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

PART 10 Records and information

Patient records

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(3) The consent of the Board required by paragraph (1)(b) may not be withheld or withdrawn provided the Board is satisfied, and continues to be satisfied, that—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

(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(2).

(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.

(5) The contractor must send the complete records relating to a patient to the Board—

(a) where a person on the contractor’s list of patients dies, before the end of the period of 14 days beginning with the date on which the contractor was informed by the Board of that person’s death, or (in any other case) before the end of the period of one month beginning with the date on which the contractor learned of that person’s death; or

(b) in any other case where the person is no longer registered with the contractor, as soon as possible at the request of the Board.

(6) To the extent that a patient’s records are computerised records, the contractor complies with paragraph (5) if it sends to the Board a copy of those records—

(a) in writing; or

(b) with the written consent of the Board, in any other form.

(7) The consent of the Board to the transmission of information other than in writing for the purposes of paragraph (6)(b) may not be withheld or withdrawn provided it is satisfied, and continues to be satisfied, with the following matters—

(a) the contractor’s proposals as to how the record is to be transmitted;

(b) the contractor’s proposals as to the format of the transmitted record;

(c) the manner in which the contractor proposes to ensure that the record received by the Board is identical to that transmitted; and

(d) the manner in which a written copy of the record may be produced by the Board.

(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.

Summary Care Record

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, at least on a daily basis, 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 practices

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 number

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 services

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).

(7) The requirements in paragraph (5) do not apply where the contractor—

(a) does not have access to GPSOC accredited computer systems and software which would enable it to offer the online services described in that paragraph to its registered patients; and

(b) has, by 30th September 2015, publicised its plans to achieve that requirement by 31st March 2016 by displaying a statement of intent on the practice premises and, where the contractor has a website, on the practice website.

(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(3); and

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

Confidentiality of personal data: nominated person

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 website

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 information

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(4) (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.

Inquiries about prescriptions and referrals

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.

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(5) (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.

Annual return and review

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 leaflet

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.

(1)

GP 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.

(2)

This 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.

(3)

GP 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.

(4)

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

(5)

S.I. 2002/254; as amended by section 127 of the Health and Social Care Act 2008 (c.14), section 81(5) of the Policing and Crime Act 2009 (c.26), sections 213, 214(2) to (4), 215, 216, 218 and 219 of the Health and Social Care Act 2012 (c.7), section 5(2) of, and paragraph 6 of the Schedule to, the Health and Social Care (Safety and Quality) Act 2015 (c.28), and by S.I. 2003/3148, S.I. 2004/1947 and 2033, S.I. 2007/3101, S.I. 2009/1182, S.I. 2010/233, S.I. 2011/1043, S.I. 2012/1479 and 2672 and S.I. 2014/1887.