may have had with other Health and Social Care providers, for example if your GP practice has referred you for treatment
How we keep your information confidential and safe
We are committed to protecting your privacy, complying with the law and best practice.
Best Practice and law of specific interest to this Privacy Notice includes:
- General Data Protection Regulation
- Data Protection Act 2018
- Human Rights Act
- Common Law Duty of Confidentiality
- NHS Codes of Confidentiality and Information Security
- Children’s Act 1989
- Health and Social Care Act 2015
- Local Audit and Accountability Act 2014
- The Audit Commission Act 1998
- Records Management NHS Code of Practice for Health and Social Care
And all other applicable legislation
Legal basis for using your information
We maintain our duty of confidentiality to you at all times. We will only share your information where there is a legal basis, such as:-
- For your medical diagnosis and treatment
- To provide you with health or social care
- To manage and plan our local health and social care services
- Where it is required by law, for example the Children’s Act 1989 requires information to be shared in Safeguarding cases
- Protection of vital interests, for example to protect someone’s physical integrity of life
- With your consent, providing you have capacity to give this, or with consent from your authorised representative
Everyone working for our organisation is subject to the Common Law Duty of Confidentiality. Information provided in confidence will only be used for the purposes advised, unless there are other circumstances covered by the law.
The NHS Digital “code of practice on confidential information”
The NHS Digital “Code of practice on confidential information” applies to all our staff and they are required to protect your information, inform you of how your information will be used, and allow you to decide if and how your information can be shared. All our staff are expected to make sure information is kept confidential and receive regular training how to do this. Our information systems are set up to prevent and track any misuse of information.
Your records are backed up securely in line with NHS standard procedures. We ensure that the information we hold is kept in secure locations, is protected by appropriate security and access is restricted to authorised personnel.
We also make sure any other organisations, for example suppliers that support us, are legally and contractually bound to the standards of confidentiality. Before they begin any work they have to provide evidence in the form of a Data Security Policy, that adequate security arrangements are in place to protect confidentiality.
How your information may be used
To ensure you receive the best possible care, your records are used to facilitate the care you receive. Information held about you may be used to help protect the health of the public and to help us manage the NHS. NHS Digital can request personal confidential data from GP Practices without seeking patient consent for specific purposes as defined in the Health and Social Care Act 2015.
In some cases you can object to your personal information being shared with other healthcare providers but should be aware that this may, in some instances, affect your care as important information about your health might not be available to healthcare staff in other organisations. If this limits the treatment that you can receive then the practice staff will explain this to you at the time you object.
Publication of this Privacy Notice
We will display prominent notices in the Practice and on our website before we make any change to the way we share data and if there is the opportunity to opt-out, should you wish not to benefit from a service. Please be aware that it may not be possible to opt out of one scheme and not others, so you may have to opt out of all the optional schemes.
What else might information be used for?
Child Health Information
We wish to make sure that your child has the opportunity to have immunisations and health checks when they are due. We share information about childhood immunisations, the 6-8 week new baby check and breast-feeding status with the NHS Trust who provide health visitors and school nurses, and with the Child Health Information Service (CHIS) in Buckinghamshire, who provide this on behalf of NHS England.
Information may be used for clinical audit to monitor the quality of the service provided. Some of this information may be held centrally and used for statistical purposes e.g. the National Diabetes Audit. Where we do this we take strict measures to ensure that individual patients cannot be identified and the information is anonymised.
Department for Work and Pensions
Our practice is legally required to provide anonymised data on patients who have been issued with a fit note under the Fit for Work scheme. The purpose is to provide the Department for Work and Pensions with information from fit notes to improve the monitoring of public health and commissioning and quality of health services.
National Registries (such as the Learning Disabilities Register) have statutory permission under Section 251 of the NHS Act 2006 to collect and hold information about you.
Individual Funding Requests (IFR)
An ‘Individual Funding Request’ is an application made with your consent, but on your behalf, by a clinician to fund care which falls outside the range of services and treatments which are routinely funded. Requests are considered by an Individual Funding Request Panel which considers evidence of clinical and cost effectiveness, as well as equity for the whole population. A detailed response, including the criteria considered in arriving at the decision, will be provided to the patient or carer and their clinician.
Invoice validation is an important process for the NHS to manage its budget and flow of money within the NHS. Section 251 of the NHS Act 2006 provides a statutory legal basis to process data for invoice validation purposes. Where required, your NHS number to check for authorisation for any costs relating to your care funded either within Buckinghamshire or nationally (through “specialist commissioning” from NHS England).
