Report

by the Comptroller
and Auditor General

NHS England

Investigation into clinical correspondence handling in the NHS

HC 778 Session 2017–2019 2 February 2018

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The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Sir Amyas Morse KCB, is an Officer of the House of Commons and leads the NAO. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund, nationally and locally, have used their resources efficiently, effectively, and with economy. The C&AG does this through a range of outputs including value-for-money reports on matters of public interest; investigations to establish the underlying facts in circumstances where concerns have been raised by others or observed through our wider work; landscape reviews to aid transparency; and good-practice guides. Our work ensures that those responsible for the use of public money are held to account and helps government to improve public services, leading to audited savings of £734 million in 2016.

Report by the Comptroller and Auditor General

Ordered by the House of Commons
to be printed on 1 February 2018

This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act

Sir Amyas Morse KCB
Comptroller and Auditor General
National Audit Office

31 January 2018

At the October 2017 hearing of the Committee of Public Accounts to consider our investigation into NHS SBS, NHS England informed the Committee that it had discovered a new backlog of 162,000 items of clinical correspondence that had not been redirected. This investigation sets out: responsibilities for redirecting clinical correspondence; the build-up of the backlog of clinical correspondence within Capita; and action taken by NHS England and Capita to investigate, understand, and rectify the problem.

Investigations

We conduct investigations to establish the underlying facts in circumstances where concerns have been raised with us, or in response to intelligence that we have gathered through our wider work.

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11686 02/18 NAO

The National Audit Office study team consisted of:
Rosie Buckley, Pablo Burns-Roa and Dhan Hussain, under the direction of Ashley Mcdougall.

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What this investigation is about

1 In March 2016 NHS Shared Business Services (NHS SBS) informed NHS England and the Department of Health that it had discovered a backlog of approximately 435,000 items of unprocessed clinical correspondence. NHS England declared a national incident as soon as it discovered the backlog. We reported on the origin and handling of this backlog in Clinical correspondence handling at NHS Shared Business Services in June 2017.

2 On occasion organisations or individuals writing to GPs about their patients misdirect clinical correspondence, for example when patients have changed GP practice or correspondence is sent to the wrong practice. Figure 1 shows that up to 31 May 2015, NHS SBS was one of a number of NHS and private providers responsible for redirecting correspondence that GPs received in error. In May 2015 NHS England introduced new arrangements and since that date GPs are to return misdirected correspondence to the sender. NHS SBS and private providers ceased responsibility for redirecting correspondence from 31 March 2016. NHS England is responsible for arranging primary care support services in England and for the process for redirecting clinical correspondence.

3 At the October 2017 hearing of the Committee of Public Accounts to consider our investigation into NHS SBS, NHS England informed the Committee that it had discovered a new backlog of 162,000 items of clinical correspondence that had not been redirected. NHS England stated that a small proportion of GPs had not been complying with guidance and had erroneously been sending clinical correspondence and other material to Capita, the current provider of primary care support services for NHS England.1 Capita has no contractual responsibility for redirecting clinical correspondence.

4 This investigation is therefore a follow-up to our previous work on clinical correspondence. It will set out:

responsibilities for redirecting clinical correspondence;

the build-up of the backlog of clinical correspondence within Capita; and

action taken by NHS England and Capita to investigate, understand and rectify the problem.

Key events

Summary

Key findings

Responsibilities for redirecting clinical correspondence

1 NHS England introduced new arrangements in May 2015 for handling correspondence that GPs receive in error. Until 31 May 2015 the guidance was for GP practices to forward correspondence for patients that are not registered at the practice to local Primary Care Services (PCS) centres, which would attempt to redirect the mail. After that date recipients of incorrectly addressed clinical correspondence were to return mail to senders to comply with legislation and NHS England information governance (paragraphs 1.2 and 1.3).

2 On 1 September 2015 Capita took over the provision of PCS centres from NHS England. Services from three other private providers transferred to Capita on 1 April 2016. The new PCS contract with Capita did not require it to redirect clinical correspondence, as the May 2015 change in policy should have removed the need for any redirection service (paragraph 1.4).

