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

Status:

Point in time view as at 01/10/2021.

Changes to legislation:

The National Health Service (General Medical Services Contracts) Regulations 2015, PART 10 is up to date with all changes known to be in force on or before 07 August 2024. There are changes that may be brought into force at a future date. Changes that have been made appear in the content and are referenced with annotations. 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(3) The consent of the Board required by paragraph (1)(b) may not be withheld or withdrawn provided the Board is satisfied, and continues to be satisfied, that—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.

[F4Record of ethnicity informationE+W

67A.—(1) This regulation applies if a contractor, or a person acting on behalf of a contractor, makes a request to a patient (“P”) for P to disclose their ethnicity to the contractor so that information can be recorded in P’s medical record (a “relevant request”).

(2) If P, or where P is a person to whom paragraph (4) applies, an appropriate person [F5acting on behalf of P], discloses P’s ethnicity in response to the relevant request, the contractor must record P’s ethnicity in P’s medical record.

(3) If P, or where P is a person to whom paragraph (4) applies, an appropriate person [F6acting on behalf of P], indicates that they would prefer not to disclose P’s ethnicity in response to the relevant request, the contractor must record that response in P’s medical record.

(4) This paragraph applies to a person if they—

(a)are a child, or

(b)lack the capacity to respond to the relevant request.

(5) Any information recorded in accordance with this regulation may only be processed if the processing is necessary for medical purposes.

(6) Nothing in this regulation authorises the processing of personal data in a manner inconsistent with any provision of the data protection legislation.

(7) In this regulation—

F7...

“data protection legislation”, “personal data” and “processing” have the same meanings as in the Data Protection Act 2018 (see section 3 of that Act);

“medical purposes” has the meaning given for the purposes of section 251 of the Act.]

Textual Amendments

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, [F8when 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 [F9(other than any information recorded in accordance with regulation 67A [F10or any information about ethnicity provided under regulation 71ZC])] taken from the patient's electronic record; and

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

Textual Amendments

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.

[F11Transfer of patient records between GP practices: time limitsE+W

69A.—(1) This regulation applies where—

(a)a patient on a contractor’s list of patients has registered with another provider of primary medical services, and

(b)the contractor receives a request from that provider for the complete records relating to that patient.

(2) The contractor must, before the end of the period of 28 days beginning with the day on which it receives the request from the provider—

(a)send the complete records (other than any part of the records held only in paper form) to the provider via the GP2GP facility in accordance with regulation 69, and

(b)send to the Board in accordance with regulation 67(5A), the complete records, or any part of the records—

(i)for which the contractor does not receive a confirmation, or

(ii)held only in paper form.

(3) In this regulation—

“confirmation”, in relation to records sent via the GP2GP facility, means confirmation of safe and effective transfer via that facility;

“GPG2P facility” has the same meaning as in paragraph (2) of regulation 69.]

Textual Amendments

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.

[F12Use of fax machinesE+W

70A.—(1) Where a contractor can transmit information by electronic means (other than facsimile transmission) securely and directly to a relevant person, the contractor must not—

(a)transmit any information to that person by facsimile transmission, or

(b)agree to receive any information from that person by facsimile transmission.

(2) Paragraph (1) does not apply to any information which relates solely to the provision of clinical services or treatment to a patient under a private arrangement.

(3) In this regulation, “relevant person” means—

(a)an NHS body,

(b)another health service provider,

(c)a patient, or

(d)a person acting on behalf of a patient.]

Textual Amendments

Patient online services [F13: appointments and prescriptions] E+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.

[F14(3) A contractor must when complying with the requirements in paragraph (1)(a)—

(a)ensure that a minimum of 25% of its appointments per day during core hours are made available for online booking, whether or not those appointments are booked online, by telephone or in person, to include all appointments which must be made available for direct booking by NHS 111 in accordance with paragraph 11B of Part 1 of Schedule 3 to these Regulations; and

(b)consider whether it is necessary, in order to meet the needs of its registered patients, to increase the proportion of appointments which are available for its registered patients to book online and, if so, increase that number.

