Copying referral letters to patients: the views of patients, patient representatives and doctors

doi:10.1016/j.pec.2003.08.003

Patient Education and Counseling

Volume 55, Issue 1, October 2004, Pages 94-98

https://doi.org/10.1016/j.pec.2003.08.003 Get rights and content

Abstract

To discover the views of patients, patient representatives and doctors on copying referral letters to patients. A three-part study: an analysis of 50 GP referral letters against a standard template; 35 patient interviews using a semi-structured questionnaire in outpatient waiting rooms; 3 focus groups of patients, patient representatives and doctors. There was general agreement that copying referral letters to patients could improve information and decision sharing with patients. Copying referral letters could provide an opportunity for patients to correct mistakes, prepare for their appointments and have a personal record that they could keep and show to others. However, there were concerns about letter content, particularly medical terminology, character judgements and ‘sensitive’ patient information. It was also recognised that providing more information to patients could increase patient anxiety. The style and content of some referral letters may need to change. This is particularly relevant where certain types of information included in referral letters could cause distress for patients or influence the time that patients have to wait for their outpatient appointments.

Introduction

The National Health Service (NHS) Plan for UK [1] recommends that from April 2004, letters between clinicians about an individual patient’s care will be copied to patients. Evidence exists that poor communication during the referral process can lead to inappropriate referrals and that lack of adequately communicated information leads to duplication of investigations and longer patient waiting times [2], [3].

Patient leaflets [4], [5], [6], tape recordings of consultations [7], [8], [9], access to patient records [10], [11], [12], and interactive decision aid computer programs [13], [14] have all been found useful by patients in enhancing communication. The copying referral letters to patients initiative shares this aim and it is the first time in UK, the Department of Health has directed that such a communication aid will be obligatory. Relatively little is known about patients’ and doctors’ views on receiving information about referrals through copies of letters from general practitioners to specialists. Some evidence suggests that copying letters to patients can improve communication. A number of studies from secondary care found that copying letters enhanced communication and understanding [15], [16], [17]. However, most of this evidence has come from hospital paediatric clinics where conditions may differ from primary care.

In primary care, a small study of 20 patients who received copies of their referral letters has shown that patients found receiving copies of referral letters improved their understanding of the situation and also their involvement in their own care [18]. Similarly, Hamilton et al. [19] found that copies of referral letters were likely to be considered helpful by patients although they found no effect on attendance rates at hospital outpatient clinics when patients were given a copy of their referral letter. Others have emphasised the importance of patients’ knowledge and understanding of a likely diagnosis, particularly a potential diagnosis of cancer, when optimising referrals from primary care for urgent evaluation [20]. We have therefore undertaken a study to obtain more information about the views of patients, patient representatives and doctors on this topic.

Section snippets

Methods and patients

In the first part of the study, a total of 50 randomly selected and anonymised referral letters from two general practice clinics (RJ and PW) were examined for content against a set of pre-specified criteria based on the recommendations of previous research (Table 1) [21]. We used the results of this analysis to develop a questionnaire designed to investigate patients’ knowledge and understanding of their referral. This questionnaire was used in semi-structured interviews with 35 patients who

Referral letters

Table 2 shows the results of the analysis of the referral letters. All the referral letters specified a clinical problem for which the referral was being made but only 25 (50%) gave information about a specific or differential diagnosis and only 1 letter (2%) mentioned the information that had been given to the patient about the investigation, diagnosis and likely treatment of their problem.

Patient interviews

Table 3 shows a summary of the results of the outpatient interviews. The majority of patients reported

Discussion and conclusion

Our findings that some patients valued receiving copies of their referral letters fits with previous research accounts [15], [16], [17], [18], [19]. However, we found no evidence of this taking place in practice, and our patients did not know that it was possible to request a copy of their referral letter except during complaints procedures, and private or emergency referrals.

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Citation Excerpt :
The same study, however, found that health professional views were very different, with 90% of the interviewed GPs and consultants having concerns that copying letters would “take time, cost money and bring few benefits”.13 There have also been concerns that GP referral letters have an increased potential to add anxiety, as the possibility of serious diagnoses may be raised for the first time, and that anxiety may be amplified due to the long waiting times patients often have before their outpatient appointment.14 However, this same study showed that the patients highly valued the letters and believed that the letter would give them an opportunity to prepare useful questions for their outpatient appointment.14
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The response rate was 68%. Ninety four percent of the responders believed receiving a copy of the letter was a good reinforcement of the information they received at the consultation. Ninety three percent of responders also found being copied into correspondence helpful and 96% understood the contents of the letters. Ninety seven percent wished to receive more letters in the future.
These results suggest that vascular surgery patients both value and understand clinic letters, and that health professionals should consider adopting this practice into their vascular outpatient clinics.
Where have all the copy letters gone? A review of current practice in professional-patient correspondence
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This article reviews the literature in relation to patients receiving copies of health professional correspondence. It examines progress in adopting the practice 3 years on from its introduction as policy in the UK, and considers potential benefits and obstacles to implementation.
A review of the literature on copy correspondence, accessed via Medline, PubMed, CINAHL and also online resources, using the search terms “patient letter”, “copy letter”, “copy correspondence” and “doctor letter”.
Studies describe a range of benefits from copying letters, but implementation remains inconsistent, ranging from 8 to 87% of patients reporting receiving copy correspondence. A number of concerns are identified which may be delaying whole scale adoption of the policy by health professionals.
This review suggests that researchers should move from examining the benefits and concerns around copying letters to patients, and instead focus on exploring the quality of correspondence and the optimum process of implementing the practice. As patients can “opt out” of receiving copy correspondence, audit of service delivery may be better assessed by whether patients have been offered a letter, rather than the current measure of whether one has been received.
Copying letters to patients may have a number of important benefits and should be routine practice where patients wish to receive correspondence. Further discussion regarding the style and content of letters would be beneficial, together with attention paid to the mechanisms for recording patient preference. There is also a need for studies in non-medical professions.
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View full text

Copying referral letters to patients: the views of patients, patient representatives and doctors

Abstract

Introduction

Section snippets

Methods and patients

Referral letters

Patient interviews

Discussion and conclusion

Ann. Oncol

Avoidable referrals? Analysis of 170 consecutive referrals to secondary care

Br. Med. J

Referral for ‘prostatism’: developing a ‘performance indicator’ for the threshold between primary and secondary care?

Fam. Pract

Effects of written drug information on patient knowledge and compliance: a literature review

AJPH

Written advice: compliance and recall

J. R. Coll. Gen. Pract

Randomised controlled trial of self management leaflets and booklets for minor illness provided by post

Br. Med. J

Consultation audio-tapes: an information aid, and a quality assurance and research tool

Support. Care Cancer

Cancer and communication: information-giving in an oncology clinic

Br. Med. J

Our patients have access to their medical records

Br. Med. J