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Patient and clinician opinions on copying letters to patients

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VOL: 103, ISSUE: 41, PAGE NO: 32-33

Vandana Naik, MA, MSc, PsychD; Anton Valmana, LMS, MSc, MRCPsych; Charmain Keane, BSc

Vandana Naik is consultant counselling psychologist, Surrey and Borders Partnership NHS Trust; Anton Valmana is consultant psychiatrist, Surrey and Borders Partnership NHS Trust; Charmain Keane is team quality assistant, Surrey and Borders Partnership NHS Trust.

To conduct a two-month evaluation on patients’ and clinicians’ views on the ‘copying letters to patients’ scheme in a primary care mental health team (PCMHT) setting

Abstract Naik, V. et al (2007)Patient and clinician opinions on copying letters to patients.

AIM: To conduct a two-month evaluation on patients’ and clinicians’ views on the ‘copying letters to patients’ scheme in a primary care mental health team (PCMHT) setting.

METHOD: Patients and clinicians were sent a questionnaire to explore their experiences of receiving copied letters of their reports written by clinicians.

RESULTS: Some 84% of patients reported feeling more informed; 53% felt there was improvement in communication; two-thirds (66%) reported greater trust in services; and 31% reported more commitment to services as a result of receiving a copied letter.

CONCLUSION:The importance of the impact of sharing letters with patients needs to be emphasised in clinical settings.Increased levels of trust and commitment are likely to have a positive impact on the working alliance and therapeutic relationship, which have been extensively linked to better clinical outcomes in the area of mental health.

Background Since the recommendations made in The NHS Plan (Department of Health, 2000), followed by the Good Practice Guidelines issued by the DH (2003), the copying of correspondence between clinicians to patients should have been incorporated as a routine practice across the NHS from April 2004. The scheme builds on the existing Data Protection Act (1998), through which patients have the right to access their records (see DH, Data Protection Act 1998). As with this act there are certain exclusions to patients having access to records such as:

  • When information contained in the letter is anticipated to affect the recipient adversely;
  • Where identity of or information on another person (who has not given consent) is disclosed;
  • Where patients do not want a copy;
  • Where special safeguards for confidentiality may be needed.

The Caldicott Report (Department of Health and the Caldicott Committee, 1997) stated that sensitive information needs to be channeled via a ‘safe haven’ or secure system route. Although the initiative of copying clinical letters to patients is recommended as good practice, this change of traditional practice may generate anxieties in the writer as well as for the recipient of such correspondence.

Literature review A number of arguments, including ethical, legal, outcomes and financial, have been explored in relation to the practice of copying clinical letters to patients (Vaidya, 2004). In the discussion about the risks and benefits of copying letters to patients, it is proposed that patients and their carers should gain from this initiative (Cowan, 2003). There have been a number of studies exploring patients’ views and their satisfaction following the introduction of initiatives that include patients receiving clinical information (Asch et al, 1991; Lloyd, 2004; Marzanski et al, 2005). Most of these studies have shown a high degree of satisfaction from patients following the introduction of this practice. In addition to increased satisfaction, active participation in healthcare decisions is associated with improved health outcomes (Stewart, 1995). Mental health professionals have been providing copies of the Care Programme Approach plans for many years but it has been suggested that the copying of all correspondence to patients may present a challenge to clinicians and that letter-writing practice would be altered in the knowledge that patients would receive copies of such letters (Nandhra et al, 2004).

Aim To conduct a two-month evaluation on patients’ and clinicians’ views on the copying letters scheme in a primary care mental health team (PCMHT) setting.

Method This evaluation was carried out in a primary care mental health team setting where adult patients aged between 18-65 years with moderate to severe mental health problems were seen in an outpatient setting. The PCMHT consisted of multidisciplinary staff (including community psychiatric nurses and mental health social workers), who were carrying out the ‘copying letters to patients’ scheme for the first time. It was decided within the team that initially ‘copying letters to patients’ be offered to all new patients seen during a two-month period. This was with the exception of psychiatrists in the team, who offered the scheme to every patient seen during the two-month period. First, patients were given an information sheet on copying letters and asked if they wanted to opt in or out of the copying letters scheme, giving consent if they did. If patients opted into the scheme, clinical correspondence relating to them, sent to other professionals (usually the patient’s GP) would now be copied to them.