(3A) In the case of appointments required to be made available for direct booking by NHS 111, in accordance with paragraph 11B of Part 1 of Schedule 3 to these Regulations, those appointments can be released to be booked by a contractor’s registered patients by any means in the two hour period within core hours prior to the appointment time, or such other period agreed pursuant to a local arrangement, if they have not been booked by NHS 111 prior to this time.]

F15(4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F16(5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F17(5A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F18(6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F19(7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(8) F20... The contractor must also promote and offer to its registered patients the facility referred to in paragraph (1)(a) and (b) on [F21the home page (or equivalent) of] [F22its practice website or online practice profile].

[F23(9) In this regulation—

(a)“local arrangement” means an arrangement between the contractor and the Board as to the timeframe within which appointments not booked by NHS 111 can be released for booking by the contractor’s registered patients; and]

F24(b). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Textual Amendments

[F25Patient online services: provision of online access to coded information in medical record and prospective medical recordE+W

71ZA.—(1) Where a contractor holds the medical record of a registered patient (“P”) on its computerised clinical systems, the contractor must promote and offer to P the facility to access online the information from P’s medical record which is held in coded form other than—

(a)any excepted information, or

(b)any information which the contractor’s computerised clinical systems cannot separate from any free-text entry in P’s medical record.

(2) The contractor must, if its computerised clinical systems and redaction software allow, offer to P the facility to access online the information (other than any excepted information) entered onto P’s medical record on or after the relevant date (the “prospective medical record”).

(3) If P accepts an offer made under paragraph (2), the contractor must, as soon as possible, provide P with the facility to access online P’s prospective medical record.

(4) But the contractor may—

(a)delay providing the facility to P, if the contractor considers that providing P with it is likely to have an adverse impact on its provision of essential services;

(b)delay giving P online access to any information added to P’s prospective medical record after the facility is provided to P, if the contractor considers that providing P with access to that information is likely to have an adverse impact on its provision of essential services.

(5) If the contractor decides to delay providing P with access to the facility or giving P access to any information, it must notify P—

(a)of that decision (including the period for which it anticipates access will be delayed), and

(b)when the facility, or that information, becomes available.

(6) In this regulation, “relevant date” means—

(a)1st April 2020, where P became a registered patient before 1st October 2019;

(b)in any other case, 1st October 2019.

(7) For the purposes of this regulation and regulation 71ZB, information is “excepted information” if the contractor would not be required to disclose it to P in response to a request made by P in exercise of a right under Article 15 of the GDPR.

(8) For the purposes of paragraph (7), “GDPR” has the meaning given in section 3(10) of the Data Protection Act 2018.

Textual Amendments

Patient online services: provision of online access to full digital medical recordE+W

71ZB.—(1) A contractor must provide a registered patient (“P”) with the facility to access online relevant medical information if—

(a)its computerised clinical systems and redaction software allow it to do so, and

(b)P requests, in writing, that it provide that facility.

(2) In this regulation “relevant medical information” means any information entered on P’s medical record other than—

(a)any information which P can access online via a facility offered in accordance with regulation 71ZA(1) or (2), or

(b)any excepted information.]

Textual Amendments

[F26Patient online services: providing and updating personal or contact informationE+W

71ZC.—(1) A contractor must offer and promote to its registered patients a facility for providing their personal or contact information, or informing the contractor of a change to that information, which meets the condition in paragraph (2).

(2) A facility meets the condition in this paragraph if it enables—

(a)P, or

(b)where P is a person to whom paragraph (3) applies, an appropriate person acting on behalf of P,

to provide the contractor with, or inform it of any change to, P’s personal or contact information in P’s medical record, either online or by other electronic means.

(3) This paragraph applies to a person if they—

(a)are a child, or

(b)lack the capacity to provide the contractor with their personal or contact information or to authorise a person to provide such information on their behalf.

(4) For the purposes of this regulation, P’s personal and contact information is—

(a)their name;

(b)their ethnicity;

(c)their address;

(d)their telephone number or mobile telephone number (if any);

(e)their electronic mail address (if any).]

Textual Amendments

[F26Patient online services: provision of an online consultation toolE+W

71ZD.—(1) A contractor must offer and promote an online consultation tool to its registered patients.

