Last reviewed 20 December 2022

A last-minute decision by NHS England (NHSE) has halted automatic blanket rollout of the scheme that would have given all NHS patients in England prospective online access to GP-held records. In this feature article, Deborah Bellamy investigates why this decision was made and what the next steps are for patient access to records.

Why was automatic access to records a concern?

NHSE had proposed all patients over 16 years of age would automatically have prospective (future) access to medical records held electronically in GP systems, including consultations; documents, sent and received; laboratory results; problem headings; immunisations; and free text entries. As a result, any data essentially recorded in a patient’s GP system record from 1 November 2022 meant the staff member would have had to consider if this should be visible via the patient online record.

As data controllers of the GP record, and custodians of patient care, GPs are obliged on a dual basis to maintain responsibilities to their patients in terms of information governance and clinical safety. Concerns were raised by the British Medical Association (BMA) regarding patient safety and data protection laws, and a negotiated agreement was reached with NHSE and DHSC.

Although the hiatus may affect future practice workload with individual processing of future requests from patients, it will enable practices to implement this in a manner that does not compromise safe care delivery, ensuring practices and commissioners can be confident the service can be provided safely, according to NHSE.

Patients can still request access to their digital records on an individual basis, as is currently the case, being made aware of the consequences of such, with GPs ensuring it is safe and appropriate for them to do so.

NHSE position

NHSE agreed to extend the preparedness period to support practices ensuring they have guidance, support and time required.

Acknowledging current pressures, NHSE will work with the BMA, RCGP, local commissioning teams and GP IT system suppliers to enable patient access to prospective health information via the NHS App.

NHSE suggests practices who feel they are not ready to proceed should engage with local commissioners, to access additional support and agree a way forward to enable the offer of prospective access to records for their patients and utilise NHS Digitals’ practice readiness checklist. The checklist is available on the NHS Digital website.

GP IT suppliers

For practices who requested EMIS and TPP not to enable automatic access, NHSE directed both suppliers to pause at this stage. For practices that had not requested a pause, automatic access will be implemented in a phased way with system suppliers contacting practices to agree a switch on date.

A phased rollout will now ensue, where IT suppliers will inform practices in advance of scheduled switch on date and only data the date of switch will be visible, so practices should not need to review information entered since 1 November.

Considerations with redaction and safeguarding

Advantages of automatic access need to be balanced against risks of harm. For those deemed at increased risk, it is probable some elements of the medical record may be inappropriate to be shared in full.

It is deemed good practice to assume all records may contain sensitive or harmful data and appropriate safeguards put in place for all patients, not just those considered more vulnerable, such as those in coercive relationships or at risk of domestic violence. 

According to the BMA, redaction functionality needs to be improved so it can operate in a way that satisfies requirements of the Information Commissioner's Office.

Recorded consultation information may be redacted from the patient’s online view where it has potential to cause harm to either the individual patient or the other person, and only elements of the record that would not be available via a Subject Access Request should be redacted.

Where there are safeguarding concerns, practices can prevent patients gaining automatic access to the prospective full record by adding a specific Snomed CT  code. There has been some confusion around which codes can or should be used and what effect they have on the online access.

NHSE has produced guidance which may be downloaded from the FutureNHS website, as well as guidance found on the NHS Digital website, Using Enhanced Review (SNOMED) Codes when Giving a Patient Access to Their Health Record.

Such patients will need to be reviewed on a case-by-case basis to ascertain if access may be provided without significant risk of harm, dependent on contractual safeguards, if a direct request for access submitted.

Clinical safety issues

Practices are currently under immense pressures, so without extra resources to support implementation caused apprehension.

Significant clinical safety concerns regarding current redaction software not being fit for purpose were raised, as sizeable portions will be concealed from the patient view because of limited functionality, potentially obscuring vital clinical information from patients.

Redaction does not remain in place after GP2GP transfer, resulting in duplicated reviews of medical records, whereby a patient who had full access request this again after moving practice. GPC England is considering a flag to alert newly registered GPs to formerly GP redacted elements of the record.

Unintentional consequences arising from patients being given automatic access to their records, especially where known vulnerable patients are involved and for whom access to their records may constitute a clinical safety risk need consideration.

There has not been a public campaign forewarning patients their NHS App may become a portal to accessing full health records. Many users have passwords saved in their phones, with others potentially aware of PIN codes so could acquire access to confidential health records potentially leading to breaches in confidential data sharing.

What staff need to know

Practices should agree the best course of action for their patients and this delay will enable necessary preparations and training to facilitate safe implementation of the programme, allowing for business continuity whilst maintaining delivery of essential services.

NHS Digital suggest staff should be aware of the following.

  • Patients are being provided with an online account access to their future, or prospective, full GP health record including free text, letters and documents.

  • Where practices use TPP or EMIS systems, patients will see new entries in their GP record.

  • Be mindful patients will be able to see new records following such change.

  • Patients will see new information once entered, or filed, onto their record in the clinical system.

  • This alteration will not provide new access to historic, or past, health record information unless individually authorised by their GP practice. 

  • Patients will not have access to view communications or administrative tasks between practice staff.

  • Consider how this change to workflow can be managed, ensuring sensitive information is redacted as it is entered onto the clinical system, or in exceptional circumstances know when it may be inappropriate to provide a patient access to their record.

See Access to Patient Records Through the NHS App, NHS Digital.

Next Steps

According to the BMA, training resources should also be developed for secondary and community and mental health services as they are responsible for creating material which is integrated into the GP record and as additional sources may generate third party material. This also includes the following.

  • A resource for patients to support better understanding the risks and benefits related to online access.

  • GP2GP must be upgraded to enable transfer of redaction information from one practice to another to prevent unnecessary duplication.

NHS Digital suggests practices may consider assigning an online services champion/lead to ensure staff are familiar with specific practice policies/processes as there may a be potential increase in patient queries regarding access to records.

All staff, including locums, should be offered training including checking and entering information into patient records, identifying at risk patient, how to remove access, amended business processes/updated GP IT system functionality and amendments to the registration process(es) of new patients to enable those patients potentially at risk, to be identified.

Resources

The BMA offers guidance which includes further information on redaction, clinical safety concerns and legal context.