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NHS Data Security and Protection Toolkit

Mandatory annual self-assessment for all organisations that have access to NHS patient data and systems. 40 requirements across 10 National Data Guardian standards covering leadership, staff responsibilities, training, managing data access, process reviews, responding to incidents, continuity planning, unsupported systems, IT protection, and accountable suppliers. Aligned with the National Data Guardian's 10 data security standards and NCSC Cyber Essentials. Applies to all NHS trusts, CCGs, GP practices, social care providers, and third-party suppliers processing NHS data.

Clause Title SP 800-53 Controls
NDG-1.1 Standard 1 — Confidentiality of personal confidential data
NDG-1.2 Standard 1 — Caldicott Guardian appointment and registration
NDG-1.3 Standard 1 — Staff understanding of DPA 2018 and UK GDPR obligations
NDG-2.1 Standard 2 — Staff understand NDG data security standards
NDG-2.2 Standard 2 — Annual data security awareness training completion
NDG-2.3 Standard 2 — Data security induction for new starters
NDG-3.1 Standard 3 — Role-appropriate data security training
NDG-3.2 Standard 3 — Annual training needs analysis
NDG-4.1 Standard 4 — Role-based access controls for personal confidential data
NDG-4.2 Standard 4 — Access reviews (joiners, movers, leavers)
NDG-4.3 Standard 4 — Multi-factor authentication
NDG-4.4 Standard 4 — Least privilege principle
NDG-5.1 Standard 5 — Annual process reviews for data security improvement
NDG-5.2 Standard 5 — Data Protection Impact Assessments
NDG-5.3 Standard 5 — Information asset register and data flow mapping
NDG-5.4 Standard 5 — Records of processing activities (ROPA)
NDG-6.1 Standard 6 — Incident response plan for cyber attacks and data breaches
NDG-6.2 Standard 6 — Data breach notification to ICO
NDG-6.3 Standard 6 — Major incident (CareCERT) reporting
NDG-6.4 Standard 6 — Root cause analysis and lessons learned
NDG-7.1 Standard 7 — Business continuity planning for data security
NDG-7.2 Standard 7 — Disaster recovery
NDG-7.3 Standard 7 — Backup and restore testing
NDG-7.4 Standard 7 — Critical clinical system availability
NDG-8.1 Standard 8 — Unsupported system management and end-of-life planning
NDG-8.2 Standard 8 — Vulnerability patching within 14 days
NDG-8.3 Standard 8 — IT asset inventory
NDG-9.1 Standard 9 — Cyber security strategy
NDG-9.2 Standard 9 — Firewalls and network segmentation
NDG-9.3 Standard 9 — Malware protection
NDG-9.4 Standard 9 — Email security (DMARC, SPF, DKIM)
NDG-9.5 Standard 9 — Web filtering
NDG-9.6 Standard 9 — Encryption in transit and at rest
NDG-9.7 Standard 9 — Mobile device management
NDG-9.8 Standard 9 — Annual penetration testing
NDG-9.9 Standard 9 — Vulnerability scanning
NDG-10.1 Standard 10 — IT supplier security assessments
NDG-10.2 Standard 10 — Data processing agreements
NDG-10.3 Standard 10 — Sub-processor controls
NDG-10.4 Standard 10 — Supply chain security