SAFE care requires clear and prompt communication between primary and secondary care. Failures in communication between sectors underlie many complaints and claims for negligence. Writing outpatient clinic letters is a topic that has generated a recent spate of guidance and this has prompted MDDUS to consider the risks that members face, both in a hospital setting and in primary care.
Generating outpatient letters undoubtedly requires skill, time and care. It is essential that they provide accurate and unambiguous information to the patient and GP. Poor quality clinic letters can lead to failures to clearly address specific clinical questions or set out the necessary action required regarding onward referral, follow-up, additional investigations or changes to medication. This can then lead to delays/failure to investigate or amend treatment, resulting in patient harm.
Following on there may be complaints, GMC investigations, negligence claims and fatal accident inquiries or coroner’s inquests. Significant or repeated failures by hospital doctors to produce appropriate quality letters in a timely fashion can also lead to hospital disciplinary action.
As these letters are so important, they have been the focus of particular attention and recently the Academy of Medical Royal Colleges (AoMRC) published guidance: Please, write to me: Writing outpatient clinic letters to patients. In it the AoMRC advises doctors to write most of their outpatient letters directly to patients and to copy in their GP. This provides information in a way that complies with GMC guidance, wider professional guidelines and legal requirements. It has also been shown to improve communication with patients and clinical colleagues.
The AoMRC says: “GPs find the letters easier to understand and spend less time interpreting the contents for the patient”. Such an approach also avoids the awkwardness of writing about patients in the third person and can help avoid errors: for example if there is a mistake in a letter the patient can take steps to have it corrected.
The new guidance advocates using simplified language and avoiding complex medical terms: for example, writing ‘kidney’ instead of ‘renal’ and clearly explaining the meaning of technical terms or acronyms such as ‘atrial fibrillation’ or ‘CRT-D’. Latin phrases such as ‘bd’ should be avoided in favour of their plain English equivalent (‘twice daily’), and any medication changes should be highlighted in bold.
A clearer writing style will also mean that patients can more easily share information with relatives and carers. While doctors may initially spend more time writing letters in the new style, the Academy says they will quickly adjust and may find improvements to the way they communicate with patients during consultations as a result.
The AoMRC document also provides useful examples of patient feedback, letter structure and the appropriate use of plain English. From an MDDUS perspective, anything that improves communication in this area is to be welcomed.
The guidance from AoMRC is in line with that from the Professional Records Standards Body, which must be followed in accordance with NHS contractual requirements in England: “The provider must send the Clinic Letter as soon as reasonably practicable and in any event within 10 days (with effect from April 2018, within seven days)”. These standards are necessary for safe and effective clinical care and to fulfil professional responsibilities.
Whilst the contractual obligation refers to England, this is nonetheless a useful guide for any practitioner. Whilst the GMC does not comment specifically on outpatient letters, there is abundant guidance about appropriate standards for communication with patients and colleagues. Good Medical Practice states: “You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must… promptly provide or arrange suitable advice, investigations or treatment where necessary”. It adds: “You must give patients the information they want or need to know in a way they can understand”.
Read the full AoMRC guidance
ACTION • Clear/comprehensible outpatient letters are vital for safe care.
• Stay up-to-date with good practice guidelines. • Take steps to check that your letters meet these standards and continue to do so.
Dr Gail Gilmartin is a medical and risk adviser at MDDUS