UK Cabinet Office
The use of data by the UK Cabinet Office for data matching is carried out with statutory authority under Part 6 of the Local Audit and Accountability Act 2014. It does not require the consent of the individuals concerned under Data Protection legislation.
The Audit Commission Act 1998 defines data matching as the comparison of sets of data to determine how far they match. The purpose of data matching is to identify inconsistencies that may indicate fraud.
Data matching by the Cabinet Office is subject to a Code of Practice. View further information on the Cabinet Office’s legal powers and the reasons why it matches particular information.
Supporting Locally Commissioned Services and Quality Premiums
Clinical Commissioning Groups support GP practices by auditing anonymised data to monitor locally commissioned services, measure prevalence and support data quality. The data does not include identifiable information and is used to support patient care and ensure providers are correctly paid for the services they provide.
Supporting Medicines Management
Clinical Commissioning Groups support local GP practices with prescribing queries. Commissioning Group pharmacists work with GP practices to provide advice on medicines and prescribing queries, and review prescribing of medicines to ensure safety and cost-effectiveness. The Clinical Commissioning Group medicines management team can order medications on behalf of the practice to support your care.
To ensure that adult and children’s safeguarding matters are managed appropriately, access to identifiable information will be shared in some limited circumstances where it’s legally required for the safety of the individuals concerned.
Sometimes your information may be requested to be used for research purposes – the practice will always seek your consent before releasing information for this purpose.
Summary Care Record (SCR)
The NHS in England uses a national electronic record called the Summary Care Record (SCR) to improve the safety and quality of your care. The Summary Care Record only contains basic information from your GP record and is not the full patient record. SCR provides authorised healthcare staff with faster, secure access to essential information about you in an emergency or when you need unplanned care wherever you are, where such information would otherwise be unavailable.
The core information of the Summary Care Record comprises your allergies, adverse reactions and medications. An SCR with additional information can also include reason for medication, vaccinations, significant diagnoses / problems, significant procedures, anticipatory care information and end of life care information. Additional information can only be added to your SCR with your agreement.
You can choose to Opt-Out of the Summary Care Record by completing an Opt-Out form available from your GP Practice. Please be aware that if you choose to opt-out of the Summary Care Record (SCR), staff caring for you outside of this practice may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had.
Buckinghamshire’s My Care Record (MCR) and the Thames Valley and Surrey Local Health and Care Record (LHCR)
If you require attention from a health or social care professional, such as an Emergency Department, Minor Illness and Injury Unit, 111, Out Of Hours location, or specialised health and social care team, those treating you are better able to give appropriate care if information from your GP patient record is available to them. Within Buckinghamshire this practice participates in our Shared Care Record called “My Care Record” delivered in partnership with Graphnet Health Limited. Not all care is delivered within our county borders either because of convenience for you or access to specialist care. The Thames Valley and Surrey LHCR also in partnership with Graphnet Health Limited, ensures that your data is available wherever you receive care and equally importantly this practice can see that data when we plan or deliver care for you. Both Bucks MCR and the Thames Valley and Surrey LHCR are used to address any variances in care and ensure that local needs are met but without compromising your privacy.
Records and their access are audited by nominated privacy officers, on a regular basis to ensure compliance.
Local information sharing – Specialist service teams
This Practice works with specialist health and social care service teams such as the diabetes and Locality Integrated and Community Nurse Teams, to provide safe and joined up services in Buckinghamshire. The shared My Care Record provides authorised health and social care staff with controlled access to relevant information, which helps them to make informed, timely decisions about your care and treatment and for new information to be instantly updated in your record.
Groups of Buckinghamshire GP practices are now offering routine appointments between 8am and 8pm, five days a week and 9am – 1pm at weekends. Improved access services also include ensuring access is available during peak times of demand, including bank holidays and across the Easter, Christmas and New Year periods. The appointments offered can be face to face consultation, a telephone consultation and in some areas a video consultation. Your full GP data will be shared to ensure you get the same quality and safety as if you saw your own GP. However, if you have opted out of sharing your record these appointments will not be available to you. Please see your practice website for details as to whether it is taking part in Improved Access.
You may be given the option to convert a telephone consultation into a video call where your GP determines it would be of value. This will only happen with your agreement by clicking on the link to the video consultation and you can leave the call at any time. The video consultation is only visible to participants on the call, it is not recorded or stored on any server and it is transmitted over a secure connection so no third party can ‘listen in’.
