Does a business-like letter written for a general practitioner meet the standards for patients?

AIMS AND METHOD

To gauge the acceptability of copying a business-like clinicletter for general practitioners, written by a doctor workingin the Newbury Community Mental Health Team for Older Adults.Between August 2004 and March 2006 every letter written byeach doctor was stored electronically. The letters contained a clear statement of the diagnosis, the active problems anda bullet-point care plan. Any concerns or reactions to theletters were documented as they were received. Between Septemberand October 2006, 50 service user or carer recipients of theletters were sent a questionnaire, checking whether the lettermet standards of clarity, helpfulness and content.

RESULTS

Over 20 months 427 service users and carers received a totalof 731 letters. One carer asked for the letter not to be sentin future; four carers asked for details of the letter to bemodified; in only one was the content of the letter to thegeneral practitioner modified before it was sent to the serviceuser. The questionnaire about the suitability of the clinicletter had a 90% reply rate and all respondents said the letterswere clear, understandable and that their content was of nosurprise to them.

CLINICAL IMPLICATIONS

This report of a successful use of a frank business-like lettercopied to service users or carers should be understood in thecontext of the following factors: the doctor who wrote themwas familiar with and confident about the clinical work andcomfortable with the style of the letter; he had a good rapportwith a generally well-educated population and positive supportfrom his colleagues. With these factors in place, the directstyle of the letter was well received by patients and carers.

Introduction

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Introduction

It is good practice for patients to receive their clinical correspondence (Boaden & Harris, 2005) and despite objections (Huline-Dickens, 2004;Sturge, 2004) it is gradually becoming routine practice inmental healthcare (Department of Health, 2003; Lask, 2004) and is welcomed by patients (Lloyd, 2004; Okolo, 2004; Marzanski et al, 2005; Uher & Timehin, 2006). However, it still generates anxietyamong psychiatrists for a variety of reasons (Thair et al, 2005;Combe et al, 2006). For one thing, there is a question of whatstyle to adopt with the letters and whether or not they shoulddiffer from the ones sent to the general practitioner (Nandhra et al, 2004).Also, are there situations where information should be withheldfrom patients? For example, should upsetting diagnoses such as dementia be concealed from service users (Wald et al, 2003)? These questions are open to debate and this brief report describesone doctor’s experience of copying over 700 letters thatused a frank, direct style to service users of a communitymental health team for older adults.

There are certain requirements that all such letters need tomeet (Royal College of Psychiatrists, 2004): information shouldbe accurate and understandable; the letter should not be unnecessarilydistressing to the recipient, nor should it contain surprisinginformation of which they were previously unaware; the serviceuser or an appropriate carer should give consent to the receiptof the letter.

In Berkshire Health Care Trust there is organisational momentumbehind information sharing including the copying of lettersto service users. The success of copying letters relies onan open and clear clinical engagement, so that the letter isno more than a reminder of everything that has been discussedduring clinical contact. The workload of the author would bereduced by drafting only one letter, suitable both for thegeneral practitioner and service user (Spiessl et al, 2006).

In our study, we had three main goals. We wanted to keep prospective information about all letters sent to general practitionersand check how many of them were copied to patients. We alsowanted to record any difficulties encountered as a result ofcopying the letters to service users or their carers and checkthe acceptability of the letters to their recipients.

Method

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Method

Between August 2004 and March 2006, 747 letters concerning 443service users were sent to general practitioners by the NewburyCommunity Mental Health Team (CMHT) for older adults. It wasintended that all service users or, where more appropriate,carers, received a copy of the letter. Before any letters weresent out their style was agreed upon: business-like; aimingto give clear and accurate information; patient copy was tobe the same as the general practitioner’s copy; standardstructure (Box 1).

If the letter was to be copied to anyone else, such as socialservices, then permission from the service user was also sought.If the plan for further action made reference to nursing colleaguesor other professionals, the importance of everyone involvedin the case receiving the letter was emphasised. Finally, verbalconsent for receipt of the letter by service user or carerwas taken.

