'Copying letters to patients is coming to a clinic near you'
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7402.1330 (Published 12 June 2003) Cite this as: BMJ 2003;326:1330
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In her article entitled 'Sick Notes' 16 June 2004,( Spiked On-line-
health site) Liz Frayn a surgical trainee working in South West England
reveals that the guidelines issued by DOH in England which require that
all individuals should be given copies of letters ,are being 'temporarily
shelved' in the hospitals where she completes her training in the S.W. of
England. Liz Frayn has it seems missed the point - the official policy has
come into force in England since April 2004. She is wrting her article a
month and a half later. The stage of rehearsing arguments for and againt
has been completed and overrides her personal opinion ,yet nevertheless
Liz seems influenced less by the consultation process which has led up to
the policy than individual opinions of doctors who regard it in negative
terms; importantly sees cost implications as a good reason for withholing
letters, sympathises with the medical secretaries who'just haven't got
time to deal with that', relies on individuals being given leaflets about
their condition,fears doctors will be barred from frank discussions about
other people's lives,and is angry that politicians, who do in fact
represent the public view as well as their own party political interests,
should have an input in drawing up policy on this issue. Throughout the
article the individual who consults the health worker as a decision maker
in important areas of their lives, is sadly missing.
In contrast, although Wales, as so often ,is last to adopt such
policies,the attitude of some lead practitioners is very much in line with
modern thinking in terms of partnership, empowerment, equality of health
professionals with those who consult them . At the Neurology SYMPOSIUM
held on 13 May 2004 at UCHW (University Hospital College of Wales)(On-line
link with BMJ+Symposium) Philip Smith (Neurologist) stressed the
advantages of having an open and transparent relationship with all parties
involved, most importantly the person at the centre of any discussion
should have copies of letters which they can follow up in a way
appropriate to them and not only as decided by a pratitioner who has let's
be honest a minor albeit extremely important role to play overall in
individuals' lives.
The idea that a doctor should disagree with policy is not in itself
worrying of course. But the thought that some doctors, including the
trainees they are teaching, are covertly shelving policies, rather than
being open and honest with people who use their services - is worrying.
Even now some doctors deliberately withhold information about rights
to read files; rights to second opinions, information about use of
information - how many more rights are being 'quietly shelved'?
Competing interests:
None declared
Competing interests: No competing interests
In his perspective on copying letters to patients (BMJ
2003;326:1330-
1331 (14 June)) Dr. Essex argues that “a person with an opinion and no
data is just another person with an opinion”. Yet his piece is replete
with his own uncorroborated views. What evidence, for example, does
he have for his assertions that “mental health professionals rarely
communicate with others” or that adult services are more paternalistic
than those for children? Moreover, his contempt for mental health
patients is betrayed by his flippant assertion that psychiatrists should
“live with” the risk that psychiatric patients may commit suicide as a
direct result of receiving copies of GP letters.
The Department of Health Good Practice Guidelines on copying letters
to
patients recommend that “In some cases involving particularly sensitive
areas, however, such as child protection or mental health problems, it
may not be appropriate to copy a letter to the patient.” I recently
assessed a patient in a chronic fatigue clinic who had an undiagnosed
psychosis. She was initially unwilling to try an antipsychotic but we
developed a good rapport and I hoped that after two or three further
sessions she could have been persuaded. About a week later she
returned to the clinic in an agitated state, claiming that, as the seventh
son of a freemason, I planned to poison her. I then discovered that a GP
trainee had shown her my assessment letter, in which I had raised
concerns that she was psychotic. Needless to say she refused to return
and the GP was forced to arrange a mental health act assessment.
Perhaps I should instead have ensured that my letter contained nothing
to alarm her, rendering it a worthless bureaucratic exercise rather than a
useful clinical document.
I fully support Dr Essex’s practice of copying letters to the parents
of his
paediatric patients, but he appears to have little understanding of the
subtlety and fragility of doctor patient relationships in some other
fields
of medicine.
James MacCabe MRCPsych
Institute of Psychiatry
Competing interests:
None declared
Competing interests: No competing interests
Dr Warner writes that the psychiatry profession is well used to the
misperceptions that (its members) are slightly odd and intellectually less
gifted than their medical and surgical colleagues.
I would venture to suggest that the psychiatry profession, as represented
by Dr Warner, is itself labouring under a misperception. Most of his
medical and surgical colleagues have always believed that the oddness of
the archetypical psychiatrist can be explained on the grounds of his/her
vastly superior intellect. This generates a feeling of intellectual
inferiority in the non-psychiatric members of the profession.