Audit tools Three audit tools - a data collection sheet, patient satisfaction questionnaireandclinician feedback questionnaire - were devised. The information governance manager and relevant professionals and managers were consulted on all the audit tools and their comments sought. The data collection sheet was devised primarily to record all the patients who were offered the copying letters scheme. This included: the number of patients who opted in and out; if they opted out, the reasons why they opted out; and special requirements needed, such as font size or translation to a different language. The patient satisfaction questionnaire consisted of 12 questions. Questions 1-8 and 11 consisted of a five-point Likert rating scale. The clinician feedback questionnaire was similar to the patient satisfaction questionnaire and consisted of 11 questions. Both questionnaires aimed to look at the effect of receiving copied letters and to highlight any problems. At the start of the evaluation the data collection sheet was distributed to all clinicians so that they could keep a record throughout the evaluation. At the end of the two-month period, patient satisfaction questionnaires and clinician feedback questionnaires were distributed. Patient satisfaction questionnaires were sent via post with stamped, self-addressed envelopes (except where patients had asked for correspondence not to be sent home; in these cases, a copy of the questionnaire was left for patients to collect at their next appointment). Clinician feedback questionnaires were given out by hand. Both questionnaires were returned anonymously.

ResultsData collection sheetPatients’ decision to opt in or out In total, 176 patients were given the opportunity to receive copied letters during the two-month period; 89% of these patients opted in and11% opted out. Reasons given by the 11% of patients for not wanting a copied letter were not always specified but they included: feeling that it would cause them high anxiety to receive a letter; or because they felt that they already had the information they needed.

Preferred method of receiving a letter Nearly all (97%) of patients preferred to have the copied letter sent to them by post. Some 3% of patients opted to collect their letter at their next outpatient appointment.

Withholding letters There were six occasions when clinicians decided not to send a copied letter. On three occasions this was because it contained information about a third party. On two occasions it was because the clinician felt it could be harmful for the patient to see a copied letter. One clinician did not explain their reason for not sending the copied letter.

Special requirements Some 53 patients stated that they did not have any special requirements, such as requiring a larger font or letter to be written in another language or via audio format. The answer was left blank for the remaining 103 patients. Therefore it is not known if these patients were asked this question.

Did the patient change their mind? There was onepatient who changed their mind about receiving copied letters. In this case the patient concerned decided not to continue to receive copied letters.

Patient satisfaction questionnaire In total, 104 patient satisfaction questionnaires were sent randomly to patients who had been offered the copying letters scheme at the end of the two-month evaluation. Questionnaires were sent via the preferred method stated by the patient. A total of 39 questionnaires were completed and sent back. Of the 39 who returned the questionnaires, 32 had received a copied letter and seven had not. From these, 16% had been with the PCMHT between 0-2 months, 21% between 2-6 months, 21% between 6-12 months, 13% between 1-2 years and 29% were with the PCMHT for two years and over. There were five patients (16%) who said there were mistakes/errors in their copied letters. The vast majority (97%) of patients wanted to continue receiving copied letters. Table 1 shows the ratings given by patients to the items on the questionnaire.

Table 1. Patients’ rating of questions

 Great improvement/ very helpfuln (%)Improvement/ helpfuln (%)No changen (%)Deterioration/ unhelpfuln (%)Great deterioration/ greatly unhelpfuln (%)
1. In terms of feeling INFORMED how did receiving copied letters affect you?3 (10)24 (74)5 (16)0 (0)0 (0)
2. In what way did receiving copied letters affect COMMUNICATION between yourself and the service?3 (10)14 (43)15 (47)0 (0)0 (0)
3. In what way did receiving copied letters affect TRUST between yourself and the service?4 (13)17 (53)11 (34)0 (0)0 (0)
4. In what way did receiving copied letters affect COMMITMENT to treatment?2 (6)8 (25)22 (69)0 (0)0 (0)
5. How easy was it was to UNDERSTAND your copied letter?18 (56)7 (22)6 (19)1 (3)0 (0)
6. How HELPFUL was it to receive a copied letter?10 (32)20 (62)1 (3)1 (3)0 (0)

