Sending patients a copy of the letters that are produced for their referring general practitioners (GPs) from an out-patient consultation is a policy of the UK Department of Health. Little research has been done to establish how patients attending out-patient departments feel about this practice and the effect this may have on the department itself.

We asked 500 patients attending our out-patient department to complete a questionnaire. Patients were only included if they had previously been offered a copy letter by our department.

Of patients, 95% were in favour of the practice and 93.4% understood all or most of the contents of the letter. Dictation in front of the patients made them less likely to request a copy of the letter (P < 0.001). Impact of queries related to the letters was minimal with only three patients making contact with the department during the 3 months that the study was being conducted.

Our experience has shown that copying patients into their GP letters is a useful and popular practice for patients and has little impact on the running of the department. Patients also are in favour of having their letter dictated in their presence and this reduces their need to have a copy sent to them.

Increasing pressure is being brought to bear on NHS hospital departments to begin copying their patients into general practitioner (GP) letters. As part of the UK Department of Health's policy to involve patients in their care and treatment, it has been stated that letters between clinicians about an individual patient's care will be copied to the patient as of right.1 Hospital departments are likely to become obliged to send the patient a copy of any correspondence that is sent to the patient's GP following a consultation. This initiative has its origins in the both the NHS Plan2 and the Kennedy Report of the Public Inquiry into children's heart surgery at the Bristol Royal Infirmary.3

Previous, similar policies have been received with considerable resistance by GPs4,5 as well as specialist clinicians. Some small questionnaire68 and qualitative studies,9 however, indicate that patients are in favour of the practice. The implications for departments implementing this practice has been the subject of concern, particularly the cost implications of sending additional letters6 as well as fielding additional queries from patients regarding the content of the letters. Concern has also been expressed about the fact that the information contained in the letters may not be fully understood by the patients10 and may result in unnecessary distress. Linked to this is the concern that the clinician may need to alter the language used in the letter to make it more understandable to the patient and that the opportunity to deliver a totally accurate assessment of the consultation may be compromised by the need to avoid language that may be misinterpreted by the patient.

Saunders et al.11 showed that receiving copied GP letters increased patient satisfaction in the out-patient department, but little research has been done to determine what patients think of the various aspects of this practice, how the process could be improved and how this impacts on a hospital department that commences this practice.

We set out to determine the attitude the patients attending our ENT out-patient department had towards various aspects of being copied into their GP letters as well as the amount of impact that these letters have on the running of the department.

Patient questionnaire

From 1 November 2005 to 6 February 2006, 500 consecutive patients attending the Royal United Hospital (RUH) ENT outpatient department and fulfilling the inclusion and exclusion criteria, were given a questionnaire to complete (Appendix 1). The patients were asked to fill in the questionnaire and return it to a collection box in the department, or return it to one of the doctors or nurses in clinic.

INCLUSION CRITERIA

  1. Patients who had been seen in the RUH ENT out-patient department during the preceding 2 years during which copy letters were being offered routinely.

  2. Adults or parents of children who were patients.

EXCLUSION CRITERIA

  1. New patients.

  2. Children.

Where patients were unable to complete the questionnaire by themselves, assistance was offered.

Prospective data collection by secretaries

All telephone calls from patients regarding their out-patient attendances were transferred to the medical secretaries in the ENT Department. Each secretary was given a proforma (Appendix 2) to complete for every phone call received that concerned a query about a copied GP letter. These proformas were completed concurrently while the questionnaire part of the study was being conducted.

Receiving and understanding the letter

A total of 500 questionnaires were distributed and 411 completed questionnaires were returned, representing a response rate of 82.2%. Of respondents, 83% accepted the offer of a copy of their GP letter; 10.6% did not receive the letter that they requested. Only five of the patients who received their letters did not read them (2%); of the 241 respondents that did receive and read their letter, 166 (68.9%) understood all of the contents, 59 (24.5%) understood most of it and 16 (6.6%) understood only some of the contents. No patient stated that they did not understand any of the contents of the letter.

