Patient Records

HC Deb 14 February 2000 vol 344 cc385-6W

Dr. Iddon

To ask the Secretary of State for Health in (1) what circumstances health authorities may gain access to patient records held by general practitioners without compromising confidentiality; [108611]

(2) if he will examine ways of preventing doctors retrospectively changing the computer records of patients. [108612]

Mr. Denham

Under their terms of service, general practitioners are currently required tokeep adequate records of the illnesses and treatment of his patients on forms supplied to him for the purpose by the HA and to forward such records to the HA on request as soon as possible".

It is generally accepted that patients who disclose information to a doctor do so on the understanding that information may be used by the National Health Service to monitor and improve the standards of care through research, clinical audit and the maintaining of registers. We have said that we intend to press ahead with the proposals for mandatory clinical audit in the Chief Medical Officer's consultation paper "Supporting Doctors, Protecting Patients", and that clinical governance will apply to all doctors. This will introduce accountability, promote high care standards, and ensure that an individual doctor's pattern of practice is not hidden.

Medical records are also routinely referred to by designated health authority staff for Post Payment Verification purposes, using a process agreed with Local Medical Committees so as not to contravene patient confidentiality.

It is essential that computer-based records must have a robust audit trail so that any changes to, or deletions from, the medical record are fully recorded so that it is always possible to re-create the record in the form in which it would originally have appeared.

The Department has published minimum standards to which general practice computer systems should conform and these include a detailed requirement for such an audit trail. These requirements are periodically reviewed to keep pace with changing technology and the latest version was published in October 1999.