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GP online services toolkit

Site: Royal College of General Practitioners - Online Learning Environment
Course: Clinical toolkits
Book: GP online services toolkit
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Date: Sunday, 28 April 2024, 12:47 PM

Description

This toolkit helps practices provide GP online services effectively, efficiently, safely and securely.

Table of contents

Introduction

For many patients, online access to their GP’s services is a normal part of their everyday interaction with the NHS.  The majority of patients in England use at least one GP Online Service to request prescriptions, book appointments or access their electronic health record.  It is part of modern, responsive primary care services for patients, their families and carers.  It is convenient and reliable for patients and useful for practices.  It can foster a person-centred approach to care, especially for patients with long term conditions or complex multi-morbidity. 

The Royal College of General Practitioners (RCGP), in collaboration with NHS England, have developed the guidance and resources in this Toolkit to help practices provide GP online services effectively, efficiently, safely and securely.  The Toolkit includes clinical exemplars which demonstrate how GP online services can empower patients to take greater control of the management of their health conditions.  It does not cover online consultations.

The contents of the toolkit

Providing GP online services

The first section of the Toolkit presents guidance on how to organise and provide GP online services and supporting resources that you might find helpful. 

Practices in England have been required by their contract to offer online services since 2015 and full prospective record access since 2019 and have well established policies and procedures in place.  The majority of people in England have access to their practice’s online services with over 50 million transactions a month.  

Nevertheless, this section may be useful to practices seeking to improve their management of online services or to practice team members who are new to GP Online.

Each supplier has interpreted the requirement to provide record access slightly differently.  This Toolkit does not replace your IT system supplier’s training materials in explaining exactly how to use your systems for GP online services.

Section: Providing GP online services 

Patient registration for GP online services

Patients may register for GP online services without applying to their practice.  Several patient facing services (PFS) apps and web portals work with NHS Login, which people can use to prove who they are safely and securely so they can be connected to their NHS records. This enables access to book and cancel appointments, request prescriptions, and access their full prospective record without needing to come into general practice.  In rare circumstances, patients may still need to apply to the practice to obtain login credentials so they can have their identify verified to use NHS Login, or to use an app or web portal that does not use NHS Login. They will also need to apply in order to access their historic record or consent to a trusted third-party having proxy access to their GP online services on their behalf.

This section describes how practices should manage applications for GP online services, including the steps to clinically assure the safety of historic records for online access, to verify the identity of applicants before they are given login credentials and ensure that applicants understand how to make best use of their services and how to maintain their privacy by keeping their record access secure before their access is switched on.   

Section: Patient registration for GP online services

GP online services in clinical care

Improving the care of patients with multimorbidity remains one of the most important challenges facing general practice.  It requires a consistent emphasis on collaborative care planning, solution-focused coaching, goal setting and action planning by health professionals taking into consideration the patient’s personal goals and priorities to enable patients to work in partnership with their health professionals. Patients need accessible and trusted information delivered through reliable sources and effective communication with their health professionals.  Online access to their health record is an essential part of this. 

Online services can also bring benefits for the practice.  It can save time when patients use it to book appointments, order repeat prescription and check recent test results and hospital reports.  “Did not attend” rates are lower with appointments booked online.  Communication is less prone to error and patients can use record access to prepare for consultations, saving time in the consultation and improving patients’ ability to make decisions about their care.  Patients can help to improve the accuracy of their record. 

Section: GP online services in clinical care

Working with online record access - the challenges

This section of the Toolkit discusses the impact of online record access on the work of everyone in the practice team who enters or files new information in patients’ records or discusses GP online services with patients.  This includes temporary staff, including locums and trainees.  It should be remembered that any patient may obtain record access at any time and safeguarding risks may fluctuate.  It covers  data quality, potentially harmful information and clinical safety. 

Section: Working with online record access - the challenges

A note on this iteration of the Toolkit

The GP Online Services Toolkit is intended to support and inform general practice teams who are offering online services for their patients, including transactional services and record access.  It updates the previous guidance provided by the RCGP, in collaboration with NHS England.  It does not cover online consultations.

