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Lloyd George envelopes, named after the British former Prime Minister David Lloyd George, are paper wallets used by family physicians 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 130 mm × 180 mm and has provision for additional inserts.

Lloyd George cards were first used for workers who paid into 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 ineligible handwriting.

From the 1950s, as record keeping became more detailed and hospital interventions resulted in more correspondances, 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 folders, and eventually digitised with the adoption of computerised medical records.

Origin

British former Prime Minister David Lloyd George, introduced a card to record medical information for low-income male workers who paid into National Health Insurance, a scheme introduced following the National Insurance Act 1911, when he was Chancellor of the Exchequer.^[1]^[2] Its creation has been seen as the beginning of the development of a nationally compatible records system.^[3]

Between 1911 and the formation of the NHS in 1948, the record keeping cards were in general use by health boards.^[2] The envelopes were introduced during the First World War.^[4] Their size was based on the large number of available ammunition boxes during the First World War.^[5]^[6]

Design and usage

Lloyd George envelopes are beige coloured card wallets and measure 130 mm × 180 mm^[2]^[7] with red or blue markings for male or female patients, respectively.^[2] One was allocated for every individual in the UK population, from birth and upon registration with a general practitioner.^[8] 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.^[9]^[10] Continuation cards can be inserted inside.^[6]^[11] These have the date of printing in the bottom right hand corner.^[12]

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.^[13] Their small size was seen by some as "easy to handle".^[6] The notes generally served as an aide-mémoire for the doctor.^[14] 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.^[6]

Limitations

Recorded detail varied between physicians, and ranged from documenting every illness to omitting major surgical procedures.^[2] Not all doctors utilised the inserted summary card, until after 1990 and financial incentives to treat some longterm conditions such as asthma and diabetes.^[2]

The limited space to document details reflected to some extent the type of medicine practiced in the early twentieth century.^[2] People's expectations, limited medical knowledge, short consultation times, and limited medical tests, give consideration to the brief notes that were made by general practitioners.^[2] The compact record discouraged detail and encouraged ineligible handwriting.^[2] In addition it led to using acronyms such as "FLK" for "funny looking kid", and "TATT" for "tired all the time".^[2] Recording treatment of a Strep throat would be shortened to "ST.Pen", without any elaboration on the person's history, examination findings or drug dose.^[2]

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.^[15] Hospital letters typically arrived in an A4 form and needed to folded to fit into a Lloyd George envelope. New sheets were easily added into the larger folders.^[15] Medical record keeping varied among practices from solely using Lloyd George records, adapting them, using a combination of Lloyd George and A4, or in a few, moving to computer records.^[15] Effective use of Lloyd George records was seen to require an obsessional trait.^[15]

Discontinuation

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.^[2] 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.^[2] For people with longterm conditions, the envelopes became full, frequently requiring joining envelopes together, which was typically done using sellotape or rubber bands.^[2] 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.^[16] They were phased out in the late twentieth century and mostly replaced with A4 folders, and eventually digitised with the adoption of computerised medical records.^[2]

The NHS stopped issuing new envelopes for first-time registrations in January 2021.^[17] Since then, no further Lloyd George envelopes are produced.^[18]^[19]

Lloyd George envelopes stacked in box: compact, with insertion cards and folded hospital letters
Lloyd George envelopes held by rubber band
Lloyd George envelopes held by sellotape