(2) An “online consultation tool” is an online facility provided using appropriate software—

(a)through which—

(i)a patient, or

(ii)where the patient is a person to whom paragraph (4) applies, an appropriate person acting on behalf of the patient,

may, in writing in electronic form, seek advice or information related to the patient’s health or make a clinical or administrative request, but

(b)which does not require the response to be given by the contractor in real time.

(3) An online consultation tool may incorporate—

(a)any of the facilities which the contractor is required to offer under regulations 71 to 71ZC, or

(b)the communication method which the contractor is required to offer under regulation 71ZE.

(4) This paragraph applies to a person if they—

(a)are a child, or

(b)lack the capacity to communicate with the contractor through an online facility or to authorise a person to communicate with the contractor through such a facility on their behalf.]

Textual Amendments

[F26Secure electronic communicationsE+W

71ZE.—(1) A contractor must—

(a)offer and promote to its registered patients a relevant electronic communication method, and

(b)use the relevant electronic communication method to communicate with—

(i)a registered patient, or

(ii)where the registered patient is a person to whom paragraph (4) applies, an appropriate person acting on behalf of that patient.

(2) But paragraph (1)(b) does not require the contractor to use the relevant electronic communication method where—

(a)it would not be clinically appropriate to do so for the patient on that occasion, or

(b)it is otherwise not appropriate to the needs or circumstances of the patient.

(3) For the purposes of this regulation, a “relevant electronic communication method” is a method of electronic communication which is provided using appropriate software and can be used—

(a)by the contractor to respond, in writing in electronic form, to requests made through the online consultation tool, and

(b)by the contractor and its registered patients or appropriate persons acting on behalf of registered patients (as the case may be) to otherwise communicate with each other in writing in electronic form.

(4) This paragraph applies to a person if they—

(a)are a child, or

(b)lack the capacity to communicate with the contractor using the relevant electronic communication method or to authorise a person to do so on their behalf.]

Textual Amendments

[F26Video consultationsE+W

71ZF.—(1) A contractor must offer and promote to its registered patients the facility of participating in their consultations with the contractor by video conference using appropriate software (“video consultations”).

(2) But paragraph (1) does not require the contractor to offer a patient a video consultation where—

(a)it would not be clinically appropriate to do so for the patient on that occasion, or

(b)it is otherwise not appropriate to the needs or circumstances of the patient.

(3) The contractor must not be party to a contract or other arrangement under which the software mentioned in paragraph (1) is provided unless—

(a)it is satisfied that any software which a patient needs to participate in a video consultation with the contractor’s practice is available free of charge to the patient, and

(b)it has taken reasonable steps, having regard to the arrangement as a whole and disregarding the costs of any software, to satisfy itself that patients will not have to pay more to participate in video consultations with the contractor’s practice than they would to participate in a meeting by video conference with any other person in the contractor’s area.]

Textual Amendments

[F26Meaning of “appropriate software” for the purposes of regulations 71ZD, 71ZE and 71ZFE+W

71ZG.—(1) For the purposes of regulations 71ZD, 71ZE and 71ZF the software used for the purposes of providing a facility or method of communication (as the case may be) is appropriate if the software meets—

(a)the requirements in the GPIT Operating Model relevant to that software, or

(b)requirements which are equivalent in their effect to the relevant requirements in the GPIT Operating Model.

(2) In this regulation “GPIT Operating Model” means the document published by the Board which sets out the commissioning framework for the provision of general practice digital services F27.]

Textual Amendments

F27The current version of the document is titled “Securing Excellence in Primary Care (GP) Digital Services: The Primary Care (GP) Digital Services Operating Model 2019-21” and is available at: https://www.england.nhs.uk/publication/securing-excellence-in-primary-care-gp-digital-services-the-primary-care-gp-digital-services-operating-model-2019-21/ . The document can be obtained in alternative formats by telephone (on 0300 311 22 33), by email (England.contactus@nhs.net) or by writing to NHS England and NHS Improvement, PO Box 16738, Redditch, B97 9PT.

[F28Patient 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 [F29or regulation 71ZA(1) or (2)] 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.]

Textual Amendments

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.

