Email Policy - Barnsley CCG

Putting Barnsley People First
February 2014
Approved By:
Governing Body
Date Approved:
13 February 2014
Name of originator / author:
Richard Walker
Name of executive lead:
committee/ Governing Body (Approval)
IG Group (review)
Vicky Peverelle
Date issued:
Review Date:
2 years from approval
Target Audience:
Barnsley CCG staff
Amendment Log
Version No Type of
Description of change
Approved by Governing Body
Page 2 of 15
1. Introduction
2. Objectives
3. Scope
4. Compliance with this policy
5. Generic responsibilities of staff and the CCG
6. CCG responsibilities and rights
Access to and use of email systems
Retention and destruction
Investigating breaches of this policy
7. User responsibilities and rights
Access to and use of email systems
Managing emails
Legal requirements
Sending confidential information by email
Personal use
Forwarding email
Misuse of the system
Sending attachments
7.10 Reporting incidents
7.11 Further information
Page 3 of 15
Email Policy
Email is an increasingly popular method of internal and external
communication. It can be of great benefit to Barnsley NHS Clinical
Commissioning Group (the CCG) when used appropriately. Its use,
however, also exposes the CCG and individual users to new risks. These
include legal action due to breaches of data protection and confidentiality
requirements, threats to IT and information security, and ineffective
communication. These risks and threats can compromise the CCG’s
ability to deliver effective care and services. Consideration should
therefore be given to whether it is appropriate in any given situation to
communicate by email.
Email is not always the best way to communicate information as email
messages can often be misunderstood and the volume of email messages
people receive can be prohibitive to receiving a meaningful reply as a
result of email overload. Emails should be treated with the same level of
attention that is given to drafting and managing formal letters and memos.
As well as taking care over how email messages are written, emails
should be managed appropriately after they have been sent or received.
This policy sets out the CCG’s expectations of staff when using the email
system, including accessing non-work email accounts on CCG systems.
Procedural documents implementing this policy will be made available on
the intranet. These documents and the policy itself should be crossreferenced with other information governance and procedural documents.
An up to date list of documents will be made available on the information
governance intranet page. Staff should ensure that they are familiar with
the content of this policy and use it as a point of reference when dealing
with email messages.
The purpose of the policy is to aid staff in the effective and appropriate use
of email on CCG systems and to reduce the risk of adverse events by:
 Setting out the rules governing the sending, receiving and storing of
 Establishing CCG and user rights and responsibilities for the use of its
 Promoting awareness of and adherence to current legal requirements
and NHS information governance standards.
This policy applies to:
 NHS email accounts (* and * for business and
personal use on CCG and non-CCG premises including from home,
internet cafes and via portable media such as ipads and smart phones.
 Personal email accounts accessed from CCG systems.
Page 4 of 15
Compliance with this policy
All staff are expected to comply with this policy.
This policy is based on current law, NHS Information Governance
standards and accepted standards of good practice; your duty to
handle CCG corporate and person confidential information
appropriately arises out of common law, legal obligations, staff
employment contracts and professional obligations.1
Any breaches of this policy will be fully investigated in
accordance with CCG processes which may result in disciplinary
action and, if appropriate, your employment or association with
the CCG being terminated. It may also bring into question your
professional registration2 and may result in disciplinary, civil or
criminal proceedings.
If there is anything that isn’t clear or which you do not understand in
this policy you must contact your line manager, in the first instance, or
the Information Governance Lead for further information.
Please note that the procedures and policies outlined in this policy and
any related policy may be changed at any time. You will be alerted to
this via established CCG communication routes.
Generic Responsibilities of Staff and the CCG
All staff, in particular users of CCG systems and equipment including
CCG employees and non-CCG employees who work within NHS
Barnsley Clinical Commissioning Group or under contract to it. This
includes, but is not limited to, staff on secondment to the CCG,
students on placement, CSU staff working on behalf of Barnsley and
people working in a voluntary capacity.
(For convenience, the term ‘staff’ is used in this document to refer to all
those to whom the policy applies.)
All managers are responsible for ensuring that the staff they manage
are aware of the Email policy and their individual responsibility for
complying with it. They should ensure their staff are equipped to fulfil
those responsibilities; this will include covering it at their local induction
and by identifying and meeting specific and generic training needs
through personal development plans.
Managers should ensure ALL new staff have signed the Confidentiality
and Information Security declaration. This should be done prior to
giving them access to the CCG network. (The requirement to sign the
declaration applies to ALL staff who work in the CCG and have access
to CCG information and not only those with network access.)
Managers are required to countersign this declaration to indicate that
they have checked that the member of staff has read the relevant
information governance policies and has had an opportunity to ask
questions about anything they do not understand.
