The ‘Citizen’s Access Programme’ – which gives patients automatic access to their prospective GP records through the NHS app – has been marked by chaos and confusion. It was due to come in on 1 November, but there seems to have been a delay.
The issue has dominated talk within general practice for the past few weeks. There have been reports of practice managers threatening to quit, and a number of groups and organisations have warned about patient safety issues.
But most of all, there is confusion. We have looked at what we know, and don’t know, about practices’ responsibilities and duties.
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Are patients currently able to access their GP records through the NHS app?
According to the latest information from NHS England, practices that asked their system supplier not to enable the functionality by 4 November will see a delay applied until 30 November. Those that have not opted out by the deadline will see the introduction of the ‘citizen access’ programme earlier, in a phased manner.
Are practices allowed to apply blanket exclusion codes to all patients?
Many practices are currently asking how they pause the rollout through opting all their patients out of the scheme – a position recommended by the BMA.
NHS Digital has said that this approach ‘is not advisable’, and that practices who are struggling to provide the necessary safeguards should contact their commissioner for ‘support to meet their obligations’. Some local commissioners are also discouraging practices from applying blanket exclusion codes to their whole practice list.
Contractually, however, it seems as though practices are allowed to do this. The obligation for practices to offer access to prospective records is set out in the GP contract. The requirements are dense, but worth quoting in full: ‘The contractor must, if its computerised clinical systems and redaction software allow, offer to [patients] the facility to access online the information (other than any excepted information) entered onto [patient]’s medical record on or after the relevant date [1 November 2022, when the functionality was switched on].’
So as long as an ‘offer’ is made to all patients, there is no requirement to have them all opted in to automatic access. The definition of this ‘offer’ is not completely clear and NHS Digital say they won’t decree what this means. They have said that ‘communication must be effective so that it is made to all registered patients’. They say that placing a poster in the waiting room would therefore not be acceptable. Importantly, they say practices ‘should agree a plan with their local commissioner’ with regards to communication about the scheme.
In addition to prospective records access, practices are also required to promote and offer access to information ‘held in the coded form’ and the entire historic record upon written request, NHS Digital said.
How do practices block patient access to their records on their systems?
If you need to block access, you can do this by:
- Adding exclusion SNOMED codes to individual patients’ records or those of groups of ‘at-risk patients’ ahead of the switch-on – or even to your whole practice list, depending on whether you have made the offer of access to all patients;
- Amending an ‘individual patient configuration’ – although it remains unclear how practices can do this – or redact the records after the switch on;
- Updating the practices’ organisational settings to ‘disable the record access functionality’ – NHS England has said this is an option although it would mean practices reversing an action they were previously told they were contractually required to do. Pulse has enquired whether taking this step would mean practices are in breach of their contract;
- Disabling patient access to parts of their record that are ‘of concern’, such as disabling their access to documents stored in their record – although this option may not be available in all GP clinical systems.
How do the SNOMED codes work?
NHS Digital guidance has set out that practices can use two different SNOMED codes relating to records access.
An ‘enhanced review indicated’ code (1364731000000104) applied before the switch-on will prevent the patient from automatically receiving access to the new entries in their record because it will stop the online services account from being updated.
However, this won’t change any access settings the patient already has. So if a patient is identified as being at risk of harm, any access they already have must be reviewed by the practice. And the code must still be applied to relevant patients who have previously been denied access to their records to prevent automatic access to data added after 1 November.
This code will also prevent patients who create a new GP Online Services account after 1 November 2022 from automatically receiving access to future information when they sign up, NHS Digital said. Patients create a new account when they register for the NHS App or when they move practice (see below).
If the patient is no longer considered to be at risk, adding an ‘enhanced review not indicated’ code (1364751000000106) will override the ‘enhanced review indicated’ code. This means they will automatically receive access to information on 1 November 2022 or when a new GP online services account is created.
What happens when patients move practice?
If patients change practice, any SNOMED codes will transfer across with their record via the GP2GP transfer. But NHS Digital has admitted that when patients transfer, their GP online services account at the old practice is deleted and when the patient next logs into the NHS app, a new account is automatically created at the new practice.
