A clinic letter from a paediatric surgeon hit the headlines recently. Written to the child’s GP and copied to her parents, it began “Thank you for referring this lovely young lady… Unfortunately her mum could not be at the clinic visit today as she has not been well and father stepped in manfully”. The parents were taken aback by the wording, which they regarded as “archaic and sexist.”
Reaction in the press has focussed on the sexist angle but, in our opinion, this misses the main point. Writing the clinic letter to the GP is like talking about someone behind their back. We shouldn’t be surprised if sometimes patients get offended by reading what is being said about them. Why wasn’t the letter written directly to the patient, and her parents, and copied to the GP?
Back in 2000, the NHS Plan recommended that “patients should as of right receive copies of all correspondence between health professionals about their care.” The NHS Constitution (2015) states that patients “have the right to be given information about the test and treatment options available to [them], what they involve and their risks and benefits” and have “the right of access to [their] own health records and to have any factual inaccuracies corrected.” In addition staff should aim to “involve patients, their families, carers or representatives fully in decisions about prevention, diagnosis, and their individual care and treatment.”
Initial concerns that copying letters to patients would cause problems with consent, confidentiality, cost, and anxiety have been shown to be largely unfounded and the practice is increasingly widespread. [1] However, some clinicians have felt that copying the GP letter to the patient does not go far enough and have started writing the clinic letter directly to the patient and copying this to the GP. This practice has been common in clinical genetics for many years. [2] Concerns about how to explain medical issues clearly and accurately in plain English have been overcome without any great difficulty. The information content does not need to be “watered down” and, if necessary, medical and technical details are laid out in a separate section. Such letters are highly valued by patients and usually preferred by GPs, who find them easier to understand. [3-5]
Writing letters directly to the patient has prompted doctors to rethink the way they carry out the consultation. Having to gather one’s thoughts to construct a letter that is readily understood, informative, and educational reinforces the role of the doctor as educator and helps focus the discussion on the issues that matter most to the patient.
However, writing letters directly to patients does require some retraining and new learning. The letters need to be easily readable, which can be measured using measurement tools such as the Flesch Reading Ease score. They are also an opportunity to try out different ways of explaining the natural history of disease, risk, prognosis, and treatment to the patient and to other clinicians [6].
The proposal that “all out-patient letters and discharge summaries that are currently written to GPs and copied to patients should be revised and written directly to patients with a copy to the GP” has been adopted as a quality improvement project by the Academy of Medical Royal Colleges. A working party is developing generic guidance that can be developed by individual colleges according to the needs of their specialities. The planning team contains representatives from patient organisations as well as from General Practice and Secondary Care. The aim is to incorporate training and assessment of the skills and attitudes required for writing appropriate letters to patients in all post-graduate curricula.
Good Medical Practice (2013) states: “You must give patients the information they want or need to know in a way they can understand.” This academy project will contribute to the ongoing review of Outcomes for Graduates; the document produced by the General Medical Council that sets out the knowledge, skills and behaviours that new UK medical graduates require to meet the standards set out in Good Medical Practice.
The time has come for all doctors in both primary and secondary care to ensure that they put the patient at the centre of care by writing their letters directly to them. We are delighted that the Academy of Medical Royal Colleges is leading the way on this.
Hugh Rayner, consultant nephrologist, Heart of England NHS Foundation Trust.
Nigel Mathers, emeritus professor of Primary Medical Care, University of Sheffield.
Robina Shah, senior lecturer, University of Manchester, Chair UK Patients and Carers Partnership Group.
Competing interests: None declared.
References:
- http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4086054.pdf.
- Baker, D. L., Eash, T., Schuette, J. L., & Uhlmann, W. R. (2002). Guidelines for writing letters to patients. Journal of Genetic Counseling, 11(5), 399.
- O’Reilly M, Cahill MR, Perry IJ. Writing to patients: a randomised controlled trial. Clinical Medicine 2006; 6: 178-82.
- Jenny Taylor, Hugh Rayner, Steve Smith. Writing letters to patients. British Journal of Renal Medicine 2013; Vol 18 No 1 Supplement P21. Available at http://www.wmrn.co.uk/assets/BJRM-Shared%20Decision%20Making.pdf
- https://www.rcplondon.ac.uk/news/writing-letters-patients-what-s-big-deal
- Trevena LJ, Davey HM, Barratt A, Butow P, Caldwell P. A systematic review on communicating with patients about evidence. Journal of Evaluation in Clinical Practice 2006; 12: 13-23.