An Introduction to Legitimate Relationships and Workgroups
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An introduction to Legitimate Relationships and
Workgroups
An Introduction to Legitimate Relationships and Workgroups
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NPFIT-SHR-QMS-PRP-0015 Glossary of Terms
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Contents
1.
Introduction ....................................................................................................................... 5
1.1.
Purpose of document ............................................................................................... 5
1.2.
Background .............................................................................................................. 5
1.3.
Definitions ................................................................................................................. 5
2.
Introduction to Legitimate Relationships and Workgroups ............................................... 6
2.1.
Legitimate Relationships .......................................................................................... 6
2.2.
How Legitimate Relationships work ......................................................................... 6
2.3.
Workgroups .............................................................................................................. 7
2.4.
Workgroup hierarchies ............................................................................................. 7
2.5.
Phasing in Legitimate Relationships and Workgroups............................................. 7
2.6.
Temporary staff ........................................................................................................ 8
2.7.
Workgroup Administration ........................................................................................ 8
2.8.
Workgroup Membership Administration ................................................................... 8
Appendix A: Legitimate Relationship Types .............................................................................. 9
Appendix B: Anytown Hospital Trust Workgroup Hierarchy .................................................... 12
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1. Introduction
1.1. Purpose of document
The purpose of this paper is to describe an overview of the NHS Connecting for Health
concepts for Legitimate Relationships and Workgroups, and how these are expected to be
applied within organisations using NHS Care Record Service (NHS CRS) applications.
1.2. Background
“Legitimate Relationships” is one of a set of complementary information governance
mechanisms deployed within NHS Care Record Service applications to control access to
sensitive personal data about patients. Other mechanisms (which are described elsewhere)
include:



Role-based access controls;
Patient consent to NHS CRS information sharing across organisational boundaries; and
Patient "sealed envelopes".
Legitimate Relationships were devised in order to control which users gain access to sensitive
personal data about a patient. They are to be deployed by all NHS CRS applications which
provide access to such data.
1.3. Definitions
The term "sensitive personal data" is used in this document. “Personal data” means data
which identify a living person (e.g. demographic information) and “sensitive personal data" are
data which identify a living person and which reveal particularly sensitive information about
that person, such as their mental or physical health. These terms are defined in full in the
Data Protection Act 19981.
1
See http://www.opsi.gov.uk/ACTS/acts1998/19980029.htm
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2.
Introduction
Workgroups
2.1.
to
Legitimate
Relationships
and
Legitimate Relationships
Legitimate Relationships control who has access to a patient's sensitive personal data broadly equivalent to identifiable information within a patient’s clinical record. An NHS Care
Record Service (NHS CRS) user is unable to access “sensitive personal data” about a patient
without a Legitimate Relationship. There are ten types of Legitimate Relationship, each of
which can be applied to different health and social care settings. The following eight types of
Legitimate Relationship enable a Workgroup (i.e. a team of staff who work together) to gain
access to a patient's clinical record:








Patient Referral Legitimate Relationships;
Patient Self-Referral Legitimate Relationships;
Patient Registration Legitimate Relationships;
General Practice Registration Legitimate Relationships;
Subject Access Request Legitimate Relationships;
Patient Complaint or Litigation Legitimate Relationships;
Expressed Patient Consent to Access Legitimate Relationships; and
Court Order or Other Legal Demand Legitimate Relationships.
Two types of Legitimate Relationship enable a single NHS CRS user to gain access to a
patient clinical record:


Self-Claimed Legitimate Relationships; and
Colleague-Granted Legitimate Relationships.
Each of these types is described in Appendix A.
2.2.
