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 in relation to content and style. This has prompted MDDUS to consider the risks that members face, both those working 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 which in some cases can be serious. Following on there may be complaints (both NHS and GMC), negligence claims and fatal accident inquiries or coroner’s inquests. Significant or repeated failures on the part of hospital doctors to produce appropriate quality letters in a timely fashion can also lead to hospital disciplinary inquires.
Because these letters are so important they have been the focus of particular attention and last month the Academy of Medical Royal Colleges (AoMRC) published guidance: Please, write to me: Writing outpatient clinic letters to patients. In the guidance the AoMRC states that best practice now is for doctors to write most of their outpatient letters directly to patients and to copy in their GP. This provides information in a way that is in line with GMC guidance, wider professional guidelines and legal requirements. In addition it has been shown to lead to better 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".
The guidance also advocates using simplified language and avoiding complex medical terms or Latin abbreviations. This improves doctor-patient understanding and helps to avoid errors: for example if there is a typo or mistake the patient will see this and can take steps to have it corrected. 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 line with NHS contractual requirements in England: "The provider must send the Clinic Letter as soon as reasonable practicable and in any event within 10 days (with effect from April 2018, within 7 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 (para 15) 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 also states: "You must give patients the information they want or need to know in a way they can understand…".
Note that the term "must" is used by the GMC which indicates "an overriding duty or principle".
- Remember that clear/comprehensible outpatient letters are of vital importance for safe patient care.
- Ensure you are aware of current 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