We will approach the longer term management of our patient records in line with the Records Management NHS Code of Practice for Health and Social Care. This sets out the required standards of practice for managing the records that staff working within or under contract to NHS organisations in England must follow; and it is based on current legal requirements and professional best practice. Currently the NHS is required to keep GP records for 10 years after a patient has died, exceptions to these rules are detailed in the code of practice.
Population Health Management (PHM)
What is Population Health Management?
This work is aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people and making sure that access to services is fair and equal. It helps to reduce the occurrence of ill-health and looks at all the wider factors that affect health and care.
A population health management programme has been introduced in Buckinghamshire. The programme will combine information from GP practices, community service providers, hospitals and other health and care providers.
The project requires health care organisations to work together with communities and partner agencies. The organisations will share information with each other in order to get a view of health and services for the population in a particular area.
How Will my Personal Data be Used?
The information will include information about your health care.
The information will be combined and anything that can identify you (like your name or NHS Number) will be removed and replaced with a code.
This means that the people working with the data will only see the code and cannot see which patient the information relates to.
If we see that an individual might benefit from some additional care or support, we will send the information back to your GP or hospital provider and they will use the code to identify you and offer you services.
The information will be used for a number of healthcare related activities such as;
- improving the quality and standards of care provided
- research into the development of new treatments
- preventing illness and diseases
- monitoring safety
- planning services
Who Will My Personal Data Be Shared With?
Your GP and hospital providers will send the information they hold on their systems to the South Central and West Commissioning Support Unit, who are part of NHS England.
They will link all the information together in order to review and make decisions about the whole population or particular patients that might need support.
The Commissioning Support Unit use a company called Optum to help them with this work.
Both the Commissioning Support Unit and Optum are required to protect your information and maintain confidentiality in the same way that your doctor or hospital provider is.
Is Using My Information in This Way Lawful?
Health Care Providers are permitted by data protection law to use information where it is ‘necessary for medical purposes’. This includes caring for you directly as well as management of health services more generally.
Some of the work that happens at a national level with your information is required by other parts of the law. For more information, speak to our Data Protection Officer.
Sharing and using your information in this way helps 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 and in the majority of cases, anonymised data is used so that you cannot be identified.
What will Happen to My Information When the Project is Finished?
Once the 20-week programme has completed the information will be securely destroyed.
Can I Object?
You have a right to object to information being used in this way. You also have a number of other information rights. See elsewhere within this Privacy Notice for more information.
To find out more or to register your choice to opt out, please visit www.nhs.uk/your-nhs-data-matters.
Risk stratification is a process for identifying and supporting patients who are most likely to need hospital or other healthcare services in the future. Section 251 of the NHS Act 2006 provides a statutory legal basis to process data for risk stratification purposes.
Risk stratification uses de-identified personal data from health care services to determine which people are at risk of experiencing certain outcomes, such as unplanned hospital admissions.
Risk stratification tools used in the NHS help determine a person’s risk of suffering a particular condition and enable us to focus on preventing ill health and not just the treatment of sickness.
Unidentifiable, anonymised information about patients is collected from a number of NHS organisations and then analysed to create a risk score. Data is securely managed throughout the whole process to ensure that identities are kept confidential. Further information on risk stratification is available from: https://www.england.nhs.uk/ourwork/tsd/ig/risk-stratification/
Data Processing activities for Risk Stratification
Risk stratification tools are used by CCGs to analyse the overall health of a population using data which is anonymised in line with the Information Commissioner’s Office (ICO) Anonymisation Code of Practice.
The combined CCGs Secondary Use Service (SUS) data and GP data which contains an identifier (usually NHS number) is made available to clinicians with a legitimate relationship with their patients to enable them to identify which patients should be offered targeted preventative support to reduce their risk of long term illness.
The commissions several providers (data processors) to provide risk stratification and other population health analysis services. Currently these are NHS South, Central and West Commissioning Support Unit (SCWCSU) , Graphnet Health Limited and Optum Health Solutions (UK) Ltd.
This processing takes place under contract following the below steps:
- NHS Digital has a legal obligation to obtain data from providers of NHS care such as the local hospital or community service. This data is then sent to our processors and amended so that only your NHS number could identify you. The data is then provided to our processors for processing in the risk stratification software. The CCG has signed a Data Sharing Contract with NHS Digital for the use of this data, called Secondary Use Services (SUS) data.
