1. NHS Connecting for Health is delivering the National Programme for Information Technology Updating the Retention Schedules for the NHS Code of Practice for Records Management – The Process

2. NHS Connecting for Health is delivering the National Programme for Information Technology Who has been leading on developing & drafting the new retention schedules?  Lorraine Nicholson, Health Record Consultant, NHS CFH CEO IHRIM  Rob Baker, Archivist, Chelsea & Westminster NHS Trust, Chair of Health Archives Group

3. NHS Connecting for Health is delivering the National Programme for Information Technology Why us??!!....... … there have been many times when we’ve asked ourselves the same question when we have been ploughing through the lengthy and complex retention schedules!!

4. NHS Connecting for Health is delivering the National Programme for Information Technology Seriously – why us?  Both have long experience of working in the NHS  Two different backgrounds but both with a “health” focus  I was involved in the drafting of HSC 1999/053  I was the lead consultant in the development of the Health Records Requirements in the IG Toolkit  Rob is Chair of the Health Archives Group which has produced guidance publications relating to health records and health archives  He is a working Archivist in a large NHS Trust

5. NHS Connecting for Health is delivering the National Programme for Information Technology What has been my role in developing the new retention schedules?  Researching the stakeholder communities for both retention schedules (Health and Business & Corporate Records)  Liaising with stakeholders and expert groups where necessary  Drafting & redrafting the retention schedules and amending or updating them as work progressed……many times!!

6. NHS Connecting for Health is delivering the National Programme for Information Technology Updating the Retention Schedules (1)  Start with existing retention schedules;  Map the retention schedules in HSC 1999/053 to “Good Management; Good Records” (PRONI) to identify potential new categories of records  Consult with domain experts on the requirements for disease surveillance & research into new diseases & conditions (e.g. variant CJD)  Scan new legislation, guidance & new techniques to check if any or all will affect the retention periods for records and amend the retention schedules where necessary

7. NHS Connecting for Health is delivering the National Programme for Information Technology Updating the Retention Schedules (2)  Identify new categories of records from:-  The mapping exercise  Comments from professional groups  Comments from practitioners in the NHS  Input from the Dept of Health & NHS Connecting for Health  Refine, refine and then refine again before going out to consultation (internally and externally)

8. NHS Connecting for Health is delivering the National Programme for Information Technology Updating the Retention Schedules (3)  Consult with NHS Connecting for Health to determine new record retention requirements for the NHS Care Records Service, PACS etc (e.g. registration authorities, audit trails)  Take advice from specialist groups e.g. HAG, HFEA  Take advice from DH Solicitors’ Branch where necessary e.g. Human Tissue Act, Blood Safety Regulations

9. NHS Connecting for Health is delivering the National Programme for Information Technology Points to note about the Retention Schedules  The Retention Schedules provide MINIMUM retention periods  Records can be retained for longer BUT…  They may not be retained for more than 30 years without approval from the Lord Chancellor  Where records need to be kept for a longer period NHS organisations should contact The National Archives to seek approval

10. NHS Connecting for Health is delivering the National Programme for Information Technology The Public Records Act 1958 (1)  All NHS records are Public Records under the terms of the Public Records Act 1958  NHS organisations have a responsibility to make arrangements for selecting those of their records which ought to be permanently preserved  These arrangements are to be carried out under the guidance of the Keeper of Public Records, who is responsible for co-ordinating and supervising the work of selection (s.3(2)).

11. NHS Connecting for Health is delivering the National Programme for Information Technology The Public Records Act 1958 (2)  The Public Records Act requires that documents selected for preservation shall be sent to The National Archives not later than 30 years after their creation; but that their transfer may, for administrative or other special reasons, be postponed with the Lord Chancellor’s approval (s.3(4))

12. NHS Connecting for Health is delivering the National Programme for Information Technology The Public Records Act 1958 (3)  Any mode of disposal of records which are not suitable for preservation other than destruction – for example, presentation to an academic institution or an overseas Government – requires the approval of the Lord Chancellor (s.3(6))

13. NHS Connecting for Health is delivering the National Programme for Information Technology The Public Records Act 1958 (4)  Records selected for permanent preservation should be transferred to The National Archives or an Approved Place of Deposit  Some of the larger hospitals have been appointed as Places of Deposit and the records deposited there are under the care of a professionally qualified archivist

