By Tony Collins
Today’s Financial Times and other newspapers cover a National Audit Office report into GP clinical notes and correspondence, some of it urgent, that was not directed to the patient’s GP.
The correspondence was archived by Capita under its contract to provide GP support services. But patient notes were still “live”. They included patient invitation letters, treatment/diagnosis notes, test results and documents/referrals marked ‘urgent’.
What isn’t well reported is that ministers were left in the dark about the problems for more than a year. The National Audit Office does not blame anyone – its remit does not include questioning policy decisions – but its report is impressive in setting out of the facts.
Before NHS England outsourced GP support services to Capita in 2015, GPs practices sent correspondence for patients that were not registered at their practice to local primary care services centres, which would attempt to redirect the mail.
By the time Capita took over GP support services on 1 September 2015, GPs were supposed to “return to sender” any correspondence that was sent to them incorrectly – and not send it to primary care services centres that were now run, in part, by Capita.
But some GPs continued to send incorrectly-addressed correspondence to the primary care services centres. Capita’s contract did not require it to redirect clinical correspondence.
An unknown number of GP practices continued to send mail to the centres, expecting the centre’s staff to redirect it. A further complication was that Capita had “transformation” plans to cut costs by closing the primary care services support centres.
Capita made an inventory of all records at each site and shared this with NHS England. The inventories made reference to ‘clinical notes’ but at this point no one identified these notes as live clinical correspondence. Capita stored the correspondence in its archive.
In line with its contract, Capita did not forward the mail. It was not until May 2016 – eight months after Capita took over the primary care services centres – that Capita told a member of NHS England’s primary care support team that there was a problem with an unquantified accumulation of clinical notes.
It was a further five months before Capita formally reported the incident to NHS England. At that time Capita estimated that there was an accumulation of hundreds of thousands of clinical notes. When the National Audit Office questioned Capita on the matter, it replied that, with hindsight, it believes it could have reported the backlog sooner.
In November 2016, Capita and NHS England carried out initial checks on the reported backlog of 580,000 clinical notes. It wasn’t until December 2016 that ministers were informed of problems – more than a year after Capita took over the contract.
Even in December 2016 ministers were not fully informed. Information about a backlog of live clinical notes was within in a number of items in the quarterly ministerial reports. NHS England did not report the matter to the Department of Health until April 2017 – about two years after the problems began.
Even then, officials told ministers that clinical notes had been sampled and were considered “low clinical and patient risk”. But a later study by NHS England’s National Incident Team identified a backlog of 1,811 high priority patient notes such as documents deemed to be related to screening or urgent test results.
The National Audit Office says, “NHS England expects to know by March 2018 whether there has been any harm to patients as a result of the delay in redirecting correspondence. NHS England will investigate further where GPs have identified that there could be potential harm to patients. The review will be led by NHS England’s national clinical directors, with consultant level input where required.”
Last month Richard Vautrey, chairman of British Medical Association’s General Practitioners Committee, wrote to the NHS Chief Executive Simon Stevens criticising a lack of substantial improvement on Capita’s contract to run primary care service centres.
In December, the GP Committee surveyed practices and individual GPs on the Capita contract. The results showed a little improvement across all service lines, when compared to its previous survey in October 2016, but a “significant deterioration” in some services. Vautrey’s letter said,
“While any new organisation takes time to take over services effectively, the situation has gone from bad to worse since Capita took over the PCSE [Primary Care Support England] service almost two and a half years ago …
“This situation is completely unacceptable. As a result of the lack of improvement in the service delivery of PCSE we are now left with no option but to support practices and individual doctors in taking legal routes to seek resolution. While this is taking place, we believe it is imperative that NHS England conducts a transparent and comprehensive review of all policy, procedures and processes used by PCSE across each service line.”
It’ll be clear to some who read the NAO report that the problems with urgent patient notes going astray or being put mistakenly into storage, stems from NHS England’s decision to outsource a complex range of GP support services without fully considering – or caring about – what could go wrong.
It’s not yet known if patients have come to harm. It’s clear, though, that patients have been caught in the middle of a major administrative blunder that has complex causes and for which nobody in particular can be held responsible.
That ministers learned of a major failure on a public sector outsourcing deal over a year after live patient notes began to be archived is not surprising.
About four million civil and public servants have strict rules governing confidentiality. There are no requirements for civil and public service openness except when it comes to the Freedom of Information Act which many officials can – and do – easily circumvent.
Even today, the fourth year of Capita’s contract to run GP support services, the implications for patients of what has gone wrong are not yet fully known or understood.
It’s a familiar story: a public sector blunder for which nobody will take responsibility, for which nobody in particular seems to care about, and for which the preoccupation of officialdom will be to continue playing down the implications or not say anything at all.
Why would they be open when there is no effective requirement for it? It’s a truism that serious problems cannot be fixed until they are admitted. In the public sector, serious problems on large IT-related contracts are not usually fixed until the seriousness of the problems can no longer be denied.
For hundreds of years UK governments have struggled to reconcile a theoretical desire for openness with an instinctive and institutional need to hide mistakes. Nothing is likely to change now.
National Audit Office report – Investigation into clinical correspondence handling in the NHS.