How Legitimate Relationships work
Most types of Legitimate Relationship are created as a result of routine patient-related events
being recorded within the NHS CRS, such as referrals and GP registrations. As the
relationship between the patient and Workgroup providing a service to the patient changes,
the status of the Legitimate Relationship changes accordingly. When a patient is discharged,
this signals that the Legitimate Relationship is nearing its end, although the relationship does
not end immediately. When a patient is discharged, the Legitimate Relationship remains
active for a period time to allow the patient’s record to be updated, and then becomes inactive
for a further period of time just in case there is any follow-up on care by the care professional
or the patient.
The National Application Service Provider (NASP) and Local Service Providers (LSPs) work
together to maintain Legitimate Relationships within the NHS CRS. LSPs provide the clinical
software applications and when an NHS CRS user, like a doctor, records a relevant event like
a referral to a local hospital, the LSP software automatically sends a message to the NASP.
On receiving the message, the NASP will create a new Legitimate Relationship (e.g. with the
Workgroup to which the patient is referred), or change the status of an existing Legitimate
Relationship, depending on the content of the LSP message.
When a user of the NHS CRS, like a doctor or a nurse, tries to access a patient's clinical
record, the LSP software will send a message to the NASP to check if the user has a
Legitimate Relationship with the patient. The NASP will return a message of either "yes" or
"no". If the answer is "no", the user will be denied access to the patient's record. An
appropriate message will be displayed, and guidance offered if no Legitimate Relationship
exists.
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2.3.
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Workgroups
A Workgroup is a team, or set of teams, that work together to provide a service to patients.
For example, a general practice may typically includes GPs, practice and community nurses,
and practice administrators who work as a team to provide primary care to patients, and so all
of these people would be members of a general practice Workgroup. So people like the
practice receptionist must be part of the Workgroup because they require access to the
records of all patients in the practice, even if they are only entitled to see a very limited part of
the clinical record (e.g. appointments).
In a hospital setting, the Workgroups will reflect the way people work together in secondary
care. For example, there may be a Workgroup for every ward, a Workgroup for every surgical
team, and a Workgroup for all the staff who work in Accident and Emergency. All of these
Workgroups would be linked together into a single Workgroup hierarchy representing the
legal organisation for the hospital NHS Trust.
2.4.
Workgroup hierarchies
Suppose that a junior doctor works nights in a hospital, and is expected to cover five medical
wards whilst on duty. The doctor needs to be able to access the records of any patient who is
staying in one of the five medical wards. This could be achieved by making the doctor a
member of the Workgroups of all five wards, but this would mean that when the junior doctor
moved on to a new rota, the membership of the Workgroups would have to be changed for all
five medical wards. In order to reduce unnecessary administration, the NHS CRS recognises
the concept of a Workgroup hierarchy and automatically applies rules according to a
Workgroup’s position in the hierarchy.
For example, a Workgroup could be created of "all medical wards". This Workgroup would sit
within a Workgroup hierarchy above the five Workgroups for the five individual wards. A
member of the "all medical wards" Workgroup would have exactly the same rights to access
patient records as if he or she was added as a member of each individual medical ward
Workgroup.
NHS Connecting for Health is working with NHS representatives to identify (and then later
publish) exemplar Workgroup hierarchies for different types of organisation. An early example
of what a hospital Workgroup hierarchy might look like is provided in Appendix B.
2.5.
Phasing in Legitimate Relationships and Workgroups
A single member of staff may work in multiple teams, and the team may comprise people
drawn from more than one organisation. Workgroups must reflect the structure of the NHS so
that Legitimate Relationships are formed between the right combination of patients and staff.
If the wrong Legitimate Relationships are formed, staff will be able to access the records of
patients with whom they have no relationship, and/or they will be shut out of the records of
patients who they are trying to treat.
Given the complexity of NHS structures, and given that Legitimate Relationships and
Workgroups are new concepts being pioneered by the NHS CRS, it is likely to take time
before Legitimate Relationships provide precise control over who gains access to a particular
patient's record. The new controls will take time to "bed in", particularly in a complex
organisation like a large hospital. In the early stages of implementation, it will not always be
feasible to ensure that all the people, and only the people, who require access to a particular
patient's record, are given it. In the early stages, in some organisations, Legitimate
Relationships are likely to be assigned to large Workgroups (e.g. departments, directorates),
rather than to small teams. This will enable the right people to access the patient's record,
but it will also mean that some people who do not need access to the patient record will not
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be prevented from gaining access. However, such access was possible before the NHS
CRS, and every member of staff has a legal duty of confidence and is subject to disciplinary
procedures if they access a patient's record without reason.
