Lloyd George (LG) envelopes were first used in 1911, when the politician David Lloyd George, introduced a national health insurance scheme for low-paid workers. The envelopes are still used today and provide a tangible reminder that there are continuities, as well as changes, in the provision of health and care over time.
The LGs still form an important record of a patient’s broader, detailed, medical history. It is essential these records are stored and are available if they are needed. Physical records, however, take up vital space in organisations and can take hours of practice time to sort through.
GP surgeries currently hold the Lloyd George records for their registered patients but the production of new patient, paper, Lloyd George envelopes stopped in January 2021 as a first step in the digitisation project.
At the time of writing (August 2023) paper records follow patients around when they change GP practice, but practice staff rarely refer to them as a high proportion of patient records are already summarised electronically and the online record is the only record that is updated.
General practice patient record digitisation involves the bulk scanning of all hard copy patient notes. These are then available in digital format and can be uploaded as episodes into the clinical system.
Stakeholder engagement and user research by NHS England has shown that paper LG records are considered to hold legacy, out of date information, and are therefore no longer used for clinical care.
If a paper LG record envelope for a person under 20 years’ old exists, it is empty. Paper LG records for other patients have been summarised into GP IT systems since 2004, and for those who are frequent attenders the coded digital record is expected to be comprehensive.
NHS England is developing an alternative model of a national digitisation service that will support general practice, ensure national standards are met and be more affordable in the long term.
This will use the existing paper LG records transfer service to move records into the digitisation service. Each year around 6 million paper LG records are handled by Primary Care Support England (PCSE).
To support GP practices that have an urgent requirement to release the space occupied by paper records in their surgeries, NHS England is reviewing existing commercial frameworks for ‘storage and scan on demand’ services to ensure that they meet national standards for scanning quality, storage of paper and the route to store scanned records. These services would need to be funded locally.
NHS England will commission the creation of a repository to store scanned paper LG records that can be accessed by GP clinical systems. This will reduce the challenge on clinical system suppliers and will complete the creation of the digital archive for unregistered patient records.
To implement this digitisation service, any remaining guidance around summarisation and coding of paper LG records will need to be reviewed.
The national continuity and digitisation of GP records programme aims to make all GP records continuous and digital at the point of use. The objectives are to reduce the administrative burden on primary care, improve patient care, release estates capacity, and contribute to the NHS’s Net Zero ambition.
The reduction in environmental impact for GP practices will occur through the reduction in printing records for transfer and storage purposes. This has already seen progress with the contractual requirement for practices to use the GP2GP record transfer process.
The scans will need to meet the standards set out in the local digitisation scanning specification. You can access the last information about these by emailing the NHS England team at email@example.com.
The digitisation programme aims to:
- reduce the administrative resources required by practices to digitise their own records
- make best use of NHS funds by supplying an affordable, value for money solution
- reduce the administrative burden associated with the management of paper records
- set out realistic and manageable timescales
- develop a consistent approach and standardisation of the process following the Records Management Code of Practice
Patient health information currently may take the form of computer-generated and/or paper records. Summarising, in general practice, is the process of entering all key pieces of information from these sources into a patient’s electronic health record, creating a useful and up to date clinical summary.
The summarisation of records was mandated in 2004, as part of the then General Medical Services (GMS) contract. Practices, and those who commission primary care services, integrated care boards (ICBs), should ensure records have been, and continue to be, summarised. Records should be summarised prior to digitisation.
