A Study of How Urology Out-Patients like to Receive Clinical Information

Abstract

INTRODUCTION

As part of the NHS Plan the UK Department of Health has suggested that both patients and general practitioners (GPs) are written to following hospital consultations. We audited the responses of patients and GPs to this practice.

PATIENTS AND METHODS

A total of 160 patients in one consultant urologist's clinic were included. The consultant had never routinely copied GP letters to patients. The SpR in the same clinic had routinely done so in previous posts. Patients who had received letters (group A) and those who had not (group B) were asked to complete a postal questionnaire. GPs were also sent a questionnaire to assess their opinion. The responses were analysed.

RESULTS

Questionnaires were sent out to patients (80 to group A and 80 to group B. From this, 100 (62.5%) responses were received (A 48 [60%]; B 52 [65%]). Of respondents, 81% were male. Overall, 98% of those patients who received a letter agreed with its contents, and stated they would keep the letter and take it to a subsequent doctor's appointment. Of respondents, 83% (A) and 96% (B) had never received a doctor's letter before but 83% (40 [83%, A], 43 [83%, B]; P > 0.05) of respondents would like to receive doctors' letters in the future. some 22 GP practices received and completed questionnaires at a PCT meeting and 74% of GPs agreed with the practice of copying patients their letters.

CONCLUSIONS

The results of this study suggest that patients should be offered a copy of their letter and that their response should be documented in the notes. This may serve to improve communication with the patient but should not be undertaken without their agreement.

The NHS Plan outlines many new policies that are aimed at modernisation of the NHS service. As part of this, the UK Department of Health recently suggested that both patients and general practitioners (GPs) are written to following hospital consultations.¹ There is currently a working party that is examining this practice.² We performed a postal audit of patients from a urology out-patient clinic to investigate this adjunct to patient care. Patients who saw the specialist registrar (SpR) were sent a copy of his letter to the GP – this had been his previous practice. Those who saw the consultant did not routinely get a copy – this had been his practice to that point. Local GPs were also surveyed to gauge their response to the practice.

It is important to establish how best to implement such a practice to ensure that such letters can be readily understood by patients but are not so diluted as to provide little useful information for GPs. Previous authors have shown it to be useful in patient care for other specialties.^3,4 Lloyd⁵ showed that, in a paediatric clinic, parents/patients who had a copy of a letter dictated in front of them liked this practice but found no significant difference in the clarity of information contained in the letter if it was not dictated in front of them.

The NHS Plan and the Kennedy Report have both suggested that the copying of letters to patients will improve patient communication as part of future care.^1,6

Patients and Methods

Following Trust approval to undertake the study, 160 consecutive patients in one consultant urological surgeon's clinic were included. The consultant had never routinely copied GP letters to patients. The SpR in the same clinic had routinely done so in previous posts. Patients who had received letters (group A) and those who had not (group B) were asked to complete an identical postal questionnaire (Table 1). The responses they gave were assessed.

Table 1.

Patient perception questionnaire

Did you receive a copy of the letter sent by your hospital doctor to your GP? Yes (if yes go to Q2) No (If no go to Q 7) When you opened the letter what did you think? I was interested and read it I did not read it I could not see the point Did you agree with what the letter said (did it summarise the conversation as you remembered it)? Yes No What did you do with the letter? I kept it in a safe place for future reference I put it down somewhere I threw it away I can't remember Would you take these letters with you to see a doctor in the future? Yes No Would you like to get letters from all your doctor's appointments in the future? Yes No Don't mind Have you ever had a copy of a doctor's letter before? Yes No Would you like to receive copies of your doctors letters? Yes No Are you Male? Female?

Letters were not routinely dictated in front of the patients as this had not been standard practice in this clinic. Data were analysed using a chi-squared test.

Following the completion of the patient survey phase of the study, GPs representing 22 practices within Havering Primary Care Trust (PCT) were asked to give their opinion of this practice in the form of a short questionnaire (Table 2).

Table 2.

GP questionnaire

Do you know of any of your patients who have received copies of their GP letters after a hospital appointment? Yes/No Have you had patients contact you about such letters? Yes/No Why were they contacting you? More info/Other/No contact How do you think they felt about the letter? Pleased/Unhappy/Indifferent/Don't know Do you think it is helpful for patients to get a copy of their hospital letters? Yes/No If you have any additional comments please add them here. ---------------------------------------------------------------------------

Results

In all, 160 patient perception questionnaires were sent out (80 to group A and 80 to group B) and 22 local GP practices were handed questionnaires at a PCT meeting.

There were 100 patient responses (62.5%) – group A, 48 (60%) and group B, 52 (65%). Of respondents, 81% were male in keeping with the population of a general urology clinic. The responders were stratified by age – 25% were aged 41–60 years, 35% aged 61–80, years and 10% were over 80 years. Of those patients who received a letter and responded to the questionnaire, 98% agreed that its contents were in keeping with their recollection of the consultation, and answered that they would keep the letter and take it to a subsequent doctor's appointment. However, 83% (group A) and 96% (group B) had never received a doctor's letter before. Of all respondents, 83% (40 [83%], group A; 43 [83%[, group B; P > 0.05) said they would like to receive their doctor's letters in the future (Fig. 1).

