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The National Health Service (General Medical Services Contracts) Regulations 2015

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Point in time view as at 01/10/2018.

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There are currently no known outstanding effects for the The National Health Service (General Medical Services Contracts) Regulations 2015, PART 10. Help about Changes to Legislation

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PART 10E+WRecords and information

Patient recordsE+W

67.—(1) The contractor must keep adequate records of its attendance on and treatment of its patients and must do so—

(a)on forms supplied to it for the purpose by the Board; or

(b)with the written consent of the Board, by way of computerised records,

or in a combination of those two ways.

(2) The contractor must include in the records referred to in paragraph (1), clinical reports sent in accordance with paragraph 12 of Schedule 3 or from any other health care professional who has provided clinical services to a person on the contractor's list of patients.

(3) The consent of the Board required by paragraph (1)(b) may not be withheld or withdrawn provided the Board is satisfied, and continues to be satisfied, that—

(a)the computer system upon which the contractor proposes to keep the records has been accredited by the Secretary of State or by another person acting on the Secretary of State's behalf in accordance with “General Practice Systems of Choice Level 2”M1;

(b)the security measures, audit and system management functions incorporated into the computer system as accredited in accordance with sub-paragraph (a) have been enabled; and

(c)the contractor is aware of, and has signed an undertaking that it will have regard to, the guidelines contained in “The Good Practice Guidelines for GP electronic patient records” (Version 4) published on 21st March 2011 M2.

(4) Where the patient's records are computerised records, the contractor must, as soon as possible following a request from the Board, allow the Board to access the information recorded on the computer system on which those records are held by means of the audit function referred to in paragraph (3)(b) to the extent necessary for the Board to confirm that the audit function is enabled and functioning correctly.

[F1(5) Where a patient on the contractor’s list of patients dies, the contractor must send the complete records relating to that patient to the Board—

(a)in a case where the contractor was informed by the Board of that patient’s death, before the end of the period of 14 days beginning with the date on which the contractor was so informed; or

(b)in any other case, before the end of the period of one month beginning with the date on which the contractor learned of that patient’s death.

(5A) Where a patient on a contractor’s list of patients has registered with another provider of primary medical services and the contractor receives a request from that provider for the complete records relating to that patient, the contractor must send to the Board—

(a)the complete records, or any part of the records, sent via the GP2GP facility in accordance with regulation 69 for which the contractor does not receive confirmation of safe and effective transfer via that facility; and

(b)any part of the records held by the contractor only in paper form.

(5B) Where a patient on a contractor’s list of patients—

(a)is removed from that list at that patient’s request under paragraph 23 of Schedule 3, or by reason of the application of any of paragraphs 24 to 31 of that Schedule; and

(b)the contractor has not received a request from another provider of medical services with which that patient has registered for the transfer of the complete records relating to that patient,

the contractor must send a copy of those records to the Board.

(5C) Where a contractor’s responsibility for a patient terminates in accordance with paragraph 32 of Schedule 3, the contractor must send any records relating to that patient that it holds to—

(a)if known, the provider of primary medical services with which that patient is registered; or

(b)in all other cases, the Board.

(5D) For the purposes of this regulation, “GP2GP facility” has the same meaning as in paragraph (2) of regulation 69.]

F2(6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F3(7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(8) A contractor whose patient records are computerised records must not disable, or attempt to disable, either the security measures or the audit system management functions referred to in paragraph (3).

(9) In this regulation, “computerised records” means records created by way of entries on a computer.

Textual Amendments

Marginal Citations

M1GP Systems of Choice is a scheme by which the National Health Service funds the cost of GP clinical IT systems in England. Guidance about this scheme is available from the Health and Social Care Information Centre, 1 Trevelyan Square, Boar Lane, Leeds, LS1 6AE.

M2This guidance is available at http://www.gov.uk/government/publications/the-good-practice-guidelines-for-gp-electronic-patient-records-version-4-2011. Hard copies are available from the Department of Health, Richmond House, 79 Whitehall, London SW1A 2NS.