The incident

3 Between 1 June 2015 and 31 March 2016 an unknown number of GP practices continued to send mail to their previous PCS centres for redirection. Capita told us that during this period it operated procedures it inherited from the 36 PCS centres it was then managing. As these sites were closed under Capita’s PCS transformation plans from March 2016 onwards, Capita made an inventory of all records at each site and shared this with NHS England. The inventories made reference to ‘clinical notes’ but at this point no one identified these notes as unprocessed clinical correspondence.2 Capita stored the correspondence in its archive (paragraphs 2.1 and 2.2).

4 GP practices continued to send mail to Capita for redirection after 1 April 2016. In line with its contract, Capita did not forward the mail. Capita informed a member of NHS England’s primary care support team in May 2016 that there was a problem with an unquantified accumulation of clinical notes (paragraphs 2.3 and 2.4).

5 In October 2016 Capita reported the incident to NHS England. In its report, Capita estimated that there were 580,000 clinical notes. Capita told us that, with hindsight, it believes it could have reported the backlog sooner (paragraph 2.6).

6 In November 2016 Capita and NHS England carried out initial checks on the reported backlog of 580,000 clinical notes; these checks identified an estimated 170,000 items of clinical correspondence. NHS England’s primary care support team sought clinical advice and reviewed a small sample of the correspondence. Following the review, NHS England considered that the clinical correspondence was low-risk, and advised internally that Capita should simply send the correspondence to the relevant GPs. However, NHS England did not ask or contract Capita to return the correspondence at this point (paragraphs 2.7 and 2.8).

7 By July 2017 Capita and NHS England had identified and logged 277,000 items of clinical correspondence. The logging of clinical correspondence was part of an agreed process to return correspondence to the correct GP. NHS England and Capita made a formal contractual change, with set rates for processing the backlog and reviewing and returning high-priority clinical correspondence (paragraph 3.2).

8 NHS England paused the review and return of clinical correspondence in August 2017. This followed an incident in which NHS England sent clinical correspondence containing the child protection notes of three children to a practice without showing the name of the practice in the address. The package was delivered to a supermarket with the same postcode, which then passed the package to the practice. The incident triggered wider knowledge within NHS England of the return of correspondence and as a result it immediately paused the work. Capita sent the backlog of clinical correspondence to NHS England’s National Incident Team in September 2017, for it to assess clinical and reputational risk (paragraphs 3.4 and 3.5).

NHS England’s response

9 NHS England’s National Incident Team has now identified and clinically reviewed a backlog of 373,000 items of unprocessed clinical correspondence. Following initial clinical review, by 20 November 2017 NHS England had sent 18,829 items of misdirected correspondence to relevant GPs, so that they could assess whether there had been any actual harm to patients. Clinicians within the National Incident Team reviewed another 8,343 items for patients that were deceased or did not have a GP. NHS England plans to complete its clinical review by the end of March 2018. It estimates that it will cost £2.4 million to review clinical correspondence for evidence of harm, including £0.3 million that it will pay to GPs. No actual harm has been identified yet (paragraphs 2.12, 3.8, 3.9 and 3.11).

10 NHS England is only paying GPs for reviewing items of clinical correspondence after they have confirmed they have done the work. In its report, Clinical correspondence handling at NHS Shared Business Services, the Committee of Public Accounts reported that NHS England had paid GPs in advance for reviewing correspondence, and had assumed without evidence that no patients had been harmed as a result of the delay.3 NHS England told us that as a result of its own learning from the SBS incident-handling and the Committee’s report, it has stopped the practice of paying GPs in advance for reviewing the current backlog (paragraph 3.13).

11 NHS England has not yet stopped GPs from sending clinical correspondence to Capita in error. NHS England told us that since September 2017, it has continued to receive boxes of clinical correspondence from Capita, running at approximately 5,000 to 10,000 items of clinical correspondence a month. NHS England told us that it is planning an information campaign to reinforce its earlier communication and ensure that GPs understand the guidance for handling correspondence for patients that are not registered at their practice (paragraph 3.14).

