A change has been made to the way Summary Care Records are made available. Where a patient has not previously expressed a preference with regard to their Summary Care Record, both the core and Additional Information will be included in a patient’s SCR by default.
In practical terms, the only thing that will change is that those patients whose current SCR consent preference is set to 'Implied consent for Core Summary Care Record Dataset upload' will have a Summary Care Record with Additional Information uploaded to the NHS Spine. All the remaining SCR consent preference options will continue to function as previously. When the Additional Information is uploaded for a patient, your GP IT system will automatically make an auditable entry in the patient’s GP record. Get more information on this change on the NHSX website.
Additional Information includes:
- significant medical history (past and present)
- reason for medication
- anticipatory care information (such as information about the management of long term conditions)
- end of life care information (from the SCCI1580 national dataset)
There will also be a temporary change made to Summary Care Record Additional Information to include COVID-19 specific codes in relation to suspected, confirmed, Shielded Patient List and other COVID-19 related information. This will be surfaced within the significant medical history of the record.
This information is identified within the system through the codes for significant medical history (known as active problems and significant past problems, local summary and active problems, or priority 1 items and active problems, depending on which clinical system is being used) or those included in the NHS Digital SCR inclusion dataset overview. (To see the complete list of codes currently in the inclusion set used by GP suppliers implementing SCR v2.1, download the NHS Digital SCR inclusion dataset)
To make change requests for SCR including suggestions for future Additional Information content, please complete the form and submit to email@example.com. Please note, this form is not to be used by patients to request additions to their own SCR. If they wish to do this they should visit their registered GP practice.
Specific sensitive information like fertility treatments, sexually transmitted infections, pregnancy terminations and gender reassignment will not be automatically included when the information is added. Sensitive information is excluded through the RCGP sensitive dataset. Full downloads of the GP Summary Code List releases (Generalpracticesummarydatasharingexclusionforassistedfertilisation, Generalpracticesummarydatasharingexclusionforgenderrelatedissues, Generalpracticesummarydatasharingexclusionforsexuallytransmitteddisease and Generalpracticesummarydatasharingexclusionforterminationofpregnancy) are available on the Technology Reference Data Update Distribution site.
Other items, including sensitive items that the patient would like to be included, can be manually added to the record. The patient can view a preview before they consent, and items can be added or removed.
View an example SCR with Additional Information created by TPP SystmOne
View an example SCR with Additional Information created by Emis
Identification and management of patients with frailty
From 1 July 2017, the General Medical Services (GMS) contract requires GPs to identify patients with moderate or severe frailty, and promote the inclusion of Additional Information in the SCRs of those with severe frailty by seeking their consent to add it. NHS Digital have sent a resource pack, Supporting Guidance for promoting enriched Summary Care Records for patients with frailty, to CCGs, to be distributed to GP practices, containing support and guidance on their new duties and how to include Additional Information in SCRs.
Read NHS England guidance on the requirements to support frailty in the GMS contract 2017-18.