'Copying letters to patients is coming to a clinic near you'

BMJ 2003; 326 doi: (Published 12 June 2003) Cite this as: BMJ 2003;326:1330
  1. Charles Essex (room101{at}, consultant neurodevelopmental paediatrician
  1. Child Development Unit, Gulson Hospital, Coventry

    According to the NHS Plan, from April 2004 patients will automatically receive copies of correspondence between health professionals. Although such correspondence would include letters from health visitor to speech therapist, physiotherapist to occupational therapist, and so on, most arguments about the issue have centred on communication between doctors. I suppose that shows who does the work, who carries the can, of whom patients have the highest expectations, and who does most of the things that make a major difference in the care of patients.

    Most of the objections to copying letters to patients have come from three groups: administrators, providers of health services to adults, and mental health professionals (OK, so I generalise, but you get the picture). These are people who have difficulty regarding parents and patients as adults who have autonomy and who can and should take personal responsibility.

    Administrators have lost sight of what our core business is—in my case, to deliver services to children and their families. Professionals in health services for adults are, paradoxically, often more paternalistic than professionals providing services to children. And mental health professionals rarely communicate with others, so they can't be accountable. No one knows what they do, and they can't be accused of not sending copies of letters if there are no letters—which will be one of the excuses for not copying letters to patients. The other excuse, which mental health services will also undoubtedly use often, is that sending a copy of the letter to the patients might harm them. “They might kill themselves if they read that they have a personality disorder that is probably untreatable.” They might, but you have to live with that risk. Not telling patients hardly seems conducive to a therapeutic relationship. “What if they suffer from, say, paranoia?” Surely they are exactly the patients you should write to, so they know you're not saying something else behind their backs.

    Actually I don't think sending copies of letters to patients is the answer. It is like travelling economy class. People will eventually want to upgrade—so why not travel first class from the start? For more than seven years, after each consultation I've sent one letter to the patient's parents and, with their consent, copies to the usual suspects (general practitioner, health visitor, physiotherapist).

    A person with an opinion and no data is just another person with an opinion. I've heard lots of opinions on why we shouldn't copy letters to patients, let alone write to them, from professionals who have never written to patients or who have written two separate letters, one to the patient and a different one to the doctor. “What about confidentiality and consent?” “What about possible child protection or fabricated or induced illness?” “What if you're considering cancer or a fatal illness in your differential diagnosis?” In seven years I've faced all these questions and dealt with them. Sending letters to patients will certainly generate complaints from patients or parents. (If they don't get a letter they can't complain about its contents.) I have apologised if I've got the information wrong and have corrected factual errors. And I've been assertive and not apologised to parents if I don't believe that I'm in the wrong but rather that the parents are not being honest about what it is really upsetting them.

    Sending letters to parents has undoubtedly improved parents' satisfaction. It has, however, increased my work, in that I get a lot more calls from parents who seem to think—presumably because I write to them—that I'm approachable and are therefore less inhibited about ringing me with questions or to ask for advice.

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    The most bizarre aspect of this, however, comes from the people charged with drawing up guidelines for copying letters to patients. I was involved in a Kafkaesque debate about consent. It went like this: when you send a letter to another professional, you should ask for the patient's consent to send a copy of the letter about the patient to the patient. In other words, if I go to my doctor, she has to ask for my consent to send me a copy of any letter she writes about me. Surely the consent should be whether I mind if she sends a copy to another professional?

    Copying letters to patients—or, better still, writing directly to patients—is coming to a clinic near you. It shouldn't need a central government directive, a working party, and many meetings, which cost many thousands of pounds. (One meeting, lasting a day, that I attended cost the NHS the equivalent of an epilepsy nurse's annual salary. An epilepsy nurse would significantly improve my service to children with epilepsy, but my bids for funding keep being turned down because of “lack of money.”) All that is needed is for professionals to treat patients with respect and to treat other people in the way they themselves would like to be treated. It is a management style that is about 2000 years old.


    • Competing interests None declared.

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