Summary Care RecordE+W

68.—(1) A contractor must, in any case where there is a change to the information included in a patient's medical record, enable the automated upload of summary information to the Summary Care Record, [F4when the change occurs], using approved systems provided to it by the Board.

(2) In this regulation—

Summary Care Record” means the system approved by the Board for the automated uploading, storing and displaying of patient data relating to medications, allergies, adverse reactions and, where agreed with the contractor and subject to the patient's consent, any other data taken from the patient's electronic record; and

summary information” means items of patient data that comprise the Summary Care Record.

Electronic transfer of patient records between GP practicesE+W

69.—(1) A contractor must use the facility known as “GP2GP” for the safe and effective transfer of any patient records—

(a)in a case where a new patient registers with the contractor's practice, to the contractor's practice from the practice of another provider of primary medical services (if any) with which the patient was previously registered; or

(b)in a case where the contractor receives a request from another provider of primary medical services with which the patient has registered, in order to respond to that request.

(2) In this regulation, “GP2GP facility” means the facility provided by the Board to a contractor's practice which enables the electronic health records of a registered patient which are held on the computerised clinical systems of a contractor's practice to be transferred securely and directly to another provider of primary medical services with which the patient has registered.

(3) The requirements of this regulation do not apply in the case of a temporary resident.

Clinical correspondence: requirement for NHS numberE+W

70.—(1) A contractor must include the NHS number of a registered patient as the primary identifier in all clinical correspondence issued by the contractor which relates to that patient.

(2) The requirement in paragraph (1) does not apply where, in exceptional circumstances outside of the contractor's control, it is not possible for the contractor to ascertain the patient's NHS number.

(3) In this regulation—

clinical correspondence” means all correspondence in writing, whether in electronic form or otherwise, between the contractor and other health service providers concerning or arising out of patient attendance and treatment at practice premises including referrals made by letter or by any other means; and

NHS number”, in relation to a registered patient, means the number, consisting of ten numeric digits, which serves as the national unique identifier used for the purpose of safely, accurately and efficiently sharing information relating to that patient across the whole of the health service in England.

Patient online servicesE+W

71.—(1) A contractor must promote and offer to its registered patients the facility for a patient to—

(a)book, view, amend, cancel and print appointments online;

(b)order repeat prescriptions for drugs, medicines or appliances online; and

(c)view and print a list of any drugs, medicines or appliances in respect of which the patient has a repeat prescription,

in a manner which is capable of being electronically integrated with the computerised clinical systems of the contractor's practice using appropriate systems authorised by the Board.

(2) The requirements in paragraph (1) do not apply where the contractor does not have access to computer systems and software which would enable it to offer the online services described in that paragraph to its registered patients.

(3) A contractor must, when complying with the requirement in paragraph (1)(a), consider whether it is necessary, in order to meet the reasonable needs of its registered patients, to take action to increase the proportion of appointments which are available for its registered patients to book online and, if so, take such action.

(4) A contractor must promote and offer to its registered patients, in circumstances where the medical records of its patients are held on the contractor's computerised clinical systems, the facility for a patient to—

(a)access online any summary information derived from the patient's medical records and any other data which the contractor has agreed that the patient may access; and

(b)view online, electronically export or print any summary information derived from the patient's medical records and any other data which the contractor has agreed that the patient may access.

(5) A contractor must promote and offer to its registered patients, in circumstances where the medical records of its registered patients are held on the contractor's computerised clinical systems, the facility for any such patient to access online all information from the patient's medical record which is held in coded form unless—

(a)in the reasonable opinion of the contractor, access to such information would not be in the patient's best interests because it is likely to cause serious harm to—

(i)the patient's physical or mental health, or

(ii)the physical or mental health of any other person;

(b)the information includes a reference to any third party who has not consented to its disclosure; or

(c)the information in the patient's medical record contains a free text entry and it is not possible under the contractor's computerised clinical systems to separate that free text entry from other information in that medical record which is held in coded form.

