Summary Report: Systemic Failures in GP Clinical System Migration (EMIS to SystmOne)

Prepared for: ICB, PALS, Practice Manager and PPG Review Group

By: Andrew Hodges (a patient at the practice)

This report summarises the failures experienced by thousands of patients following the Phoenix Health Group, Cirencester, GP practice's migration from the EMIS clinical system to TPP SystmOne. The issues span lack of basic patient communication to ensure a smooth transition and critical patient safety failures related to cross-system data access, including hospital access to patient records, and weaknesses in the NHS app.

Please note: This report is from a 'patient reality' point of view. As such I am using my own language to describe what I have observed. Every organisation I have worked with in my former professional life has their own jargon so I have had to use (or invent) my own. It is my hope that those responsible are able to 'translate' my jargon into theirs.

The GP Practice Manager deserves to be commended for her efforts in encouraging TPP UK SystmOne staff to open up channels of communication with NHS App people.

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Due to her persistence some faults in the NHS App are currently being corrected. JUYI might also have been reconnected to GP patient records earlier than expected. This is awaiting confirmation.

Executive Summary

The transition resulted in widespread patient dissatisfaction and created a critical patient safety risk due to a fundamental failure in pre-planning, communication, and technical verification. The local failures demonstrate a significant disconnect between the "NHS internal implementation bubble" and "Patient Reality": Patients need continuity of access and safety.

The most severe failure is the loss of hospital access to patient records, forcing vulnerable patients to recall complex medical histories during critical pre-assessment for surgical procedures. This is an unacceptable breakdown of care continuity.

1. Failure of Patient Communication and Service Continuity

Patient expectations were fundamentally mismanaged, leading to immediate distrust and high administrative burden on the practice.

2. Critical Interoperability and Patient Safety Failure

The most severe consequence of this transition is the immediate safety risk posed by the loss of access to the GP record by secondary care providers.

The Failure: Local hospitals are currently unable to view patient records necessary for pre-assessment screenings for operations. This failure indicates that the new SystmOne installation was not correctly configured to "Share Out" data to the wider health economy (via established mechanisms like GP Connect, Shared Care Record or JUYI).

The Patient Safety Impact: Patients, often in pain, distressed, or dealing with acute illness, are being forced to recall their complete medical history, including allergies, medication reactions, and diagnoses, from memory. This was further exacerbated by the disappearance of documents in the NHS app, useful if consultants are unable to access GP patient records.

Currently the GP practice system transition is inherently unreliable and significantly increases the risk of:

Adverse Drug Reactions: Due to missed allergy/medication data.
Procedural Delays/Cancellations: Due to incomplete pre-assessment information and patients loss of access to their own documents.
Emotional Harm: Due to the burden placed on vulnerable individuals.

3. Analysis of Responsibility and the NHS 'Bubbles'

The inability to link patient needs with implementation choices demonstrates a systemic failure of governance and prioritisation across multiple actors:

TPP UK (System Supplier): Accountable for ensuring its training and migration support materials highlight the maintenance of interoperability as a non-negotiable patient safety step. Given their extensive experience, this specific failure is a known, preventable risk that their process should have actively guarded against.
Integrated Care Board (ICB) / Digital Delivery Partner: Accountable for Oversight and Assurance. The ICB is responsible for the entire local care system. They failed to implement a mandatory, independent verification step with the local Acute Trust to confirm GP record access was operational before confirming the GP migration as complete.

Action Recommendations

To address the immediate fallout and prevent recurrence of these systemic failures, the following actions are recommended for implementation and policy review:

A. Immediate Service and Patient Safety Restoration

Mandatory Interoperability Check: The ICB must immediately liaise with the local Acute Trust and the GP Practice to jointly verify and test the SystmOne configuration to restore hospital read/write access (JUYI) to GP records as soon as possible.
Public Acknowledgment: The ICB and TPP UK must issue a clear, written apology to all registered patients & the GP practice, acknowledging the failures in communication and assuring them that the safety risk regarding hospital access is being immediately resolved.

B. Systemic Policy Changes for Future Migrations

Formal ICB Assurance Gateway: Implement a mandatory, non-negotiable 'Patient Safety Assurance Gateway' in the GP migration process. This gateway only opens when the local Acute Trust (Hospital) formally confirms its ability to view patient records (via GP Connect/JUYI/Shared Care Record) from the new system.
Supplier Accountability (TPP/EMIS): Future national contracts must require suppliers like TPP UK to include patient safety verification staff on site during go-live to assist the Practice Manager in validating key interoperability settings, with clear financial penalties for post-migration interoperability failures that compromise patient care.
PPG Empowerment and Training: The ICB and PALS must develop a training module for PPGs specifically on IT Migration Risk, focusing on patient-facing systems (Apps, prescriptions) and the importance of advocating for continuity of care. PPGs should be mandated to receive training and remain engaged during transition periods.
National App Improvement Mandate: The NHS App development team must be mandated to improve the utility for chronic disease management, allowing for clearer presentation, graphing, and filtering of specific results (e.g.,HbA1c) to support self-management.

Area of Failure	Observed Impact (Patient Reality)	Analysis of Responsibility
Online Services	Patients expected little difference. Instead, EMIS services (Patient Access) vanished immediately, and were replaced without warning. Additionally all patients regardless of longevity with the practice were treated as 'new' to the practice which meant that important documents and test results prior to the transition 'disappeared'.	Those with responsibility for the GP transition failed to be mindful of the impact on patients. TPP UK: Failed to inform the GP Practice of necessary patient pre-migration communications detailing the change in online access portals (e.g., from EMIS to Airmid). TPP UK: Failed to inform the Practice Manager that previously visible patient documents would disappear from view.
Prescription Ordering	Changes to the ordering process (e.g., app/portal change) were not communicated, leading to high volumes of complaints and disrupted medication access. The GP Practice was unable at first to communicate the new prescription ordering process.	TPP UK: Did not adequately train the Practice Manager on how to manage the patient-facing side of prescription continuity during the switch.
Patient App Adoption	The GP Practice was not informed of the new app (Airmid) which meant that patients were not told about Airmid (TPP's patient-facing app) and were redirected only to the NHS app. The existing NHS App is currently difficult to use and poorly organised for managing chronic conditions.	NHS Digital: Responsible for the design and utility of the national NHS App, which, for patients, is demonstrably inadequate for complex clinical data presentation (e.g., tracking HbA1c trends for diabetics).

Mastering Chaos: