Lloyd George envelope

{{Short description|Paper wallets used by UK doctors}} [[File:Lloyd George envelope with insert.jpg|thumb|Lloyd George envelope with insert]]

'''Lloyd George envelopes''', named after the British former prime minister [[David Lloyd George]], are paper wallets used by [[general practitioners]] in the United Kingdom to record and store medical information on their patients. They were produced in beige card, and distributed to general practices until January 2021. Envelopes for male patients have red print, those for female patients blue print. Each measures {{Convert|130 x 180|mm|abbr=on}} and has provision for additional inserts.

Lloyd George cards were first used for workers who paid into [[National Insurance|National Health Insurance]], a scheme introduced following the [[National Insurance Act 1911]]. The envelopes were introduced during the [[First World War]] and continued in use following the formation of the [[National Health Service]] (NHS) in 1948.

The records provided an easy to visualise summary, prevented unnecessary lengthy note making, and could be carried in a doctor's coat pocket when out on a home visit. However, limited writing space resulted in brief inconsistent record keeping, and encouraged illegible handwriting.

From the 1950s, as record keeping became more detailed and hospital interventions resulted in more correspondences, the relatively small Lloyd George envelopes became increasingly bulky. They were phased out in the late twentieth century and replaced to some extent with [[A4 paper size|A4]] folders, and eventually digitised with the adoption of computerised medical records.

[[David Lloyd George]] introduced a card to record medical information for low-income male workers who paid into [[National Insurance|National Health Insurance]], a scheme introduced following the [[National Insurance Act 1911]], when he was [[Chancellor of the Exchequer]].<ref name=CET1912>{{cite news |title=Topics of the day |work=Coventry Evening Telegraph |date=8 October 1912 |page=2}}</ref><ref name=Sherifi2022>{{cite book |last1=Sherifi |first1=James |chapter-url=https://books.google.com/books?id=ESl3EAAAQBAJ&pg=PT57 |title=General Practice Under the NHS: Past, Present and Future |date=2022 |publisher=CRC Press |isbn=978-1-000-62557-8 |pages=57–60 |language=en |chapter=5. Information management and technology}}</ref> Its creation has been seen as the beginning of the development of a nationally compatible records system.<ref name=Livingstone1990>{{cite journal |last1=Livingstone |first1=A |last2=Widgery |first2=D |title=The new new general practice: the changing philosophies of primary care. |journal=BMJ |date=3 October 1990 |volume=301 |issue=6754 |pages=708–710 |doi=10.1136/bmj.301.6754.708 |language=en |issn=0959-8138|doi-access=free |pmid=2224242 |s2cid=12411559 |pmc=1664070 }}</ref>

Between 1911 and the formation of the NHS in 1948, the record-keeping cards were in general use by health boards.<ref name=Sherifi2022/> The envelopes were introduced during the [[First World War]].<ref name=Sullivan2016>{{cite journal |last1=Sullivan |first1=Frank |title=Atomic data: James Mackenzie Lecture 2015 |journal=The British Journal of General Practice |date=May 2016 |volume=66 |issue=646 |pages=e368–e370 |doi=10.3399/bjgp16X685153 |pmid=27127292 |pmc=4838451 |issn=0960-1643}}</ref> Their size was based on their storage in the large number of available [[ammunition box]]es during the First World War.<ref name=Lakhani2003>{{cite book |last1=Neary |first1=Joe |chapter-url=https://books.google.com/books?id=OeiJ8rEkDroC&pg=PA155 |title=A Celebration of General Practice |date=2003 |publisher=Radcliffe Publishing |isbn=978-1-85775-923-5 |editor-last=Lakhani |editor-first=Mayur |editor-link=Mayur Lakhani |location=Abingdon |page=155 |language=en |chapter=13. Achievements in record keeping: the use of information management and technology}}</ref><ref name=Floyd1986>{{cite journal |last1=Floyd |first1=CB |last2=White |first2=DH |title=A medical record folder for the Lloyd George envelope. |journal=The Journal of the Royal College of General Practitioners |date=January 1986 |volume=36 |issue=282 |pages=19–20 |pmid=3701688 |pmc=1960341 |url=https://bjgp.org/content/bjgp/36/282/19.full.pdf}}</ref>

==Design and usage== [[File:Lloyd George envelopes.jpg|thumb|Lloyd George envelopes (red for males, blue for females)]]

Lloyd George envelopes are beige-coloured card wallets and measure {{Convert|130 x 180|mm|abbr=on}}<ref name=Sherifi2022/><ref name=Collins2023>{{cite book |last1=Collins |first1=Kenneth E. |url=https://books.google.com/books?id=nbmvEAAAQBAJ&pg=PT38 |title=Patient and Staff Voices in Primary Care: Learning from Dr Ockrim and her Glasgow Medical Practice |date=2023 |publisher=CRC Press |isbn=978-1-032-43901-3 |location=Boca Raton |page=38 |language=en}}</ref> with red or blue markings for male or female patients, respectively.<ref name=Sherifi2022/> One was allocated for every individual in the UK population, from birth and upon registration with a general practitioner.<ref name=Smith1999>{{cite book |last1=Smith |first1=Jack |title=Health Management Information Systems: A Handbook for Decision Makers |date=1999 |publisher=McGraw-Hill Education (UK) |isbn=978-0-335-20565-3 |page=272 |url=https://books.google.com/books?id=8YjlAAAAQBAJ |language=en}}</ref> Owned by the Secretary of State for Health, the Lloyd George record stayed with the individual's GP, wherever they moved to in the UK, and hence contain a person's lifelong health record.<ref name=Loudon1998>{{cite book |last1=Morrell |first1=David |editor1-last=Loudon |editor1-first=Irvine |editor2-last=Horder |editor2-first=John |editor3-last=Webster |editor3-first=Charles |title=General Practice Under the National Health Service 1948-1997 |date=1998 |publisher=Clarendon Press |location=Oxford |isbn=0-19-820675-5 |page=10 |chapter-url=https://books.google.com/books?id=aD6K2_t4EMsC&pg=PA10|language=en |chapter=Introduction and overview}}</ref><ref name=Starey2003>{{cite book |last1=Starey |first1=Nigel |title=The Challenge for Primary Care |date=2003 |publisher=Radcliffe Publishing|location=Abingdon, Oxon |isbn=978-1-85775-569-5 |chapter-url=https://books.google.com/books?id=oPm1eo4JtHcC&pg=PA2|chapter=1.The heritage|pages=2-3 |language=en}}</ref> Continuation cards can be inserted inside.<ref name=Floyd1986/><ref name=Pierry1986>{{cite journal |last1=Pierry |first1=A. A. |title=General practice record folders |journal=The Journal of the Royal College of General Practitioners |date=1 March 1986 |volume=36 |issue=284 |pages=138 |url=https://bjgp.org/content/36/284/138.1 |language=en |issn=0035-8797}}</ref> These have the date of printing in the bottom right-hand corner.<ref name=Buchan>{{cite book |last1=Buchan |first1=Andrew |last2=Lewis |first2=Charles James |title=Lewis and Buchan: Clinical Negligence: A Practical Guide |date=2012 |publisher=Bloomsbury Publishing |isbn=978-1-84766-673-4 |page=468 |url=https://books.google.com/books?id=As7qtY5YK8IC&pg=PA468 |language=en}}</ref>

The Lloyd George record has been seen by some to have a certain sense of privacy, with notes tucked away in the wallet, unlike being visible on a computer screen.<ref name=Orme2018>{{cite book |last1=Orme-Smith |first1=Anne |last2=Spicer |first2=John |title=Ethics in General Practice: A Practical Handbook for Personal Development |date=2018 |publisher=CRC Press |isbn=978-1-315-34851-3 |url=https://books.google.com/books?id=1RypDwAAQBAJ&pg=PT42|page=42 |language=en}}</ref> Their small size was seen by some as "easy to handle".<ref name=Floyd1986/> The notes generally served as an [[aide-mémoire]] for the doctor.<ref name=Moreton1999>{{cite book |last1=Pringle |first1=Mike|author-link=Mike Pringle (physician)|editor1-last=Moreton |editor1-first=Philippa |title=The Very Stuff of General Practice |date=1999 |publisher=Radcliffe Publishing |isbn=978-1-85775-390-5 |page=122 |chapter-url=https://books.google.com/books?id=NjLErpUeAXQC&pg=PA122|language=en|chapter=7. Understanding our discipline: the growth of informatics}}</ref> They provided an easy to visualise summary, prevented unnecessary lengthy note making and could be carried in the doctor's coat pocket when out on a home visit.<ref name=Floyd1986/>

==Limitations== Recorded detail varied between physicians, and ranged from documenting every illness to omitting major surgical procedures.<ref name=Sherifi2022/> Not all doctors even utilised the inserted summary card, until after 1990 when financial incentives to treat longterm conditions such as [[asthma]] and [[diabetes]] arose.<ref name=Sherifi2022/>

The limited space to document details reflected, to some extent, the type of medicine practised in the early twentieth century.<ref name=Sherifi2022/> People's expectations, limited medical knowledge, short consultation times, and limited medical tests all contributed to the brief notes that were made by general practitioners,<ref name=Sherifi2022/> which discouraged detail and encouraged illegible handwriting.<ref name=Sherifi2022/> It also led to the use of acronyms, such as "FLK" for "funny looking kid", and "TATT" for "tired all the time".<ref name=Sherifi2022/> Recording treatment of [[Streptococcal pharyngitis|strep throat]] would be shortened to "ST.Pen", for example, without any elaboration on a person's history, examination findings, or drug doses.<ref name=Sherifi2022/>

