14 September 2022: Armstrong - A

Professor Armstrong came as an expert witness on the specific issue of medical record keeping. (Unfortunately for him in the context of this Inquiry, the witness has an uncanny resemblance to Prof Gordon Lowe formerly the Glasgow Royal Infirmary where he was the Haemophilia Centre Director.) He has a medical qualification but moved to academic sociology. He has carried out various studies using large data sets. The system, as far as there was one from the start, was named after Lloyd George as part of the 1911 National Insurance Act.

The 1956 Minister of State health guidance introduced the concept of holding records for 6 years, but overall, the systems of record keeping had been very different and in no way standardised. GP records were very scant on detail since these doctors knew all their patients personally. The Tunbridge Report of 1965 sought to standardise records and introduced the A4 folders which became normal. In 1948, hospitals joined the NHS with a great variety of quality and content in terms of records.

The witness noted how chaotic the medical records system had been (and to some extent still was) with a patient seeing different doctors, with some doctors holding on to records, different files being in different places, and not at all joined up. He suggested there were still issues nowadays. Some pruning of records may have been necessary when pulled together, and this might have lost some information. There were retention policies but some of the protocols that applied created problems when different clinics or hospitals used them. There was/is also a terrible difficulty with hospitals losing records. When patients were given their own records to look after, they were not lost.

Many clinicians were against any destruction of medical records, however microfilming was considered too expensive, but a few places did use it. The retaining of all records also causes problems when a person’s record is very full, for example to a new treating clinician who might have to go through many pages until he or she found the important content. Removal of extraneous content would likely not be done consistently, or at all. It is haphazard everywhere according to the witness. It might take a doctor three hours to properly edit a single patients’ record, and that would be three hours not seeing current patients.

The function of the record has changed over time. They may have started as a simple set of notes for a doctor, then they became part of a somewhat paternalistic process which had nothing to do with patients as far as many doctors were concerned, to the increasing situation nowadays of a more inclusive and collegiate approach. There is still a great deal of inconsistency. There was also the issue of a record not being found, so a new department dealing with a patient would start a new record, and so it was possible for there being several sets of records for a patient, not all including all the same information, including the more significant matters being missed.

Counsel asked about “culling” documents. This was meant to be, from the US in the 1990s, a process to highlight for any new clinician what were the main clinical conditions related to a patient at the front of the file. Very often it would be junior doctors doing the culling. They would have to judge what was ripe to be removed. The example was given that a blood transfusion which happened many years ago might be thought of as no longer helpful to retain, and so removed. There was no clear guidance on what definitely had to be retained. Many records just didn’t get culled, but it created the problems of storage or of collating, for example during a hospital merger.

Hospitals “closing down” (which should be thought of a merger) would have the problem for the newly combined records office when a load of new records arrived, with the temptation being to get rid of them as much as possible. Notes not available can jeopardise care. Even as recently as 1995, attempts to make record keeping easier to do and more useful for the clinicians to use are seen due to ongoing and seemingly insurmountable problems. There could also be the situation of a clinician deciding to hold a record in case they needed it in a few days because otherwise another department might take out the record. Of course, that means the other department cannot access the notes for their clinical purposes.

The digitisation opportunity was seen to be potentially very effective and helpful, but that involves putting the older files into a digital format, which is an enormous endeavour. Much of the digitisation process relies on codes to be a shorthand for known conditions. There is also space for written notes. The use of this function can be very differently maintained. The GPs in the UK were among the first in the world to benefit from electronic records, with several commercial providers offering ready-made solutions. The bigger challenge is for acute care because hospitals have much more complex needs for interoperability. A hybrid system of digital and paper was (has been) in place due to the huge task of digitising, with key material being electronically available, but then the doctor going back to the written or printed record in the actual paper file for any detail they might need. Of course, the transition process with the potential for material to be lost or incorrectly copied over continues to be an issue. Clearly, digital storage is much easier that paper files. There is still a lot of work to do when it comes to different parts of the NHS being able to link up. The systems are different. There are a few examples of joined-up systems, which might allow a GP to read (but not change) a digital record. The process is no longer about a single clinician treating a patient, whereas now it is more a team approach. Also, increasingly people have several health conditions instead of them encountering the health service one department at a time.

On the issue of “access”, there are historical examples of a doctor writing something in a file which can be cruel, judgemental, or simply rude. There is also the matter of record entries being unhelpful for some patients to see (for example, if it could damage their mental health). The shift to more open records has caused a sanitisation of records. The question is complex due to the difficulties of judgement about what people should see. (Who even decides that?) There are fears by some clinicians that they cannot be candid if what they write will be seem by more people than the immediate team, and especially if they are seen by the patient.

Counsel turned to the wider prospect of patients having full access to their records. Studies appear to favour greater access, including there being better health outcomes. In these cases, the medical record becomes part of the “shared care” approach. The issues include security and access. For example, should families of deceased patients, parents of children at different ages, have full access or some restrictions. There is a sense that a joint access to records improves the conversation between the doctor and the patient.

There was then some time for core participant questions, which required a short break.