For example, an "All Wards" Workgroup could be created and all of the doctors and nurses
who worked on wards would be assigned as members of that Workgroup. Individual wards
would also be created as Workgroups, and all linked to the “All Wards Workgroup” within the
Workgroup hierarchy. When a patient is admitted to Ward A, a Legitimate Relationship will be
created between the patient and the Workgroup for Ward A. Because all ward staff are
assigned to the “All Wards Workgroup”, all ward staff will have potential access to the patient
who has been admitted to Ward A. Over time, as working patterns and real-world
relationships between patients and teams are better understood, organisations can work with
their Local Service Providers to ensure that Legitimate Relationships are controlled more
precisely. Membership of the “All Wards Workgroup” will be cut back, and some staff working
on Ward A will be assigned only to the Workgroup for Ward A, enabling them to access only
the patients admitted to that ward.
2.6.
Temporary staff
There are many temporary staff working in health and social care, such as agency nurses,
locum doctors and pharmacists. Some of these people may work one day in one place, and
the next day in a different place and for a different team. Because most Legitimate
Relationships are between a patient and a Workgroup, and because a Workgroup is
essentially a team, Workgroup membership must be maintained to reflect the (often frequent)
movement of such staff from one team to another. Local organisations will be able to
exercise discretion when controlling Workgroup membership, maintaining a balance between
precise Legitimate Relationship control and excessive administration. For example, an
agency nurse who works for several weeks at a hospital, working on Ward A on Mondays and
Ward B on Tuesdays, could be added to the Workgroups for both Ward A and Ward B for the
period of his/her contract.
Some organisations are already using software that enables team membership to be
recorded, and so some staff are already keeping track of who works where. Where possible,
NHS CRS software applications provided by Local Service Providers (LSPs) will integrate the
concept of teams and Workgroups, so that Workgroup membership information need only be
entered information once. However, in the early stages of NHS CRS, there may be a need to
maintain the membership of teams and Workgroups separately.
2.7.
Workgroup Administration
Every organisation implementing Legitimate Relationships and Workgroups must undertake
the task of Workgroup administration. This involves setting up the Workgroups for that
organisation, and constructing them into hierarchies where appropriate. The organisation
needs to understand how the NHS CRS applications used assign Legitimate Relationships to
Workgroups, and ensure that these are appropriate. Depending on the application, it may be
possible for the organisation to directly control within the NHS CRS which Workgroups are
assigned Legitimate Relationships, or it may be that the NHS CRS application provider makes
such assignments.
2.8.
Workgroup Membership Administration
Workgroup membership administration involves assigning user role profiles to Workgroups,
thereby enabling members of staff to gain access to the clinical records of patients that have
a Legitimate Relationship with the Workgroup. This will need to be done routinely when staff
join and leave teams.
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Appendix A: Legitimate Relationship Types
Patient Referral Legitimate Relationships
When a patient is referred, for example from a GP to an outpatient service in a hospital, it
implies that a relationship exists between the patient and those staff providing the outpatients
service which justifies access to the patient's clinical record. When a referral like this is
recorded within the NHS CRS a Patient Referral Legitimate Relationship will be created
between the patient and the Workgroup providing the outpatients service. Patient Referral
Legitimate Relationships are created automatically by the NHS CRS as a result of many
different types of referrals and service requests, such as:





a referral between consultants in a hospital;
a request for a laboratory test;
booking an appointment for a patient from a radiology service;
an admission to a hospital ward;
a referral made by a social worker to a community mental health service;
A Patient Referral Legitimate Relationship can be applied in any situation where one member
of staff request a service from another member of staff or team on behalf of a patient (or
service user).