12 NHS England has not finalised its process with Capita for handling any correspondence that Capita receives in error. In November 2016 and January and March 2017 Capita continued to request guidance from NHS England on how to handle the correspondence it receives. An interim process is now in place to ensure correspondence is properly handled and forwarded by Capita (paragraph 3.15).

13 NHS England has agreed a process for assuring itself that there are no more boxes of unprocessed correspondence in archives. It has commissioned its National Incident Team to undertake a review, in conjunction with Capita, of records held for archive storage in order to confirm that all potential sources of unprocessed correspondence have now been identified and processed. Where there is any cause for concern the archive will be physically inspected. This process was due to have been completed during January 2018 (paragraph 3.16).

1 The performance of Capita in delivering the Primary Care Services contract for NHS England is the subject of separate work by the Comptroller and Auditor General and is not discussed in this report.

2 ‘Clinical correspondence’ is a record of a patient’s interaction with a healthcare professional or service. ‘Clinical notes’ is a much wider category which can include a range of material which is less sensitive than ‘clinical correspondence’. Where we use ‘clinical notes’ in this report this was the description used at the time.

3 HC Committee of Public Accounts, Clinical correspondence handling at NHS Shared Business Services, Fourth Report of Session 2017–2019, HC 396, November 2017. Available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/396/396.pdf

Part One

Responsibilities for redirecting clinical correspondence

1.1 Clinical correspondence is a record of a patient’s interaction with a healthcare professional or service. It includes clinical papers, child protection notes, treatment plans and changes to patients’ medication regimes. On occasion clinical correspondence is misdirected, for example when patients have changed GP practice or correspondence is sent to the wrong practice. In all such cases, the mail needs to be redirected to the correct recipient.

1.2 NHS England is responsible for arranging primary care support services in England and for the process for redirecting clinical correspondence. Until September 2015 primary care support services were delivered by local Primary Care Services (PCS) centres. Some PCS centres were provided in-house by NHS England, while others were contracted to private providers. These provided a range of services such as updating patient registration lists, moving hard copies of patient medical records between practices and into storage, and redirecting correspondence. Before 31 May 2015 NHS England’s guidance was for GP practices to forward correspondence for patients that are not registered at their practice to their local PCS centre, which would attempt to redirect the mail.

1.3 In May 2015 NHS England introduced, and communicated to GPs, the cessation of redirection services and new arrangements for handling correspondence that GPs receive in error. After 31 May 2015 GPs receiving correspondence intended for patients that are no longer registered at their practice, or not relevant for other reasons, were to return mail to senders to comply with NHS England information governance and legislation. The three private providers continued providing a reducing redirection service, while GPs put in place those arrangements, until their contracts ended in March 2016.

1.4 In June 2015 NHS England awarded the private company Capita a seven-year contract to deliver primary care support services. On 1 September 2015 Capita took over the provision of PCS centres that had been delivered by NHS England, and on 1 April 2016 it took over the services from three private providers. NHS England’s contract with Capita does not require Capita to redirect clinical correspondence, as the May 2015 change in policy was believed to have removed the need for any redirection service. However, the contract does include moving patient records between practices and archiving records for patients who are not registered with a GP or are deceased. Therefore Capita may need or be required to match clinical correspondence to patient records that are stored in its archive.

Part Two

The incident

Where the clinical correspondence came from

2.1 Following the May 2015 policy change requiring GPs to return misdirected mail to senders, an unknown number of GPs continued to send mail to their Primary Care Services (PCS) provider for redirection. Capita told us that once it took over NHS PCS sites from 1 September 2015, it continued until March 2016 to operate the procedures it inherited for redirecting mail at those sites.

Correspondence from closed PCS sites

2.2 Capita, as part of its seven-year PCS contract, had a plan to rationalise the network of 36 NHS and three private-provider PCS services that it took over as part of the contract. From March 2016 Capita therefore started a site closure programme. Under this programme, when a site was closed Capita drew up an inventory of all remaining records at the site, and shared this with NHS England. The inventories made reference to ‘clinical notes’ but at this point no one identified that these notes included unprocessed clinical correspondence. Capita stored the material in its archive.

