How undelivered hospital letters have caused chaos for GPs

In the past year, Pulse has reported on several very similar incidents in which hospital trusts failed to deliver patient documents to GPs, creating huge backlogs and potential risks to patient safety. Anna Colivicchi investigates the full scale of the problem

Mid and South Essex Foundation Trust recently disclosed a backlog of around 30,000 patient documents which it failed to deliver to local GP practices on time. This wasn’t a trivial admin error. It caused widespread ‘anxiety’ for patients – but even worse, it put patient safety at risk due to delayed actions and clinical investigations.

This wasn’t the first time that trust had been affected: last year, it made the headlines after around 100,000 pieces of communications – affecting 53,000 patients – were not sent to GPs. These were dating back to 2008 and had gone unsent due to an IT fault.

However, this isn’t an issue confined to Essex. It has been happening across England, and has been happening for years, as our investigation reveals.

‘In many cases the same or similar problems have occurred repeatedly,’ Londonwide LMC CEO Dr Michelle Drage tells Pulse, ‘and there really does need to be some accountability for the effect this has on patients and their GPs.’

FOI data from hospital trusts in England, obtained by Pulse, revealed incidents dating back to 2013. During this time period, at least 18 trusts experienced IT failures, leading to more than 700,000 patient letters not reaching GPs.

The scale of the issue

The problems in Essex are indicative of what is happening in other trusts. Pulse’s FOI request to hospital trusts in England revealed that similar issues, affecting considerable numbers of letters, have been happening for the past 10 years across the whole country.

The incident involving the largest number of documents recorded so far affected Nottingham University Hospitals Trust, where it emerged that some of the 411,000 letters and medical documents that had been sat unauthorised on Medical Office (a paperless system for typing letters) dated back to 2017 .

Trusts use different ways to categorise patient safety incidents so Pulse asked how many ‘serious incidents’ were identified, specifically affecting ‘communications (including discharge summaries, clinic letters and anything similar) to GPs’ in the past 10 years.

A number of London trusts seem to be among the worst affected. Lewisham and Greenwich Trust reported 93 incidents affecting GP communications since 2013, and there were five serious incidents declared in this timeframe related to letters or reports ‘not being sent to or being available to GPs due to IT issues’.

Similarly, London North West University Trust has been recording incidents affecting GP patient communications since 2014, with the biggest one affecting approximately 18,056 communications. ‘A delay of even a day or two in identifying a problem can mean that letters quickly stack up given the volumes involved,’ the trust tells Pulse.

Our investigation found that trusts in Surrey, Hampshire, Oxfordshire, Yorkshire, Birmingham, Northamptonshire, Newcastle and Somerset have also been experiencing by similar issues, with the number of communications affected varying from 1,700 to 75,000.

And some have been recording multiple incidents a year for the past decade. Northampton General Hospital, for example, identified 77 safety incidents that affected communications to GPs in the past 10 years – including one event just last year in which communications affecting 2,500 patients were not sent to the their GPs.

As explained, trusts categorise the incidents differently and use different systems locally, so it is likely that additional data on other similar incidents was not included in the FOI responses that Pulse received. Some trusts could not respond to our request as this would ‘significantly exceed the appropriate 18-hour limit provided under the FOI Act’, or because that they did ‘not hold this data in a readily accessible format’.

Why is this happening?

Most trusts have indicated these issues are related to ‘IT failures’ or ‘system breakdowns’ – as declared by East London Foundation Trust earlier this year, when it failed deliver 22,000 patient letters to GPs. But for other trusts the reasons remain unclear, and some of the incidents are still being investigated.  

In Essex, the issue was the result of letters meant to be sent electronically from Southend and Basildon hospitals to named GPs, rather than practices, which were not sent when the individual GP retired or was no longer at the practice.

According to Oxford University Hospitals – which has recorded 21 serious incidents involving GP communication failures since 2016, affecting a total of 5,330 documents – some of these errors occur due to patients not updating their GP, or their address with GPs, so the trust’s IT system doesn’t update and match.

Two serious incidents caused by IT faults were also declared at Hampshire Hospitals, one of which the trust is still investigating. In September last year, 2,479 patient records were affected with a total of 1,764 letters not electronically sent to GPs. A spokesperson from Hampshire Hospitals says that this was due to ‘a national IT issue’ affecting digital correspondence between hospital trusts and primary care service providers. The inquiry into the second serious incident is still underway, so the trust was ‘unable to provide confirmation of final numbers until this investigation has been completed’.

