The idea of a paperless NHS has been around a long time, but in 2023 there is a growing realisation that paper and digital records can live side by side to deliver optimal efficiencies in patient care.
If that sounds like a disappointing ‘big reveal’ for those who dreamt of an entirely digital service by 2020, then it shouldn’t do – because it’s a solution routed in reality and one which sets us on a smoother path to a digital future.
Nobody is saying that ‘paper is best’ but physical storage can still be part of a digital solution and in reality, there is no ‘one size fits all’ solution for going digital.
That’s because there are significant differences between NHS Trusts in where they stand on the paperless journey.
There are excellent examples of Trusts which have gone digital and are reaping the benefits of doing so. If it is done properly, going digital is the correct thing to do and delivers long-term efficiencies.
But for others, especially those which still have a large paper inventory, optimising their physical records to get them ‘digital ready, is a more cost-effective and realistic way forward.
What’s the dream looking like now?
Our estimate is that reliance on paper in the NHS has gone from 70% to 40% in recent years, but it certainly hasn’t gone away.
The focus has been on ‘going digital’ but that can mean different things to different people – and the same solution does not necessarily work for all Trusts.
For most Trusts it would not be cost effective to scan all their records, not least because many of those records are rarely required and do not need to be scanned. Most Trusts have at least a million records – and the larger ones considerably more, so there is a cost implication, too.
What’s important is that any hybrid solution is properly thought through.
Even for Trusts that want to go fully digital, they also need to be able to create electronic records from the start. A step-change needs to take place in which clinical staff move away from paper records. A hybrid system can be that steppingstone.
Because if there is one rule of going digital it is to understand what you have before deciding what should be scanned.
What about early adopters?
Trusts who were ahead of the game and who jumped on the digital bandwagon were lauded, deservedly so. But technology has moved on significantly since then – and what looked like a perfect solution in 2013 can now, already, seem out of date.
Some of those who in the past wanted to be exemplars of going digital didn’t think about data capture carefully. They scanned records to view on a PDF on a screen without maximising the value from this process.
The reality is it can be even more clunky than having a paper folder.
You have a 200-page PDF to search through on screen, which isn’t easy – and as a result, many clinicians still prefer a paper folder. So, despite previous digitisation projects taking place, in many cases physical documents have not gone away.
A scan on demand service for the most-requested files is better and cheaper – because many legacy records stored are never or rarely needed
Paperless Dream Timeline
2013: The Health Secretary challenges the NHS to go paperless by 2018
2016: The NHS sets itself a target to be a paperless service by 2020 and commits £1.8bn towards achieving that target
2017: A report from Digital Health Intelligence suggested there was little chance of achieving that target before 2027
2019: Just one in 10 Trusts are fully digitised
2022: The government launches its Plan for Digital Health & Social Care. It sets a target of 75% of adults registered with the NHS app by 2024
2023: NHS Digital and NHS England merge.
How reliant is the NHS on physical records?
We estimate there are over 100 million records still stored by NHS Trusts across the country, many of them housed in medical libraries sat right in the centre of hospitals – in prime clinical space that could be better used for direct patient care.
So, why do medical libraries still exist?
It’s a good question, because many people hoped that digitisation would have transformed the way the NHS stores and accesses patient records by now. But change has been slower than hoped due to a myriad of factors - from the cost of going digital to overcoming a deep-set reliance on paper.
Many Trusts still manage libraries themselves, often with high costs attached and limited tacking systems. It’s not unusual for documents to be misfiled.
With a heavy focus, quite rightly, on saving lives and treating patients, it’s understandable that the medical library can sometimes be overlooked when it comes to strategic thinking. But it’s time to put that right. Outsourcing and updating physical storage is the answer for Trusts that need to consider how physical records are dealt with as part of their digital strategy.
How can NHS Trust find an effective hybrid solution?
The first step is for NHS Trusts to look at their patient records inventory and consider how best it can be optimised, putting aside a narrative that an entirely digital solution is the only way there.
Many Trusts have made giant strides in the digital field and seen improvements in patient care as a result. But the historic pressure to scan everything and remove paper altogether is flawed and has lacked a cohesive vision.
The cost of scanning, and the sheer volume of physical patient records, mean it would be prohibitively expensive to take that route for many Trusts, especially in the current climate, and that’s without taking into consideration the cultural changes required to make it happen.
Cultural change will come organically over time, doctors, nurses and clinicians already live in a digital world and are increasingly comfortable with it. But money in the NHS will be a perennial issue – and nobody can deny that.
Some of the benefits of outsourcing storage of physical records include:
- Space taken up by the medical library is freed up, now available for patient care.
- Legacy records which are rarely required can be kept in physical format and given a secure destruction date.
- Fast retrieval process can be put in place so that records can be delivered on demand.
- Clinic prep is made more efficient, with a clear user guide developed to standardise the process and standardise each patient record. This can make future digitisation more cost-effective.
- Patient records are bar-coded and logged – so you always know where they are.
- Significant cost savings can be made simply by outsourcing physical records prior to going digital – as well as helping the change management process.