[F30Requirement to have and maintain an online presenceE+W

73.—(1) A contractor must have—

(a)a practice website, or

(b)an online practice profile.

(2) The contractor must publish on its practice website or profile (as the case may be) all the information which is required to be included in its practice leaflet.

(3) The contractor must publish that information otherwise than by making its practice leaflet available for viewing or downloading.

(4) The contractor must review the information available on its practice website or profile at least once in every period of 12 months.

(5) The contractor must make any amendments necessary to maintain the accuracy of the information on its website or profile following—

(a)a review under paragraph (4);

(b)a change to—

(i)the address of any of the contractor’s practice premises,

(ii)the contractor’s telephone number,

(iii)the contractor’s electronic-mail address (if made available on its website or profile), or

(iv)any other stated means by which a patient may contact the contractor to book or amend an appointment, or to order repeat prescriptions for drugs, medicines or appliances.

[F31(5A) The contractor must also ensure there are links on its website or profile which direct people to—

(a)its online consultation tool, and

(b)the symptom checker and self-care information available on the NHS website.

(5B) The links mentioned in paragraph (5A) must be displayed prominently on the home page (or equivalent) of its website or profile (as the case may be).]

(6) The requirements in this regulation are in addition to those in regulation 27 and paragraph 8(8) of Schedule 3.

(7) In these Regulations, “online practice profile” means a profile—

(a)which is on a website (other than the NHS website), or an online platform, provided by another person for use by the contractor, and

(b)through which the contractor advertises the primary medical services it provides.

Textual Amendments

Requirement to maintain profile page on NHS websiteE+W

73A.—(1) A contractor must review the information available on its profile page on the NHS website at least once in every period of 12 months.

(2) The contractor must make any amendments necessary to maintain the accuracy of the information on its profile page following—

(a)a review under paragraph (1);

(b)a change to—

(i)the address of any of the contractor’s practice premises,

(ii)the contractor’s telephone number,

(iii)the contractor’s electronic-mail address (if made available on its profile page), or

(iv)any other stated means by which a patient may contact the contractor to book or amend an appointment, or to order repeat prescriptions for drugs, medicines or appliances.]

Textual Amendments

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 M3 (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

M3Section 98A was inserted by section 49(1) of the Health and Social care Act 2012 (c.7).

Provision of information: GP access dataE+W

F3274A.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Textual Amendments

[F33National 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.

Textual Amendments

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.

[F34Table

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 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
CVD-PP002The percentage of patients diagnosed with hypertension (diagnosed after or on 1st April 2009) who are given lifestyle advice in the preceding 12 months for: smoking cessation, safe alcohol consumption and healthy diet
DM005The percentage of patients with diabetes, on the register, who have a record of an albumin: creatinine ratio test in the preceding 12 months
DMO11The percentage of patients with diabetes, on the register, who have a record of retinal screening in the preceding 12 months
EP002The percentage of patients 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
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
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
MH007The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 12 months
MH008The percentage of women aged 25 or over and who have not attained the age of 65 with schizophrenia, bipolar affective disorder and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years
PAD002The percentage of patients with peripheral arterial disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
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
PAD004The percentage of patients with peripheral arterial disease with a record in the preceding 12 months that aspirin or an alternative anti-platelet is being taken
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 toll adjusted for RA in the preceding 24 months
SMOK001The percentage of patients aged 15 or over whose notes record smoking status in the preceding 24 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]

Textual Amendments

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.

Textual Amendments

[F35NHS Digital Workforce Collections]E+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 [F36NHS Digital Workforce Collection] (known as the “Workforce Minimum Data Set”) in accordance with paragraph (2).

[F37(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 the Health and Social Care Information Centre, and must be submitted to the Centre using the data entry module on the National Workforce Reporting System, which is a facility provided by the Health and Social Care Information Centre 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.

