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Copying letters to patients – benefits and practicalities

The Government ordered all GP practices to copy referral letters

to patients from April 1, but the vast majority have failed to do so – Dr Brian Fisher examines some

of the scheme's pros and cons

Our practice has been allowing patients access to their medical records for years. Our experience of this, and the evidence from the copying letters to patients pilots conducted at 12 sites, has convinced us this process is safe and helpful to health professionals and patients. But some important practicalities of the process remain unsolved.

Policy background

In 2000, the NHS Plan said the following: 'Patients will...have the option of having much greater information about the treatment that is being planned for them...letters between clinicians about an individual patient's care will be copied to the patient as of right.' Full implementation of the policy was expected by April 2004 but the vast majority of practices have failed to act.

Studies have almost all been positive about the outcomes of this process. Benefits include providing written notes, summaries and shared records, improving outcomes and helping patients understand and retain information about their condition. Sending a copy of hospital letters to the patient results in high satisfaction among them and feelings of being 'fully consulted and treated as an intelligent adult'.

Summary letters can clarify what has been said, avoid confusion and lessen the risk of conflicting advice. The patient has a record of what has been said to back up the information given in the consultation.

Organisational benefits

Patients correcting information in letters Important as patients' records are notoriously inaccurate and incomplete. At the point of referral, agreeing an understanding about the reason for the referral saves mutual frustration and wasted time, and may sometimes save the referral itself.

Hospitals receiving letters from GPs

A number of benefits have been identified:

lthe hospital doctor knows what the patient's expectations are

lthe patient knows what they are to do – the management plan is more likely to be carried out, reducing wasted follow-up appointments

lpatients respond positively to the change in the relationship – this is extremely rewarding and good for morale

lthe doctor knows the patient is aware if the letter contains any possibly sensitive information

lletters that have been shared with the patient are generally better in style and content than those that have not – this improves the quality of information exchange between clinicians.

Benefits for GPs receiving letters from hospital doctors

lGPs may not be familiar with all the terms used in specialists' letters and plain English and explanation can be very helpful for them too. lThey know what the patient expects and understands about diagnosis, prognosis, management and follow-up.

lPatients do not need to come to the GP to find out what the consultant said.

Practicalities of setting up copying letters system at your practice

lStart small and take a systematic, incremental approach, eg just copy letters from one partner to start with.

lBuild on current practice.

lInvolve all of your team, especially secretaries.

lInterpret letter sharing in a way that works for you and your patients.

lLet people know what you intend to do.

lBuild in an evaluation by patients and colleagues.

A helpful website summarising a lot of this can be found at: www.4ps.com/programmes/ lettersharing/index.htm

Another approach

The PAERS system allows patients to see their medical records electronically on a touch screen in the waiting room. To meet the requirements of the copying letters initiative, letters must be scanned on to the practice system. PAERS will not support those who have difficulty getting to the surgery, but it is very acceptable to the vast majority of patients. More information: www.paers.net

The cost both in terms of time and money cannot be ignored and an economic evaluation of the copying letters initiative in a Leeds practice, one of the copying letters pilot sites, estimated the national cost of the programme to a UK GP partner making an average number of referrals to be £609 per annum and the cost to UK primary care to be £15 million per annum.

Letters going astray or being seen

by the wrong people This can happen but it seems to be a fairly rare occurrence.

Information about a third party included in patient's referral letters cannot be seen by the patient – systems in the practice need to ensure that.

Litigation is an expressed concern.

The evidence is that this process and that of record access does not lead to more litigation. Indeed the increase in satisfaction and communication is likely to make litigation less likely.

Extra time There is conflicting evidence about this. Some studies suggesting it takes longer to ensure a clear letter and copy it, others suggesting it takes no longer than normal.

Language is a problem in two main ways First, there is a concern for those who cannot read English for whom a tape might be more helpful (personal communication).

The second issue is the way the letters are written: although their prime aim is to transmit accurate information between professionals, there is extensive experience to show that writing the letters in a more basic way allows access without reducing accuracy. Also a template format (which would suit e-booking in any case) may be helpful.

Fear of letting patients into the inner sanctum of our thoughts is a big issue. There is evidence that we find truth a dangerous resource and we worry that we will be viewed dimly by patients if they see us in this raw light. Again, the evidence is reassuring. Patients gain trust and confidence in the profession following record access.

Brian Fisher is a GP and PEC member of Lewisham PCT

and was a member of the Government's copying letters

to patients working group

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