Supporting information

  • Patient online: The Road Map, RCGP, 2013 (1.9 MB PDF) – Report on workshops held to define the professional standards for the provision access by patients to online services (booking and cancelling of appointments, ordering of repeat prescriptions), online communication with the practice and online records.  

Acknowledgements 

We would like to thank the many people who have given their time to contribute to the material on this toolkit.  

Our thanks go to Dr Imran Khan and Dr Joy Shacklock for their work this year on automatic record access; Dr Nutan Patel, Joyce Pickering, Dr Geoff Schrecker and Dr John Lockley for their work on the previous iterations of the Toolkit.  Thanks to Dr Ralph Sullivan, RCGP Clinical Champion for Patient Online for leading the work from the beginning.  And lastly, we would like to acknowledge the invaluable support and input from colleagues at NHS England and many more organisations who have shared their knowledge and insight with us over the years.

Providing GP online services

Most practices now offer some form of GP Online Services.  In England practices are required by their contract to offer services to book and cancel appointments, order repeat prescriptions and record access.  Since 2019 practices the requirement has been to offer full prospective record access.  Prospective access means access to information recorded after a specified date, with no access to earlier information.

This section of the Toolkit offers guidance on how to provide GP online services and supporting resources that you might find helpful.

NHS England and BMA, Patient access to records online: Prospective record access..

Transactional services

Transactional services are the online facilities patients use to book and cancel appointments, order repeat prescriptions and send messages to the practice about their medication.  They are popular because they are efficient and convenient for patients and practices.  In 2022 more than 45% of people in England had signed up for them.

Since 1st April 2015 it has been a contractual requirement for English GP practices to offer these services.  Practices must routinely ensure that the number of appointments available to be booked online meets the reasonable needs of their registered patients.

Practices have found online booking quick and easy to set up. Registration for online booking of appointments is a relatively simple process.  Patients appreciate the convenience of this service and it has several benefits for practices, which are detailed in the Online Appointment and Prescriptions guidance.

Record Access

GP Online Services is an efficient and effective method of providing patients with access to their current GP clinical record, which empowers patients to manage their health. It is particularly useful for patients with multiple long-term conditions, and their carers, because it enables them to take a more active role when, for example, preparing for consultations, reviewing care plans and hospital reports, and making informed decisions about what matters to them as part of a person-centred approach to care.

Practices in England have a contractual requirement to offer the prospective record. Patients who have a patient facing services account and app will have automatic access to their full prospective record (with the exception of administrative messages and emails about the patient).  Practices may offer online access to the full record, including past information to patients and trusted proxies. Practices must  ensure that the record is safe to share and that the patient is not subject to coercion to share their record unwillingly.

When patients move general practice, they will lose access to their record at their previous practice. They will usually gain automatic access to new record entries at the new practices but will not be able to see their previous practice’s record anymore.  If they want to have access to that data again, they will have to apply to gain access any record transferred from the old practice.  

In certain circumstances, if patients may not be able to protect the privacy of their online record, it may be safer to limit a patient’s online record access.  Ideally this decision should be done in collaboration with the patient.

The risk that patients may view harmful information or confidential third-party information online or may be coerced to share their record with others places a responsibility on practices to maintain high quality records, ready to be shared with the patient, and, when necessary, to consider withholding record access from the patient.  The practice is responsible for ensuring that any potentially harmful or confidential third party information in the patient’s record is not visible to the patient online.  Such information should be redacted.  This prevents it being visible through GP online services but does not affect the visibility of the information in the practice and when shared for direct patient care or used for decision support software and clinical audit.

Subject Access Requests

The Information Commissioner’s Office (ICO) has agreed that practices may be able to comply with a subject access request (SAR) from a patient under data protection legislation by offering to provide a patient with online access to their full health records. This applies to requests on behalf of the patient from legal representatives and insurers. However, if the record is not fully digitised, paper copies may need to be provided on any data, including letters and reports, not available online.