(6) The requirements in paragraph (4)—

(a)do not apply where the contractor does not have access to computer systems and software which would enable it to offer the online services described in that paragraph; and

(b)only apply until such time as the contractor is able to fully comply with the requirements in paragraph (5).

F5(7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(8) Where the contractor has a practice website, the contractor must also promote and offer to its registered patients the facility referred to in paragraph (1)(a) and (b) on that practice website.

(9) In this regulation—

(a)GPSOC accredited computer systems and software” means computer systems and software which have been accredited by the Secretary of State or by another person in accordance with “General Practice Systems of Choice Level 2 M3; and

(b)summary information” has the meaning given in regulation 68(2).

Textual Amendments

Marginal Citations

M3GP Systems of Choice is a scheme by which the National Health Service funds the cost of GP clinical IT systems in England. Guidance about this scheme is available from the Health and Social Care Information Centre, 1 Trevelyan Square, Boar Lane, Leeds, LS1 6AE.

[F6Patient access to online servicesE+W

71A.(1) This regulation applies to any contractor which has less than ten per cent of its registered patients registered with the contractor’s practice to use the online services which the contractor is required under regulation 71 to promote and offer to its registered patients (“patient online services”).

(2) A contractor to which this regulation applies must agree a plan with the Board aimed at increasing the percentage of the contractor’s registered patients who are registered with the contractor’s practice to use patient online services.]

Confidentiality of personal data: nominated personE+W

72.  The contractor must nominate a person with responsibility for practices and procedures relating to the confidentiality of personal data held by it.

Provision of information on practice websiteE+W

73.  Where a contractor has a practice website, the contractor must publish on that website details of the contractor's practice area, including the area known as the outer boundary area (within the meaning given in regulation 20(3)) by reference to a sketch, diagram, plan or postcode.

Provision of informationE+W

74.—(1) Subject to paragraph (2), the contractor must, at the request of the Board, produce to the Board, or to a person authorised in writing by the Board, or allow the Board, or a person authorised in writing by it, to access—

(a)any information which is reasonably required by the Board for the purposes of or in connection with the contract; and

(b)any other information which is reasonably required in connection with the Board's functions.

(2) The contractor is not required to comply with any request made under paragraph (1) unless it has been made by the Board in accordance with directions relating to the provision of information by contractors given to the Board by the Secretary of State under section 98A of the Act M4 (exercise of functions).

(3) The contractor must produce the information requested, or, as the case may be, allow the Board access to such information—

(a)by such date as has been agreed as reasonable between the contractor and the Board; or

(b)in the absence of such agreement, before the end of the period of 28 days beginning with the date on which the request is made.

Marginal Citations

M4Section 98A was inserted by section 49(1) of the Health and Social care Act 2012 (c.7).

[F7Provision of information: GP access dataE+W

74A.(1) Subject to paragraph (4), a contractor must collect such information relating to patient access to primary medical services at the contractor’s practice (“GP access data”) as the Board may reasonably require for the purposes of, or in connection with, the contract.

(2) The contractor must submit an online return to the Board in respect of any GP access data collected by it using the Primary Care Web Tool (“PCWT”) facility which is provided by the Board to the contractor for this purpose.

(3) The contractor must submit an online return of GP access data to the Board twice in every financial year—

(a)by 31st October 2016 and 31st March 2017 in respect of the financial year that ends on 31st March 2017; and

(b)by 30th September and 31st March respectively for each subsequent financial year until 31st March 2021.

(4) The requirements of this regulation do not apply where the contractor does not have access to computer systems and software which would enable it to use the PCWT facility to submit an online return of GP access data to the Board.]

[F8National Diabetes AuditE+W

74B.(1) A contractor must record any data required by the Board for the purposes of the National Diabetes Audit in accordance with paragraph (2).

(2) The data referred to in paragraph (1) must be appropriately coded by the contractor and uploaded onto the contractor’s computerised clinical systems in line with the requirements of guidance published by NHS Employers for these purposes.

