Access to records

Providing access to records has many benefits to patients and is an important step in patient empowerment, however, GPs are faced with the challenge of balancing the need for patient access with the need to protect sensitive patient information. All GP surgeries are required to give all patients in England online access to new information as it is added to their GP health record. Patients with online accounts, such as through the NHS App, should be able to read new entries, including free text, in their health records. Currently, this Applies to future (prospective) record entries, whilst access to historic records is still to be requested by patients, to allow practices the opportunity to screen entries which may need to be hidden from online visibility. – Online access to GP health records

To address this challenge, GP practices should adopt a risk-based Approach to patient record access. This involves assessing the potential risks associated with granting access to patient records and taking Appropriate measures to mitigate these risks. For example, GPs may need to consider the risk of data breaches, unauthorised access, and patient confidentiality.

Overall, GPs should Approach patient record access with caution and take Appropriate measures to protect patient confidentiality and data security. By adopting a risk-based Approach, GPs can ensure that patients have access to their records while safeguarding sensitive information from potential threats. The NHS has provided lots of guidance including films to support staff with providing online services.

Benefits for GP practices

  • Online access to records can reduce the number of phone calls and inquiries to GP practices as patients can access the information they need online.
  • Online access to records can improve the efficiency of GP practices by reducing administrative tasks such as printing and mailing records or answering patient inquiries.
  • Online access to records can improve continuity of care as patients easily access and review all their health information, allowing them to be better prepare for consultations with different clinicians. Patients can also check their records and ensure everything is accurate and up-to-date.

Benefits for patients

  • Online access to records allows patients to have a better understanding of their health and medical history
  • Patients can review their records to see what treatments they have received, what medications they have been prescribed and what tests they have undergone. This information can help patients make informed decisions about their health and lifestyle choices
  • Online access to records improves patient awareness and understanding of their medical history. This can help patients when they are discussing their health with clinicians, potentially improving the outcomes of their care. This is particularly important for patients with chronic conditions who may see multiple healthcare providers
  • Online access to records means a patient can easily review their records to ensure that the information is accurate and up-to-date, which can help to prevent errors in treatment or medication
  • Online access to records can save time can save patients time by them not having to contact their practice about their medical history

Resources

Good practice guidelines for GP electronic patient records

The guidelines for good practice have been updated to version 5, with the last published date being in 2011. The first batch of topics is now accessible to GP practices for the Digital Primary Care: The Good Practice Guidelines for electronic patient records (version 5). These guidelines provide the latest information to GP practices on how to effectively use digital tools and services while ensuring safety and compliance with the law and national standards.

Digital systems are essential in building a modern, efficient, and responsive health service. The information flow between care providers and patients is crucial to achieving a safe, personalized, and convenient health and care service. General Practice is at the forefront of modernizing and improving healthcare. They are leading the way in embracing digital transformation and innovation. This is demonstrated through an advanced level of digital record-keeping and the adoption of digital tools that meet the growing demand from patients for a choice of digital channels.

This provides various benefits, including improved care and access for patients, reduction of administrative burdens, and other efficiency benefits. The guidelines provide practical information about digital tools, Approaches, and services to General Practice and primary care providers. The content has been written and reviewed by teams of primary care clinicians and managers with knowledge, expertise, and experience. The guidelines include all guidance associated with GP Electronic records, including patient records and information systems functionality, clinical safety, information governance and data protection, data sharing and interoperability, online patient-facing services, education and training, working in a digitally transformed NHS, and NHS organizations with an impact on Digital General Practice.

The guidelines have been updated to reflect modern general practice. The patients benefit from consistency of experience and access to safe and secure digital services.

Benefits for GP practices

  • One place for all guidance associated with GP Electronic records, including:
  • Patient records and information systems functionality
  • Clinical safety
  • Information governance and data protection
  • Data sharing and interoperability
  • Online patient-facing services
  • Education and training
  • Working in a digitally transformed NHS
  • NHS organisations with an impact on Digital General Practice
  • Updated to reflect modern general practice

Benefits for patients

  • Consistency of experience and access
  • Access to safe and secure digital services

National Care Records Service (NCRS) (formerly known as Summary Care Records)

Summary

Summary Care Record Application (SCRa) was retired SCRa on 31 October 2023 for the majority of users. National Care Records Service is the successor to SCRa.

A small number of users will continue to have access to SCRa, those who use the Chargeable Status tab. This group of users will be switched over to NCRS in early 2024.

NCRS is a service that allows health and social care professionals to access and update a range of patient and safeguarding information across regional Integrated Care Services (ICS) boundaries.

The service provides a summary of health and care information for care settings where the full patient record is not required to support their direct care. The service is a web-based Application and can be accessed regardless of what IT system an organisation is using and is the improved successor to the Summary Care Record Application (SCRa).

It enables any authorised clinician, care worker and/or administrator, in any health or care setting, to access a patient’s information to support that patient’s direct care. Putting the right information in the hands of doctors, nurses, and other care professionals at the right time saves lives and improves outcomes.

NCRS uses a standalone portal. It can, therefore, be accessed regardless of what IT system an organisation is using. NCRS can also be integrated directly into a local record system accessible via an in-context link. The summary information it provides may be useful in care settings when more detailed patient information is not required to support direct patient care.

Benefits for Practice

  • providing relevant information for emergency or out-of-hours providers, making unwanted admissions less likely and avoiding delays in urgent care
  • health and care professionals providing care in any setting have key clinical information, reducing the risk of prescribing and other errors
  • for patients with a disability, information such as communication needs, carers’ details, likes, and dislikes, and specific care preferences can all be included. (It is widely acknowledged that carers benefit from ‘contingency planning’ conversations and have these recorded in SCRs so that care professionals know when and how to action such plans when needed)
  • awareness of health problems like diabetes or dementia
  • identifying patients eligible for flu or other vaccinations
  • end of life preferences, lasting power of attorney details and advance decisions are available to care professionals
  • non-English speakers’ clinical information is available immediately

NHS provides expert views on the benefits of additional information in summary care records including a useful case study.

Benefits for patients

  • having an NCRS that includes extra information can be of particular benefit to patients with detailed and complex health problems.

Resources

CPCS