- Our processors extract primary care data identifiable by your NHS Number for those patients that have not objected to Risk Stratification or where no Type 1 objection has been made by an individual. The data containing the same verified NHS numbers are then stored within a secure environment owned and managed by SCWCSU which is then processed through the risk stratification algorithms and the output made available in the IPA user interface.
- The primary care data and SUS data are linked and pseudonymised. It is then processed through the risk stratification algorithms to produce a risk score for each patient. The output is made available to GP practices and Primary Care Networks. Aggregated, unidentifiable data is made available to the CCG. No identifiable data of any patient is seen by the CCG.
The risk scores are only made available to authorised users within the GP Practice where you are registered via either the practice clinical system or through a secure portal managed by our data processors.
This portal allows only the GPs to view the risk scores for the individual patients registered in their practice in identifiable form. The outputs can be made available if Practices are working as a locality, federation, Primary Care Network or super practice and they are involved ion your care, and this access is agreed by the Caldicott Guardian for each Practice.
If you do not wish information about you to be included in our risk stratification programme, please contact your GP Practice. They can add a code to your records that will stop your information from being used for this purpose.
Please be aware that this may limit the ability of healthcare professionals to identify if you have or are at risk of developing certain serious health conditions.
Further information about risk stratification is available from: https//www.england.nhs.uk/ourwork/tsd/ig/risk-stratification/
NHS England has gained approval from the Secretary of State, through the Confidentiality Advisory Group (CAG), for its application for the disclosure of commissioning data sets and GP data for risk stratification purposes to data processors working on behalf of GPs which provides a statutory legal basis under Section 251 of the NHS Act 2006 to process data for risk stratification purposes. We are committed to conducting risk stratification effectively, in ways that are consistent with the laws that protect your confidentiality.
As regards compliance with the General Data Protection Regulation (GDPR), conditions relied upon for processing personal data are “Performance of a task in the public interest or the exercise of official authority” (article 6e) and special category data “Medical and Health diagnosis, treatment or management of health or social care systems and services” (article 9h).
CCGs and GPs use risk stratification tools as part of their local strategies for supporting patients with long-term conditions and to help and prevent avoidable admissions. Typically this is because patients have a long term condition such as Chronic Obstructive Pulmonary Disease. NHS England encourages CCGs and 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 will help the CCG to commission appropriate preventative services and to promote quality improvement in collaboration with our GP practices.
Who are our partner organisations?
All organisations that we work with are subject to strict data sharing and/or processing agreements which set out how data will be used; which form part of their contractual obligations. The sorts of organisations we work with are as follows:-.
- NHS Trusts (for example Buckinghamshire Healthcare Trust)
- GP Federations (which are groups of GP practices working together for your care)
- Out of Hours GP providers (for when your GP practice is closed)
- Independent contractors such as dentists, opticians, pharmacists – working to an NHS contract
- Private sector or voluntary sector providers – providing services on behalf of the practice
- Ambulance services
- Clinical commissioning groups
- Social Care providers
- Local authorities
- Education services
- Fire and Rescue Services
We will never share your information outside of health and social care partner organisations without establishing the legal basis to do so, unless there are exceptional circumstances such as when the health or safety of others is at risk, where the law requires it.
Our guiding principle is that we are holding your records in strictest confidence; we are required by law to report certain information to the appropriate authorities. This is only provided after formal permission has been given by a qualified health professional. There are occasions when we must pass on information, such as notification of new births, where we encounter infectious diseases which may endanger the safety of others, such as meningitis or measles (but not HIV/AIDS), and where a formal court order has been issued.
Third party processors
In order to deliver the best possible service, the practice will share data (where required) with other NHS bodies such as other GP practices and hospitals. In addition the practice will use carefully selected third party service providers. When we use a third party service provider to process data on our behalf then we will always have an appropriate agreement in place to ensure that they keep the data secure, that they do not use or share information other than in accordance with our instructions and that they are operating appropriately. Examples of functions that may be carried out by third parties includes:
- Companies that provide IT services & support, including our core clinical systems; systems which manage patient facing services (such as our website and service accessible through the same); data hosting service providers; systems which facilitate appointment bookings or electronic prescription services; document management services etc.
- Delivery services (for example if we were to arrange for delivery of any medicines to you).
- Payment providers (if for example you were paying for a prescription or a service such as travel vaccinations).
Further details regarding specific third party processors can be supplied on request to the practice, which may be in the form of a copy of the practice data flow map.