It is therefore a surprise to me to read that Dr Warner is so
conscious of the many stigmata under which he feels the psychiatrist
labours. Perhaps that too is a result of a misperception.
Jeremy Jones
Competing interests:
I am one of the Dr Warner's intellectually inferior medical colleagues
Competing interests: No competing interests
Charles Essex has done well to think up several novel ideas to add to
the extensive list of stigma to be applied to psychiatrists. As a
profession we are already well used to the misperceptions that we are
slightly odd, and intellectually less gifted than our medical and surgical
colleagues. Together with providers of services to adults, (does this mean
everyone except paediatricians?) and the poor old administrators, mental
health workers according to Dr Essex are "people who have difficulty
regarding parents and patients as adults who have autonomy and who can and
should take personal responsibility." Moreover mental health
professionals rarely communicate with others, and can�ft be accused of not
sending copies of letters to patients, if there are no letters to copy.
These ideas are complete nonsense. Psychiatrists write thousands of
letters, as their secretaries will testify. They have long been at the
forefront of working in partnership with their patients. Letters to
patients are frequently part of the therapeutic process in psychotherapy.
Maybe the reason why the writer never gets letters from mental health
professionals is because there is no one to send the letters: mental
health services are in a recruitment crisis. Is there somebody out there
putting people off?
Competing interests:
None declared
Competing interests: No competing interests
The perspective by Essex is hair-raising. Does he really believe that
"mental health professionals rarely communicate with others, so they can't
be accountable"? Or "no one knows what they do, and they can't be accused
of not sending letters if there are no letters"! Come off it. We regularly
write to patients and colleagues and are proactive as a profession
ensuring patients are involved in their care planning.
I think what he mean is that HE does not know what we do, after all "a
person with an opinion and no data is just another person with an
opinion". Rather than attending day meetings on writing to patients maybe
he should spend a morning with a psychiatrist in clinic to reflect on his
opinions.
Ray Goggins
Specialist Registrar in General Adult and Old Age Psychiatry
Competing interests:
None declared
Competing interests: No competing interests
I completely agree with Dr Essex in his article on writing letters to
patients. Furthermore, I feel very strongly that the correct direction is
indeed writing directly to the patient or carers rather than simply
copying them the letter. This is more than simply an "upgrade" but is
fundamental to the principles of patient-centredness and providing the
information and ability for an individual to make informed decisions about
their condition and its treatment.
This issue should not be lost under the knee-jerk responses of
doctors who see the proposal that we could do things differently as a
criticism of present practice. Singling out certain specialities may not
be that useful, but these are the areas where most of the debate has
occurred and, as far as I can see, been most negative.
Expanding this debate is essential to ensure that the policy decision
regarding copying letters to patients is not just considered as an
inconvenience imposed by government. This actually represents a huge
opportunity to reconsider the way we provide healthcare. Most of us would
accept that things could be done better. We rationalise the patient not
remembering what we told them at the last appointment or being poorly
"compliant" with medication as if it is a failing of the patient. However,
it is the traditional, hierarchical system that continues to fail.
Why should an "ideal" consultation be so implausible? Why should we
just laugh this off as an impossible dream? True patient-centredness
requires the views and concerns of the patient to be paramount, requires
open and honest discussion of these issues and allows the patient to agree
a plan of action, if one is required. Patients should not feel there is
not time or opportunity to disagree with or challenge the doctor. If this
means we need to change the way we hold consultations then so be it. I
believe that writing directly to the patient, making them feel valued and
making them feel that this is truely about them, is one of the steps to do
this.
Clearly, an evidence base is urgently required. I agree that
anecdotal stories of success in individual practice is not sufficient to
guide long-term changes in healthcare provision. However, copying letters
to patients is about to happen - without an evidence base, without wide
consultation and with considerable opposition. We should not just rebel
against this but see it as an opportunity to do so much more. If we are
serious about being patient-centred, and if it works, it could herald one
of the most important changes in healthcare provision we have ever seen.
Our profession needs to remain open-minded to these issues and not
just pass them off as a new fad or inconvenience. Furthermore, the
modernisation agenda and policy makers should engage and fund those who
wish to address these questions. This article by Dr Essex, and indeed the
whole BMJ issue, should be the start of the debate not an end to it.