Supporting information

Patient registration for GP online services

The guidance in this section is for practice clinicians, managers and staff manage GP online services and make decisions about patients’ online access.  Anyone in the practice who interacts directly with patients should be aware of the patient registration process for online services, especially reception staff.

It describes in detail how to sign up new applicants for GP online services, including the procedures for verifying the identity of the person requesting an online account, clinically assuring the patient record for online access and discussing access with the patient before services are switched on.  It also covers applications from people acting on behalf of the patients, such as parents, family members and carers (proxy access).

Patients may book an initial appointment online as soon as they have completed a simple online registration process.  Full access to appointment, repeat prescription ordering or record access services require a secure identity verification process.  This may be carried out by the practice or remotely by the NHS as part of an application for an NHS Login.

Automatic record access

When patients move practice, they will lose any access to their record at their previous practice. They will gain access to their new records at the new practices but will not be able to see their previous practice’s record anymore.

If they want to have access to that data again, they will have to apply to the new practice for access to the record after it has been transferred from the old practice.

Useful resources and guidance when registering new applicants

Applications for proxy access

Patients may find it helpful if someone else, usually a trusted family member, close friend, carer or care home, has access to their GP online account to book appointments, order repeat prescriptions, or view their GP record on their behalf.  This is proxy access.  In certain circumstances, particularly when patients lack capacity or have complex multimorbidity, it can be very helpful for a proxy to have access to their record to keep up-to-date and collaborate in their healthcare.

The proxy should have their own login credentials. This means that the proxy can be given different levels of access to the patient and their access can be switched off and the patient’s request or if the practice judges it to be in the patient’s best interest. Normally the patient must complete a form that gives consent to the proxy access.

NHS England has provided guidance for practices and care homes on how to establish proxy access for patients who are resident in care homes (see below).

Supporting information

Practice preparation for automatic record access

Automatic record access is new and will be switched on nationally in 2022. This section offers guidance on the steps that practices may take to prepare for automatic record access. It may not be relevant once automatic record access is active across England.

People aged 16 and over who are registered with a practice in England and have an account for any GP Online Services will have automatic prospective access to their GP record. This includes coded information, medication, consultations, and documents but not administrative messages and emails that refer to the patient. Nor does not include online consultations.

Patients who obtain a GP Online Services account for the first time once automatic record access begins will have access to their full GP record from the date when automatic record access was rolled out.

Patients who transfer to a new practice will lose their access to the record from their previous practice. If they have an NHS Login, their access will be automatically transferred to their new practice when they register. If they use a PFS app or web portal that does not use the NHS Login, they will have to register for login credentials at their new practice in the usual way (see the section on Patient registration for GP Online Services).

Once a patient has automatic record access, the clinical benefits of enhanced person-centred care and the risks from viewing potentially harmful information online will be the same as when record access is agreed for an individual patient by the practice.

GP online services in clinical care

Anyone in England with a patient facing services account will automatically have access to their full prospective record and GPs in England are required by their contract with the NHS to offer and promote online access to the full prospective GP record. 

Practices may also provide online access to the patient’s past electronic health record, referred to as the historical record.  This may be helpful for patients who have complex health needs and want to keep up to date with care plans and hospital reports.  It may also replace the need to provide paper-based subject access request reports (SAR) commonly requested by patients for legal purposes.

Clinical benefits of record access

Patients can use record access as part of routine clinical care to self-manage complex health conditions, meet their personal health goals and achieve better health outcomes. Examples include:

  • using access to coded laboratory results to monitor long-term conditions and prepare for consultations
  • using the coded data recorded by the practice to check on immunisations, adverse drug reactions, allergies, screening and preventive procedures and preferences and advance decisions recorded in care plans
  • reading clinical correspondence from hospital admissions, outpatient appointments and investigations to gain a better understanding of their health and care
  • using portable access to the record on tablet computers or smartphones to share data with other health professionals in all health settings.