14. NHS Connecting for Health is delivering the National Programme for Information Technology The Data Protection Act 1998  Section 33 and schedule 8 part IV of the DP Act, plus section 9 of the Data Protection (Processing of Sensitive Personal Data) Order 2000 provides for data, including sensitive personal data, that has been identified as being of historical value or statistical research value, to be kept as archives without breaching principle 5 of the Act

15. NHS Connecting for Health is delivering the National Programme for Information Technology Circulars to be cancelled & incorporated within the NHS Code of Practice (1)  HSC 1999/053; “For the Records” and Appendix B2 (additional guidance on retention and storage of maternity records previously issued with HSG(94)11)  HSC 1998/153; “Using Electronic Patient Records in Hospitals: Legal Requirements and Good Practice”

16. NHS Connecting for Health is delivering the National Programme for Information Technology Circulars to be cancelled & incorporated within the NHS Code of Practice (2)  HSC 1998/217; “Preservation, Retention and Destruction of GP General Medical Services Records Relating to Patients”  “Electronic patient medical records in primary care; changes to the GP terms of service” 29/9/2004

17. NHS Connecting for Health is delivering the National Programme for Information Technology Guidance & Legislation taken into consideration in drafting the Health Records Retention Schedules (1)  The National Archives Records Management web site http://www.nationalarchives.gov.uk/recordsmana gement/  The Public Records Act 1958

18. NHS Connecting for Health is delivering the National Programme for Information Technology Guidance & Legislation taken into consideration in drafting the Health Records Retention Schedules (2) “Good practice guidelines for general practice electronic patient records” (version 3.1) Prepared by The Joint General Practice Information Technology Committee of the General Practitioners Committee and the Royal College of General Practitioners Sponsored by The Department of Health

19. NHS Connecting for Health is delivering the National Programme for Information Technology Guidance & Legislation taken into consideration in drafting the Health Records Retention Schedules (3)  “The Retention & Storage of Pathology Records & Archives, V5, Royal College of Pathologists – under consultation  Human Tissue Act 2000  Guidance on the use of videoconferencing in health care – NHS Wales (Telemedicine etc)

20. NHS Connecting for Health is delivering the National Programme for Information Technology Guidance & Legislation taken into consideration in drafting the Health Records Retention Schedules (4)  Recommendations on retention periods issued by the Hospital Pharmacists Group & published in Hospital Pharmacy in May 2003  HSG(95)3, "Health Service Use of Ionising Radiations“  Blood Safety and Quality Regulations;  Human Fertilisation & Embryology Act 1990

21. NHS Connecting for Health is delivering the National Programme for Information Technology Guidance & Legislation taken into consideration in drafting the Health Records Retention Schedules (5)  BIP 0008: Code of Practice for legal admissibility and evidential weight of information stored electronically (3rd edition 2004) – BSI  BS ISO15498 (Parts 1 & 2) – Effective Records Management – BSI  Directive 2003/98/EC on the re-use of public sector information

22. NHS Connecting for Health is delivering the National Programme for Information Technology Notes to Accompany The NHS Retention & Disposal Schedules  Introduction outlining the NHS’ obligations for retention & preservation of all records  Responsibilities and decision-making  Interpretation of the schedules  Type of record  Minimum Retention Periods  Derivation of the retention period  Final Action

23. NHS Connecting for Health is delivering the National Programme for Information Technology Notes to Accompany The NHS Retention & Disposal Schedules …….(continued)  Retention Periods  Who makes the decision regarding disposal & destruction of records?  Archives - Selection of NHS Records for Permanent Preservation

24. NHS Connecting for Health is delivering the National Programme for Information Technology Organisation of the Retention Schedules There are 3 Retention Schedules:- 1.HEALTH 2.BUSINESS & CORPORATE (NON HEALTH) and 3.ELECTRONIC RECORD/AUDIT TRAILS

25. NHS Connecting for Health is delivering the National Programme for Information Technology Health Records Retention Schedule Covers Health Records of different types & other Hospital Records Relating to Healthcare ……(regardless of the media on which they are held including paper, electronic, images and sound and include all records of NHS patients treated on behalf of the NHS in the private healthcare sector):