It is interesting to note that, of the 332 patients that answered the question, 146 (44%) believed that they should be able to understand all of the contents of the GP letter; a further 136 (41%) thought that they should at least be able to understand most of the contents. Only 45 (13.6%) were happy to be able to understand only some of the letter. No patient thought that they need not be able to understand any of the letter.

Enquires about the letter

Thirty-three patients (13.7% of those that requested and read their letters) reported that they went on to contact someone about their letter. Of these, 22 contacted their GP and 10 contacted the ENT Department; one patient contacted another unspecified professional for advice.

During the course of the study (3 months), the secretaries recorded only three telephone calls or letters regarding patient letters; all concerned the accuracy of the content of the letters and were received within 2 weeks of the appointment that resulted in the generation of the letter. All took less than 5 min to deal with by the secretary and specialist registrar. None had contacted their GP first as they considered this to be a clerical error.

Patients' feelings about the practice

Of respondents, 93% felt that the practice of copying patients into their GP letters helped them to understand their consultation. Overall, 95.5% of patients thought the practice was a good thing, but only 85.1% said that they would request a copy letter at the next consultation.

Dictating in front of the patient

Of the 101 patients that had their clinician dictate their letter in front of them, 49 liked the practice, 4 did not and 48 reported that they did not mind whether or not this was done. Patients who had the letter dictated in front of them were less likely to request a copy of the letter (P < 0.001).

The majority of patients are in favour of being copied into their GP letter; when asked if they wanted a copy of the letter sent to them, most accepted. Although most received the letter that they requested, a significant proportion did not. This is an area that needs further investigation, particularly as the postal service is relied upon to send appointments and results to patients.

It is interesting to note that, although the letters are primarily addressed to the GP with the patient only copied into them, a significant number of patients thought that all of the contents should be understandable when read by them. In our series, most patients were able to understand all or most of the letter copied to them, but it is important to note that expectations of understanding are high and that care should be taken to avoid jargon or difficult language where possible.

It is the practice of two experienced clinicians in our department to dictate the GP letter while the patient is still in the consultation room; this practice was introduced a number of years ago and has been found to be supported by the majority of patients, with a very small minority disliking the practice. Importantly, it would appear that, as this practice is associated with fewer requests for letters by patients, it may increase the understanding that the patient has of the recent consultation. Owing to the wide-spread support for this practice, both by patients and by clinicians, we can recommend its use.

Despite the wide-spread concern that large numbers of patients would contact the ENT Department, only a small number of patients actually contacted anyone about the letter, the majority contacting their GP.

Copying patients into their GP letters is a practice supported by the majority of patients. It appears to have little impact on the running of the department and is likely to add significantly to the understanding that patients have of their consultation. Hospital departments should consider implementing this useful practice.

We would be very grateful if you would take the time to complete this questionnaire to help us evaluate our service. Please answer all the questions that apply to you.

  1. When you went to the receptionist after your last clinic visit, were you offered a copy of the GP letter written at your last appointment?

    Table

    Table

    YES / NO / DON'T KNOW
    If yes, did you accept a copy? YES / NO
    If you did, did you:
     Receive it? YES / NO
     Read it? YES / NO
     Understand it? ALL / MOST / SOME / NONE / DON'T KNOW
     Contact anyone about what it said? YES/NO

    If yes, who? ENT Department / GP / NHS Direct / Other_________________

    Did receiving the letter help you to understand your consultation?

    YES / NO / DON'T KNOW

  2. How much of the contents of a copy of a letter to your GP do you expect to understand?

    ALL / MOST / SOME / NONE / DON'T KNOW

  3. Did the doctor dictate the letter in front of you?

    YES / NO / DON'T KNOW

    If yes, how did you feel about him/her doing so?

