The key to good data security is having a system with multi-layered security using differing tools and techniques. That way, if one level is compromised, then others are in place to prevent further damage. It's important to remember that no one single product can be 100 per cent secure.
The following guidance, standards and tools should be used to aid the development of security policies and processes:
- NHS Digital Information Governance (IG) Toolkit application and score
- ISO 27001 - best practice for information security management systems (ISMS)
- ISO 27002 - code of practice and controls for ISMS
- ISO 27017 - code of practice and controls for cloud services
- ISO 27018 - code of practice for providers with personally identifiable data
- Information Commissioner's Office (ICO) code of practice data sharing agreements
- Information Commissioner's Office (ICO) Data Protection Act compliance and registration
- Information Commissioner's Office (ICO) Privacy Seal (Due 2016)
- NHS Digital code of practice on confidentiality
- NHS Digital good practice guides
Providing evidence for your application
To support your application to NHS Digital for data you need to supply evidence of your processes and procedures for security. This can be one of the following:
- A satisfactory Information Governance (IG) Toolkit score of at least 66%
- ISO 27001:2013 certification with alignment of policies, procedures and controls to ISO 27002:2013 and, if utilising third party services ISO 27017:2015, ISO 27018:2014 (where the third party has a multi-tenanted location)
- System Level Security Policy (SLSP)
We will verify the references from IG Toolkit scores and validate ISO certifications.
To provide SLSP evidence you need to supply a report on how your area/department will administer, secure, handle and use the requested data with the technical and physical controls employed to enforce your organisation's information governance and security policies and procedures. You can also reference your corporate policies.
An SLSP report must include:
- a heading, author, date and version number
- a document and version control section with details of who created, revised and approved
- an index to any sub-sections
- a glossary
- any additional information to support your application
- elaboration on the technical and physical controls in place to enforce your policies and procedures
- a high level network topology diagram
- confirmation that the storage architecture is compliant with the NHS Digital contract where NHS Digital can issue a data destruction notice for the immediate destruction of all data from all forms of storage and backups
- confirmation that any data destruction will be via multi pattern pass data wiping to NHS Digital guidelines using a commercially licenced tool (not freeware)
- specific address details of the location where your data is stored and where the disaster recovery/backups are located
- confirmation of penetration testing and the date of the last test with a pdf formatted copy of the report - where the test highlighted issues, include a copy of the mitigation and action plan to address
You must also ensure that:
- appropriate permissions on a 'need to know' basis are applied to the network shares holding the data (meaning those who have signed the relevant data access agreement)
- data is not held on any un-encrypted machines or device
- data stored on an NHS Digital SLSP and transmitted across a security approved network is encrypted to Advanced Encryption Standard 256 as a minimum.
- when referring to policies and procedures, please reference by document name, page number and section and include a pdf formatted physical copy
- access to data will be from within the network using NHS Digital security approved devices
- access to the above network data via remote methods will only be approved on an individual basis - if approved, this method must meet NHS Digital virtual private network (VPN) security guidance
- firewalls protecting the NHS Digital data must be ITSEC E3, Common Criteria EAL4+ or Protected Profile (EAL4+ equivalent)
Where Office for National Statistics (ONS) data is involved, we also look to confirm that:
- ONS data can only be accessed by users working in a secure environment with access only permitted to those users who are physically accessing the data through the organisation's on-site NHS Digital security assured network - no remote access (such as through a VPN/RDP connection) is permitted
- mobile devices must be running local software firewalls that deny all untrusted inbound network connections
The data must be situated on a subnet that uses a non-routable RFC1918 compliant Internet Protocol address scheme for IPv4 and/or RFC 4193 for IPv6.
We advocate the use of remote wiping software on all mobile devices.
We will be looking at your data policies and procedures for evidence of the following:
- Physical security
- Anti-virus and anti-malware
- Intrusion defence
- Access controls
- Employee awareness and training
- Asset registration policy
- Information governance policies
- Data disposals policy - multi pass wiping, degaussing, physical destruction
- Password policy - complex construction with duration less than or equal to 90 days
- Mobile computing policy - full encryption to Advanced Encryption Standard 256 (AES-256)
- Acceptable use policy
- Compliance policy - appropriate legislation compliance
- Software management policy
- System management policy
- User management policy
- Network management policy
- Information handling policy
- Physical security policy
- Data protection policy - appropriate ICO registration
- Remote access policy
- Back and recovery policy - encryption of data at rest and in backup
- Incident response policy
- Virtual private network (VPN) - type and level of encryption
- Policy guest access
- Wireless policy
- Third party connection policy
- Network security policy
- Encryption policy - type and levels of encryptions employed
- Confidential data policy
- Data classification policy
- Retention policy / records management policy
- Cloud services policy
- Outsourcing policy
- Network topology
Data on your systems should be protected against break-ins that could mean equipment containing confidential, sensitive or personally identifiable data is stolen. Servers should be in a separate room with secure lockable doors using access codes or entry combination/cards. All back-up devices must be encrypted to NHS Digital minimum encryption standards, never left unattended and must be locked away when not in use. Desktop and mobile devices should be fully encrypted and locked down to prevent unauthorised access and where appropriate we would advocate the use of remote wiping technology implementation.
Anti-virus and anti-malware
Your network should be regularly scanned by up-to-date anti-virus and/or anti-malware products to detect and prevent threats.
You should be using a well-configured ITSEC E3, Common Criteria EAL4+ or Protected Profile (EAL4+ equivalent) compliant firewall to help prevent any breaches and stop them penetrating your network. Your servers and workstations should have up-to-date operating systems, be patched to manufacturers' recommendations and not be de-supported in the lifetime of the agreement. A schematic of your network, workstation and peripherals should be provided in your application.
Access to your systems should be restricted to users and sources you trust. All users must have their own username and password and these must never be shared.
Hackers, cyber criminals and casual users should be prevented from accessing your local area network (LAN), wide area network, wi-fi network and workstations by strong passwords, limited login attempts and enforced regular password changes.
Passwords and other access should be cancelled as soon as a user leaves the organisation or if they are absent for a long period.
Employee and user awareness and training
Users need to be trained to recognise system threats, such as phishing emails, malware and unauthorised use. Users at all levels need to be aware of what their roles and responsibilities are.
Your network components should be separate, and access between them limited, in order to prevent or limit data breaches. For example, web servers should be separate from main file servers so that any attacks on your website cannot access your central data store.
Well-written data policies should be integrated into your business processes. Policies should enable you to investigate, mitigate and address risks in a consistent manner.
All unused software and services must be removed from your devices. Any default passwords used by applications software or hardware must be changed as this is a well-known route for cyber-attacks and hackers.
Where data is backed up from legacy systems where the data has been loaded and installed in systems (it would be very difficult if not completely impractical to separate out our data from legacy systems). NHS Digital are content with 3 months, so long as the backups are encrypted to at least AES-256, held at one of the storage locations stated in the Data Sharing Agreement, and none of the NHS Digital data will be restored without our prior permission (should it previously have been subject to a data destruction certificate).
If the data is being held and processed at the same location, then the risk of unencrypted network traffic is minimised and NHS Digital are content. If it's across their own site (such as one building to another) NHS Digital are less comfortable and would seek further assurances. NHS Digital would not be content if it's across multiple sites.
This is assuming that files and workstations are encrypted to AES-256, and that the organisation is committed to moving to encryption over the LAN (for example as elements are replaced). NHS Digital would not accept an unencrypted LAN if a client installed a completely new network which doesn't have encryption built in.