Correspondence Capita has received directly since March 2016

2.3 Once sites were closed, as agreed with NHS England, Capita put in place new business-as-usual procedures for the new central PCS sites, principally at Clacton, Leeds and Preston. The new procedures were focused on delivering contracted performance. However, some GPs continued to send mail to their PCS service (now Capita) for redirection, even though Capita was not contracted to redirect clinical correspondence.

2.4 In April 2016 NHS England and Capita provisionally agreed a process for handling mail for redirection once it arrived at the central PCS record site in Preston. NHS England was aware in May 2016 that Capita was receiving correspondence from GPs, but as an issue requiring attention rather than as a quantified backlog of mail. Due to a change in Capita’s process for its primary care services business, Capita stopped processing the redirected correspondence at an unknown point in spring 2016. In the absence of any agreed and contracted process for handling correspondence for redirection, all such correspondence arriving at Capita was stored, but not processed, by Capita.

Correspondence identified by Capita in its archive

2.5 While it was transferring legacy archives into a new PCS store, Capita identified material that was not correctly indexed in medical record envelopes, and in some instances was labelled as ‘clinical notes’. Its initial checks showed that some of this related to patients who were registered with GPs and alive, and should not therefore have been in the archive.

Initial assessment of the incident

2.6 In October 2016 Capita formally reported to NHS England that it had a backlog of clinical notes that it had received from closed PCS centres and GPs. At that time, Capita estimated that the backlog consisted of 580,000 clinical notes, although it later reduced its estimates after carrying our further checks on the backlog (Figure 3). It reported the incident to NHS England’s Service Management Team, which manages NHS England’s contract with Capita. Capita told us that, in hindsight, it believes it could have reported the backlog sooner.

2.7 In early November 2016 NHS England’s primary care support medical director reviewed the contents of three random boxes from several hundred held at PCS Preston. This identified clinical correspondence from the 1990s to early 2016. The medical director considered that GPs would not have ignored correspondence that they received about a serious condition, or that needed follow-up action, simply because the patient was not registered at the practice. They therefore concluded that there was a low risk that the backlog included clinical correspondence relating to serious cases. They also considered that it was likely that the patient would contact their GPs if they were expecting follow-up action. The medical director recommended that the correspondence be sent on to the proper recipient by Capita. NHS England’s managing director for PCS considered that a very small proportion of the overall backlog was likely to be misdirected mail, and that it was not on the scale seen in the NHS Shared Business Services incident. NHS England did not ask or contract Capita to return the correspondence at that point.

2.8 Following the same review in November 2016, Capita estimated that the backlog included 170,000 items of clinical correspondence. It told us that it changed its estimate from 580,000 to 170,000 after identifying that some of the items were not clinical correspondence. In November 2016 and January and March 2017 Capita continued to request guidance from NHS England on how to handle the correspondence it had received and continued to receive from GPs. NHS England did not issue any guidance.

2.9 Figure 3 and Figure 4 show that between November 2016 and November 2017 the size of the backlog grew as Capita continued to receive misdirected mail from GPs.

NHS England’s reporting of the incident

2.10 In December 2016 and March 2017 NHS England reported to the Parliamentary Under-Secretary of State for Public Health and Innovation that there was a backlog of clinical notes as part of quarterly ministerial reports. It reported the matter to the Department of Health in April 2017. In both the March 2017 briefing to the minister and the report for the Department of Health, NHS England stated that the clinical notes had been sampled, with clinical input, and were considered to be a low clinical and patient risk.

2.11 NHS England informed its Audit Risk and Assurance Committee in March 2017 that Capita had identified approximately 220,000 clinical notes. However, it did not inform the Committee that this backlog included unprocessed clinical correspondence.

Part Three

NHS England’s response

3.1 NHS England took 152 boxes of records from Capita for further assessment in batches between December 2016 and May 2017. On 27 March 2017 a team in NHS England started a clinical assessment of the backlog that Capita had received from GPs since September 2015, as well as the items from a closed GP practice. The material was reviewed by clinicians and categorised as high or low priority.

