‘Why we’re urging hospitals to address patients – not GPs’

Dr Hugh Rayner argues the case for specialists to write directly to patients – not GPs – as the Academy of Medical Royal Colleges publishes new guidance for clinicians to improve communication

Poor communication is at the heart of a large proportion of complaints from patients. Those who experience it report that their confidence in the NHS as a whole is undermined.

The Academy of Medical Royal Colleges has published ‘Please, write to me’, updating its guidance published in 2018. This document sets out the major benefits to be gained from hospital doctors writing directly to patients and gives detailed guidance about how to do it well.

Writing directly to patients has been endorsed by NICE and previously adopted as Government and NHS policy and we believe it is one simple and inexpensive way that this problem can be addressed.

The idea itself is not new. When patients first began routinely receiving copies of clinic letters in the early 2000s – as laid out in the Labour Government’s new plan for the NHS – a colleague of mine observed that medicine was unusual among professions in the way it did not write directly to the person concerned: the patient. As he put it, a lawyer or estate agent would write to you, not about you. The question then became: why not do the same in healthcare?

My first instinct when considering writing to patients was that GPs would not welcome it. To test this, we piloted the approach in our renal department. Over six months 1,099 letters were sent directly to patients under the care of 374 GPs in 201 practices. The GP received a copy, and both letters included a reply envelope asking for feedback.

The response was striking. We received almost universal positivity from patients – bar one man who felt it was a waste of a stamp. To my surprise, GPs were similarly supportive. Many told us it made their lives easier. I had not appreciated that previously patients would book appointments specifically to ask the GP to explain the content of the letter written about them.

Writing to patients is not about ‘dumbing down’ clinical content but clarifying it. The same clinical information is included, but it is expressed in a way that makes clear what was discussed, what has been agreed, who is responsible for next steps, and what the patient should do if they have questions. Examples are given throughout the guidance. In contrast, traditional letters often function more as records for the clinicians and can leave both patients and GPs having to extract what matters.

GPs complain about how responsibility for patient management is often poorly communicated between secondary and primary care. These issues are also addressed in the guidance.

Medical jargon and abbreviations can be included but must be explained in plain English. Care must be taken with some words that have different meanings in medical and lay usage. For example, to a doctor, ‘chronic’ simply means long-term, whereas to a patient it means really bad.

The increasing use of AI-scribe software has made it easier to generate documents that patients are more able to understand. The need for safeguards around using AI are included in the guidance.

These technologies can produce a letter from a recording of the consultation that is, tailored to a specified reading level or format. Special interest groups with differing needs should be involved in their development to ensure that documents are accessible and appropriate.

Since 2018, hospital doctors who have started writing directly to patients report how positive the effect on their communication has been. The challenge now is to make this practice the norm rather than the exception.

I believe one reason why the practice has not spread widely is cultural. Some clinicians remain unconvinced there is a problem with their current modes of communication and are more comfortable using familiar medical language. Others worry that their authority and expertise will be undermined and are not confident that they have the skills needed to do it safely. In practice, those who adopt this approach often find it is easier than they had feared and that their consultations improve, with clearer, more collaborative conversations.

Two developments are needed to help the practice spread. First, education about how to write directly to patients should be included in the teaching programmes for all undergraduates and trainee doctors.

Some medical schools are already doing this, recognising that writing to patients is a skill that must be taught rather than assumed. As AI tools become embedded in practice, training in how to control and improve the quality of AI-generated content is essential for doctors to use it responsibly.

Second, care quality regulators such as the CQC and the National Quality Board, should require hospital trusts to report data by clinical department on whether clinic letters and discharge summaries are routinely written directly to patients. Patients would then be able to see where good practice exists and where change is needed. If adoption was monitored transparently, variation between organisations could be reduced and the current postcode lottery addressed.

Back in 2018, support from GPs and the RCGP was instrumental in producing the ‘Please write to me’ guidance. We at the AoMRC are now encouraging GP practices and commissioners to lobby their local hospital trust leadership on behalf of their patients to finally get writing to patients adopted in their area.

Dr Hugh Rayner is a retired consultant physician and nephrologist and was a medical director for a trust in Birmingham. He chaired the AoMRC working group that developed the ‘Please, write to me’ guidance.