Patient Records Audit

A regional Electronic Patient Record (EPR) is currently being deployed, covering Acute Care, Secondary Care, Social Care and Mental Health sectors. Deployment is scheduled to complete by May 2025, followed by a stabilisation phase of one year. Reviews will be carried out as part of an optimisation stage to ensure processes are fit-for-purpose and can be improved.

Patient access to information held is provided through multiple channels including an App and a website. The EPR solution also enables patients to share selected information with others. The easy access to information will support patients to exercise their existing rights (under UK GDPR & Data Protection legislation) to ensure their records are accurate.

Northern Ireland is currently exploring how a holistic record, to include input from independent sector providers under controlled conditions, can be created. Several governance matters have been identified and consideration is being given to addressing these.

Once the regional EPR is fully rolled-out across the five HSC Trusts, it is anticipated that planned optimisation work will include an element of review and audit. Discussions with the Departmental Chief Digital Information Officer will seek to explore how the solution in place will continue to meet the requirements of Recommendation 4d). As part of the system’s implementation, timelines and performance reports have been and are still being published as part of ongoing continuous monitoring, a formal audit as such will not be required.

The Welsh Government agrees that digital record access empowers patients, and the NHS Wales App has been introduced as the front door to digital services. Progress has been made in primary care services. The goal is for patients and the public to:
personalise their health journey;
monitor health conditions more easily;
share and receive important health information;
take an active part in their own health and wellbeing;
plan for and take control of their health and care journey; and
stay healthy for longer.

The Welsh Government will be commissioning with its system partners the development of an Electronic Health Record in secondary care which is planned to improve the wider accessibility of digital records for clinicians and patients. The NHS App continues to develop in Wales and is at the heart of plans to increase access to records for patients during 2025.

The Scottish Government agrees that digitisation of patient records is essential, and that patients should have full access to relevant information about them. The Scottish Government is committed to this. As well as modernising existing infrastructure, such as via new GP IT systems, plans are being developed for a new national personalised digital health & social care service which will provide the enabling capability for patients to interact with their health information. The 'digital front door' programme will launch an initial prototype version of an online app for health & social care in Lanarkshire in December 2025. This will, for the first time, allow people to access elements of their core health information. This will be expanded over the next few years to be the primary means of people being able to access their personal records and identify and seek resolution of any apparent errors, with the range of information accessible increasing over time.

Health Boards will be required to continue with their local digitisation progress and assurance of delivery will involve adapting the Digital Maturity assessment to check on Health Board progress in digitising patient records. All Health Boards are asked to submit an update by the end of July of each year on their Digital Maturity Assessments. This is already a publicly reported process with the work on reporting on the 2024 assessments recently concluded (see Digital Maturity Assessment 2024 - Digital Healthcare Scotland for the most recent overview). The question set will be expanded in 2025 so that this assurance can be taken forward in line with the Inquiry’s recommended timescales by the end of 2027. Progressing this in 2025 will provide us with baseline intelligence around spring 2026, which will then allow the Scottish Government to identify appropriate next steps in terms of how we coordinate digitisation of patient records more broadly.

NHS England is supporting the NHS frontline to digitise its data. Linked to this, the Frontline Digitisation programme aims for all secondary care trusts to have an electronic patient record system (EPR) that meets its standards.

This work is informed by ongoing Digital Maturity Assessments, which capture most of the content called for within the audit set out within this recommendation. NHS England is determining the best means to capture the remaining items, such as the views of care professionals.

This approach aims to collate the information called for in this recommendation as efficiently as possible, making best use of existing processes and ensuring it’s joined up with wider work. NHS England is continuing work to confirm how this could be publicly reported and identify next steps as set out in the recommendation and will be able to outline a plan for this by the summer 2025.

Using this process, NHS Boards and Social Care Partnerships are asked to submit an update on their progress by the end of July of each year. This is a publicly reported process with a summary report for the 2025 update due to be published. By the end of 2027 SG will be able to report on the extent of success in meeting the recommendation and any specific findings in the areas detailed.