Patient Self-Referral Legitimate Relationships
When a patient attends an accident and emergency service, this can be considered as a selfreferral. In normal circumstances, a patient is registered by the accident and emergency
service as soon as they enter the department. A clerk will record the patient’s identifying
details, like name and address, and try to find the record for the patient. Recording the
accident and emergency attendance causes the NHS CRS to automatically create a SelfReferral Legitimate Relationship with the patient, and that enables the clinical staff (such as
the doctors and nurses) to view the patient’s clinical record. In an emergency situation, where
a patient has lost consciousness, a self-referral is implied, and so the same type of Legitimate
Relationship can be created.
There are other circumstances where patients can self-refer to a service. For example, an
attendance at a walk-in clinic, or at a sexually-transmitted disease clinic, or the birth of a new
baby, are all considered examples of a self-referral. In all such situations, a Patient SelfReferral Legitimate Relationship can be created automatically by the NHS CRS between the
patient and a group of staff providing the service.
Patient Registration and General Practice Registration Legitimate Relationships
When a patient registers with a new general practitioner, a General Practice Registration
Legitimate Relationship between the patient and the practice is created. For the period that
the patient stays registered with the practice, the GPs and nurses who are members of the
Workgroup for the practice will be entitled to access relevant parts of the patient’s clinical
records by using the Legitimate Relationship that was created when the patient registered.
Sometimes administrators working in a general practice need access to limited clinical
information about the patient, and so the Legitimate Relationship created at registration must
enable access to the whole practice team. For example, a practice manager will make use of
the Legitimate Relationship when issuing a repeat prescription because this requires access
to a limited set of clinical information within the record of the patient receiving the prescription.
So practice administrators should also be members of the practice Workgroup.
Patient Registration Legitimate Relationships will be applied in the NHS CRS to other
situations such as registration with NHS dentistry, preventative health services, screening,
and other situations where patients are added and removed from a well-defined, and usually
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long-term, registered service. The behaviour of these Patient Registration Legitimate
Relationships will be equivalent to those created for general practice; the only difference is
that general practice relationships have a different LR Type code in the messages.
Subject Access Request Legitimate Relationships
Under the Data Protection Act 1998, a person, or someone acting for a person, is entitled to
submit a subject access request to an organisation that maintains "personal data" about the
person. The organisation receiving the subject access request must process the request
within a set period of time and provide the subject of the request with a copy of all the
personal data held within their record. So a patient may apply to their general practice, or
other NHS organisation, and expect to be sent a full copy of their record. In order to provide
this, the organisation must be able to gain access to the patient’s full record through a
Legitimate Relationship. In a general practice setting, this normally would be achieved
through an existing Patient Registration Legitimate Relationship, but if the patient has left the
practice, that Legitimate Relationship will have expired, and so a Subject Access Request
Legitimate Relationship would be created. In a hospital setting, there may well be a specific
team of people who process subject access requests. That team would be defined as a
Workgroup within the NHS CRS, and a Subject Access Request Legitimate Relationship
would be created automatically with that Workgroup whenever a subject access request is
received. This Legitimate Relationship gives the Workgroup access to the patient's record for
just long enough to process the request.
Patient Complaint or Litigation Legitimate Relationship
When a patient complains or begins litigation with respect to some aspect(s) of the service
that they receive from an NHS organisation, their complaint must be investigated. Some
complaints, such as a general criticism of a hospital catering service, require no access to a
patient's clinical record, so no Legitimate Relationship needs to be created. In many cases,
patients submitting complaints or beginning litigation against an NHS organisation do so
because they are unhappy with the clinical care that they have received. This type of
complaint can only be investigated properly if it is possible to see relevant information within
that patient’s clinical record. When such a complaint is received and recorded within the NHS
CRS, a Patient Complaint or Litigation Legitimate Relationship will be set up automatically
between the patient and the Workgroup processing the complaint. When the case is closed,
the NHS CRS terminates the Legitimate Relationship.