    I LIKED IT / IT MADE NO DIFFERENCE TO ME / I DID NOT LIKE IT

  4. Will you request to receive a copy of the GP letter for the appointment you are about to attend?

    YES / NO / DON'T KNOW

  5. Do you think offering patients a copy of their GP letter is a good thing?

    YES / NO / DON'T KNOW

Please place this questionnaire in the envelope provided and hand it to a nurse or doctor in the clinic when you are seen. This information will be kept anonymous; we will not collect any details about you.

Please complete this proforma whenever you receive a call from a patient about a clinic letter that they received

Table

Table

PATIENT DETAILS
Age ......................
Sex M / F
DETAILS OF CALL
Days since OPA that generated letter ...........
Number of OPAs since then ...........
Nature of enquiry ..................................................................................
...................................................................................................
...................................................................................................
Who handled the question? Secretary / SHO / SpR / Consultant / Other
Was another OPA required to deal with an explanation? YES / NO
Had the patient spoken to their GP about the issue? YES / NO
Time taken to complete call _________min
Extra time taken to answer question _________min

The authors would like to thank Mr Robert W Slack FRCS, Consultant Otolaryngologist, for his assistance in the production of this paper, as well as the secretarial, administrative and out-patient nursing staff of the ENT Department at the Royal United Hospital, Bath for their invaluable assistance in their administration of the questionnaire.

We would be very grateful if you would take the time to complete this questionnaire to help us evaluate our service. Please answer all the questions that apply to you.

  1. When you went to the receptionist after your last clinic visit, were you offered a copy of the GP letter written at your last appointment?

    Table

    Table

    YES / NO / DON'T KNOW
    If yes, did you accept a copy? YES / NO
    If you did, did you:
     Receive it? YES / NO
     Read it? YES / NO
     Understand it? ALL / MOST / SOME / NONE / DON'T KNOW
     Contact anyone about what it said? YES/NO

    If yes, who? ENT Department / GP / NHS Direct / Other_________________

    Did receiving the letter help you to understand your consultation?

    YES / NO / DON'T KNOW

  2. How much of the contents of a copy of a letter to your GP do you expect to understand?

    ALL / MOST / SOME / NONE / DON'T KNOW

  3. Did the doctor dictate the letter in front of you?

    YES / NO / DON'T KNOW

    If yes, how did you feel about him/her doing so?

    I LIKED IT / IT MADE NO DIFFERENCE TO ME / I DID NOT LIKE IT

  4. Will you request to receive a copy of the GP letter for the appointment you are about to attend?

    YES / NO / DON'T KNOW

  5. Do you think offering patients a copy of their GP letter is a good thing?

    YES / NO / DON'T KNOW

Please place this questionnaire in the envelope provided and hand it to a nurse or doctor in the clinic when you are seen. This information will be kept anonymous; we will not collect any details about you.

Please complete this proforma whenever you receive a call from a patient about a clinic letter that they received

Table

Table

PATIENT DETAILS
Age ......................
Sex M / F
DETAILS OF CALL
Days since OPA that generated letter ...........
Number of OPAs since then ...........
Nature of enquiry ..................................................................................
...................................................................................................
...................................................................................................
Who handled the question? Secretary / SHO / SpR / Consultant / Other
Was another OPA required to deal with an explanation? YES / NO
Had the patient spoken to their GP about the issue? YES / NO
Time taken to complete call _________min
Extra time taken to answer question _________min
1. Department of Health. Copying letters to patients 2006; <http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/PatientAndPubliclnvolvement/CopyingLettersToPatients/fs/en> [Accessed 22 January 2006). Google Scholar
2. Department of Health. The NHS Plan. 2000; <http://www.dh.gov.uk/assetRoot/04/05/57/83/04055783.pdf>. Google Scholar
3. Kennedy I. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984–1995. (Kennedy Report) 2001; <http://www.bristol-inquiry.org.uk/finaLreport/report/>. Google Scholar
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