The qualitative data from question 6 of Table 1 ‘How helpful was it to receive a copied letter?’ revealedseveral key themes. Theme 1 was concerned with record-keeping, with comments such as: ‘It helps to refer to this letter for future information and knowledge’; ‘It is sometimes difficult to take in all of the information during appointments and having it in writing allows me to understand details more easily and I feel more informed’. Theme 2 was about feeling empowered and comments included: ‘I find it empowering to receive the letters’; ‘Felt more involved’. Theme 3 was around transparency, for example, patients reported: ‘No sense of mystery or secrecy’; ‘I now know what my GP knows’. Theme 4 focused on gaining knowledge of professionals’ views, for example: ‘Important to me to be able to read what was being discussed about me with professionals’; ‘Helpful to know how the doctor was reacting to what I was telling him’.Theme 5 was concerned with communication, for instance: ‘Awareness that communication with my GP was happening’; ‘Reassuring to know that healthcare professionals are communicating with each other’. There was one patient who said that copying letters wasunhelpful - the reason that they gave for this was: ‘I found it hard to read about myself in such an objective way. The information seemed too cold and lacked any warmth.’ In summary, 84% of patients reported feeling more informed; 53% felt there was improvement in communication; two-thirds (66%) reported greater trust in services; and 31% reported more commitment to services as a result of receiving a copied letter.

Clinicians’ feedback questionnaire Eight clinicians out of 11 returned their questionnaire. All of the disciplines in the team were represented in these replies. Table 2 shows responses given by clinicians.

Table 2. Clinicians’ rating to questions

 Great improvementn (%)Improvementn (%)No changen (%)Deteriorationn (%)Great deteriorationn (%)
1. In terms of feeling INFORMED about their care how do you think your patients felt?0 (0)3 (37)5 (63)0 (0)0 (0)
2. In what way did receiving copied letters affect COMMUNICATION between yourself and your patients?0 (0)2 (25)6 (75)0 (0)0 (0)
3. In what way did receiving copied letters affect the level of TRUST between yourself and your patients?0 (0)1 (12)7 (88)0 (0)0(0)
4. In what way did receiving copied letters affect your patients’ COMMITMENT to treatment?0 (0)0 (0)8 (100)0 (0)0 (0)

The qualitative data from the question ‘What would you describe as the positiveoutcome of copying letters?’ that was put to clinicians, revealed themes concerned with better communication with patients; transparency; patients knowing what was being communicated about them to other professionals; having a written record; and greater awareness among patients. In response to the question to clinicians ‘What would you describe as the negative outcomes of copying letters?’ the themes that emerged were that it was time-consuming, had implications on their workload and generated anxiety for the patient. Some 50% of clinicians said that they had changed the way they write letters. One-quarter (25%) of clinicians were asked by a patient for clarification on a letter. Over a third (38%) of professionals said that they held back information that they usually would have included in a letter either because the content of the letter might cause harm/distress to patients or because there was information about a third party that was held back. One-quarter (25%) of clinicians used supervision to discuss difficulties with copying letters and reported that the supervision helped overcome these problems. The vast majority (88%) of clinicians wanted to continue sending copied letters. Table 3 shows comparisons between patient and clinician ratings.

Table 3. Comparison of patient and clinician ratings on ‘improvement’ or ‘great improvement’ on each of the areas

n (%)n (%)n (%)n (%)
Patients27 (84)17 (53)21 (66)10 (31)
Clinicians3 (37)2 (25)1 (12)0 (0)