References

^ "Topics of the day". Coventry Evening Telegraph. 8 October 1912. p. 2.
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o Sherifi, James (2022). "5. Information management and technology". General Practice Under the NHS: Past, Present and Future. CRC Press. pp. 57–60. ISBN 978-1-000-62557-8.
^ Livingstone, A; Widgery, D (3 October 1990). "The new new general practice: the changing philosophies of primary care". BMJ. 301 (6754): 708–710. doi:10.1136/bmj.301.6754.708. ISSN 0959-8138.
^ Sullivan, Frank (May 2016). "Atomic data: James Mackenzie Lecture 2015". The British Journal of General Practice. 66 (646): e368–e370. doi:10.3399/bjgp16X685153. ISSN 0960-1643. PMC 4838451. PMID 27127292.
^ Neary, Joe (2003). "13. Achievements in record keeping: the use of information management and technology". In Lakhani, Mayur (ed.). A Celebration of General Practice. Abingdon: Radcliffe Publishing. p. 155. ISBN 978-1-85775-923-5.
^ ^a ^b ^c ^d Floyd, CB; White, DH (January 1986). "A medical record folder for the Lloyd George envelope" (PDF). The Journal of the Royal College of General Practitioners. 36 (282): 19–20. PMID 3701688.
^ Collins, Kenneth E. (2023). Patient and Staff Voices in Primary Care: Learning from Dr Ockrim and her Glasgow Medical Practice. Boca Raton: CRC Press. p. 38. ISBN 978-1-032-43901-3.
^ Smith, Jack (1999). Health Management Information Systems: A Handbook for Decision Makers. McGraw-Hill Education (UK). p. 272. ISBN 978-0-335-20565-3.
^ Morrell, David (1998). "Introduction and overview". In Loudon, Irvine; Horder, John; Webster, Charles (eds.). General Practice Under the National Health Service 1948-1997. Oxford: Clarendon Press. p. 10. ISBN 0-19-820675-5.
^ Starey, Nigel (2003). The Challenge for Primary Care. Radcliffe Publishing. ISBN 978-1-85775-569-5.
^ Pierry, A. A. (1 March 1986). "General practice record folders". The Journal of the Royal College of General Practitioners. 36 (284): 138–138. ISSN 0035-8797.
^ Buchan, Andrew; Lewis, Charles James (2012). Lewis and Buchan: Clinical Negligence: A Practical Guide. Bloomsbury Publishing. p. 468. ISBN 978-1-84766-673-4.
^ Orme-Smith, Anne; Spicer, John (2018). Ethics in General Practice: A Practical Handbook for Personal Development. CRC Press. p. 42. ISBN 978-1-315-34851-3.
^ Moreton, Philippa (1999). The Very Stuff of General Practice. Radcliffe Publishing. p. 122. ISBN 978-1-85775-390-5.
^ ^a ^b ^c ^d Jones, F. A. (31 October 1981). "Innovations in medical records in the United Kingdom". British Medical Journal (Clinical Research Ed.). 283 (6300): 1164–1165. doi:10.1136/bmj.283.6300.1164. ISSN 0267-0623. PMID 6794804.
^ "Written Answers To Questions". Hansard.parliament. 19 January 1988. Retrieved 26 November 2023.
^ Talora, Joe (5 June 2023). "'Archaic' and risky patient records still used by most GP practices". Health Service Journal.
^ "Lloyd George envelopes & paper records | PCSE". pcse.england.nhs.uk. Retrieved 26 November 2023.
^ "Lloyd George envelope". People's History of the NHS. 30 June 2017. Retrieved 26 November 2023.

@@ Line 1: / Line 1: @@
 [[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|family physicians]] 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. Male envelopes have red parameters and females blue. Each measures 130 mm × 180 mm and has provision for additional inserts.
+'''Lloyd George envelopes''', named after the British former Prime Minister [[David Lloyd George]], are paper wallets used by [[general practitioners|family physicians]] 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 130 mm × 180 mm 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 ineligible handwriting.
 From the 1950s, as record keeping became more detailed and hospital interventions resulted in more correspondances, 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 folders, and eventually digitised with the adoption of computerised medical records.
 ==Origin==
@@ Line 13: / Line 13: @@
 British former Prime Minister [[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 |url=https://www.semanticscholar.org/paper/The-new-new-general-practice%3A-the-changing-of-care.-Livingstone-Widgery/ec638cec4845afad797c2da6d0ea04c9f7977fc0 |language=en |issn=0959-8138}}</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 the large number of available [[ammunition box|ammunition boxes]] 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 |url=https://bjgp.org/content/bjgp/36/282/19.full.pdf}}</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 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 |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 130 mm × 180 mm.<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> Male envelopes have red parameters and females blue.<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 |isbn=978-1-85775-569-5 |url=https://books.google.com/books?id=oPm1eo4JtHcC&pg=PA2 |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=138–138 |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>
+Lloyd George envelopes are beige coloured card wallets and measure 130 mm × 180 mm<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 |isbn=978-1-85775-569-5 |url=https://books.google.com/books?id=oPm1eo4JtHcC&pg=PA2 |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=138–138 |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=Moreton |first1=Philippa |title=The Very Stuff of General Practice |date=1999 |publisher=Radcliffe Publishing |isbn=978-1-85775-390-5 |page=122 |url=https://books.google.com/books?id=NjLErpUeAXQC&pg=PA122|language=en}}</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==
@@ Line 30: / Line 30: @@
 ==Discontinuation==
 [[File:GP records in envelopes.jpg|thumb|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> They 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 |website=pcse.england.nhs.uk |access-date=26 November 2023}}</ref><ref name=People>{{cite web |title=Lloyd George envelope |url=https://peopleshistorynhs.org/museumobjects/lloyd-george-envelope/ |website=People's History of the NHS |access-date=26 November 2023 |date=30 June 2017}}</ref>