3.2 In July 2017 NHS England and Capita agreed a contract change notice to cover handling the return of the backlog of clinical correspondence and to develop a business-as-usual solution to the ongoing work of receiving clinical correspondence for redirection. The logging of clinical correspondence was part of an agreed process to return correspondence to the correct GP. NHS England and Capita agreed set rates for the processing of the backlog and reviewing and return of high-priority clinical correspondence. A joint team was created to work on the solution.

3.3 By July 2017 Capita had populated and shared with NHS England a tracker with 290,000 items of clinical correspondence for processing (revised to 277,000 after review). Some 400 high-priority items of clinical correspondence were dispatched to GP practices for their review.

3.4 NHS England paused the review and return of clinical correspondence in August 2017, following an information governance incident. As part of the process to return correspondence to the appropriate registered GP, NHS England had sent clinical correspondence to a GP practice, which shared the same postcode as a supermarket in the same area, but without naming the practice in the address. The correspondence, which contained the child protection notes of three children, had been included in a postal delivery to the supermarket in error. NHS England reported the matter to the Information Commissioner’s Office, which advised no further action to be taken, but this triggered senior management in NHS England to review the treatment of the backlog. In August 2017 NHS England recalled an estimated 116,000 items of correspondence that Capita had received from closed Primary Care Service (PCS) centres and which had been stored in its archive.

3.5 NHS England considered at this point that, as the documents it received from Capita were similar to those identified in the NHS Shared Business Services (SBS) incident, they required a similar response. In September 2017 the clinical assessment and return of the documents was transferred to NHS England’s National Incident Team (NIT), which had been set up in March 2016 to deal with the backlog of 709,000 similar items of clinical correspondence. The NIT’s responsibilities in this case included reviewing the backlog to assess clinical and reputational risks, and developing an action plan to deal with the backlog and monitoring its implementation. We reported on the causes and handling of the NHS SBS backlog in June 2017. The work on the backlog of correspondence received from Capita is being overseen by a steering group chaired by NHS England’s chief financial officer. Capita sent the backlog of clinical correspondence to NHS England’s NIT in September 2017, for it to assess the clinical and reputational risk.

3.6 In September 2017 NHS England provided its Audit Risk and Assurance Committee with a more detailed account of how the backlog of correspondence from GPs and other NHS providers had arisen. In addition, it highlighted that the decanting of legacy archives into a new PCS store was revealing material which was not indexed in medical record envelopes, and in some circumstances was labelled clinical notes. The medical records were being placed in the relevant location by Capita and NHS England in accordance with the policy that the PCS store contains records for the last 10 years, and the remainder stored in archives in line with the appropriate policy.

3.7 On 16 October the NHS chief executive told the Committee of Public Accounts that, since the publication of the National Audit Office report into NHS SBS, NHS England had taken a look back at the processes used for the correspondence items not processed by NHS SBS. He said that this had been carried out on a “belt-and-braces” and “abundance-of-caution” basis. He said this covered whether GPs were following the new processes, which were intended to avoid the need for a redirection service by having GPs return correspondence for patients that are not registered at their practice back to the sender. He reported that about 5% of GPs were not following the proper practice and that, as a result, there were probably about 150,000 items of correspondence that needed to be returned to the correct GP, in addition to 12,000 items that transferred from SBS. NHS England told us that the 150,000 represents the number of items of correspondence which the NIT had identified for further triage at that point, having discounted other non-clinical correspondence items that had been identified.

The work of the National Incident Team

3.8 Figure 5 shows that by 13 November 2017 the NIT had identified a total of 373,868 pieces of clinical correspondence. These included, for example, pathology reports, coroners’ reports, discharge notifications, patient invitation letters, treatment/diagnosis notes, test results and documents/referrals marked ‘urgent’. It also identified some non-clinical documents such as staff documentation and patient questionnaires. The clinical correspondence that transferred from closed PCS centres was found to include material from centres run by NHS England (91,953 items), NHS SBS (12,053 items) and Serco (3,196 items). The 21 boxes from NHS SBS showed no evidence of having been processed. Of the remaining 139 boxes, 43 boxes showed no evidence of processing or had been processed incorrectly, and 96 boxes showed some evidence of correct processing.