For example, with the General Medical Council, Nursing and Midwifery Council or Health Professions Council
See note 1 above
Page 5 of 15
Senior managers should ensure that managers within their Service are
aware of their responsibilities in relation to informing staff about
acceptable standards of information governance.
The CCG allows short communications of a personal nature if it does
not interfere with work. Although the personal use of email is
discouraged due to the detrimental effect it may have on CCG
business. (See section 7)
All staff must ensure that they are aware of the requirements and
standards of behaviour that apply, and adhere to this policy.
All staff are responsible for reporting information incidents and near
misses, including breaches of this policy, using the CCG’s Incident
Reporting procedures.
The CCG’s incident reporting process can be obtained from line
managers in the first instance. Further information can be obtained
from the CCG Quality Manager.
The CCG’s Information Governance Group is responsible for
overseeing the implementation of this Email Policy including
monitoring compliance. It is responsible for ensuring it is reviewed
CCG specific responsibilities and rights
Access to and use of email systems
 The CCG provides access to email systems to employees and
authorised non-CCG employees only for use in their:
 Work duties
 Work related educational purposes
 Work related research purposes
 No one has a right of access to an email account. The inappropriate
use or abuse of email may result in access being withdrawn or
 The CCG reserves the right to remove or amend access to the email
system at any time in order to protect and preserve the integrity and
confidentiality of the system.
The CCG will:
 Provide users with appropriate training in the use of email.
 Provide the appropriate and authorised software for email.
Page 6 of 15
 Any information held or passing through the email system is the
property of the CCG.
 All email used on local NHS systems is monitored for viruses.
 All email (incoming and outgoing) on local NHS systems is logged
 Monitoring logs are audited periodically.
 The use of email is not private. The content of email is not routinely
monitored but the CCG reserves the right to access, read, print or
delete emails at any time.
 Any monitoring or interception of communications will be carried out in
accordance with legislation such as the Regulation of Investigatory
Powers Act 2000, the Telecommunications (Lawful Business Practice
Practice) (Interception of Communications) Regulations 2000, the Data
Protection Act 1998, the Human Rights Act 1998 and specific
procedures around monitoring and privacy.
Retention and destruction
 The CCG reserves the right to retain email as required to meet its legal
Investigating breaches of this policy
The CCG will:
 Investigate breaches of this policy, actual or suspected, in accordance
with CCG procedures.
 Where appropriate, invoke the CCG’s disciplinary procedure for
breaches of this policy.
 Where appropriate, make a complaint to an individual’s employing
organisation and co-operate fully into any investigation of that
complaint where breaches of this policy are committed by users who
are not employees of the CCG (such as staff on secondment to the
CCG, Honorary Contract holders and users given access to systems
by agreement between the CCG and the user’s employing
 Where appropriate take legal action (that is, criminal or civil
proceedings) in respect of this policy.
 The CCG will not be liable for any financial or material loss to an
individual when using email for personal use or when using personal
equipment to access work email.
Staff specific responsibilities and rights
Access to and use of email systems
 Users should use email only when it is appropriate to do so and not as
a substitute for verbal communication.
 Emails should be worded with care because voice inflections cannot
be picked up and it can be difficult to interpret tone.
Page 7 of 15
Email messages must not include anything that would offend or
embarrass any reader or would embarrass the CCG if it found its way
into the public domain.
Write ALL emails on the assumption that they may be read by others,
particularly people who do not normally work for the CCG such as
temporary staff or staff in external organisations. Email is easily
forwarded and may be read by unintended recipients.
A concise meaningful title must be put in the subject heading of every
email to indicate its content. The use of ‘For Action’ or For Information
must be used.3 This will assist the recipient in prioritising the opening
of email and aids the retrieval of opened messages.
Users should not use email as the only method of communication if an
urgent response is required.
Where important information has been sent by email, confirmation of
receipt must be obtained either by email or by a follow up telephone
Users must access email regularly and respond to messages in a
timely manner.
Users should indicate when they are not able to read their email (for
example, when on annual leave) using the tools within the email
Users must only use disclaimers that have been authorised by the
Communications Department.
Please note:
 Inappropriate use of email may result in poor communication, impede
the function of the CCG’s network system, impede the effective
functioning of email, or compromise the security of the system.
Managing emails
 Email should be managed and stored in accordance with the CCG’s
Records Management Policy and other relevant policies.
 Email is a communication tool and not a records management system.
Where the content of an email may be needed in the future it is the
responsibility of the user to ensure it is stored appropriately. Where
the content of an email or attachments forms part of a record it is the
responsibility of the user to ensure it is added to, and becomes part of,
that record whether held in hard copy or electronic format.