In the 1970s and 80s the debate about whether the Lloyd George record had any advantage in switching to A4 folders was a major issue.<ref name=Jones1981>{{cite journal |last1=Jones |first1=F. A. |title=Innovations in medical records in the United Kingdom |journal=British Medical Journal (Clinical Research Ed.) |date=31 October 1981 |volume=283 |issue=6300 |pages=1164–1165 |doi=10.1136/bmj.283.6300.1164 |pmid=6794804 |issn=0267-0623|doi-access=free |pmc=1507365 }}</ref> Hospital letters typically arrived in an A4 form and needed to be folded to fit into a Lloyd George envelope, whereas new sheets were easily added into the larger folders.<ref name=Jones1981/> Medical record-keeping varied among practices, from solely using Lloyd George records, to adapting them, to using a combination of Lloyd George and A4, to, in a few cases, moving to computer records.<ref name=Jones1981/> Effective use of Lloyd George records was seen as requiring an almost obsessional attention to detail.<ref name=Jones1981/>

==Discontinuation== [[File:GP records in envelopes.jpg|thumb|upright|GP records in A4 folders]]

In the latter part of the twentieth century, as record keeping became more detailed and hospital interventions resulted in more documentations, the Lloyd George envelopes became increasingly bulky.<ref name=Sherifi2022/> Whether hospital letters should be inserted into the envelopes folded with the writing on the inside for confidentiality, or outside for easy visibility, was just one matter for debate.<ref name=Sherifi2022/> For people with longterm conditions, the envelopes became full, frequently requiring joining envelopes together, which was typically done using [[Sellotape]] or rubber bands.<ref name=Sherifi2022/> In 1974, a recommendation to replace the small envelopes with larger A4 folders, came from a joint working party of the Health Departments for England, Wales and Scotland, health authorities and general practitioners.<ref>{{cite web |title=Written Answers To Questions |url=https://hansard.parliament.uk/commons/1988-01-19/debates/0488caaa-a0a4-421c-a4c1-f2dedc149fc9/WrittenAnswers |website=Hansard.parliament |access-date=26 November 2023 |date=19 January 1988}}</ref> The envelopes were phased out in the late twentieth century and mostly replaced with A4 folders, and eventually digitised with the adoption of computerised medical records.<ref name=Sherifi2022/>

The NHS stopped issuing new envelopes for first-time registrations in January 2021.<ref name=Talora>{{cite journal |last1=Talora |first1=Joe |title='Archaic' and risky patient records still used by most GP practices |journal=Health Service Journal |date=5 June 2023 |url=https://www.hsj.co.uk/technology-and-innovation/archaic-and-risky-patient-records-still-used-by-most-gp-practices/7034908.article |language=en}}</ref> Since then, no further Lloyd George envelopes are produced.<ref name="NHS2021">{{cite web |title=Lloyd George envelopes & paper records {{!}} PCSE |url=https://pcse.england.nhs.uk/help/medical-records/lloyd-george-envelopes-paper-records |archive-url=https://web.archive.org/web/20240122170634/https://pcse.england.nhs.uk/help/medical-records/lloyd-george-envelopes-paper-records |archive-date=22 January 2024 |access-date=26 November 2023 |website=pcse.england.nhs.uk}}</ref><ref name="People">{{cite web |date=30 June 2017 |title=Lloyd George envelope |url=https://peopleshistorynhs.org/museumobjects/lloyd-george-envelope/ |archive-url=https://web.archive.org/web/20240122173706/https://peopleshistorynhs.org/museumobjects/lloyd-george-envelope/ |archive-date=22 January 2024 |access-date=26 November 2023 |website=People's History of the NHS}}</ref>

<gallery widths="200px" heights="200px"> File:Lloyd George envelopes in box.jpg|Lloyd George envelopes stacked in box: compact, with insertion cards and folded hospital letters File:Lloyd George envelopes with inserts- joined.jpg|Lloyd George envelopes held by rubber band File:Lloyd George envelope with inserts and extension.jpg|Lloyd George envelopes held by Sellotape </gallery>

==References== {{Reflist}}

==Further reading== * {{Cite web |title=1948–1957: Establishing the National Health Service |url=https://www.nuffieldtrust.org.uk/chapter/1948-1957-establishing-the-national-health-service |publisher=Nuffield Trust |access-date=3 December 2023 |language=en}} * {{Cite journal |last=Goodridge |first=D. M. G. |date=April 1982 |title=An Analysis of Fat Folders |url=https://bjgp.org/content/32/237/239 |journal=[[The Journal of the Royal College of General Practitioners]] |volume=32 |issue=237 |pages=239-241}}

[[Category:David Lloyd George]] [[Category:Envelopes]] [[Category:Medical records]] [[Category:National Health Service]]