The decision to send the letter to either the service user orthe carer was based on discussion with the doctor and commonsense. There were four common scenarios. First, competencewas assumed for all patients and, unless there was evidenceto the contrary, the doctor suggested that they should receivea copy of their clinical letter. Second, in those cases wherethere was established significant cognitive impairment thatwould prevent the user understanding and benefiting from theletter, they were asked if they were happy for the correspondenceto be sent to an appropriate carer. Third, in individuals withadvanced cognitive decline who lacked capacity to consent to the letter being presented to someone else, it was offeredto a carer without consulting the user. Finally, there wasa small minority of clients who did not fit into the firstthree categories, and in these cases the destination of theletter was discussed with the client and their carers.

If a service user wanted to have the letter sent to other peoplethan their carers, it was explained that they were free todo so, but that they were responsible for the confidentialityof its contents and the cost of copying and posting additionalletters.

A great effort was made to inform colleagues that the serviceuser/carer was also receiving the clinical correspondence.When areas of contention surfaced during the interview, suchas the effect of alcohol misuse or the diagnosis of dementia,the doctor discussed this as fully as possible with the user/carerand explained that the recipient may disagree with this particular point in the letter. The letter always concluded with a clearstatement inviting the reader to contact the CMHT to discussits content (Treloar & Adamis, 2005).

For 50 consecutive letters sent out during September and October2005 a questionnaire (Box 2) was enclosed to obtain the recipient’sviews of the letter.

Results

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Results

Those who refused the letter
Of the 747 people who were offered a letter, 14 service usersrefused to receive it; in each of these cases the user sawthe doctor on only one occasion. Eight service users/carersinitially refused the letter but on meeting the doctor fora second time they accepted it and received copies of previouslyrefused letters. Two service users were unable to consent andhad no suitable carer or relative to give a letter to. Twenty-oneservice users were initially ‘missed’ - all eventuallyreceived a copy of their letters.

Box 1. Letter structure

Statement of when and why the serviceuser came to the service and who accompanied them

Diagnosis(using ICD-10; in case of uncertainty the diagnosis would be classified as tentative or provisional)

Active problems

Currentlevel of functioning and support

Current medication

Lettersconcerning initial assessments would include relevant background such as past psychiatric history, family history, past medicalhistory and personal history

A brief summary of the overallsituation

A bullet-point plan, stating who was responsiblefor each part

Recipients

Subotsky, 2005

Those who accepted the letter
In total, over the 20 months of the duration of the study, 731letters about 427 service users were sent out; 199 were sentto service users and 532 to carers. Of those sent to carers,474 were sent to family members and 58 to friends of the serviceuser. The diagnosis given to service users and clearly statedin the letter, as well as the list of the recipients, is setout in the online Tables DS1 and DS2.

Box 2. Questionnaire on the quality of the letter
QUALITYOF CLINICAL LETTER YOU HAVE RECEIVED
Thank you for taking timeto fill in this questionnaire about the letter you have received.To help us maintain and improve the standard of the letters sent to service users or their carers could you please circlea response to each question.

Did the letter contain inaccurateinformation? Yes No
If yes, please write here what the mistakeswere.

Was the letter clear? Yes No
Please write here any termsthat you could not understand.

Did the specialist tell youthat you would receive the letter? Yes No

Did you find theletter useful?
Very useful Quite Useful Of little use Of nouse

Was there anything in the letter that you had not discussedwith the doctor in the clinic? Yes No
If yes, please writehere what it was.

Did the letter miss out any information?Yes No
Please write here anything that you would have likedto be in the letter.

If you wanted to discuss the letter doyou know how to contact an appropriate person? Yes No

Wasthe letter upsetting instead of helpful? Yes No
Any other commentsyou would wish to make:

Questionnaire
In September and October 2006, 50 questionnaires were sent outto service users/carers; 45 were returned without promptingor sending the questionnaire again. This very high responserate was probably due to appreciation of the letter and itsnovelty - the recipients were both pleased and surprised to receive it and they responded in kind. One letter containedinaccurate biographical details, but on the whole the letterswere accurate. All respondents said the letter was clear. Theyknew from the specialist they consulted that they would receiveit; no information was was missed (Box 1, question 6); recipients knew who to contact if they were concerned about it; and therewas no unexpected or upsetting material in the letter. For32 respondents the letter was ‘very useful’ andfor 13 it was ‘quite useful’. Other comments weregeneral thanks for the letter, statements that it reassuredrecipients that they had been listened to and, paradoxically,that its value was undermined by having known its contentsbefore receiving it. Though the questionnaire was anonymous,responders may have felt constrained from adding additionalinformation for fear of being readily identifiable. This mayhave prevented a full and honest response to the letters andthis should be taken into consideration when interpreting thefindings.

