Question to the Department of Health and Social Care:

To ask the Secretary of State for Health and Social Care, what steps his Department is taking to monitor NHS Trusts' adherence to (a) General Medical Council and (b) National Institute for Health and Care Excellence guidance on patient records.

Each National Health Service trust is a data controller under the Data Protection Act 2018, and therefore responsible for ensuring the accuracy and integrity of their records. To assist trusts in fulfilling these responsibilities, a range of guidance and assurance is in place.

For example, NHS England publishes a Code of Practice on Records Management for all NHS trusts to follow. This covers all aspects of records management, including the accuracy and reliability of medical records. Each trust is responsible for following the principles and guidance set out in the code, which may include local measures, such as a record keeping audit, or monitoring the availability of records.

In addition, in line with the Code of Practice, NHS trusts are responsible for ensuring they have appropriate policies and procedures in place to manage their records. This will usually be a standalone records management policy, with associated procedures, such as how to destroy records.

Furthermore, NHS England’s Data Security and Protection Toolkit (DSPT) requires NHS trusts to understand legal and professional obligations for records management. The DSPT involves a periodic audit in which trusts have to demonstrate they are adhering to this requirement.

Regulators also set out professional standards for health and care professionals. For example, the General Medical Council’s Good Medical Practice requires doctors to make sure that formal records of their work, including patients' records, are clear, accurate, contemporaneous, and legible.

The Care Quality Commission has powers, under section 63(2)(b) of the Health and Social Care Act 2008, to access records held by the service that they are inspecting, where necessary, as part of their regulatory functions.