The summary care record roll out
1. What it set out to be
The origins of the Summary Care Record go back to 2002 when the previous government set out its vision for NHS informatics in the white paper ‘Delivering 21st Century IT’. With what now seems like wild optimism, the Department of Health hoped to deliver a National Health Record Service with core data and links to local electronic patient record systems by December 2007. In 2005, NHS Connecting for Health split the NHS Care Records Service into two parts; with a Summary Care Record and a Detailed Care Record. The aim of the SCR was to provide information for first contact care out-of-hours, in A&E and for temporary residents.
2. What it is now
The SCR is starting life as medications, allergies and contraindications, which are uploaded from GPs’ records. It can be added to each time a patient is seen by a healthcare organisation. This ‘enhanced’ summary can be uploaded without the patient’s explicit consent. CfH has also proposed that other organisations, such as A&E departments, could create an SCR where one does not already exist.
In some primary care trusts -14 by March this year – patients can access their SCR via the online organiser HealthSpace. However – by March again – only 752 patients had done so.
The list of clinician type and use that could be made of an SCR now includes district nurse access, access for those involved in caring for patients with long term conditions, and mobile access. Two key areas for access are seen to be pharmacy – already enabled for pharmacists in medical admission units and due to be piloted for community pharmacists this summer – and access for end of life care – which has also been enabled in some PCTs.
3. Consent and confidentiality
Patient information programmes must run for a minimum of 12 weeks before records are uploaded to the Spine. Following that period, and with a practice’s agreement, the summary records of all patients will be uploaded, except those of patients that have opted-out. Clinicians must get patients “consent to view” an SCR on each occasion before it is accessed.
CfH argues that information is further protected because it is held on the N3 network and can only be accessed by staff with a smartcard and with a legitimate relationship, backed up by audit trails and alerts and professional and contractual requirements, So far there have been no public revelations of inappropriate access. No action was taken against a doctor in Scotland accused or accessing the Emergency Care Summaries of high profile politicians and celebrities.
4. How it compares with other UK countries
In Scotland, Wales and in the proposed Northern Irish systems, information is extracted from the GP record and uploaded on a daily basis. In England, the information is uploaded once and then only changed as changes are made at the GP practice. The other three countries of the UK have also limited the summary to GP information only.
Scotland is the most advanced in terms of coverage with 5.4m patients – its entire population minus opt-outs – now having an Emergency Care Summary. Extracts are made from GP record twice a day and cover demographics plus allergies, adverse reactions and medications. Currently, out-of-hours services, A &E departments, NHS 24 and GP practices have a right to access the information.
In Wales, the Individual Health Record can only be accessed from within a health board and is so far available in Gwent and Hywel Dda. Consent to view applies in all countries. Northern Ireland will use the same system as Scotland but with its own hosting arrangements. None of the systems interoperate with each other.
5. Its detractors
Those campaigning against the SCR argue that it exposes confidential patient information to potential abuse by anyone in the NHS with a smartcard. Many, including the BMA, believe patients should give their explicit consent before any health information is uploaded to a national database. Some clinicians also question to the usefulness of the SCR, claiming that it would rarely be needed and that inconsistencies in the data uploaded would mean clinical decisions could not be reliably made based on its contents.
6. Its supporters
Those in favour of the SCR argue that it can provide information to clinicians where none is available, improving confidence in clinical decision making and patient safety. A survey of 50 out-of-hours doctors in Bury and Bolton found that 50% felt that access to the SCR helped inform their clinical decisions with just under 25% reporting that it also affected their prescribing decisions. CfH also reports that hospital pharmacists have logged reductions in the time taken to reconcile medications from 30 to 40 minutes to 20 seconds.
7. What the first evaluation said
The first evaluation of the SCR, published in May 2008, recommended an urgent review of the SCR’s implied consent model and questioned whether a national system should be rejected in favour of a series of linked smaller systems. The researchers from University College, London, found that patients remained ignorant of the basic issues despite receiving information about the SCR and recommended that CfH look at the ‘consent to view’ system used elsewhere in the UK. The DH later agreed to adopt this. It also criticised CfH for what it described as too narrow a focus on implementing technology rather than a broader focus on socio-technical change.
8. How widely is it deployed now?
An accelerated roll-out of the SCR launched in the New Year has increased deployments significantly. By this Monday (7 June) a total of 259 GP practices had uploaded records, 1,658,697 SCRs had been created, and almost 30m patients had been contacted about the SCR as part of a public information programme. CfH statistics show that 0.73% of patients have so far decided to opt-out.
Four GP systems are compliant for the SCR – EMIS LV, INPS Vision, TPP’s SystmOne and iSoft’s Synergy covering about 70% of GP systems in England.
9. Who is using it?
Information from 12 March this year shows that 25 SCR viewing sites were technically live and the record had been viewed just over 15,000 times at a time when 1.3m records had been uploaded. The introduction of the integrated Adastra application led to a large increase in accesses because it was much easier for clinicians to view the SCR.
10. What the future holds
An agreement between CfH and the BMA means uploads are continuing following an earlier suspension, subject to the agreement of practices and satisfaction with data quality. The independent evaluation of the SCR is likely to take a closer look at several aspects of the SCR, including GP data quality, the effectiveness of the current patient consent system, the impact on GP workload and the usefulness of the SCR to clinical practice. We can expect the new government to make a series of amendments as a result, even if it continues to support the roll-out of the scheme.