Corrections
There were four letters where the recipients asked for changesto be made. In response to two letters, carers challenged theaccount of cognitive decline believing that the letter exaggeratedthe symptoms. In neither case were the diagnoses challengedand there was no breakdown in the therapeutic relationship,with clinical contact carrying on as normal. In reply, the doctorwrote a new letter highlighting the concern raised and at subsequent visits time was spent agreeing the severity of the symptomsof cognitive impairment that were to be recorded in the casenotes and the letter.

One carer and one service user asked to correct biographicaldetails. For one it related to the professional grade thatthe patient’s father had reached during his working lifeand for the second it was the length of time that the serviceuser had lived in their current accommodation. In both cases apologies were expressed and corrected correspondence was sentout to the general practitioner and the user.

Modification of content
Only one letter had the content modified in comparison to theone sent to the general practitioner. At the request of a familycarer, third-party information was removed from a letter thata service user received.

Reaction to the letter
The reaction to the letters was generally positive and onlyone carer, of a person with Alzheimer’s disease, askedthat the letter not be sent in future, as it upset the serviceuser. The only terms that needed clarification in the letterwere the acronyms: MMSE (Mini Mental State Examination); BADLS (Bristol Activities of Daily Living Scale) and DemTect (a screeningtool for cognitive impairment; Kalbe et al, 2004), but thesewere explained to recipients by the professionals who administeredthese instruments before sending out the letter.

Author’s impression
The clear sustained response to the letters was that of appreciation. Service users and their carers, when motivated, readily understood correspondence that was primarily written for general practitioners.Ensuring all aspects of the care plan progressed as plannedwas easier because, once armed with the correspondence, theservice user/carer would contact the CMHT to ask why they hadnot received a radiology appointment or a visit from socialservices. Though this was embarrassing if it turned out thatthe request for the service had not been sent off, it was infinitelybetter than appearing at the next clinical appointment withoutthe intended report.

The letters also reduced splitting within families and betweenteam members (Cape et al, 2005). The clear statements of thediagnosis, problems and care plan prevented users/carers havingfalse expectations. Though the diagnosis can often be upsetting,the recipients appreciated that a clear statement of the diagnosis from a doctor gained them access to support services.

Discussion

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Discussion

Sending clinical correspondence to service users should be promotedas good practice for all clinical and social contexts. Thisreport shows that the service users of the Newbury CMHT forolder adults appreciated clear and direct information abouttheir diagnosis, problems and care plan. The style of the letterused is acceptable to service users and carers, and can be usedfor both general practitioner and user. However, owing to itslimitations, this study is insufficient to answer many of thequestions surrounding copying letters to patients (Sawhey et al, 2007).In this report, all those who received the letters spoke Englishas their first language; the level of education among the populationwas generally high and almost all had reasonable expectationsof what mental health and social services could provide. Itwas relatively easy to develop rapport and a respectful opentwo-way therapeutic relationship with service users and theircarers, which fitted with the style of the letter. The doctorhad known the team he was working with for over 2 years andthus it was easy to ensure their cooperation during the study.

To improve the practice of copying clinical correspondence toall service users, reports from the full array of clinicaland social contexts are required. Different subspecialtiesand different social groups, such as non-English speakers,ethnic minorities and those with limited educational attainment,potentially present different challenges not met in the population who received the letters in this report. Novel and successfulapproaches to dealing with copying clinical correspondenceto patients should be reported so that clinical teams can adoptproven, suitable strategies. This should include methods oftraining and supervising inexperienced clinicians in what is expected of letters sent to service users and their carers.

References

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