The Toolkit includes five clinical exemplars where the role of GP online services in helping people manage long-term conditions is discussed in more detail. Each clinical exemplar includes a guidance document, a webinar and slide set, a podcast and relevant supporting information. The aim of each exemplar is to demonstrate the different ways in which online transactional services and record access support patients and carers to manage multiple long-term conditions.


Supporting information

Working with online record access - the challenges

Providing record access can be beneficial for patients allowing them to better manage their health and ultimately reduce burden on staff. However, it can also present ongoing challenges for practices.  

The impact of online record access should be considered for every patient, not just those who currently have record access or who may currently have known safeguarding risks.  Patients are entitiled to access their health information and may obtain record access at any time. Any risk of harm from a safeguarding risks may fluctuate.  Everyone who enters or files new information in patients’ records or discusses GP online services with patients should have awareness of these concerns.  This includes temporary staff, including locums and trainees.

This section of the guidance is about how managing record access affects the everyday work of the practice.

Data quality

The quality of data in a patient’s record can be assessed by the extent to which it meets the various purposes that the record is used for. For online services this means that it must be clear and unambiguous for the patient to understand, without displaying information that might be harmful to the patient or others or confidential information relating to third-parties.  

Poor data quality may confuse or mislead both patients and clinicians and have a negative impact on the patient’s health care and safety.  

Health and care professionals have a legal duty and professional responsibility to keep health and care records accurate and up to date. However, mistakes in record keeping can occasionally happen. Patients and service users have the right to request for their records to be rectified if they feel inaccurate information is held about them. If you believe that the amendment request concerns health or care information that is factually accurate, you should not amend the record. However, it is good practice to give patients and service users the opportunity to have an entry put into the record to say they do not agree with a particular part and why. See NHS England website for more information.

  • Data quality for record access (88 KB DOC) – Guidance on how to create and curate patient records that are ready for patient online access, including how to respond to patient’s comments or complaints on the content of their record.

Potentially harmful data

GP records sometimes contain confidential information that relates third party which the patient must not see. There may also be information that may harm the patient: a diagnosis, abnormal result or opinion that the patient is not aware of or records of a past traumatic event that might re-traumatise the patient.There may be information that a patient who is coerced to share their online record access may want to have redacted.

As a principle it is helpful to consider “Ask before release”, which means if you are uncertain whether information you are entering in the patient’s record may be something the patient would prefer not to be visible online, ask the patient if it should be redacted.

All GP systems have a method of preventing information in the record being visible via GP online services. This is redaction. Before online access to historic records is switched on all the information that the patient will see should be checked for potentially harmful information that needs to be redacted. 

It is important to establish a practice record keeping policy about recording and redacting new entries of potentially harmful and confidential third party data even if patients do not currently have online record access, as they may gain access in the future.

Clinical safety

Patients who are subject to controlling coercion by an abuser are the most common group at risk from record access

Patients who register for the NHS App will automatically receive access to book and cancel appointments, order repeat prescriptions and record access.

If the patient is not able to keep these services secure, providing access  could allow abusers to monitor:

  • If the victim has revealed abuse
  • If the victim has accessed healthcare, especially issues like injuries, mental health, contraception or sexual health
  • Evidence in documents that other agencies have recognised abuse
  • Infer any of these from the absence of expected consultations or documents in the online record.

The Toolkit has guidance on how to recognise coercion and the safeguarding risks. This is relevant to every patient, not just those who currently have record access or who may currently have known safeguarding risks.  Any patient may obtain access, and safeguarding risks may fluctuate. 

Clinical exemplars

In these five clinical exemplars, the role of GP online services in helping people manage long-term conditions is discussed in more detail. Each clinical exemplar includes a guidance document, a webinar and slide set, a podcast and relevant supporting information. The aim of each exemplar is to demonstrate the different ways in which online transactional services and record access support patients and carers to manage multiple long-term conditions.