This type of Legitimate Relationship will also be used to enable authorised investigations to
be carried out. If a member of staff becomes concerned that a colleague is not practising
good clinical care, they may raise the issue with someone who has responsibility for clinical
governance. That person will then have a duty to investigate the problem. This may require
access to one or more patient records so that an assessment can be made of whether patient
care was provided according to agreed standards. Access to the patients' records will be
enabled through Patient Complaint or Litigation Legitimate Relationships.
Expressed Patient Consent to Access Legitimate Relationships
Researchers will be able to gain access to analyse anonymised patient information within the
NHS CRS through the Secondary Uses Service. Occasionally, research requires access to
identifiable patient information including clinical data. Access to NHS CRS clinical records will
be granted for research purposes only if the patient has given their explicit consent. When
the patient’s consent is recorded within the NHS CRS, this will trigger a new Expressed
Patient Consent to Access Legitimate Relationship to be set up between a patient and the
Workgroup carrying out the research. These Legitimate Relationships last for the period of
research or the period of consent granted by the patient (whichever is shortest). This type of
Legitimate Relationship can also be applied to other situations such as epidemiology, and
financial audit.
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Court Order or Other Legal Demand Legitimate Relationship
A court may demand information from a patient’s clinical record. It is a relatively rare
occurrence, but it will require someone from an NHS organisation to access the patient’s
clinical record. In these cases, a Court Order or Other Legal Demand Legitimate Relationship
will be established within the NHS CRS between the patient and the Workgroup, thereby
allowing relevant information to be accessed and extracted from the patient’s record in order
to satisfy the court.
It may be necessary to gain access the patient record for other legal reasons, although the
need for this will be extremely rare. This type of Legitimate Relationship will enable such
access.
Self-Claimed Legitimate Relationships
NHS CRS Legitimate Relationships have been designed to work "behind-the-scenes",
triggered automatically by patient events like referrals. Different types of Legitimate
Relationships have been designed to support a wide variety of reasons why a user of the
NHS CRS may require access the patient's clinical record. However, occasionally, a care
professional using the NHS CRS may be denied access to the patient record because they
have no existing Legitimate Relationship. They may have an urgent need to view the patient
record and, if they have sufficient authorisation, they will be able to gain access to the
patient's record through the creation of a Self-Claimed Legitimate Relationship. This type of
Legitimate Relationship expires after a few days.
Where a user of the NHS CRS self-claims a Legitimate Relationship, they must justify their
actions, and this justification will form part of an alert which is sent to the person(s)
responsible for dealing with alerts within the organisation to which the NHS CRS user is
accountable. The alert is sent to deter NHS CRS users from self-claiming a Legitimate
Relationship with a patient that they have no relationship with (and thus abusing their access
privileges). If a member of staff self-claims a Legitimate Relationship without good reason,
they will face disciplinary action, including possibly dismissal. Only people in certain types of
job will be entitled to create Self-Claimed Legitimate Relationships (although note that the
time of writing the national policy on which job roles may claim a Legitimate Relationship has
not been decided).
Colleague-Granted Legitimate Relationships
Suppose that, rather than make a full referral, a care professional wants to ask a colleague for
a second opinion about a patient, and agrees this with the patient. If the colleague is a
member of the same Workgroup, then no new Legitimate Relationship need be created within
the NHS CRS. However, if the colleague works in a different Workgroup, he or she is unlikely
to have a Legitimate Relationship with the patient. In such circumstances, the patient's doctor
can create a Colleague-Granted Legitimate Relationship to provide the colleague with access
to the patient’s clinical record. The Legitimate Relationship created will last for a short period
(currently set at four weeks) and will be between the patient and that colleague only; it will not
be a relationship to a Workgroup.
