When a patient registers with a practice they sign a GMS1 form , which is an application to be registered.

The GP subsequently decides whether to register the patient – or not. If the GP signs the GMS they are, from that point onwards, assuming responsibility for the care of that patient. From that point onwards the patient is no longer the responsibility of the 'old' GP.

The middle section of the GMS1, which is signed by the patient prior to signature by the GP, contains words which authorise the new GP to retrieve the patient's records.

This process is then translated and recorded on the national patient registration database via Registration Links software.

The Registration Links software identifies the patient's previous registered GP and changes the registration status to 'deducted'. It then issues a series of electronic messages to the previous practice notifying it of the change of status and that the record is being recalled. This request covers - in all practices, not just those enabled with GP2GP - the entirety of the patient's record, both electronic and paper.

'Legitimate relationship'

"Have you got my records?" - newly-registered patients expect their GPs
to receive their medical records at the earliest opportunity.

GPs are bound by their professional responsibility to transfer those records to the new GP. As soon as the patient has registered with the new GP the old GP no longer has a 'legitimate relationship' and has no more right to hold that patient's records than they do the record of any other person in the street.

Furthermore, National General Medical Services (nGMS) and Personal Medical Services (PMS) contracts usually state an explicit requirement to return records to the PCT when requested, as did the Red Book. It is the regulatory requirement.

The patient, when they sign the GMS1, is instructing the new GP to retrieve the records. It can be argued that the GP has no 'say' over the process: they are in effect being instructed to go out and get the patient's records. This explicit statement gives the new GP the right to extract the newly-registered patient's records whether the records be paper, electronic or otherwise.

For these reasons the strict legal and regulatory arrangement is that as soon as the patient is accepted by the requesting practice, they have assumed responsibility for the patient and therefore the patient is 'theirs'. From that point onwards the patient is no longer a patient of the sending practice and that practice has no right to deny the registered GP access to what is now his patient's record.

In non GP2GP-enabled practices, the above process will usually result in the practice forwarding (to the new practice via the PCT) the Lloyd George envelope plus its contents and a computer print-out.

It is the daily experience of GPs across the country that patients expect the new GP to have access to their previous records. 'Have you got my records?' is what is asked by newly-registered patients thousands of times every day.

In GP2GP-enabled practices a new functionality has been created: an ability to transfer the electronic records from the previous GP (the sending practice) to the new GP (the requesting practice).

This only applies to patients that are fully registering under Personal Medical Services (PMS) or General Medical Services (GMS) arrangements; it does not apply to other types of registration such as temporary or emergency registrations.

The system has been designed such that the request to the sending practice can only be generated after the patient's registration details on the Personal Demographic Service (PDS) have changed and that the request can only be generated by the use of the Registration Links software in a GP2GP-enabled practice.

The request cannot be generated by any other means or software and cannot be generated independently of the patient's PDS registration details changing. Neither can a request be repeated: it is only ever generated once during each registration change.

During the development of the software to support GP2GP transfer two issues were considered:

• whether to have an automatic process that extracted the record from the sending practice without intervention from the sending practice, or whether to have the sending practice 'allow' the request and determine whether the record would be extracted, i.e. in some way be able to stop or deny the request;
• and, separately, whether the extraction should occur immediately or at some other (delayed) time, e.g. 24 or 72 hours later.

These issues were considered and debated by the full committee of the General Practitioner Committee, the Royal College of GPs, the GP2GP Project Board, the GP2GP Clinical Safety Team and various other discussion fora.

The unanimous view of all of these bodies is that the GP2GP extract record should be sent automatically and immediately. Automatic sending is valid for the reasons already stated.

Immediate sending

Immediate sending is valid because one of the greatest benefits of the GP2GP process is the ability to have the new patient's records available to the new GP within (in some documented cases) minutes and certainly hours. The benefit of having this information sooner rather than information that may have been tidied or added to later is generally thought to be greater.

It is true that in some of the early adopter sites for GP2GP for there was some initial wariness about immediate sending, but these sites soon changed their minds and accepted the principle.

The issue of late-arriving information, such as pathology records or OPD letters, is a valid one but it is no more relevant to the electronic record than it is the paper record. The Lloyd George is never 'held back' because there may yet be a letter to arrive.

Electronic health records are likely to be the more up-to-date of a practice's records. As more and more practices increasingly rely on their electronic records they are thus safer to send sooner.

The GP2GP project understands that late-arriving information needs to be forwarded to the new GP and has written protocols and educational materials relevant to this.

The GP2GP record extract can only occur once during any registration and there is no facility to 're-send' a GP2GP record. It is thus evident that a process for forwarding late arriving information has to exist.

The Lloyd George envelopes are required to be forwarded within six weeks and this is a useful back-up for forwarding any late arriving information. Late arriving information that is received by the sending practice in electronic form, e.g. Path links data, should be printed out onto paper and inserted in the Lloyd George envelope.

As the electronic record is, in the vast majority of instances, a partial record there is a perception that immediate transfer may risk failure to transmit valuable historical information contained in the paper record.

However, the current GP2GP approach demands that the complete (and partially duplicated) record (consisting of the medical record envelope (MRE), its contents and paper enclosures and a paper printout of any computer records as well as the GP2GP electronic record) is sent to the new practice.

This process is triggered by the on-going paper-based patient registration process and is still a requirement of the GP Terms and Conditions of Service. The electronic GP2GP record is delivered immediately with the paper components following later via the PCT paper transfer process.

It is hoped that we will soon be able to recommend that GP2GP practices no longer need to produce a paper print-out of their computer records, although they will still need to send on the MRE and its non computerised paper enclosures.

At some point it is hoped that that we will be able to stop having to transfer even the MRE, when records are comprehensively summarised and electronic exchange is the norm rather than the exception.

In conclusion

The greatest benefit derives from immediate transfer of patient's electronic health records. This ensures that the most recent and, in most instances the most valuable, patient information will be transferred to support immediate clinical needs.

This represents a significant advance on the pre-GP2GP arrangements and completeness of the record is assured by the subsequent transfer of paper records.

GP2GP has been built to emulate the paper transaction but speed the whole record transfer process up.