Summary Care Record

The NHS is changing how patient information is stored and shared in England, to provide better care for patients.The NHS in England is using an electronic record called the Summary Care Record (SCR) to support patient care, SCRs provide healthcare staff treating patients in an emergency or out-of-hours with faster access to key clinical information.

The Summary Care Record is a copy of key information from your GP record. It provides authorised healthcare staff with faster, secure access to essential information about you when you need unplanned care or when your GP practice is closed.

Summary Care Records improve the safety and quality of your care.

About your Summary Care Record

Your Summary Care Record contains important information about any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced.

Allowing authorised healthcare staff to have access to this information will improve decision making by doctors and other healthcare professionals and has prevented mistakes being made when patients are being cared for in an emergency or when their GP practice is closed.

Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly.

You may want to add other details about your care to your Summary Care Record. This will only happen if both you and your GP agree to do this. You should discuss your wishes with your GP practice.

Healthcare staff will have access to this information, so that they can provide safer care, whenever or wherever you need it, anywhere in England.

Who can see my Summary Care Record?

Healthcare staff who have access to your Summary Care Record:

• need to be directly involved in caring for you
• need to have an NHS Smartcard with a chip and passcode
• will only see the information they need to do their job and
• will have their details recorded every time they look at your record

Healthcare staff will ask for your permission every time they need to look at your Summary Care Record. If they cannot ask you (for example if you are unconscious or otherwise unable to communicate), healthcare staff may look at your record without asking you, because they consider that this is in your best interest.

If they have to do this, this decision will be recorded and checked to ensure that the access was appropriate.

Where is the summary care record used?

Your Summary Care Record can be viewed in a number of healthcare settings to provide clinical staff with relevant information that can improve the care you receive. For example this could be if you’re visiting a walk-in centre or minor injuries Unit; using a GP out-of-hours service, admitted to hospital or attending A&E.

Examples of the types of scenarios where this could happen are below:

• When clinical staff in a hospital need to check your current medication
• When away on holiday and you are seen by a someone who is not your usual GP

The additional information included in the SCR

The ‘additional information’ content has been defined and reviewed by clinical groups and suppliers. SCRs with additional information incorporate individual coded items and associated free text and will include:

• Significant medical history (past and present)
• Reason for medication
• Anticipatory care information (such as information about the management of long term conditions)
• Communication preferences (as per the SCCI1605 Accessible Information Standard national dataset – formerly ISB-1605)
• End of life care information (as per the SCCI1580 Palliative Care Co-ordination: Core Content national dataset – formerly ISB-1580)
• Immunisations

Additional information automatically included in the SCR is manually added item from the GP record. Any code within the GP record may be ‘manually added’ to the SCR, according to patient wishes.

Why are summary care records a good thing?

There are a number of reasons why sharing key healthcare information from your GP practice with others responsible for your care is important:

• Improving Your Experience of Care – reducing the need for you to remember or repeat your medication information particularly if you have difficulties communicating
• Improving the Safety of Your Care – resulting in safer prescribing by providing timely access to accurate information – for example making sure a new drug does not affect how another one works
• Improving the Effectiveness of Your Care – by giving healthcare staff relevant information to make appropriate decisions about your care
• Improving the Efficiency of Your Care – reducing the time, effort and resources required to obtain this key information from your GP practice.

How do I get involved?

As part of our commitment to communicate with patients letters were sent to all registered patients, 16 years old and over, to inform them about what the Summary Care Record was, how it would benefit them, who would look at it and when – together with a form giving patients an opportunity to opt-out of the service if they wanted to.

That communication ended in January 2014, but we continue to involve patients and carers through local patient groups run by your GP practice or aligned with national charities.

The Summary Care Record team can attend sessions run by local groups to

• Raise awareness of Summary Care Records and how it can help patients as part of their care
• Answer questions from patients and carers.
• Hear ideas about how the Summary Care Record could be developed to further enhance patient care.
• Share stories where Summary Care Records could make, or have already made, a difference to the care that patients receive.
• Listen, understand and gather what are patients and carers saying about Summary Care Records

What are my choices?

You can choose to have a Summary Care Record or you can choose to opt out.

If you choose to have a Summary Care Record and are registered with a GP practice, you do not need to do anything as a Summary Care Record is created for you.

If you choose to opt out of having a Summary Care Record and do not want a SCR, you need to let your GP practice know by filling in and returning an opt-out form (PDF, 245.9kB). Opt-out forms can be downloaded from the the website by clicking the link above or from your GP practice. Alternatively you can opt out via our website by going to the home page.

If you are unsure if you have already opted out, you should talk to the staff at your GP practice. You can change your mind at any time by simply informing your GP practice and either filling in an opt-out form or asking your GP practice to create a Summary Care Record for you.

Children and the Summary Care Record

If you are the parent or guardian of a child under 16, you should make this information available to them and support the child to come to a decision as to whether to have a Summary Care Record or not.

If you believe that your child should opt-out of having a Summary Care Record, we strongly recommend that you discuss this with your child’s GP. This will allow your child’s GP to highlight the consequences of opting-out, prior to you finalising your decision.

Where can I get more information?

For more information about Summary Care Records you can

• talk to the staff at your GP practice
• phone the Health and Social Care Information Centre on 0300 303 5678
• Read the Summary Care Record patient leaflet