 Emails and attachments that do not relate to work activities or do not
need to be kept as part of a record must be deleted as soon as
possible after receipt.
Legal requirements
 The use of email must comply with the law such as the Data Protection
Act 1998 and adhere to CCG rules, codes of conduct, policies and
procedures such as this policy and policies relating to equalities and
For example, For action: PDR and objectives required by 5 May; For information: DH Guidance on
Access to Records; Response required by 5 July: FOI request 079-1314
Page 8 of 15
Users must comply with any licence conditions and copyright for any
software they have access to.
Users must not use email for any purpose that conflicts with their
contract of employment.
Users must not agree to terms or enter into contractual commitments
or make representations by email without having obtained the proper
authority. (A typed name at the end of an email is just as much a
signature as if it had been signed personally.)
Email messages have the same legal status as other written
documents and must be disclosed in legal proceedings if relevant to
the issues.
The content of any emails may be disclosable under legislation such
as the Data Protection Act 1998 and Freedom of Information Act 2000.
Improper statements may result in the CCG and/or user being liable
under law.
 All passwords and log in details for email systems must be kept
confidential. Sharing passwords or log in details will be considered
misconduct. (Where necessary, users can give proxy access to their
email account. This should be read access only. Alternatively, a
generic mailbox account can be set up with access via individual email
 Users must lock their terminal when not at their computer, for example,
to make a cup of tea, to attend a meeting or to go for lunch. (To
automatically lock the keyboard press the ‘windows’ and ‘L’ keys at the
same time or press ctrl–alt–del, then choose ‘lock computer’).
 Any computer or portable device that is used for work purposes must
be installed with up to date, approved anti-virus software. (Advice
about anti-virus software can be obtained from the IT Service Desk.)
 Only portable devices, including tablet devices, mobile and smart
phones, which are encrypted and are able to be remotely wiped should
be used to access email.
 If email is downloaded onto portable devices the device must not be
synchronised with personal cloud storage.
Page 9 of 15
Sending, receiving and accessing confidential information by email
 Confidential or sensitive information, including information about
patients/service users and staff, must be encrypted if it is sent by
email4. Routine transfers of such information must be part of a work
flow process and approved by the Information Governance (IG) Lead.
Routine flows of personal information must be recorded in an
information map (see the IG Lead for information). Approval for ad hoc
transfers of confidential information should be obtained from the IG
 There are several security issues associated with communicating with
patients by email: it is difficult to authenticate the identity of patients;
communication between the CCG and patients who are using a
personal email account or an account from a non-secure domain will
not be secure. The CCG should only communicate with patients on
matters of a confidential nature if they can verify the identity of the
patient and the patient is made aware that the email is not secure and
they consent. Services such as Complaints, who may have routine
email contact with patients, should gain IG approval for the process as
a whole but not individual communications.
 Safe haven procedures5 must be used when sending or receiving
confidential or sensitive information by email.
 Confidential or sensitive CCG information must not be accessed from
non-NHS equipment. (Arrangements for working outside of this policy
require prior approval from the Senior Information Risk Owner, who
should seek advice from the Information Governance Lead.)
Personal use
 The personal use of email is discouraged. If it is necessary to use
NHS provided email systems for personal communications they must
be brief, must not detract from the user’s work duties and must not
disrupt the work of others.
 Personal emails must adhere to the guidelines in this policy and must
not breach any of the CCG’s other policies or procedures
 Personal emails should be stored in a folder marked ‘personal’.
Emails sent between * accounts and the accounts listed below are encrypted in transmission (but
not at the end point so care must be taken to send emails to the correct address):
# NHS (*
# GCSX (*
# GSI (*
# SCN (*
# CJX (* or
# CJSM (*
# GSE (*
# MoD (*
# GSX (*
Local Authority staff can register for GCSX email.
The sender should contact the intended recipient prior to sending the email to ensure it will be received in
a timely manner, for example, to check the recipient is not on leave; the sender should check if any proxy
access has been given to that account and whether it is appropriate to send the information in such
circumstances; the sender should inform the recipient why the information is being sent and check that the
information will be managed appropriately, for example, that it will be deleted from the email system; the
recipient should be asked to confirm receipt of the email.
Page 10 of 15
Forwarding email
 Users must not automatically forward email from their CCG email
account or send confidential or sensitive CCG information to non-NHS
email accounts. Examples of non-NHS email accounts include
Hotmail, Yahoo, AOL, and email services provided by internet service
Misuse of the system
Users must not:
 Use the CCG’s email to conduct private or freelance work for the
purpose of commercial gain.
 Create, hold, send or forward emails that have obscene, pornographic,
sexually or racially offensive, defamatory, harassing or otherwise
illegal content. (If you receive such a message you should report it to
the IT Service Desk immediately.)