3.9 NHS England’s NIT carried out a clinical review of 361,865 of the 373,868 items of clinical correspondence. The 12,003 items from the closed GP practice were returned to the provider with responsibility for the closed practice. NHS England told us that, applying lessons learned from the SBS incident, it introduced the clinical review stage before returning correspondence to GPs for assessment and review. Following this review stage the majority – 334,693 of the 361,865 items of correspondence – required no GP action to be taken at all, and these are now being electronically repatriated to individual patient records (Figure 6). Of the remaining 27,172 items, the NIT identified a total of 1,811 high priority items (such as documents deemed to be related to screening or urgent test results) and 25,361 low priority items. Some 18,829 of the 27,172 items were returned to the relevant GP practice by 20 November so that they could assess whether there had been any harm to patients. The remaining 8,343 items out of the 27,172 related to patients that are not registered with a GP or that are deceased and have been reviewed by clinicians within the NIT. No actual harm has been identified yet.

3.10 By 20 November 2017 NHS England had sent the misdirected correspondence to the relevant GPs for action. NHS England asked GPs to look at the patient’s medical record and confirm whether they might have been harmed by the delay in receiving the correspondence. By 1 December 2017 NHS England had started returning the items requiring no GP action so that the material could be matched to the patient’s medical record. The correspondence repatriated to GPs for review and assessment is shown in Figure 6.

3.11 NHS England expects to know by March 2018 whether there has been any harm to patients as a result of the delay in redirecting correspondence. NHS England will investigate further where GPs have identified that there could be potential harm to patients. The review will be led by NHS England’s national clinical directors, with consultant level input where required.

3.12 The full costs of dealing with the incident have not yet been confirmed. However, NHS England expects it will cost £2.4 million to review the clinical correspondence for evidence of patient harm. This includes £0.3 million in payments that it expects to make to GPs to compensate them for the time spent reviewing the correspondence.

3.13 NHS England is only paying GPs for reviewing items of clinical correspondence after they have confirmed they have undertaken the work. In its report, Clinical correspondence handling at NHS Shared Business Services, the Committee of Public Accounts reported that NHS England had paid GPs in advance for reviewing correspondence, and had assumed without evidence that no patient had been harmed as a result of the delay.4 NHS England told us that as a result of its own learning from the SBS incident-handling and the Committee’s report, it has stopped the practice of paying GPs in advance for the current backlog.

How NHS England plans to manage correspondence in the future

3.14 The flow of clinical correspondence that GPs are sending to Capita in error has not yet stopped. NHS England told us that since September 2017, NHS England has continued to receive an estimated 5,000 to 10,000 pieces of erroneous correspondence from Capita each month. NHS England told us that it is planning an information campaign, and seeking help from the British Medical Association, to reinforce its earlier communications to GPs and NHS trusts. Its aims are to raise awareness among GPs and NHS Trusts of the correct procedure for handling correspondence they receive for patients that are not registered with them.

3.15 NHS England is discussing commercial arrangements with Capita for handling any correspondence that Capita receives in error. In July 2017 NHS England made a commercial agreement with Capita for them to jointly develop a business-as-usual process. In November 2017 Capita made a proposal to NHS England for how it might handle the correspondence. NHS England rejected the proposal in November 2017 on the grounds that it cost too much and because it considered that it would delay other critical work. It told Capita that it would provide a temporary service for handling the correspondence. NHS England’s NIT are operating this temporary process while permanent arrangements are being discussed and implemented.

3.16 NHS England has agreed a process for assuring itself that there are no more boxes of unprocessed correspondence in archives. It has commissioned its NIT to undertake a review, in conjunction with Capita, of records held for archive storage in order to confirm that all potential sources of unprocessed correspondence have now been identified and processed. Where there is any cause for concern the archive will be physically inspected. This process was due to have been completed during January 2018.

4 HC Committee of Public Accounts, Clinical correspondence handling at NHS Shared Business Service, Fourth Report of Session 2017–2019, HC 396, November 2017. Available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/396/396.pdf

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