Risk assessment

Data Protection Risk Assessment

Confidentiality, integrity and availability of personal and special category health data within a GP surgery

For GP SurgeryRef BS-GP-RA-002See a sample (PDF) →
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  • Instant download after checkout
  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This risk assessment is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Scope and purpose
  • 2. Legal and regulatory framework
  • 3. Risk assessment methodology
  • 4. Hazards, controls and risk rating
  • 5. Action plan
  • 6. Monitoring and review
  • 7. Disclaimer

Legislation & standards it maps to

  • UK General Data Protection Regulation (UK GDPR)
  • Data Protection Act 2018
  • Data (Use and Access) Act 2025
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 17 (Good governance) and Regulation 13 (Safeguarding service users from abuse and improper treatment)
  • Common law duty of confidentiality and the Caldicott Principles
  • Health and Social Care (Safety and Quality) Act 2015 - duty to share information
  • Privacy and Electronic Communications (EC Directive) Regulations 2003 (PECR)
  • Computer Misuse Act 1990
  • Network and Information Systems Regulations 2018
  • Data Security and Protection Toolkit (DSPT)

Who it applies to

All partners, salaried GPs, locums, nursing and clinical staff, practice management, reception and administrative staff, attached and visiting professionals, contractors and data processors of [Organisation Name]

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Alternative Provider Medical Services (APMS) contract
A flexible contract under which an organisation other than a traditional GP partnership provides primary medical services.
As low as reasonably practicable
Reducing a risk to the lowest level that is sensible once the effort and cost of further action are weighed against the benefit.
Caldicott Guardian
The senior person responsible for protecting the confidentiality of people's health and care information.
Caldicott Principles
A set of eight principles that guide how health and care organisations should handle confidential patient information.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Common law duty of confidentiality
A long-standing legal duty, developed by the courts, to keep information given in confidence private and use it only for proper purposes.
Computer Misuse Act 1990
The law that makes it a criminal offence to access or interfere with computer systems or data without authorisation.
Contemporaneous record
A record made at the time of, or very soon after, the event it describes, so it is accurate and reliable.
Data (Use and Access) Act 2025
A recent law that updates and amends the UK's data protection and data-sharing rules.
Data controller
The organisation that decides why and how personal data is collected and used, and is legally responsible for it.
Data processor
An organisation that handles personal data on behalf of, and on the instructions of, the data controller.
Data Protection Act 2018
The UK law that sits alongside the UK GDPR and sets additional national data-protection rules.
Data Protection Impact Assessment (DPIA)
A check done before a new activity to identify and reduce risks to people's personal data.
Data Protection Officer (DPO)
The person who advises an organisation on its data-protection duties and monitors that it follows the rules.
Data Security and Protection Toolkit (DSPT)
An annual online self-assessment that health and care organisations complete to show they handle data safely and meet the required standards.
Data subject
The living individual whom a particular piece of personal data is about.
DCB0160
The national clinical risk management standard that health organisations follow when deploying and using clinical software safely.
Electronic Prescription Service (EPS)
The system that lets prescriptions be sent electronically from a prescriber to a pharmacy.
Electronic Referral Service
The national system used to refer patients electronically from primary care to other services.
General Medical Services (GMS) contract
A nationally agreed contract under which many GP practices provide primary medical services.
Health and Social Care (Safety and Quality) Act 2015
The law that, among other things, places a duty on health and care bodies to share information for an individual's direct care.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting out the fundamental standards that providers of regulated health and care must meet.
Information Commissioner's Office (ICO)
The UK regulator that upholds information rights and enforces data-protection law.
Information governance
The framework for handling people's personal and health information legally, securely and appropriately.
Integrated Care Board (ICB)
The statutory body responsible for planning and arranging health services for a local area.
Lawful basis
One of the specific reasons set out in data-protection law that an organisation must have before it can use personal data.
Lloyd George envelope
The traditional paper folder historically used to hold a patient's primary care medical records.
Malware
Harmful software, such as viruses, designed to damage, disrupt or gain unauthorised access to computer systems.
Multi-factor authentication
A security method that requires two or more separate proofs of identity before access is granted.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Network and Information Systems Regulations 2018
The law requiring operators of important digital and network services to keep those systems secure and to report serious incidents.
Notifiable event
An incident a provider is legally required to report to a regulator, such as a serious data breach.
Personal data
Any information relating to an identified or identifiable living person.
Personal Medical Services (PMS) contract
A locally agreed alternative to the standard GP contract for providing primary medical services.
Phishing
A scam in which fraudulent messages trick people into revealing passwords or other sensitive information.
Primary medical services
The everyday medical care provided by a GP practice as a patient's first point of contact with healthcare.
Privacy and Electronic Communications (EC Directive) Regulations 2003 (PECR)
The rules governing electronic marketing, cookies and the security of electronic communications.
Privacy notice
A statement telling people how an organisation collects, uses and protects their personal information.
Proxy access
Permission for someone, such as a parent or carer, to access another person's online medical records on their behalf.
Ransomware
Malicious software that locks or encrypts data and demands payment to restore access.
Record of Processing Activities (ROPA)
A written record of how and why an organisation processes personal data, required by data-protection law.
Records Management Code of Practice
National guidance on how health and care records should be kept, stored and disposed of, including how long to retain them.
Redaction
Removing or blacking out information from a document so that it cannot be read before the document is shared.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Residual risk
The level of risk that remains after existing controls are taking effect.
Risk assessment
A structured check identifying what could cause harm and what is being done to prevent it.
Role-based access
Restricting what each user can see or do in a system according to their job role.
Safe haven
An agreed secure location and procedure for receiving and handling confidential information.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Senior Information Risk Owner (SIRO)
The senior person who takes overall ownership of an organisation's information risk.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Smartcard
A secure card used with a personal passcode to log in to clinical systems and prove the user's identity.
Social engineering
Manipulating people into giving away confidential information or access, rather than attacking technology directly.
Special category data
Particularly sensitive personal data, such as health information, that the law gives extra protection.
Subject Access Request (SAR)
A person's legal right to ask for a copy of the personal information an organisation holds about them.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.

How it works

  1. Buy securely with Stripe - instant, no VAT, no account needed.
  2. Download your editable Word file from the link we email you straight away.
  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

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