The National Audit Office has released on a report looking into the incident in which over 700,000 pieces of medical data on the NHS were misplaced.
The incident came to light earlier this year when it was revealed that the private contractor NHS Shared Business Service (NHS SBS), misplaced over half a million pieces of patient data between 2011- 2016.
From 2008 NHS Shared Business Service entered into contracts with 26 Primary Care Trusts (PCTs) to redirect clinical correspondence which had been sent to the wrong GP or other clinical providers. The contracts were with PCTs in North East London, East Midlands and the South West. When PCTs were abolished in 2013, NHS England took over the contracts and NHS SBS continued to redirect clinical services.
The report looks at why the incident occurred and highlights the roles that the NHS and government played. Part of the reason why so many medical files were misplaced was that there were no key performance indicators (KPIs) to review how well NHS SBS was redirecting mail.
More so, the NHS claims that before it took over the services in 2013 there was no opportunity to examine or change the terms of the NHS SBS contracts.
The National Audit Office’s report states that when NHS SBS took over contracts from East Midland’s PCTs in 2011, it inherited a backlog of over 8,000 unprocessed medical files. Over the next four years NHS SBS saw the backlog continue to grow. In 2014, a review by NHS SBS found a backlog of 205,000 items and highlighted the risk presented by the notes not being with GPs.
Between 2014 and 2016 the backlog continued to grow despite numerous concerns being raised about it. Concerns pertained to an incident where 35 sacks of medical records were destroyed which potentially included outstanding medical record reports and urgent/ clinically urgent requests. Senior managers knew about the risk that the backlog presented, and yet no plans were developed to fix the problem. In 2015, the backlog was added to the primary care services risk register, though worryingly the description of the risk had more to do with the associated costs to clear the files, rather than the potential harm to patients.
In 2016, NHS England and the Department of Heath were informed of the problem and set up a National Incident Team (NIT) to deal with the backlog. The Department of Health chose not to alert parliament or the public about the backlog, though NHS England believed that patients should be told that they may have been harmed due to the incident. Indeed, the public were only notified about the problem when The Guardian reported it in February.
Examining the impact of the incident, the National Audit office states that there are 1,788 cases of potential harm to patients as of 31 May 2017. The report also states that 333 of these patients have died, though there is no evidence linking the deaths to the backlog of medical files.
NHS England are still assessing the damage of the backlog to patients and is expecting the number to rise as GPs respond to its investigation. NHS England expects its review of the backlog to be completed by December 2017. The incident is estimated to cost upwards of £6.6 million.
Dr. Richard Vautrey, British Medical Association, said: “The failings of this private company identified in the NAO report are completely unacceptable and it is a disgrace that this service failed so badly that patient care was being compromised. The handling and transfer of clinical correspondence is a crucial part of how general practice operates and it’s essential that important information reaches GPs as soon as possible so that they can provide the best possible care to their patients.”
He continued: “At a time when the NHS is under incredible funding pressure, we can ill afford to spend £6m to clear up this administrative mess that has resulted from SBS’ failures.”