Records Management Code of Practice for Health and Social Care 2016 Sarah Graham, NHS England, 28th April 2017

Introduction Main focus of the presentation - key messages within the Information Governance Alliance Code of Practice Brief case study - how NHS England applied the Code of Practice Questions / discussion ….but happy to take queries during the presentation!

Background The Code of Practice replaces the Records Management: NHS Code of Practice parts 1 and 2 (2006) that had previously been produced by the Department of Health This Department of Health guidance was very good and detailed but was due for a refresh The new guidance has more focus on electronic records and has a reduced retention schedule User friendly and has practical case studies Main section, three appendices – final third appendix concentrates on retention schedule pgs 53-80 The Code was drafted by a working group of representatives from the Information Governance Alliance, the Health and Social Care Information Centre, NHS England, the Department of Health, The National Archives and from a range of NHS and social care organisations, including Acute and integrated Mental Health Trusts, Clinical Commissioning Groups, GP practices and professional bodies.

Section 1: Regulatory Framework Pgs 6 – 11 NHS records – patient records, corporate records The framework is based on established standards Concerns records regardless of format The Public Records Act 1958 – all of us in this room are affected by this act! DPA / FOI The Academy of Medical Royal Colleges (AoMRC) Training / Policy required The Public Records Act requires that all public bodies have effective management systems in place to deliver their functions. For health and social care, the primary reason for managing information and records is for the provision of high quality care. AoMRC provides guidance for standards of medical records specifically. Organisations advised to have suitably trained RM staff and to have adequate policies and procedures in place.

Section 2: How to Manage Records Pgs 12 – 25 Bread and butter of what the people in this room do! Lifecycle, records system ISO 15489 & DIRKS, Cabinet Office e-Government Metadata Standard v3.1 2006 Cabinet Office Government Security Classifications April 2014 Storage, maintenance, retention and disposal I don’t propose to dwell for long on this section as this is an area that people in the room will be well versed in – this section is more generic about RM standards rather than purely NHS features of records. Very useful summary of records management and records management principles. My belief is that a new starter in RM should take a look at this 14 page section as a starter for 10. Designing Information and Recordkeeping Systems

Section 3: How to deal with specific types of records Pgs 26 – 40 Specific to Health and Social Care records Section on Lloyd George papers is causing some issues within GP practices The Good Practice Guidelines for GP electronic patient records Version 4 (2011) Contract closure guidance Prison Health Care / Youth Offenders Institutions Complaint records Useful information Pg 28 on corporate records Emails guidance / scanning guidance NB: NHS England cannot advise GP surgeries whether to destroy paper and purely digitise – it is a risk assessment on the part of the GP to consider if the electronic record is complete. If so, they may choose to destroy the paper version. However, this is their decision to make, not for NHS England to advise. Contract closure has been proving challenging! Hybrid system in place at prisons / YOIs. NHS England inherited some complaints records from PCTS and SHAs – kept separately from patient files. Generic email and scanning guidance is useful to all organisations.

Section 4: Retention Schedule Pgs 41 – 48 Retentions are minimums – therefore, if there is a proven business need, then records could be kept for longer than the recommended minimum Access via DPA and Access to Health Records Act Pages 45 – 49 contains a useful list of records which may be held in health and social care settings Organisations could use the list to ensure that all these records are covered in their retention schedule DPA for living individuals, AHRA for deceased individuals (access limited to certain people – designate rep or someone with a claim on the estate). NHS England retention schedule has just been refreshed by referring to this list and to the retention schedule available later in the document.

Useful Websites and Links  Pgs 49-50 Useful resources list that could be used in developing a new member of RM staff as well as a useful glossary for seasoned professionals.

Appendix One: Acknowledgements Pg 51 Many RM professionals involved in the development of this piece of guidance Some members of the reference group may be in this very room! Colleagues at NHS England and National Archives known to me and I have benefitted greatly from their knowledge and expertise. A certain Emily Overton too….! 

Appendix Two: Standards Pg 52 Another useful list that is worth having a look at whether new or experienced RM practitioner

Appendix 3: Retention Schedule Pgs 53 – 80 Schedule is significantly stripped down from the previous code of practice which dated back to 2009 Pg 79 Complaints retention is set at 10 years (was previously 8 years) Pg 79 FOI requests retention where there has been an appeal is set at 6 years (was previously 10 years) Not many significant deviations from previous guidance available (i.e. Code of Practice).

NHS England Implementation Our key move was to align our Records Retention and Disposal Schedule to reflect the guidance – Version 2.0 published in January 2017 Some key areas had changed in terms of retention (e.g. complaints) Corporate Records Manager visited the team to ensure that paper / electronic systems were adjusted accordingly to reflect the July 2016 change in guidance. Reflect guidance within the Records Management Policy – new Version 4.0 of the Policy just being ratified at the moment NHS England also advertised the new guidance to all staff via the comms mechanisms such as ‘Engage’, Records Management Co-Ordinators meetings.

Questions / Discussion For more information, please contact: Sarah Graham, Corporate Records Manager, NHS England: sarah.graham7@nhs.net