Any new account is automatically given access to prospective information when the patient registers at the new practice. So if the GP2GP process fails, or a new GP online services account is created before the GP2GP transfer takes place, the practice must manually update the records access settings to prevent automatic access. However, if the SNOMED code is present in the record, the patient will only be able to access summary information such as medications, allergies and adverse reactions.
Official guidance previously revealed that patients moving practice will lose access to any data from their previous surgery, meaning that if they request this again their new practice will have to repeat the process of redacting their records.
Are GPs contractually obliged to respond to trivial queries from patients arising from records access?
GPs have raised concerns around whether they are contractually required to respond to patient queries related to their records, such as patients asking for clarity on an abbreviation or wanting their GP to correct details like a ‘4 weeks history of abdominal pain’ to ‘3 weeks’.
NHS Digital has said that there is a ‘professional responsibility for healthcare staff to ensure that patients understand the care they receive’. It added that additional information is provided on the NHS website ‘to support patients to fully benefit from access to their health information, including a list of common abbreviations’.
Pulse asked NHS England to clarify the contractual position, but it declined to comment so this remains unclear.
Will GPs need to change the kind of information they put on patient records?
NHS England has said that GPs will need to ‘consider the potential impact’ of each entry into a patient’s record, including documents and test results, and will need to ‘know how to manage this as a change to workflow’.
Its practice readiness checklist also set out that information in patient records should be ‘clear, accurate and legible’. An accompanying piece of guidance outlined how GPs and all staff adding to records must add information ‘with access in mind’.
It said that the use of abbreviations should be ‘limited’ because there is a ‘risk’ they could be ‘misinterpreted’ by patients or other healthcare professionals using shared care records.
The RCGP has also published guidance saying that practices are ‘responsible for ensuring that any potentially harmful or confidential third-party information in the patient’s record is not visible to the patient online’.
What will be the process for patients turning 16 after the switch-on?
GPs have also raised concerns around the lack of advice for dealing with patients turning 16 and therefore becoming eligible after automatic access is rolled out.
NHS Digital guidance said that the SNOMED codes can be applied to patients aged under 16. If applied to under-16s, the codes will prevent them from automatically gaining access to records entered after their 16th birthday when they turn 16.
It remains unclear whether there will be any support to help practices ensure they keep track of these patients and take any necessary action if they have not applied blanket SNOMED codes to all under-16s.
Meanwhile, the guidance also said that the SNOMED codes do not affect proxy access. It remains unclear whether this means that practices cannot add a SNOMED code to prevent parents or guardians from accessing a child’s records.
When will patients have access to information added to their records pre-1 November 2022, and what will practices need to do?
Pulse revealed in October that NHS England plans to enable patients to request their historical GP records through the NHS App from next year. This will not be automatic access, so patients will still need to request access to the information.
NHS England said that access to historical records will be ‘phased in carefully’, but it remains unclear when in 2023 this will take place.
It also remains unclear whether practices will need to take action ahead of this change.
What concerns are remaining?
Myriad concerns remain among the profession, including the potential for abuse of practice staff whose names appear in the record – which cannot be redacted. Anecdotally, Pulse has heard that practice managers may be considering resigning over the change.
Meanwhile, a study has found that providing patients with online access to their GP records has unintended negative consequences that limits its usefulness – such as extra workload for practices and distress for patients.
And GPs have warned via Twitter that some practices searching their patient records for codes for safeguarding and domestic abuse have identified that as many as 55% of records need reviewing.
Will it change how secondary care colleagues add information to GP records?
GPs have also raised concerns that they will be responsible for redacting information added to records by other healthcare professionals, such as letters and test results.
The Royal College of Radiologists has said that radiology departments must consider how imaging reports ‘are constructed in the future to ensure clear accurate information is conveyed to clinical colleagues but also with consideration that these will be read by patients’.
It added that it is ‘vital that resources are put in place to ensure that all patients have had a chance formally to discuss imaging findings with a member of the clinical team before they can see their report online’.