Select Committee on Health Written Evidence

Evidence submitted by the British Psychological Society (EPR 45)

  The British Psychological Society welcomes the opportunity to contribute to the Committee's inquiry into the development of the Electronic Patient Record and its use.

  The Society is the learned and professional body, incorporated by Royal Charter, for psychologists in the United Kingdom, has a total membership of over 45,000 and is a registered charity. The key Charter object of the Society is "to promote the advancement and diffusion of the knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of members by setting up a high standard of professional education and knowledge".

  The Society is authorised under its Royal Charter to maintain the Register of Chartered Psychologists. It has a code of conduct and investigatory and disciplinary systems in place to consider complaints of professional misconduct relating to its members. The Society is an examining body granting certificates and diplomas in specialist areas of professional applied psychology. It also has in place quality assurance programmes for accrediting both undergraduate and postgraduate university degree courses.

  Members of this Society, as Applied Psychologists work as Clinical, Counselling, Health, Forensic and Educational Psychologists as well Neuropsychologists. They and other members also undertake research. Their NHS patients will be directly affected by the introduction of the Electronic Patient Record. Our comments reflect our concerns in relation to aspects of electronic records, particularly in the context of mental health services. We do not propose to cover the many technical and supply problems that continue to bedevil this project, as we are sure these will be adequately addressed by other colleagues.

  In submitting our views, we recognise that there is a strong case for the introduction of electronic health records in terms of potential benefits for patients, clinicians and management.

  This response was prepared on behalf of the British Psychological Society by its representatives on the British Computing Society Forum:

    —  Dr Adrian Skinner, Department of Clinical Psychology, Harrogate—Member of the Division of Clinical Psychology and Associate Fellow, British Psychological Society.

    —  Prof Michael Berger, Royal Holloway, University of London—Member of the Division of Clinical Psychology and Fellow, British Psychological Society.

What patient information will be held on the new local and national electronic record systems, including whether patients may prevent their personal data being placed on systems?

At a Local Level

  CfH is intended to store patients' medical record, including all health episodes, centrally. NHS staff with a legitimate clinical interest in a patient will have access to that record. The Code of Conduct of the Society requires that the patient and the psychologist decide who should have access to psychological records other than under specific circumstances such as a Court Order. Centralisation of these records will remove this responsibility.

  Particular issues arise in relation to mental health data and data from vulnerable/other groups who may lack "capacity" to consent to and monitor information about themselves—people with dementia, learning difficulties, acquired brain injury dysfunctions. Such issues need to be addressed.

  Associated with this is the complex matter of mental health patients' access to records—such as determining which parts of records may be potentially harmful if revealed, dealing with third party information. Currently, such questions arise when an individual requests access. If all records are to be subject to individual scrutiny, particular attention will need to be given to how this process will be implemented.

At a National LevelContents of the summary record in relation mental health records and those of other vulnerable groups require specification. Patient access and control remain issues at this level, again specifically in relation to data for those with mental health problems and for vulnerable individuals.

Who will have access to locally and nationally held information and under what circumstances?

  The means of determining access to records is described as "Role Based Access Control". We are concerned that it will not be possible to produce a satisfactory algorithm, and that this will result in a far wider variety of people having access to records.

  Information in healthcare covers every aspect of human functioning and in mental health, it is highly sensitive and confidential information about diverse aspects of functioning and relationships, the veracity of some of which may be questionable, for instance in forensic settings. This information, commonly essential to treatment, is usually given in the context of a developing trusting relationship and in most circumstances, is private to that relationship. The possibility of access by others could block, impair or distort the information made available, undermining the treatment efforts of the clinician. Hence special consideration needs to be given to access and the related issue of protection of confidentiality in relation to mental health information.

  The issues are not just about deciding about access rights on a spectrum from no-access for anyone other than the involved clinicians, to unfettered access. They are also about validating that an individual with access to highly sensitive and confidential information is a specific individual with the specific level of access rights. The recent instance of a single smartcard being left in the card reader to counter the slow response of the validating system is an illustration of the sorts of issues involved. This raises the need for the use of biometric smartcards in certain situations.

What kinds of data are stored?

  The lay, and medical, view of a medical record is of a straightforward collection of bits and bytes of hard information eg serum potassium levels.

  However, for psychology and a number of other disciplines the information is "soft", ie expressed in language, variable, and consisting of opinion and conclusion. We are concerned that the electronic record could both give spurious authority to transient junior opinion and preserve erroneous information that could have been corrected in a paper record.


  CfH is aware that patients will not wish all clinical staff to have access to all records, for instance sexual or mental health episodes, and propose a scheme of "Sealed Envelopes" that may be breached only by senior staff under specific circumstances.

  The problem is that other NHS staff will be aware of the existence of these sealed envelopes, with sometimes undesirable consequences. For instance, employers (including the NHS) may request an inspection of medical records as part of the Occupational Health Assessment; if such an inspection found sealed envelopes it is likely that the potential employee might be required to grant access as a condition of employment.

  One solution to this problem is to give every record a "Sealed Envelope". This way, no individual will be marked out as having "something they wish to hide". Those who wish to use this facility would then insert material that would only be accessible to those with special privileges.


  There are two potentially serious consequences of the above; we stress that, because of existing computerisation, these consequences already occur.

  First, people may avoid seeking treatment for problems that they classify as embarrassing or threatening to their lifestyle in some way.

  Second, clinicians may be reluctant to record certain sorts of information for fear of this information "leaking" to the harm of the patient; an unintended consequence of this could be the failure to pass on information about someone's care to a clinician who needed it.

How Data Held on the New Systems Can and Should Be Used for Purposes Other Than the Delivery of Care eg Clinical Research

  Access to personal health data for research should be available provided ways of ensuring that usual ethical principles are followed. However, there should be a formal systematic review, involving patients and other potential user groups from within the NHS, medical and other professional training groups, to assess whether or not electronic records pose special problems so that supplementary ethical and other guidance can be introduced if necessary.

  In this regard, there will need to be provision for special informed consent about likely use for research.

Dr Martin Crawshaw

Chair, Professional Practice Board, British Psychological Society

16 March 2007

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