Provided that clinical correspondence is objective and factually correct, copying it to patients should hold no fears, says Dr Gerard Panting of the MPS
One of the many proposals in the NHS Plan was to copy correspondence between clinicians to patients as a matter of course. However, three years into the 10-year programme of reform, implementation of this idea can at best be described as patchy, despite the fact that it would be relatively easy to achieve.
So what are the pros and cons of allowing patients access to clinical correspondence?
The obvious downside is the cost of extra copies, postage and administration but this is unlikely to have a great impact on the total NHS budget.
Some may argue that the style and content of correspondence would have to change; that legitimate but unproven concerns about malignancy or other serious conditions would have to be omitted, no mention could be made of self-inflicted injury, and comments on non-compliance, poor compliance, threatening or violent behaviour would have to be excluded.
However, patients have a right to know why a particular investigation is proposed, and the potential risks; it is part of informed consent. The only justification for withholding information would be if it were likely to cause severe harm to a patient’s mental or physical health, but such circumstances are rare. Where withholding information can be justified, a telephone call can correct any deficiencies in the correspondence.
Non-compliance and failure to attend outpatient appointments are important issues, so clinicians should not be afraid to inform patients that they are aware this is happening. Patients may not like what is written about them and may even complain, but provided the comments are true and objectively phrased, they will be entirely justifiable, and possibly do some good. Individuals are unlikely to change unless they are aware of the impact of their behaviour on themselves and others.
The same may apply to threatening behaviour and in the case of actual violence, the police should normally be informed.
Some clinicians may regret lost opportunities for humour. For example, one rheumatologist wrote back to a referring GP, ‘Thank you for letting me see your French mistress.’ The patient was in fact a French teacher at a local school who did not see the funny side.
Letters that make fun of the patient or his or her family may be cathartic for the doctor, but they have no place in modern practice. For example: ‘Thank you for asking me to see the above patient at home last evening. I have now met her husband and two children and their pet rabbit and can confirm that of the five of them, the rabbit is by far the most intelligent…’. Writing comments that could be taken as insults would almost certainly result in censure by the GMC.
Another risk is that sending copy letters to patients may result in inadvertent disclosure to third parties. Mix-ups with blood transfusions, drugs and surgeons performing the wrong operations all demonstrate how easy it is for administrative errors to occur.
If clinical correspondence is routinely copied to patients, particular care needs to be taken that it is sent to the right person, not someone with a similar name, particularly, for example, if two relatives living at the same address have the same name.
All correspondence should be marked ‘private and confidential’. Email may be used provided the patient is able to confirm that no-one else has access to his or her inbox.
One advantage is that the patient will have written confirmation as to what has taken place in the consultation with the GP or specialist. Numerous studies have demonstrated how little patients retain after seeing their doctor, especially if anxious or distressed.
The clinical correspondence offers an opportunity to record the history, examination findings and any proposed investigations and why they are considered appropriate, as well as advice on management, giving medication, warnings about important side-effects, follow-up arrangements and anything else the patient was informed about. It provides an opportunity to reinforce key messages as well as promoting objectivity and openness. But the letter can only be a reinforcement of what has occurred in the consultation, not a substitute for discussion.
Having seen the correspondence, the patient is empowered and with empowerment comes responsibility. To date it has been rare for the courts to find that a patient has contributed to the substandard care he or she has received. However, with clear evidence in the correspondence that a patient was informed about potential adverse effects, symptoms to report urgently, and the need for further investigations or follow-up, the patient’s responsibilities and whether they complied will be more obvious.
In addition, letters dictated immediately after a consultation, especially with reference to contemporaneous notes, are of considerable evidential value in themselves.
Setting out everything in black and white also provides the patient with an opportunity to correct inaccuracies, some of which may be relevant to clinical care. This can work in the doctor’s favour, both when he or she has recorded a fact incorrectly and when the patient has attempted to mislead the doctor.
Provided that clinical correspondence is factually correct, objective and worthy of independent scrutiny, copying it to patients should hold no fears and has potential advantages. Some adjustment of tone and phraseology may be required but as the patient has a right of access to records held about them through the Data Protection Act, it should always be assumed that patients will see their notes or letters, whether they are sent a copy or not.
Copying correspondence from specialists to GPs has been common practice in the private sector for years and has rarely, if ever, caused any legal difficulties for the doctors concerned.