- The thickness of files can be monitored so that they are always manageable (with only up to date records delivered).
- Scan on demand solution can be implemented (if required) once the Trust has an Electronic Patient Record system in place.
- Additional targeted scanning can take place for record sets that have high activity.
- Newly created paperwork (day-forward) can be scanned until this transitioned to being born digital.
What a hybrid system looks like in real life
The best way to explain how a hybrid system works is to look at one in action.
On-demand scanning can deliver the same end user experience as scanning everything.
It is also possible to destroy paper records in line with retention policies, or once they have been scanned, reducing inventories.
Restore Records Management worked with County Durham & Darlington NHS Foundation Trust (CDDFT) recently to digitise the Trust’s records.
CDDFT had a ‘paperlite’ vision rather than ‘paperless’ and we were able to provide advice on how that should look and exactly how many of the Trust’s records should be scanned, and how many left in physical form (until the expiry of their retention period).
Find out how we delivered that solution, here:
Cost-effective digitisation and a ‘paperlite’ vision at County Durham & Darlington NHS Foundation Trust
County Durham and Darlington NHS Foundation Trust (CDDFT) is one of the largest integrated care providers in England, serving a population of more than 600,000 people and offering further community services to more than 1.2 million people.
Restore has been providing records management services to CDDFT since 2013 and took on a new contract to manage the digitisation of the Trust’s records.
Top of the wish list was cost savings, standardisation of the record archive and to achieve paperlite operations throughout the Trust.
What were the challenges?
- Patient files were stored in different filing systems across five locations, all at full capacity. With over 890,000 paper-based records stored in all, a centralised digital system was required to enable clinicians to rapidly retrieve and transfer medical files at the point of care.
- All staff within the Trust required continued access to all necessary documents and resources during the project, with an average 2,000 file retrievals per day. Needless to say, safeguarding patient data and maintaining quality of care was crucial.
To empower a more cost-effective solution, a two-stage process was put in place:
Stage One – Physical Storage
Restore engaged with the Trust’s existing records management employees, acting in a consultant position to support in:
- Developing a full understanding of the archive, allowing for identification of records essential for digitisation.
- Implementation of records management system, O’Neil, including correct application of barcoding technology across the archive to allow for accurate, live tracking of all records
- Consolidating the archive where possible, minimising the overall required storage space
- Uplift of records, where required, to either Restore’s off-site or alternative Trust premises
- Implementing industry best standard for record storage to increase the longevity of paper records
Stage Two – Digitisation
Our specialists worked alongside the Trust to ensure a fully electronic Clinical Document Management System was developed. This ensured all records were searchable.
A database was then developed to ensure records would be digitally accessible whenever needed across the Trust. All systems and process were BS10008 accredited – Best practice for the implementation and operation of electronic information. This approach was developed to minimise overall costs while maintaining efficacy, and included:
- Scan-on-demand – physical records which were requested following a certain date were sent for scanning, ensuring they were available digitally
- Day-forward scanning – records were immediately scanned upon creation from the contract go-live date, supporting immediate access to new records across the Trust
- 43,500 boxes of the Trust’s physical records, across 45 departments, are now stored offsite at a Restore facility. These patient records are predominantly legacy notes, stored and then destroyed in line with the retention policy. Boxes are consolidated to optimise space usage. This element of the project took nine months to complete
- Digitisation commenced at a rate of 2,000 files per day, and within 12 months we scanned 366,000 patient files.
- Record retrieval volumes have reduced significantly since the on-demand scanning went live - and are now at approximately 42 files per day. Saving money in the process.
- As a result of the project, CDDFT gained a centralised electronic system which has given medical staff quicker access and transferability of patient information - improving the speed of decision-making. The coordination of care and support between health providers has improved, providing the patient with a better experience.
- Staff costs were reduced with savings reinvested into patient care. Real estate was repurposed for more productive frontline patient care services, and data security improved with fully auditable databases that comply with data governance.
- Labour costs have been reduced for CDDFT, together with savings on internal transportation costs. The Trusts receives monthly Management Information reports and service metrics giving them a full audit of their patient’s records.
“Restore has saved us money and vital space for clinical care. We now have quicker access to patient information providing the patient with a better experience” Mark Herkes, Head of Health Records, County Durham & Darlington NHS Foundation Trust
The paperless dream has been around a long time, and until every NHS Trust has gone fully digital it’s a topic that will always make headlines.
But it isn’t the most important measurement of how well an NHS Trust optimises or looks after its patient records.
Ultimately, what is most important is how a Trust can best manage those records cost effectively – and in a way that helps to improve patient care.
The solution is unlikely to be the same for everyone because each Trust has a different range of challenges and different heritage systems to consider.
A hybrid solution, which retains some level of physical storage but creates a steppingstone to digital through scanning, fast retrieval and integrated clinic prep systems, can be the way forward. For Trusts that currently rely on a large paper inventory, a hybrid model is a strong solution which can help them get ‘digital ready’ for the future.
Find out more: www.restore.co.uk/records