Access to Medical records - GP Practice

The access request has been sent to you as you are the last known GP Practice the patient was registered to. Please contact NHS England if you have any further queries regarding your role in an Access to Medical Records Request.

Documents requested from PCSE will be sent to the GP in PDF format. GPs can upload all documents, including PDF documents, into the record attachments section of the electronic patient record.

Practices may have access to redact patient records using internal software, e.g. in SystmOne called Subject Access Requests. Where electronic redaction software is being used and a patient record has been deducted when the user accesses the record, there will be a prompt to add data, then confirm YES and this allow them to override and add additional information/attachments.

Alternatively, Practices may choose to use third-party software such as IGPR or Adobe Acrobat Pro.

The Application should provide a signed authority for the application setting out whether they are the personal representative or, if not, state the basis under which their application is made e.g. they are the parent, sibling, etc of the deceased and have a claim as a dependent under the Fatal Accidents Act 1976.

If a solicitor is acting on a requester's behalf, it is the solicitor's responsibility to verify that the requester is the legitimate personal representative of the deceased or has a legitimate claim arising from the patient's death. The record holder can accept the solictor's statement that they have done the necessary checks, provided that they submit it to the record holder in writing by letter or email.

The Access to Health Records Act 1990 states that the medical records should be reviewed and if necessary redacted by the most appropriate healthcare professional before release. In most cases the appropriate healthcare professional is the most recent GP.  The healthcare professional is responsible for deciding whether access should be allowed, which records are appropriate for release and if any redaction is required.  There is further guidance around the redaction of records here. 

It is no longer a requirement for GP practices to print off the electronic/digital patient record for a deceased patient. GP Practices should still return the legacy paper Lloyd George medical record (if one exists) to PCSE and PCSE will store it on behalf of the Practice.  Should a Practice require an electronic copy of the Lloyd George record to respond to an Access to Health Record application, please visit the Accessing Medical Records and patient details page for more information. 

This information can be found in the published IG Guidance for Access to Health Records requests.

You remain responsible for the AHRA request but will need to contact PCSE to request the records, please visit the Contact Us page and complete a new Medical Record Movemtn enquiry.

If you work at a Practice and are unsure of what steps to take, please contact your ICB/Commissioner regarding the recent GP contract changes.

Deceased patient records no longer need to be printed and sent to PCSE.  However, PCSE will still continue to collect any legacy paper Lloyd George records.

When an application is received by the Access to Health Records team, the steps listed in this guide,  detail the process that the application will follow. Applicants who require an update at any stage of the application should contact our Customer Support Centre on 0333 014 2884.

To appeal a decision on disclosure please email pcse.accessrequests@nhs.net

Please ensure to include a statement as to why you wish to appeal the decision.

If your appeal is accepted, it will be passed to the NHS England Redaction team to review the initial decision.

A record may not always contain the patient's full medical history. PCSE can only provide you with the information we hold.

If there are missing years, please contact the GP Practice where the patient was registered during the period you are missing the information.

PCSE will consult an appropriate health professional who will review the records and decide which records may be released.

There are certain circumstances in which the health professional may deny access to the complete records or to certain parts of the record:

The Health Professional has deemed notes not suitable for disclosure, as they are not within the scope of the request.

Where an individual other than the patient (and appropriate health professionals) could be identified from the information (unless the individual consents).

The deceased person stated that they did not wish for any part of their records to be released after death, or the information contained within the records was such that the deceased person expected them to remain confidential.

Access cannot be given to records made prior to November 1991.

If you wish to speak to someone regarding this, please contact: pcse.accessrequests@nhs.net, or phone 0333 014 2884.

If you or the person whose records you are requesting on behalf of are unregistered, PCSE will process the access application within 28 days.

In certain circumstances, this may not be possible (for example, where the record cannot be traced, or is held by a third party storage provider outside of the control of PCSE.)

If you are requesting records for a deceased person, GP practices are required to respond to Access to Health Records Act (AHRA) requests, however PCSE will process the Access to Health Records request if the last registered GP Practice has now closed. 

In these circumstances, if the request for a medical record is under the Access to Health Records Act 1990, PCSE will process the access application within 40 days. In certain circumstances, this may not be possible (for example, where the record cannot be traced, or is held by a third party storage provider outside of the control of PCSE.)

PCSE will update the applicant on likely timescales.

On behalf of NHS England, the NHS GP Practice medical records for patients should include information about:

• medication
• allergies
• vaccinations
• previous illnesses
• test results
• hospital discharge summaries
• appointment letters
• referral letters

Sometimes these records don’t always contain a full medical history.

Medical Records - Primary Care Support England can only provide a copy of GP health records. Other parts of a patient’s health record may be held by hospitals, community or mental health trusts, as well as previous GP practices. We cannot provide access to these records, and you therefore may wish to apply separately to another health organisation. Click here.

Primary Care Support England does not store:

• X-rays/transparencies – these will remain with the relevant NHS trust
  · digital records
  · hospital records – apply to the NHS trust
  · private clinic records – available from the clinic concerned.

Patient GP Registration Information and demographic information - PCSE receive requests from a range of individuals and organisations to access demographic information including last known GP Practice. Click here.