 Create, hold, send or forward emails that contain statements that are
untrue, inaccurate, misleading or offensive about any person or CCG.
 Access and use another user’s email account without permission. If it
is necessary to access another user’s account then contact the IT
Service Desk for details of the necessary procedure. (Users should be
aware that access to their email account by authorised individuals may
be necessary in periods of absence for business continuity reasons.)
 Send email messages from another member of staff’s email account
(other than with delegated access) or under a name other than their
own. Staff can give delegated access (proxy access) to their account
and give permission for colleagues or administrative support to send
emails on their behalf.
 Send global emails to ALL staff or to ALL GP practices. There are
processes that must be followed for such communications. Contact
the Communications Team for advice.
 Send unsolicited emails (spam) to large numbers of users unless it is
directly relevant to the recipient’s work. (Use staff bulletin/notice
boards where appropriate.)
 Send emails to large numbers of users unless the recipients have
been blind copied (bc)6. (If the email is not blind copied, individual
email addresses will be visible to everyone on the list which may
compromise a recipient’s confidentiality and take up a lot of space.)
 Send emails to a distribution list comprising members of the public
unless the recipients have been blind copied (bc).
 Use blind copying as a matter of course (except in the above
circumstances) where its purpose is to withhold from the primary
recipient the fact that an email has been copied to a third party.
Communication should aim to be transparent and the use of blind
copying in this manner an exception rather than the rule.
 Send or forward chain letters or other similar non-work related
 Use email for political lobbying.
To send a blind copy, put yourself in the 'To:' field and the distribution list in the 'BC:' field. (The delivered
email will show the sender and recipient as the same address and will suppress the list of other recipients.
This will prevent recipients, particularly of nhs mail, receiving pages of email addresses before getting to
the actual message.)
Page 11 of 15
Knowingly introduce to the system, or send an email or attachment,
containing malicious software, for example, viruses.
Forge or attempt to forge email messages, for example, spoofing.
Use instant messaging services, for example, Microsoft Messenger.
Sending attachments
 Users must not send or forward large messages or attachments.
10Mb is an absolute limit but good practice is below 1-2Mb. The
sending and storing of large attachments can cause the CCG network
to slow down or crash and can seriously affect the CCG’s capacity to
store files. (Examples of large attachments include photographs, large
documents, electronic greetings and flyers.)
 Consider alternative ways of making large work documents available
to colleagues such as placing documents on the intranet or a folder on
the server and emailing a link. Alternatively, use other methods of file
transfer, for example, FTP or FTPS. (Ask the IT Service Desk for
7.10 Reporting incidents
 Users must report serious incidents of unacceptable use, for example,
obscene or racially offensive emails to their line manager or, where
this is not possible, to the Head of Assurance directly. If in doubt,
contact West and South Yorkshire and Bassetlaw CSU IG Lead for
7.11 Further information
 Further information about the policy can be obtained from the CCG’s
Information Governance Lead.
 Questions about the use of the system or any problems in accessing
email should be directed to the IT Service Desk during opening hours.
There is no out of hours or home support.
Page 12 of 15
Equality Impact Assessment 2013
Title of policy or service
Name and role of officers completing the
Julie Eckford, IG Specialist
Date assessment started/completed
1. Outline
Give a brief summary
of your policy or
 Aims
 Objectives
 Links to other
policies, including
partners, national
or regional
The policy aims to raise CCG staff awareness of the CCG’s expectations in relation to the appropriate
handling of information when using email to:
Ensure information is handled appropriately and in a secure and confidential manner
Reduce the risk of adverse incidents
Prevent staff inadvertently causing an IG incident through non-compliance of CCG
The policy links to law such as data protection law, guidance issued by organisations such as DH,
Information Commissioner’s Officer and Cabinet Office, ISO security standards and other CCG IG policies
including information security and confidentiality code of conduct.
2. Gathering of Information
This is the core of the analysis; what information do you have that might impact on protected groups, with consideration of the General Equality
What key impact have you
Human rights
Religion or
Pregnancy and
Marriage and
civil partnership
What action do
you need to take
to address these
(only eliminating
Other relevant
Page 14 of 15
What difference will this
Having detailed the actions you need to take please transfer them to onto the action plan below.
3. Action plan
Issues identified
Actions required
How will you measure
4. Monitoring, Review and Publication
When will the
proposal be
reviewed and
by whom?
The EIA will be reviewed when the policy is reviewed. The Head of Assurance is responsible
for ensuring the review takes place. This policy will be reviewed not later than 2016.
Lead Officer
Richard Walker
Review date:
Page 15 of 15
13 February 2016