Additional Information in SCR

Guidance for GP practices to use SCR to make more information available across care settings.

The change to include Additional Information in a patient’s SCR will enable health and care professionals to have better medical information about the patient they are treating at the point of care. This change will apply for the duration of the coronavirus (COVID-19) pandemic only. Unless alternative arrangements have been put in place before the end of the emergency period, this change will be reversed.

Patients can be reassured that if they have previously opted-out of having a Summary Care Record or declined to provide consent to share their Additional Information,their preference will continue to be respected and applied.

Additional information user research report

We ran a user research project to understand users' experiences with Summary Care Records (SCR) and the information they provide, particularly focusing on the inclusion of Additional Information by default.

Read the report on Additional Information.

Benefits of using Additional Information in SCR

By including Additional Information in a patient's SCR, more information is available to health and care staff viewing the SCR. It will then be automatically updated when the GP record is updated. This is a quick and effective way to:

improve the flow of information across the health and care system
increase safety and efficiency
improve care

SCR Additional Information is particularly useful for people with complex or long term conditions, or patients reaching end of life.

GP guidance on including Additional Information in the SCR

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)
immunisations.

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 SCR change request form.

Please note, this form is not to be used by patients to request additions to their own SCR. Patients wishing to do this 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.

Patient groups who benefit most from including Additional Information in their SCR

Patient groups who benefit most from including Additional Information in their SCR include:

frail patients who can use SCR to give out of hours or emergency health care staff more complete information, making unwanted admission less likely
patients with long term conditions
patients eligible for flu vaccinations
those with dementia or learning disabilities
patients planning for end of life, who can use SCRs to share information about their preferences, Lasting Power of Attorney and advance decisions
patients with physical, sensory or other disabilities, who can benefit from recording any specific needs, for example communication needs, so that health and care staff can make reasonable adjustments
non-English speakers
patients with carers whose details they want to share or who have appointed someone to have Health and Welfare Lasting Power of Attorney
patients with specific care preferences

Expert views on the benefits of Additional Information in Summary Care Records

Dr Martin McShane, former NHS England Director for Long Term Conditions

'Continuity of information is a vital contributor to continuity of care and better outcomes. The ability to enrich Summary Care Records beyond medications, allergies and bad reactions mean that more and more relevant information from the GP practice will be potentially available wherever a patient is receiving treatment in the NHS. This will improve safe, effective care and contribute to a positive experience for patients.'

The British Geriatrics Society

'When treating older patients, the Summary Care Record, enriched with Additional Information gathered during the process of Comprehensive Geriatric Assessment, or as part of the proactive care processes within the primary and community care setting, can be used to support decisions from the beginning of any new episodes of care. This will increase the likelihood that complex conditions are accurately recognised and more appropriate treatment plans put in place. This will contribute to safer, more effective and efficient care for older people across the urgent care system, potentially avoiding the need for hospital admission or helping facilitate earlier and safer discharge.'

Dr Mark Spring, GP at Sandford Surgery in Dorset and clinical lead for Urgent Care Services, a GP Out of Hours service

'Creating SCRs with Additional Information empowers other people looking after my patients to be able to access accurate and detailed information. It reassures me that my patients will receive the best possible care whenever they need it.'

case_study_on_Additional_Information

Resources

Get a form for your patients to download to express their consent preferences, and use our supplementary privacy notice to be included in or linked to from your GP practice's privacy notice. The guide below is also a useful resource for the case for using Additional Information.

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SCR patient consent preference form

Download a form to opt out of having a Summary Care Record (SCR) or opt out of additional information being included in the SCR.

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SCR coronavirus (COVID-19) supplementary privacy notice

Information for patients explaining how health and social care organisations may use your Summary Care Record information within the health and social care system to protect you and others during the coronavirus (COVID-19) outbreak.

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Summary Care Record viewing guidance including Additional Information

The Summary Care Record (SCR) is an electronic patient record containing up to date information from the patient’s GP record. SCRs can also contain Additional Information over and above the core dataset where patients provide their explicit consent for this to happen.