Your right to ask us not to share your information (opt-out)
If you are happy for your data to be shared and used for the purposes described in this Privacy Notice then you do not need to do anything.
If you do NOT want your information to be used for any purpose beyond providing your care there are several forms of opt-outs available at different levels:
Type 1 opt-out. If you do not want personal confidential information that identifies you to be shared outside your GP practice you can register a ‘Type 1 opt-out’ with your GP practice. This prevents your personal confidential information from being used except for your direct health care needs and in particular circumstances required by law, such as a public health emergency like an outbreak of a pandemic disease. If you do not want your information to be used for any purpose beyond providing your care you can choose to opt-out. If you wish to do so, please let us know so we can code your record appropriately to stop your records from being shared outside of your GP Practice. Please understand that if you opt-out then we cannot guarantee that care professionals will have the information they require to deliver you the best and safest care.
National data opt-out
The national data opt-out is a service that allows you to opt-out of your confidential patient information being used by for research and planning.
Whenever you use a health or care service, such as attending Accident and Emergency or using Community Care services, important information about you is collected to help to ensure you get the best possible care and treatment.
If you do not want your confidential patient information to be used in this way or would like to find out more please visit www.nhs.uk/your-nhs-data-matters or call: 0300 303 5678.
Your access to your information
Under Data Protection legislation everybody has the right to see, or have a copy of, data we hold that can identify you and to have it amended or removed should it be inaccurate. You do not need to give a reason to see your data. Under special circumstances, some information may be withheld. We may charge a reasonable fee for the administration of the request in certain instances (e.g. where a duplicate copy is requested).
If you wish to see or have a copy of the information we hold about you please contact the practice. Alternatively, you can register to see your information through the GP practice Web site, contact the practice for more information.
Change of details
It is important that you tell the person treating you if any of your details such as your name or address have changed or if any of your details are incorrect in order for this to be amended. Please inform us of any changes so our records for you are accurate and up to date.
Mobile telephone number and text messaging
If you provide us with your mobile phone number we may use this to send you reminders about your appointments, responses to your online queries, health screening questions and information about the services we provide. Please let us know if you do not wish to receive reminders on your mobile.
You’re responsible for ensuring the practice has your most up to date mobile number.
Where you have provided us with your email address we will use this to send you information relating to your health, responses to your online queries and information about the services we provide. If you do not wish to receive communications by email please let us know.
Notification and data protection certification
Data Protection legislation requires organisations to register a notification with the Information Commissioner to describe the purposes for which they process personal and sensitive information.
This practice is registered as a data controller with the Information Commissioners Office (ICO). A ‘data controller’ determines the purposes and means of processing personal data. Our registration can be viewed online in the public register at: http://ico.org.uk/what_we_cover/register_of_data_controllers
Data Protection Officer
Should you have any data protection questions or concerns, please contact our Data Protection Officer by contacting the practice.
One of the duties of the Data Protection Officer is to ensure compliance with the annual Data Security and Protection Toolkit published by NHS Digital. This includes a Data Flow Map (DFM) of all the practice inbound and outbound data flows where fully identifiable or pseudonymised (e.g. NHS number only), together with an Information Asset Owners (IAO) register/database which lists all the assets which hold information and which records assessed risks. These documents are available on request from the practice.
If you have concerns or are unhappy about any of our services, please contact your GP Practice.
For independent advice about data protection, privacy and data-sharing issues, you can contact:
The Information Commissioner, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF
Phone: 0303 123 1113
Data Flow Maps and Information Asset Registers
The practice maps each individual data flow in and out in order to understand what data it holds and processes. These data flow maps are reviewed and updated annually as part of the requirement to complete a Data Security Protection Toolkit. The practice also holds an Information Asset Register which describes where and how these data flows are stored by the practice. Please contact the practice for further details.
Further information about the way in which the NHS uses personal information and your rights is published by NHS Digital:
The NHS Care Record Guarantee
The NHS Care Record Guarantee for England sets out the rules that govern how patient information is used in the NHS, what control the patient can have over this, the rights individuals have to request copies of their data and how data is protected under Data Protection Legislation.
The NHS Constitution
The NHS Constitution establishes the principles and values of the NHS in England. It sets out the rights patients, the public and staff are entitled to. These rights cover how patients access health services, the quality of care you’ll receive, the treatments and programmes available to you, confidentiality, information and your right to complain if things go wrong.
NHS Digital collects health information from the records health and social care providers keep about the care and treatment they give, to promote health or support improvements in the delivery of care services in England.