26. NHS Connecting for Health is delivering the National Programme for Information Technology Types of Health Record covered by the Retention Schedule (1)  Patient health records (electronic or paper based; including those concerning all specialties, including GP medical records);  Records of private patients seen on NHS premises;  Accident & Emergency, Birth, and all other Registers;  Theatre Registers & Minor Operations (and other related) Registers;

27. NHS Connecting for Health is delivering the National Programme for Information Technology Types of Health Record covered by the Retention Schedule (2)  X-Ray and Imaging reports, output and images;  Photographs, slides, and other images;  Microform (i.e. fiche / film);  Audio and video tapes, cassettes, CD-ROM etc.;  E-mails;  Computerised records;  Scanned documents

28. NHS Connecting for Health is delivering the National Programme for Information Technology Business & Corporate Records Retention Schedule –Administrative Corporate Records –NHS Organisation Records –Estates/Engineering –Financial –IM&T –Other –Personnel/Human Resources –Purchasing & Supplies

29. NHS Connecting for Health is delivering the National Programme for Information Technology Electronic Records/Audit Trails Retention Schedule  Electronic records are supported by audit trails, which record details of all additions, changes, deletions and viewings. Typically the audit trail will include information on:  Who - identification of the person creating, changing or viewing the record  What - details of the data entry or what was viewed  When - date and time of the data entry or viewing  Where - the location where the data entry or viewing occurred

30. NHS Connecting for Health is delivering the National Programme for Information Technology Electronic Records/Audit Trails Retention Schedule (1)  Audit trails are important for medico-legal purposes as they enable the reconstruction of records at a point in time. Without its associated audit trail there is no reliable way of confirming that an entry is a true record of that period.

31. NHS Connecting for Health is delivering the National Programme for Information Technology Electronic Records/Audit Trails Retention Schedule (2)  NHS CFH is considering the impact of the retention of audit trail data, e.g. whether it should be retained for at least the same period as that of the data to which it relates. There is also an unresolved issue regarding the association of audit trail data with electronic GP records transferred between practices. NHS organisations are therefore advised to retain all audit trails until further notice.

32. NHS Connecting for Health is delivering the National Programme for Information Technology Navigating the Retention Schedules  Because the new retention schedules are now very large they are coded to make navigation easier:-  N = entirely new type of record (not referenced in previous retention schedule) or a more explicit description of a record type than previously published.  C = existing type of record (referenced in previous retention schedule) but change to retention schedule  S = existing type of record with same retention period

33. NHS Connecting for Health is delivering the National Programme for Information Technology Sources of help for Records Managers (1)  NHS Code of Practice for Records Management  Setting and Achieving the NHS Standard for Records Management – A Roadmap; web-based and it contains a range of practical tools and guidance  www.dh.gov.uk/PolicyandGuidance/Organisation Policy/RecordsManagement www.dh.gov.uk/PolicyandGuidance/Organisation Policy/RecordsManagement

34. NHS Connecting for Health is delivering the National Programme for Information Technology Sources of help for Records Managers (2)  Information Governance Toolkit  Dept of Health Records Management web site recordsmanagement@dh.gsi.gov.uk recordsmanagement@dh.gsi.gov.uk  The National Archives Records Management Advisory Service http://www.nationalarchives.gov.uk/recordsmana gement/advisory.htm

35. NHS Connecting for Health is delivering the National Programme for Information Technology The Consultation Process  Informal comment invited via DH RM web site  Internal DH consultation  Internal consultation with NHS Connecting for Health  Informal consultation with various working groups e.g. Best Practice Process Redesign Group (EDMS) London & South Clusters  Informal consultation with representatives of the other home countries (Wales, NI & Scotland)  Formal 12 week external consultation with all stakeholders 1 st July – 30 th September 2005

36. NHS Connecting for Health is delivering the National Programme for Information Technology Next Steps  The Code of Practice & Retention Schedules published in early April 2006  Development of Information Governance Toolkit Requirement Set for Records Management to go into version 4 – work in progress

37. NHS Connecting for Health is delivering the National Programme for Information Technology Questions/Comments?

38. Contact Details: Lorraine.Nicholson@npfit.nhs.uk Tel & Fax: 01706 355957 Mobile: 07788 405910