Hugh Rayner: Writing to patients

How would you feel if someone described you as ‘pleasant’? You might be flattered, maybe a little uneasy, or perhaps downright insulted that 'pleasant' is the best that could be said about you! But have you used this word to describe patients in your outpatient clinic letters?

If you ask non-medical friends and relatives about letters they have received after attending outpatient appointments, it is likely they will tell you stories of how they did not understand what was written or were worried by what they read. They may even have made an appointment with their GP to have the letter explained.

I started writing my outpatient letters directly to patients in 2005, after my colleague persuaded me that it was the right thing to do. At first, I was nervous that the patient’s GP would be put out and sceptical that I could include all the medical information required.

However, I quickly came to realise that this was the most important change to my medical practice that I had made since becoming a consultant. My consultation style improved, more focussed on the patient’s perspective, and my relationships with patients became more rewarding.

Medico-legal experts [1], NICE [2], NHS England [3], the RCP [4] and the Academy of Medical Royal Colleges [5] have all recommended that clinic letters are written directly to the patient and copied to the patient’s GP, with information for the patient written in plain English.

The AoMRC guidance was written in 2018 and yet six years later only a minority of hospital doctors write their letters directly to patients. Many reasons are given why they don’t but, with some thought and a little imagination, they can almost always be overcome. And most doctors who make the change find that their patients are more satisfied and better equipped to cope with their condition as a result [6].

The launch of the AoMRC guidance was picked up by the BBC on national and local news; it even featured on that week’s radio comedy, The News Quiz [7]! I had the pleasure of contributing to an episode of Word of Mouth with Michael Rosen on Radio 4 [8]. The reaction from the public was amazing and I heard very many stories of how patients and their families had been confused and worried by letters they had received.

There are a number of reasons why uptake of this practice has been slow and patchy. The voice of patients in the drive to change practice is sadly very weak. The apprenticeship model of medical training can hinder the introduction of new ways of working. And Royal Colleges have not included education and assessment of written communication skills in their curricula or examinations.

However, new forces are coming to bear that will change the situation. Patients now have direct access to their medical records through the NHS app. If those records are not written in a way they can understand, they are likely to ask for explanations.

The most transformative change will be the use of artificial intelligence in clinical documentation [9]. Letters created by AI software, based upon the conversation in the consultation, could and should be configured to be written directly to the patient and include explanations in plain English. Inevitably, new technology will bring new challenges but patients may at last benefit from written communication that is centred on their needs.