The care professional granting the relationship will only be able to do so if they already have a
Legitimate Relationship with the patient, and that relationship must not have been selfclaimed. This rule prevents a user of the NHS CRS using their access privileges to self-claim
a Legitimate Relationship in order to grant access to a colleague.
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Appendix B: Anytown Hospital Trust Workgroup Hierarchy
Anytown Hospital
‘Root’ Workgroup
Clinical Audit
GUM
(GENITO URINARY
MEDICINE)
Child Protection
Adult Protection
Main
SUPPORT
SERVICES
SPECIALIST
TEAMS
DEPARTMENTS
Eye Unit
LOCATIONS
Paediatrics
Obs & Gyn
Data
Protection
Surgical
Palliative Care
Chiropody
Outpatients
Pathology
Critical Care
Wards
Foetal Assess’t
General Surgery
Urology
Vascular Surgery
Legal
Chest Clinic
ITU
CCU
Orthopaedics
Trauma
Medical
Records
ENT
Night Cover 1
Social
Services
Ophthalmology
Paediatric
Wards
Oral Surgery
Maxillofacial
Coroner
Maternity
Wards
Hope
Felicity
Potter
Lewis
Radiology
Night Cover 2
Oral Surgery
Medical
Wards
Grundy
Aldridge
Orthodontics
Plastic Surgery
PALS
Elderly Care
Wards
Pharmacy
Anaesthetics
Pain Management
Clinical
Governance
Gynaecology
Surgical
Wards
Audiology
General
Medical
Gastroenterology
Geriatric
Elderly Care
Respite Care
Endocrinology
Occupational
Therapy
Day Care
Snell
Perks
Haematology
Main
A &E
Cardiology
CIDU
Dietetic Unit
Paediatrics
Special Care
Babies
Family Care
Rheumatology
Operating
Theatres
Dermatology
Joint
Consultancy
Op Clinic
Radiology
Oncology
Neurology
Nephrology
Pathology
Theatre A
Theatre B
Physiotherapy
Recovery
Wards
Borchester
Felpersham
Archer
Pemberton
Wooley
Pargetter
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Description of the diagram
The diagram above shows an exemplar Workgroup hierarchy for a typical hospital. This
informal accompanying note explains the diagram and talks through some of the processes
that could go with it. It is included here only to provide an indication of what a Workgroup
hierarchy for a hospital organisation might look like.
At the top of the hierarchy is the whole hospital Workgroup of “Anytown Hospital”. No
members for this Workgroup have been identified, but it serves as an appropriate “root node”
for the hierarchy. Every Workgroup hierarchy possesses a root node such as this.
On a branch of its own lies the GUM Clinic, whose patients’ data are especially sensitive. The
clinic’s position in the hierarchy has been chosen so that only staff working there will be able
to gain access to the records of a patient attending the clinic. Clinical Auditors cannot
normally access the data of these patients – this is local hospital policy for this hospital. The
hospital does not have a Mental Health department, but if it had, it could have been similarly
inserted on a separate private branch of its own.
Below the root Workgroup lies the Clinical Auditors Workgroup. These people potentially have
access by inheritance to the records of all patient records other than those in the GUM clinic.
All of the other Workgroups hang from the Clinical Auditors Workgroup, either as leaf nodes
or as a two or (for the night cover wards) three-level hierarchies. The hierarchies may not be
needed in practice, links probably being able to be made to the leaf nodes directly from the
Clinical Auditors Workgroup, but they have been inserted in groups to illustrate better the
working hierarchy of the hospital.
The main body of the Workgroups have been broadly categorised as listed below:
1. Locations
These are places, other than support services units, where patients are generally
physically present within the hospital. It includes all of the wards, outpatients, day
care and A & E.
2. Support Services
Units providing technical support services such as radiography, and various types of
therapy.
3. Specialist Teams
Teams of specialists in various areas, each representing a group of people to whom a
patient can be referred.
4. Departments
Groups of Users requiring access to patient records for reasons other than direct
patient care.
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