(3) The contractor must ensure that the coded data is uploaded onto its computerised clinical systems and available for collection by the Health and Social Care Information Centre at such intervals during each financial year as are notified to the contractor by NHS Digital.

Information relating to indicators no longer in the Quality and Outcomes FrameworkE+W

74C.  A contractor must allow the extraction from the contractor’s computerised clinical systems by the Health and Social Care Information Centre of the information specified in the Table relating to clinical indicators which are no longer in the Quality and Outcomes Framework at such intervals during each financial year as are notified to the contractor by NHS Digital.

Table

Quality and Outcomes Framework – indicators no longer in the Quality and Outcomes Framework

Indicator IDIndicator Description
Clinical domain
CHD003The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less
CKD002The percentage of patients on the CKD register in whom the last blood pressure reading (measured in the preceding 12 months) is 140/85 mmHg or less
CKD004The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months
NM84The percentage of patients on the CKD register with hypertension and proteinuria who are currently treated with renin-angiotensin system antagonists
DEP001The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1st April to 31st March, who have had a bio-psychosocial assessment by the point of diagnosis. The completion of the assessment is to be recorded on the same day as the diagnosis is recorded
DM005The percentage of patients with diabetes, on the register, who have a record of an albumin:creatinine ratio test in the preceding 12 months
DM011The percentage of patients with diabetes, on the register, who have a record of retinal screening in the preceding 12 months
DM016The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 12 months
EP002The percentage of patients aged 18 or over on drug treatment for epilepsy who have been seizure free for the last 12 months recorded in the preceding 12 months
EP003The percentage of women aged 18 or over and who have not attained the age of 55 who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the preceding 12 months
HYP003The percentage of patients aged 79 or under with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 140/90 mmHg or less
HYP004The percentage of patients with hypertension aged 16 or over and who have not attained the age of 75 in whom there is an assessment of physical activity, using GPPAQ, in the preceding 12 months
HYP005The percentage of patients with hypertension aged 16 or over and who have not attained the age of 75 who score ‘less than active’ on GPPAQ in the preceding 12 months, who also have a record of a brief intervention in the preceding 12 months
LD002The percentage of patients on the learning disability register with Down’s Syndrome aged 18 or over who have a record of blood TSH in the preceding 12 months (excluding those who are on the thyroid disease register)
MH004The percentage of patients aged 40 or over with schizophrenia, bipolar affective disorder and other psychoses who have a record of total cholesterol:hdl ratio in the preceding 12 months
MH005The percentage of patients aged 40 or over with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood glucose or HbA1c in the preceding 12 months
MH006The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 12 months
PAD003The percentage of patients with peripheral arterial disease in whom the last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less
RA003The percentage of patients with rheumatoid arthritis aged 30 or over and who have not attained the age of 85 who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 12 months
RA004The percentage of patients aged 50 or over and who have not attained the age of 91 with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 24 months
STIA004The percentage of patients with stroke or TIA who have a record of total cholesterol in the preceding 12 months
STIA005The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA whose last measured total cholesterol (measured in the preceding 12 months) is 5 mmol/l or less
THY001The contractor establishes and maintains a register of patients with hypothyroidism who are currently treated with levothyroxine
THY002The percentage of patients with hypothyroidism, on the register, with thyroid function tests recorded in the preceding 12 months
Public Health Domain
CVD-PP002The percentage of patients diagnosed with hypertension (diagnosed after on or after 1st April 2009) who are given lifestyle advice in the preceding 12 months for smoking cessation, safe alcohol consumption and healthy diet
CON002The percentage of women, on the register, prescribed an oral or patch contraceptive method in the preceding 12 months who have also received information from the contractor about long acting reversible methods of contraception in the preceding 12 months
SMOK001The percentage of patients aged 15 or over whose notes record smoking status in the preceding 24 months

Information relating to alcohol related risk reduction and dementia diagnosis and treatmentE+W

74D.(1) A contractor must allow the extraction by the Health and Social Care Information Centre of the information specified in—

(a)paragraph (2) in relation to alcohol related risk reduction; and

(b)paragraph (3) in relation to dementia diagnosis and treatment,

from the record that the contractor is required to keep in respect of each registered patient under regulation 67 by such means, and at such intervals during each financial year, as are notified to the contractor by the Health and Social Care Information Centre.