Textual Amendments

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

[F38(b)where applicable in the case of a patient, record the fact that the patient is the holder of a document—

(i)which is—

(aa)a European Health Insurance Card;

(bb)an S1 Healthcare Certificate; or

(cc)a document which, for the purposes of a listed healthcare arrangement as defined in regulation 1(3) of the Healthcare (European Economic Area and Switzerland Arrangements) (EU Exit) Regulations 2019, is treated as equivalent to a document referred to in sub-paragraph (aa) (“EHIC equivalent document”) or (bb) (“S1 equivalent document”); and

(ii)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 [F39or EHIC equivalent document] which has not been issued to the patient by the United Kingdom, the information contained on that card [F40or document] 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—

[F41(a)electronically at nhsdigital.costrecovery@nhs.net;]

(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 [F42or S1 equivalent document], the contractor must send that certificate [F43or document], or a copy of that certificate [F43or document], to the [F44the NHS Business Services Authority]—

[F45(a)electronically to nhsbsa.faregistrationsohs@nhs.net, or]

[F45(b)by post in hard copy form to Cost Recovery, Overseas Healthcare Service, Bridge House, 152 Pilgrim Street, Newcastle Upon Tyne, NE1 6SN.]]

Textual Amendments

F38Reg. 74F(1)(b) substituted (31.12.2020) by S.I. 2019/776, reg. 8(a) (as substituted by The Reciprocal and Cross-Border Healthcare (Amendment etc.) (EU Exit) Regulations 2020 (S.I. 2020/1348), regs. 1, 4)

F39Words in reg. 74F(2)(a) inserted (31.12.2020) by S.I. 2019/776, reg. 8(b)(i) (as substituted by The Reciprocal and Cross-Border Healthcare (Amendment etc.) (EU Exit) Regulations 2020 (S.I. 2020/1348), regs. 1, 4)

F40Words in reg. 74F(2)(a) inserted (31.12.2020) by S.I. 2019/776, reg. 8(b)(ii) (as substituted by The Reciprocal and Cross-Border Healthcare (Amendment etc.) (EU Exit) Regulations 2020 (S.I. 2020/1348), regs. 1, 4)

F42Words in reg. 74F(4) inserted (31.12.2020) by S.I. 2019/776, reg. 8(c)(i) (as substituted by The Reciprocal and Cross-Border Healthcare (Amendment etc.) (EU Exit) Regulations 2020 (S.I. 2020/1348), regs. 1, 4)

F43Words in reg. 74F(4) inserted (31.12.2020) by S.I. 2019/776, reg. 8(c)(ii) (as substituted by The Reciprocal and Cross-Border Healthcare (Amendment etc.) (EU Exit) Regulations 2020 (S.I. 2020/1348), regs. 1, 4)

[F46Medicines and Healthcare products Regulatory Agency Central Alerting SystemE+W

74G.  A contractor must—

(a)provide to the Medicines and Healthcare products Regulatory Agency (“the MHRA”) on request, an electronic mail address which is registered to the contractor’s practice;

(b)monitor that address;

(c)if that address ceases to be registered to the practice, notify the MHRA immediately of its new electronic mail address; and

(d)provide to the MHRA on request, one or more mobile telephone numbers for use in the event that the contractor is unable to receive electronic mail.]

Textual Amendments

[F47Collection of data relating to appointments in general practiceE+W

74H.—(1) A contractor must participate in the collection of anonymised data relating to appointments for its registered patients (“practice appointments data”) in accordance with the “GP Appointments Data Collection in Support of Winter Pressures” referred to in the Health and Social Care Information Centre (Establishment of Information Systems for NHS Services: General Practice Appointments Data Collection in Support of Winter Pressures) Directions 2017.

(2) The contractor must ensure that all practice appointments data relating to the provision of primary medical services under its contract is recorded within the appointment book in accordance with the guidance.

(3) The contractor must ensure that the practice appointments 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 notified to the contractor by the Centre.

(4) For the purposes of this regulation, “appointment book” means a capability provided by the contractor’s computerised clinical systems and software supplier which supports the administration, scheduling, resourcing and reporting of appointments.]

Textual Amendments

[F48Collection of data concerning use of online consultation tools and video consultationsE+W

74I.  A contractor must submit to the Board such anonymised data relating to the use of its online consultation tool and video consultation facility as the Board may require.]

Textual Amendments

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 [F49Health Professions Order 2001] (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 [F50Health 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.

Textual Amendments

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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