Key messages
GPs are becoming more involved in the care of mentally ill patients.
Good quality communication is important in coordinated patient management and is fundamental to the collaboration between mental health and general practice.
Psychiatrists and GPs communicate mainly by letters which often do not cover the necessary information.
By exploring GPs views in a London borough, this study suggests that introducing a standardised clinical letter may improve communication.
Why this matters to us
GPs are usually asked to fill in standardised forms when referring to hospital teams to ensure they cover the necessary information, this practice is seldom reciprocated.
GPs are right to want the relevant information in a concise and standardised form to enable them to share care more effectively.
Keywords: communication, follow up letters, general adult psychiatry, GPs and psychiatrists, primary and secondary care
Abstract
Background Psychiatrists and General Practitioners (GPs) communicate mainly by letters which often do not cover the necessary information.
Setting Barnet PCT
Question To identify what GPs regard as important and necessary information in psychiatric follow up letters.
Method A postal questionnaire was sent to all GPs in the Borough of Barnet to determine their view on this matter.
Results Out of 187 GPs, 129 responded to the questionnaire (69%). A mismatch was found between what psychiatrists write in their follow up letters and what GPs expect. Medication details, diagnosis, name of care coordinator and changes in mental state were considered very important to GPs.
Conclusions Conveying information that GPs actually consider important may improve their ability to share care of mental health patients. This may be achievable by introducing standardised format letters.
Introduction
Concerns about communication between primary care and mental health services have been apparent for some time.1 With the advent of intermediate care and with the increased emphasis on community-based services, general practitioners (GPs) will take more responsibility for patients with mental illness and will expect more support in the form of written information and advice regarding patients in their care. Good quality communication is an important aspect of coordinated patient management and is fundamental to this collaboration.2 Psychiatrists and GPs communicate mainly by letters, which unfortunately are often regarded as inadequate in covering the necessary information.3–5
Correspondence from mental health services to primary care should include diagnosis, presenting complaint, drug treatment, management plan, follow up arrangement and mental state examination.6,7
A local survey of correspondence to GPs in the Borough of Barnet found that of 295 clinical letters assessed, 17% stated diagnosis, 86% medication details, 27% key worker and 17% follow up date.
To improve these communications, guidelines or standardised format letters have been suggested8 although guidelines are often not widely accepted.3 The aim of this study was to identify what GPs regard as important and necessary information in psychiatric outpatient follow up letters.
Method
In order to identify what GPs wanted in communication from mental health services we conducted a questionnaire survey. It contained 12 questions (11 yes/no and one free comment) some of which were derived from the communication survey checklist. The questionnaire was sent to all GPs (187) in the Borough of Barnet together with a covering letter asking GPs what information they would like to receive in the follow up letters. A single follow up telephone call to non-respondents was made four weeks after the survey was sent to check whether they had replied.
Results
Of the 187 GPs surveyed, 129 (69%) responded. GPs answered ‘yes’ to most of the questions and were interested to have almost all of that information in follow up letters (Table 1).
Table 1.
Information general practitioners want to receive in letters from psychiatric services
| No | Questions | Answered yes (%) |
|---|---|---|
| 1 | Statement of current situation | 97 |
| 2 | Comment on risk | 89 |
| 3 | Date of contact | 100 |
| 4 | Diagnosis | 97 |
| 5 | Changes in mental state | 93 |
| 6 | Current medication, dosage and frequency | 100 |
| 7 | Name of the care-coordinator (key worker) | 98 |
| 8 | Follow up date | 97 |
| 9 | Would you like to receive phone call for new patient | 16 |
| 10 | Details about activities of daily living | 63 |
| 11 | A section in the letter for requesting investigation/referral by GPs | 71 |
Sixty-three percent of GPs made free-text comments. Analysis of the free comment section showed that the GPs preferred receiving short letters with important information on top of the letters (medication, diagnosis and care coordinator's data).
The most frequent comments in the free comment section were about receiving a clear plan with appropriate instructions about medication and changes. Fifty nine GPs (46%) would like to have direct telephone numbers of the care coordinators in case of an emergency. Thirty GPs (23%) commented that they did not want to receive long letters and phone calls for every new patient.
Discussion
A high response rate (69%) indicates the importance of this matter to GPs and as we move towards increased share of the care of patients with mild to moderate mental health disorders, improving communication between secondary care and GPs is essential. We found a mismatch between what psychiatrists write in their letters and GPs' expectations. For example 97% of GPs stated they wanted a diagnosis, whereas only 17% of letters contained this. Another example is virtually all respondents wanted to know the identity of the care coordinator, but this was only supplied in 27% of letters. Only half of the letters commented on risk. We believe GPs are right to want this information as it may be pivotal in managing crises and without it their ability to share care of patients is hampered.
With the development of electronic clinical records (ECR) these communication difficulties may be solved at some point in the future. Electronic records should be easy to access and read, and if they are well structured and defined, could improve patient care. In the interim standardised letters may seem an attractive solution. However, a study on the quality of referrals to psychiatric services found a standardised format resulted in worse quality of information on every parameter measured.9
Contributor Information
Ramin Nilforooshan, Specialist Registrar in Psychiatry, South London and Maudsley NHS Foundation Trust, London, UK.
Latha Weston, Consultant Psychiatrist, Barnet, Enfield and Haringey Mental Health NHS Foundation Trust, London, UK.
Deepak Sachdeva, ST5 Psychiatry, Great Manchester West Mental Health NHS Foundation Trust, Manchester, UK.
Hagen Rampes, Consultant Psychiatrist, Barnet, Enfield and Haringey Mental Health NHS Foundation Trust, London, UK.
James Warner, Consultant Pychiatrist, Central and North West Mental Health NHS Foundation Trust, London, UK.
Maryam Nasri, General Practitioner, Barnet PCT, London, UK.
CONFLICTS OF INTEREST
None.
ETHICAL APPROVAL
Ethical approval was not needed as there was no direct patient involvement.
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