(2) The information specified in this paragraph is information required in connection with the requirements under paragraph 7 of Schedule 3.

(3) The information specified in this paragraph is information relating to any clinical interventions provided by the contractor in the preceding 12 months in respect of a patient who is suffering from, or who is at risk of suffering from, dementia.

NHS Digital Workforce CensusE+W

74E.(1) A contractor must record and submit any data required by the Health and Social Care Information Centre for the purposes of the NHS Digital Workforce Census (known as the “Workforce Minimum Data Set”) in accordance with paragraph (2).

(2) The data referred to in paragraph (1) must be appropriately coded by the contractor in line with agreed standards set out in guidance published by NHS Employers and must be submitted to the Health and Social Care Information Centre by using the workforce module on the Primary Care Web Tool which is a facility provided by the Board to the contractor for this purpose.

(3) The contractor must ensure that the coded data is available for collection by the Health and Social Care Information Centre at such intervals during each financial year as are notified to the contractor by the Health and Social Care Information Centre.

Information relating to overseas visitorsE+W

74F.(1) A contractor must—

(a)record the information specified in paragraph (2) relating to overseas visitors, where that information has been provided to it by a newly registered patient on a form supplied to the contractor by the Board for this purpose; and

(b)where applicable in the case of a patient, record the fact that the patient is the holder of a European Health Insurance Card or S1 Healthcare Certificate which has not been issued to or in respect of the patient by the United Kingdom,

in the medical record that the contractor is required to keep under regulation 67 in respect of the patient.

(2) The information specified in this paragraph is—

(a)in the case of a patient who holds a European Health Insurance Card which has not been issued to the patient by the United Kingdom, the information contained on that card in respect of the patient; and

(b)in the case of a patient who holds a Provisional Replacement Certificate issued in respect of the patient’s European Health Insurance Card, the information contained on that certificate in respect of the patient.

(3) The information referred to in paragraph (2) must be submitted by the contractor to NHS Digital—

(a)electronically at NHSDIGITAL-EHIC@nhs.net; or

(b)by post in hard copy form to EHIC, PDS NBO, NHS Digital, Smedley Hydro, Trafalgar Road, Southport, Merseyside, PR8 2HH.

(4) Where the patient is the holder of an S1 Healthcare Certificate, the contractor must send that certificate, or a copy of that certificate, to the Department for Work and Pensions—

(a)electronically to overseas.healthcare@dwp.gsi.gov.uk; or

(b)by post in hard copy form to the Overseas Healthcare Team, Durham House, Washington, Tyne and Wear, NE38 7SF.]

Inquiries about prescriptions and referralsE+W

75.—(1) The contractor must, subject to paragraphs (2) and (3), sufficiently answer any inquiries whether oral or in writing from the Board concerning—

(a)any prescription form or repeatable prescription form issued or created by a prescriber;

(b)the considerations by reference to which prescribers issue such forms;

(c)the referral by or on behalf of the contractor of any patient to any other services provided under the Act; or

(d)the considerations by which the contractor makes such referrals or provides for them to be made on its behalf.

(2) An inquiry referred to in paragraph (1) may only be made for the purpose of obtaining information to assist the Board to discharge its functions, or of assisting the contractor in the discharge of its obligations under the contract.

(3) The contractor is not obliged to answer any inquiry referred to in paragraph (1) unless it is made—

(a)in the case of paragraph (1)(a) or (b), by an appropriately qualified health care professional; or

(b)in the case of paragraph (1)(c) or (d), by an appropriately qualified medical practitioner.