‘A failure to transmit HbA1c results’ to EMIS caused one serious incident at King’s College in 2017, involving 2,000 patients; and the trust also reported a second incident in 2021, when electronic discharge notifications ‘were not sent’, relating to approximately 7,000 patients.

North Tees and Hartlepool Trust also reported two serious incidents that were the result of ‘software issues’ after upgrades to the trust’s electronic patient record management system. These caused ‘a delay in sending 9,886 letters to general practices’, dating back to 2018 and 2021.

As previously reported by Pulse, between June 2019 and January 2020 a ‘technical glitch’ caused thousands of letters containing summaries of patient consultations at Barnet Hospital and Chase Farm Hospital, in North London, not to reach GPs.

And some of the incidents related to IT system faults even went undiscovered for years before the trusts realised there was a problem. Documents dating back to 2018 failed to be sent to GPs from Birmingham Women’s and Children’s NHS FT – 3,278 letters in total – and the trust says it was ‘not aware’ of the issue, due to a ‘system error’.

‘The reason why we were not aware of the letters failing to be issued at the time was because they were being sent by an external company, a system error in that company was preventing the letters from being sent,’ the trust says.

In some cases, when trusts became aware of similar issues, the specific number of letters or patients affected have proven difficult to establish, as well as the reasons behind it. Somerset Foundation Trust says it has ‘encountered similar incidents’ and it is reviewing processes ‘to look at future mitigations’, but failed to provide specific details about the incidents.

Gateshead Foundation Trust has reported 39 similar patient safety incidents since 2014, with four happening this year alone, but was unable to give the number of letters or patients affected as it says it is ‘unable to determine the exact nature of the documentation included in the incidents’. At University Hospitals Bristol and Weston, although the trust says it did not have ‘any large-scale systematic issues’, there have been occasions when ‘technical issues’ have led to letters being delayed, including examples when servers ‘have gone down’ and therefore not passed on documents, or ‘mis-configuration of letters’ and issues with third parties – but the trust did not provide specific figures.

The clinical risks

‘There could be important or crucial information in those letters,’ says Dr Neil Bhatia, a GP and records access lead at his practice in Hampshire. ‘Patients could quite conceivably come to harm.’

He explains that usually the letters are sent to the patient, and the GP CC’d – or the other way around – but many patients ‘don’t understand the letters’. He adds: ‘They’re still written in a way for doctors to understand, and might not realise when action is needed, or might just wait for their GP to contact them about it.’

When Newcastle Hospital Trust failed to send 24,000 electronic patient documents to GPs, including discharge summaries and clinic letters, in late 2023, it was staff from the trust that raised concerns with the CQC about ‘risks to patient safety caused by delays in sending out patient correspondence’. And the local LMC was ‘worried about the implications’, saying that it was ‘quite possible’ that in a proportion of the letters there were ‘unactioned key changes for patients’.

And this was also a major worry for GPs in Essex, with the LMC raising concerns that practices were asked to accept delayed letters ‘without any knowledge of the support available from the trust’ to deal with the consequences. Essex LMC chief executive Dr Brian Balmer says that this was ‘a major safety issue’ and that the trust took ‘a significant amount of time’ to realise GPs would be ‘at the heart of fixing the issue’.

‘Why didn’t the GP respond to X letter?’ If you never saw the letter, you have a problem,’ he says, ‘this is a major safety issue, and a potential liability issue for practices.’

Dr Drage points out that delayed test results ‘mean anxiety for patients’, as well as the potential for late diagnosis and GPs having to work through ‘huge tranches of results when they do finally arrive’, often with no extra resourcing to do so.

‘We know hospital IT systems are under-resourced as capital spending has been gutted across the NHS and we do try to work with trusts when unforeseen circumstances occur,’ she adds.

The effect on GP workload

Surrey GP partner Dr David Triska, whose practice had to deal with delayed letters from the Royal Surrey, says that the issue has been ‘a real headache’, with ‘hundreds of letters in a backlog’.