1: Diabetes mellitus



The resources in this section are for GPs and practice nurses who help patients make decisions about their diabetes, especially practice nurses working in diabetes clinics, but the principles can be applied to many long-term conditions. It covers the use of Patient Online record access to enable patients to:

  • use laboratory results and other coded data that is relevant to their diabetes to monitor the impact of their self-care and adherence to treatment
  • use the information to help decide what matters most to them and prepare for consultations
  • review and contribute to their diabetes care plan.

The guidance and resources are meant for GPs and practice nurses caring for patients with all types of diabetes mellitus to help you offer your patients online access to their record safely and confidently. They describe how access to GP online services contributes to providing person-centred care to patients with diabetes. It presents the case for recommending online record access to patients with diabetes and gives advice about how the practice can help patients use it to prepare for consultations and improve their ability to self-manage their condition.

RCGP resources


2: End of life care



This guidance is for GPs and practice nurses caring for patients approaching the end of life irrespective of underlying condition or co-morbidities. The aim is to describe how access to GP online services contributes to person-centred care in this context and to present the case for recommending online record access to patients and their families and carers at the end of life.

It describes how you can help them make use of online access to information about their healthcare to improve their ability to self-manage their condition and help to co-ordinate their care. It describes how carers or relatives can use Patient Online on behalf of patients without capacity. It explains how patients can share access with supporting family members, carers and the multidisciplinary healthcare team to help them look after the patient safely and confidently.

The GP coded record is shared to support direct care in many parts of the country through electronic palliative care co-ordination systems (EPaCCS) or through direct views of the GP record. Patients do not have access to these systems but Patient Online enables them to see whether the data about them in these records is complete and up-to-date.

RCGP resources



Supporting information

3: Dementia



Dementia is typified by increasing memory loss and intellectual impairment that creates difficulties for patients, their families and carers, and health professionals alike. Forward planning with early referral to local memory services, involvement of family members and carers and a shared understanding of the patient’s priorities and preferences are at the core of good healthcare.

As patients lose the mental capacity to understand the decisions that are necessary for their health and social care, family and carers have to make decisions on their behalf. As capacity declines Patient Online becomes increasingly helpful.

Over 90% of patients with dementia have at least one co-morbidity with a median number of three co-morbidities for each patient. Primary care consultation rates, hospitalisation, prescribing rates and mortality increase with increasing co-morbidity. The complexity is difficult for patients and their families and carers to understand and manage. Access to Patient Online appointments, prescriptions and up-to-date information from the GP record can be invaluable to patients and carers.

This guidance describes how Patient Online can help patients with dementia understand and manage their healthcare in the face of complex multimorbidity and failing mental capacity. It also describes how Patient Online can be used to support family members and carers helping the patient as the patient loses mental capacity and how practices can provide access to their Patient Online services safely and effectively. The guidance is intended for GPs, practice nurses and other healthcare professionals involved in the care of patients living with dementia in the community.

RCGP resources



Supporting information

4: Inflammatory arthritis



This guidance is for GPs and practice nurses caring for patients with inflammatory arthritis. The aim is to describe how access to GP online services contributes to person-centered care in this context and to present the case for recommending online record access to patients with inflammatory arthritis.

It describes how you can help them make use of online access to access information about their healthcare to improve their ability to understand and self-manage their condition and help to co-ordinate their care. It also describes how patients can make use of online access to test results and other health information to prepare for consultations and empower them to be more engaged in their own care.

This guidance does not seek to cover aspects of shared care, but its aim is to help the patient become more engaged and informed by utilising Patient Online. Therefore, for clinical management, please refer to your local shared care agreement and NICE guidelines.

RCGP resources


Supporting information


5: Mental health



This guidance is for GPs and practice nurses. Its purpose is to describe how access to GP online services contributes to person-centred care for patients with mental health conditions, and to present the case for recommending online record access to these patients.

It describes how you can help patients use Patient Online to access information about their healthcare to improve their ability to understand and self-manage their condition; in particular, how patients can use access to test results and other health information to prepare for consultations, enabling them to be more engaged in their care. It also describes the specific risks that online record access may hold for patients with mental health conditions and the practice, and offers advice about how they can be addressed.

RCGP resources