Figure 1.

Responses from group A (black bars) and group B (grey bars); there were no statistical differences (P > 0.05).

Responses from the GP questionnaire showed that 82% knew of patients who had previously received copies of doctors' letters but only 41% had been subsequently contacted by patients regarding these letters. Of those contacted, 77% said it had been for clarification of information and only 12% felt that patients had been unhappy with receiving a copy of the letter. Of GPs questioned, 74% agreed with the practice of copying letters to patients. In the free-comment section, 14% suggested that hospital doctors should work harder at verbal communication of information.

Both questionnaires provided opportunities for additional comments. Individuals from both groups raised concerns about the cost implications of introducing such a practice as routine. The 62.5% of patients who chose to write comments were positive about their care and the practice of copying letters to them 12.5% of the comments were concerned about the additional cost of sending letters to patients. Overall, only 10% of patients and 22% of GPs took the opportunity to write comments. Of those GPs who chose to add comments, none were positive.

Discussion

This audit represents a pilot study that appears to demonstrate that the majority of NHS patients have not previously received copies of their hospital doctors' letters. The authors accept that this was a relatively small group of patients concentrated in one specialty. The data need to be interpreted with some caution. However, our results suggest that patients like to receive letters about their out-patient hospital care and that, if offered, they would like to receive future correspondence about such care. There was no significant difference between the two groups in this respect, substantiating the expectation that if patients are offered information they will readily accept it. The authors acknowledge that 37.5% of questionnaires received no reply. Of those who replied, the majority would like to have letters sent through to them in the future of the total group this amounts to 52%. The response from the majority of GPs was also positive.

The study also showed that 98% of patients said that they would keep the letter and bring it to a subsequent appointment. This could not represent a surrogate set of notes as this would be medicolegally indefensible. However, it may allow a patient to reflect on a previous consultation and come forward with relevant questions the next time they attend. This would stimulate a more equal discussion as both parties would have written record of their previous meetings.

In patients with complex conditions, it would allow them to present these letters to a receiving physician outside their own hospital in the event that they had relocated or had to be seen as an emergency elsewhere. In this situation, the letters could not be taken as comprehensive but very useful background information for those organising further care. They would also provide clear contact details of the consultant who had previously cared for the patient allowing doctors elsewhere to make easy contact and ask for a comprehensive set of notes or specialist advice, if necessary.

Dictation of such letters encourages hospital specialists to ensure that the letters are professional and yet easily understandable by both patients and GPs. This encourages a fuller explanation rather than the use of abbreviations or complex, highly specialised terminology that could be misinterpreted by either group. The authors have not attempted to deal with issues such as literacy, cultural implications or language barriers within this pilot study. These may have to be considered in departments where such practice is a routine.

The 12% of patients who GPs felt were unhappy with receiving a letter raises the point that patients should be offered the opportunity to receive a copy of their letter. It should not be a default – their preference should then be recorded at the time of the consultation. Patients may be concerned about the letter being read by another party and hence may not wish to have the letter copied to them.

It is also important that the letters are not used as a substitute for proper personal explanation in the clinic. This makes for a difficult balance between spending adequate time with patients and ensuring they are happy with any explanation of their condition and the addition of a letter summarising this that is suitable for both GPs and patients. This is set against the demands of a busy out-patient clinic where other patients, support staff and management can bring pressure for shorter consultation times. The authors feel that this is a strong argument for the dictation of one combined letter rather than separate letters. We estimate the average dictation time for one letter to be 2 min. In a clinic of 30 patients, dictating two letters would mean an extra hour used in dictation time, in addition to the increase in secretarial time. In the current climate, the authors do not feel that this is a justifiable use of time.

The free-comment section for both groups raised a few negative responses from GPs; there was a perception from 14% that hospital doctors needed to spend more time communicating and explaining diagnoses to patients. The authors were surprised by this response as the whole exercise was aimed at improving just that. It has been shown that both patients and doctors are capable of putting up communication barriers within a consultation setting.⁷ In an ideal world, all doctors should attend communication skills' courses to learn how to allay such fears. The authors also feel that patients receiving information in writing will allow them to discuss concerns amongst family or friends and encourage them to raise their concerns at future consultations. Some patients raised concerns about the cost of sending an additional letter in the post but the majority of comments were positive.

Conclusions

This is a small, pilot study performed as an audit. The aim was to examine the suggestion that patients should all be offered a copy of their GP letter. The results from this group suggest that this offer should be made. The group who did not respond to our questionnaire may be disinterested, not have received either the letter or questionnaire (due to incorrect patient data) or may not have been sufficiently able to read either document, for instance, if English were not their first language or if there were visual impairment. The issue of who opens the letter may also raise confidentiality concerns. These are important factors to take into account although beyond this study to give specific answers.

The authors, therefore, feel that patients should be offered a copy of their letter and their response to this offer be documented in the medical notes. This would allow them choice and accommodate the acknowledged faults in this practice.