Discussion Our results show that compared to Marzanski et al’s (2005) study (also carried out in a mental health setting), a higher percentage of patients wanted to receive a copied letter and almost all patients who returned their questionnaires wished to continue to receive a copied letter. As with Cape et al’s(2005) findings, most patients wanted to receive their letters by post. There were some errors made in the letters to patients but these were lower or similar in frequency to other studies (Asch et al, 1991; Cape et al, 2005) and most of the errors made seemed to be minor. The advantage is that for the first time patients had the opportunity to correct these errors. The majority of patients found it helpful to have a copied letter as it made them feel more empowered, provided greater transparency and better communication, and they had a permanent record as a result of receiving copied letters. These results are similar to those found by Cape et al (2005) and Asch et al (1991). Over two-thirds of patients reported ‘no change’ in commitment to treatment, which we would expect to find in this setting as patients are more likely to be highly committed to treatment. However, it is interesting that nearly a third of patients reported an improvement in commitment as a result of getting a copied letter. Patients’ increased commitmentcould be linked with aspects they had found to be helpful in receiving a letter, such as greater communication and transparency. It may also be linked to findings that approximately two-thirds of patients stated that trust between themselves and the service was ‘improved’ or ‘greatly improved’. It may be hypothesised that as patients trustedthe service more some of them may have also felt more committed to treatment. Trust is an important component of the working alliance and therapeutic relationship that has consistently been linked to better outcome of treatment (Martin et al, 2000). Studies have shown that even a strong early alliance - as early as session two - is shown to lead to positive treatment outcomes for patients receiving cognitive therapy (Strauss et al, 2006; Klein et al, 2003). Commitment to treatment is also associated with improvements in clinical outcome (Rosen et al, 2004). We may hypothesise that substantial increase of trust in services and commitment to treatment as a result of having a copied letter make it a powerful clinical tool. Indeed, certain therapies, such as cognitive analytic therapy, routinely use such ‘reformulation’ letters as part of the therapeutic process. There have been concerns among mental health professionals that copied letters will not be easy to understand or contain information that may cause distress for patients. In contrast to other studies, such as Harris and Boaden (2003), our study showed that a significant amount of patients in a community mental health setting found the copied letter ‘easy’ or ‘very easy’ to understand. Perhaps this was because half of the clinicians had changed the way they wrote letters thereby tailoring them to the requirements of their patients. Clinicians need to ensure that they write letters worded in a manner that patients can understand and reflect on what was discussed with their patients. It is also important that clinicians consider the tone of their letters, as one patient commented that their letter ‘lacked warmth’ and was ‘cold’. In terms of level of distress caused to patients, although this question was not asked directly, the majority of patients seemed to value receiving a copied letter and only on two occasions was a letter withheld as it would possibly cause harm or distress to the patient. It was found that although clinicians reported similar themes to patients about the positive aspects of receiving a copied letter, they considerably underestimated the positive impact of receiving copied letters on their patients. This may be due partly to clinicians not having fully experienced the impact of copied letters about their patients within the short time span of this evaluation. Fears of causing distress/anxiety to patients and adjusting to new ways of working may also have influenced their views. There are a number of limitations to this study. The patient satisfaction questionnaire did not contain demographic information or information on diagnosis but only the length of time with the PCMHT, which was well distributed across 0-2 months to two years and over. Also, this study did not include a control group of patients who had not received a copied letter.

Conclusion Copying clinical letters to patients appears to show numerous benefits and is seen positively by most patients. Results show that copying letters goes beyond just being helpful and also seems to improve trust in services and commitment to treatment. Hence, this indicates that this may not only be good practice but may also possibly impact on clinical outcomes in mental health. Further research would be helpful to look directly at the impact on clinical outcomes as a result of copying letters.

ReferencesAsch, R. et al (1991) Psychiatric out-patients’ reactions to summary letters of their consultations. British Journal of Medical Psychology; 64: 3-9. Cape, J. et al (2005) Patients’ views of the letters their psychiatrists and psychologists send to referrers. Journal of Mental Health; 14: 4, 369-382. Cowan, J. (2003) Copying letters to patients: using clinical risk management to minimise problems. Clinical Governance; 8: 4, 360-363. Data Protection Act (1998)
Department of Health (2003) Copying letters to Patients: Good Practice Guidelines. London: DH.

Department of Health (2000)The NHS Plan: A Plan for Investment, A Plan for Reform.London: DH.

Department of Health (1998, modified 2007)The Data Protection Act 1998.London: DH.
Department of Health and The Caldicott Committee (1997) The Caldicott Committee Report on the Review of Patient-Identifiable Information.London: DH.

Harris, C., Boaden, R. (2003) Copying letters to Patients: Summaries of 12 Pilot Sites.London: DH. Klein, D.N. et al (2003) Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics. Journal of Consulting and Clinical Psychology; 71: 997-1006. Lloyd, G. (2004) Medical Records: Copying letters to patients. Psychiatric Bulletin; 28: 57-59. Martin, D.J. et al (2000) Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology; 68: 3, 438-450. Marzanski, M. et al (2005) Copyinglettersto patients: a study of patients’ views. Psychiatric Bulletin; 29: 56-58. Nandhra, al (2004) Medical records: Doctors’ and patients’ experiences of copying letters to patients. Psychiatric Bulletin; 28: 40-42. Rosen, P. et al(2004) Treatment motivation and therapeutic engagement in prison-based substance use treatment. Journal of Psychoactive Drugs; 36: 3, 387-396. Stewart, M. (1995) Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal; 152: 1423-1433. Strauss, J.L. et al (2006) Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology; 74: 2, 337-345. Vaidya, G. (2004) Copying letters to patients: are we ready yet? Hospital Medicine; 65: 8, 454-455.

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