(4) The appropriately qualified person referred to in paragraph (3)(a) or (b) must—

(a)be appointed by the Board in either case to assist it in the exercise of its functions under this regulation; and

(b)produce, on request, written evidence of that person's authority from the Board to make such an inquiry on the Board's behalf.

Provision of information to a medical officer etc.E+W

76.—(1) The contractor must, if satisfied that the patient consents—

(a)supply in writing to a person specified in paragraph (3) (a “relevant person”), before the end of such reasonable period as that person may specify, such clinical information as a person specified in paragraph (3)(a) to (d) considers relevant about a patient to whom the contractor, or a person acting on behalf of the contractor, has issued or has refused to issue a medical certificate; and

(b)answer any inquiries by a relevant person about—

(i)a prescription form or medical certificate issued or created by, or on behalf of, the contractor, or

(ii)any statement which the contractor, or a person acting on behalf of the contractor, has made in a report.

(2) For the purpose of being satisfied that a patient consents, a contractor may rely on an assurance in writing from a relevant person that the consent of the patient has been obtained, unless the contractor has reason to believe that the patient does not consent.

(3) For the purposes of this regulation, “a relevant person” is—

(a)a medical officer;

(b)a nursing officer;

(c)an occupational therapist;

(d)a physiotherapist; or

(e)an officer of the Department for Work and Pensions who is acting on behalf of, and at the direction of, any person specified in sub-paragraphs (a) to (d).

(4) In this regulation—

medical officer” means a medical practitioner who is—

(a)

employed or engaged by the Department for Work and Pensions; or

(b)

provided by an organisation under a contract entered into with the Secretary of State for Work and Pensions;

nursing officer” means a health care professional who is registered on the Nursing and Midwifery Register and who is—

(a)

employed by the Department for Work and Pensions; or

(b)

provided by an organisation under a contract with the Secretary of State for Work and Pensions;

occupational therapist” means a health care professional who is registered in the part of the register maintained by the Health Professions Council under article 5 of the Health and Social Work Professions Order 2001 M5 (establishment and maintenance of register) relating to occupational therapists and who is—

(a)

employed or engaged by the Department for Work and Pensions; or

(b)

provided by an organisation under a contract entered into with the Secretary of State for Work and Pensions; and

physiotherapist” means a health care professional who is registered in the part of the register maintained by the Health Professions Council under article 5 of the Health and Social Work Professions Order 2001 (establishment and maintenance of register) relating to physiotherapists and who is—

(a)

employed or engaged by the Department for Work and Pensions; or

(b)

provided by an organisation under a contract entered into with the Secretary of State for Work and Pensions.

Marginal Citations

Annual return and reviewE+W

77.—(1) The contractor must submit to the Board an annual return relating to the contract which must require the same categories of information to be provided by all persons who hold contracts with the Board.

(2) The Board may request a return relating to the contract at any time during each financial year in relation to such period (not including any period covered by a previous annual return) as may be specified in the request.

(3) The contractor must submit the completed return to the Board—

(a)by a date which has been agreed as reasonable between the contractor and the Board; or

(b)in the absence of such agreement, before the end of the period of 28 days beginning with the date on which the request was made.

(4) Following receipt of the return referred to in paragraph (1), the Board must arrange with the contractor an annual review of its performance in relation to the contract.

(5) The contractor or the Board may, if desired, invite the Local Medical Committee (if any) for the area in which the contractor is providing services under the contract to participate in the annual review.

(6) The Board must prepare a draft record of the review referred to in paragraph (4) for comment by the contractor and, having regard to such comments, must produce a final written record of the review.

(7) The Board must send a copy of the final record of the review referred to in paragraph (6) to the contractor.

Practice leafletE+W

78.—(1) The contractor must compile a document (a “practice leaflet”) which must include the information specified in Part 6 of Schedule 3.

(2) The contractor must review its practice leaflet at least once in every period of 12 months and make any amendments necessary to maintain its accuracy.

(3) The contractor must make available a copy of the leaflet, and any subsequent updates, to its patients and prospective patients.

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