Following the implementation of a new electronic patient record system in May 2022, the trust became aware of ‘delays with letters being sent electronically to the GP’, which affected around 7,000 communications. ‘The workload is immense, it’s a real worry that we can’t rely on that communication,’ says Dr Triska. ‘For us, there are no safety issues as of yet but lots of delayed actions.’

In most cases, GPs were asked to go through the backlogs to resolve the problem, or at least to help in this process.

GPs working in practices in Essex say the issue led to ‘massive increase in workload’ and that practices have been ‘very affected’. Mid and South Essex trust responded to this saying that ‘GPs have been supported to deal with any outstanding care issues’ identified from the letters and it expects all the communications to have been checked by the end of this month. But while practices received payment for processing the delayed letters – at a sliding scale starting at £10 per letter for the first 50, then £7 per letter up to 100, then a further sliding scale after that – the LMC is still concerned about the impact this has had on workload.

Practices in North Tees and Hartlepool were sent the letters in ‘manageable batches’, according to the trust – and GPs were ‘very supportive throughout’, ensuring that ‘no patient was at risk of harm’ – but this is likely to have caused increased workload as it happened ‘over a short time frame’.

In Newcastle, the LMC wanted ‘recognition’ that this error from the trust has caused ‘serious grief and additional unresourced workload’ for GP practices ‘who are already on their knees’.

And if GPs did not have to sort through the delayed letters, they were asked to let their trust know if there was ‘any patient harm associated with a delay in receiving the letters’ – which is what Oxford University Hospitals asked its local GPs to do.

What are the chances of this happening again?

Many of the trusts experiencing the issues say that they have put ‘new systems’ in place to address similar situations, but have given no specific details on how they plan to prevent issues from occurring again.

Hampshire Hospitals NHS Foundation Trust says that ‘a full investigation’ was launched to look at how the incidents occurred, how many people were affected and if anyone was harmed as a result, and that a ‘new technical solution’ has been put in place ‘to ensure that this problem cannot recur.’

Birmingham Women’s and Children’s Trust says the issue was ‘investigated thoroughly’ and that the documents affected ‘did not require immediate action’.

A new electronic system was also adopted by London North West University Trust last autumn and there is also ‘an existing GP alert system where primary care can raise concerns’.

Oxford University Hospital also carried out ‘a full review and thorough investigation’ and says ‘no harm came to any patients’. ‘We have since put measures in place to minimise the risk of this kind of incident happening again,’ says chief medical officer Dr Andrew Brent.

Nottingham University Hospitals recently conducted a review of their investigation into the 2017 incident which concluded that ‘no significant patient harm’ had been identified. Their assessment identified that under 23,000 GP correspondence documents – out of the total 411,000 – needed action. ‘Recommendations for learning were also managed appropriately and implemented for the future, with improvements continuing to take place,’ says chief executive Anthony May, ‘I hope that patients and the public will be reassured by this review and that the investigation carried out in 2017 was thorough and robust.’

NHS England does not currently keep track of the issue nationally as it says that the IT communications systems ‘are managed locally’. But there are worries similar incidents will continue happening without accountability from the commissioner.

‘Timely, high-quality communications for patients and everyone working in the NHS remains of the utmost importance to ensure the best possible care and services for all,’ says NHS England. ‘These IT communications systems are managed locally, and it is essential that all local NHS organisations ensure their processes for sending correspondence to GPs are operating as they should.’

It is worth mentioning that in 2018, Government auditors found a backlog of hundreds of thousands of pieces of clinical correspondence that were not directed to GPs as a result of NHS England’s failure to resolve problems associated with their contract with Capita.

The Department of Health and Social Care says the new Government is ‘committed to fixing all aspects of the NHS’, a commitment embodied by recently-launched investigation led by Lord Darzi, and stresses that the risks rising from similar IT failures are managed locally.

‘This government is committed to fixing all aspects of the NHS which is why we have commissioned an independent investigation, led by Professor Lord Darzi, to help inform a new 10-year plan for the health service,’ a spokesperson says.

This is certainly not the only widespread IT issue in the NHS, and Pulse has looked at other IT problems plaguing general practice specifically, with practices all over the country facing regular IT outages that can sometimes last for days. Not surprisingly, this has also posed serious problems, with GPs reporting near misses, patient anger and – inevitably – an increase in workload. 

However, Pulse’s investigation suggests a need for a more solid monitoring of these specific incidents and a proper, country-wide inquiry into the reasons behind it.