Benefits of Lloyd George digitisation to patients and practices
The benefits of digitising Lloyd George records include:
- ease of access | ensuring that a patient’s paper record is available in a digital format at the point of care, or for administrative purposes
- saving space | freeing up valuable space in GP practices, enabling them to optimise the practice footprint with added clinic or meeting space
- saving time | having patient records available digitally can save valuable appointment time and improves point of care decision making – the electronic format of the paper notes will be as PDF file attached to a patient’s record. In some clinical systems this may be a searchable PDF file using optical character recognition (OCR) technology
- reducing the risk of record loss | having a digitised copy of a paper record removes the risk of record loss in GP practices as a result of disasters like fire or flood
- safer record transfer | when a patient leaves a practice electronic transfer takes place via GP2GP. In some instances where the patient has not re-registered within 6 months of leaving, the current process requires the practice to print the record and return it to PCSE for storage centrally until a patient re-registers somewhere else. This can be prone to error, causes an unnecessary burden on practice staff and costs money to maintain
- reducing costs | removing the need for costly record storage facilities and the administrative costs associated with paper record management and retrieval
- reducing errors | the risk of errors will reduce once a patient’s full GP medical history is scanned and saved in one place and record transfer will be a fully electronic process, removing the risk of paper notes going missing
- compliance with the General Data Protection Regulation (GDPR) | digitisation could provide a long-term GDPR-compliant storage solution with easy retrieval. Local and/or portable storage solutions are not an advisable option
- data security | digitisation can protect sensitive data by removing the need to keep physical records on site and by restricting access to digital records to those with the correct authorisation
- reducing the NHS carbon footprint | the NHS is committed to reducing its carbon footprint for services delivered, which will result in excess of 16 tonnes of paper being produced and distributed across the country
- support for national strategy | digitisation supports the NHS Long Term Plan, the General Practice Forward View, the personalised health and care Bill,(Paperless, 2020) and the Five-year framework for GP reform
Currently only EMIS is able to upload scanned LGs into the clinical system as PDF files. Although these files may contain bitmapped and textual content which could be searched, EMIS systems currently use an internal PDF viewer which lacks search features. The other system suppliers are yet to confirm whether they will upload the PDF files into the clinical system searchable files.
Challenges to digitisation
The challenges associated with digitising Lloyd George records include:
- lack of interoperability | most electronic record systems are not currently fully interoperable and do not fully support data sharing, although work is ongoing to resolve this
- technical glitches | technical issues can cripple a medical facility reliant on online records, and all clinicians are heavily reliant on a patient’s medical history to manage consultations, make accurate diagnoses and provide treatment, so power outages and internet or network crashes can mean limited, immediately necessary, treatment only
- cyber security | cloud storage solutions can be at greater risk of hacking, and the greatest disadvantage to fully digitised health records is the vulnerability to ransomware, and other data security breaches – although the loss of digitised LG records is less significant than the loss of full records
Cybercriminals could potentially restrict access to records and demand payment to restore that access. The cybercrime economy is one of theft, with cybercriminals acting as the internet’s burglars. This stays true in a medical context. Personal information is valuable to criminals and such data breaches can damage reputations and put patients at risk.
The NHS employs teams to manage network security constantly.
Practices should ensure all staff complete the Data Security Awareness training, available through eLearning for healthcare, annually and have measures in place to report suspicious emails and monitor internet usage and access. There is another article on this series on cyber security.
- violation of privacy laws | practices need to be aware of the privacy policies and data protection laws surrounding all health records and ensure that staff have access, appropriate to their roles, enabled
As nationally supported local digitisation is coming to an end, support is now provided by the NHS Commercial and Procurement Support Hub.
Practice responsibilities include:
- scanning all paperwork and paper records associated with a new patient’s record when received
- continuing to summarise existing patient records as per GP contract requirements
- have a policy on cleansing records at the same time as summarising, i.e. remove any patients who have not been seen for 5 years
Frequently asked questions
The North of England Commissioning Support Unit (NECS) has produced a list of FAQs which can be viewed in full through Mysurgerywebsite.co.uk.
You can also keep up to date with news about digitising Lloyd George records on the FutureNHS collaboration platform (you need to register to access FutureNHS groups).
Related GPG content
- GP2GP – transferred in records – processing
- GP contract
- Shared care records
- Cyber security
- Smartcards and access control (RBAC)
- NHS Care Identity Service 2 (CIS2)
- Information governance and data protection
Other helpful resources
- NHS England Transformation Directorate, Subject access request FAQs
- FutureNHS workspace (login required), Continuity and digitisation of GP health records programme