Competing interests:
None declared
Competing interests: No competing interests
A problem revealed by the responses received is that as ever some
doctors ignore agreed policy and make individual decisions whether to copy
letters to those who consult them. People as ever are not going to know
they have the right to have copies - unless practitioners tell them. eg at
the Maudsley, despite the letter in this issue from a psychiatrist
there, at least one psychiatrist there has publicly stated that his policy is to
withold persons' medical files - as a request to see them suggests it is a
lack of trust which needs addressing - hardly surprising.
It is the loss
of unacceptable levels of control which is a significant factor in some
cases, especially, and here I disagree with Sami Timini, in relationships
with mental health workers. Some people are still unaware that they have
rights of access to their medical files and/or are not confident enough to
ask for them. It is about time people held their own medical files - they
are unlikely to get lost/damaged any more than they are when held on NHS
premises.
Competing interests:
None declared
Competing interests: No competing interests
Although Dr Essex rather bizzarely and unnecessarily singles out
mental health professionals for accusations of poor practice in
communicating with their patients(Most of the child and adolescent mental
health colleagues I know routinely copy their letters to patient's
parents), I agree that we need to get better in the sort of inclusive
practice that copying letters to patients promotes. That is why I was
dissapointed by the lack, in Dr Essex's article, of a more imaginative and
radical challange to current practice.
Not only have my patient's parents (I'm a child and adolescent
psychiatrist)and my patient's been getting letters from me for years, my
standard practice now, is that all my post-assessment letters go to them
and it is the referer and other involved professionals who get the copies.
My letters that are addressed to the patients have become an integral part
of the treatment process. By writing to patient's and their parents I am
forced to write in jargon free plain English, to try and summarize our
encounter, and to repeat in a (hopefully) easily understandable way the
next step and/or treatment plan. In the few years I've been doing this
I've yet to have a patient or their family complain about my letters to
them.
In specialties like mine and I'm sure in many others (including Dr
Essex's) succesful engagement with our patients (and their carers) is key
to a positive outcome, in that respect letters can be a valuable aid to
breaking down percieved hierarchical barriers.
Competing interests:
None declared
Competing interests: No competing interests
Rarely does my friday night read of the BMJ excite such a response.
I'm now coming to realise that it wasn't just my own fury I was
expressing. What a horrible experience Dr Essex must have had of certain
healthcare sectors to culminate in such a self righteous (narcissitic
even) attack.
Roy, in his response, appropriately highlighted the areas of
Psychiatry such as Care Plans, risk assessments etc where the service user
is an integral part of the process. However Psychiatry does have an
inately paternalistic aspect. An issue which is hotly debated and kept
alive by mental health workers. Sometimes it's been known to be discussed
in our multidisciplinary team meetings where, Dr Essex assumes, 'mental
health workers rarely communicate' and 'never write anything down' for
fear of being held accountable. Dr Essex's splitting off and denial of
this paternalistic aspect of his own practice and that of the rest of the
medical world surely reflects some of his less useful defence mechanisms.
In fact his simplistic account of potential issues which may be raised
regarding sending letters to patients were met with firm assurances that
he 'dealt with them'. Next he'll be sending us up to our rooms without any
tea.
A more worrying concern is that this derogatory veiw of mental health
workers is more widely held. Frequently it feels as if we are only
respected by our medical/surgical colleagues when we are 'fire fighting'
in A and E or on the general wards. The irony being that this isn't when
most of our expertise comes into play.
Clearly there is some parallel process with the stigma experienced by
psychiatry service users. It's a good job we're finally learning ways to
join forces and show the rest of the medical profession how to be explicit
and open but also how to recognise our deficiences without denigrating our
fellow colleagues.
Competing interests:
None declared
Competing interests: No competing interests
Do we need a Big Brother to Ensure Compliance with DoH Guidelines
The Healthcare Commission, which is the new independant stage of the
NHS Complaints system is expected to be in place by August. (HEALTHCARE
COMMISSION.ORG.UK). The organisation 'will prioritise adherence to
guidelines in it's new ratings and review system'. It follows that if
decisions are being made to ignore guidelines, (and they are in some
areas) eg To Copy letters to Patients by April 2004, the H.C. will
include this information in it's published reviews of local facilities. It
will take time to trickle down to those who need to know in local
communities ,but at at least in Wales there are still Community Health
Councils and in England Patient Advocates who can asist with informing
communities of practice in their area.
The Health Commission continues to consult widely with all
stakeholders including 'patients' 'members of the public'. For information
about meetings in local areas Phone 0845 601 3012
To subscribe to the H.C site for upadates on information ,link
through Healthcare Commission.org.uk.
Competing interests:
Past member of NHS Consultation Committees
Competing interests: No competing interests