The NHS Plan stated that by April 2004 letters sent from one health professional to another should be copied to patients (Department of Health, 2000). Copying letters to psychiatric patients seems likely to raise more complex issues than correspondence sent from other fields of medicine. Lloyd (Reference Lloyd2004) discussed the implications for psychiatry and the benefits and drawbacks of this practice. Both the good practice guidelines and report from the Working Group on Copying Letters to Patients discussed important issues, including that of mental capacity, albeit briefly (Department of Health, 2002, 2003). It can be difficult to obtain informed consent from patients lacking capacity through dementia, learning disability or other psychiatric illness. Unfortunately the working group was unable to give more than general guidance on this issue. The Welsh Assembly’s Management Board has recommended that the facility to receive a copy letter should also be available to patients in Wales (Welsh Assembly Government, 2002).
Over a 10-week period, Dale et al (Reference Dale, Tardos and Adams2004) surveyed 50 older out-patients and their 38 carers (using separate questionnaires for the two groups) concerning their views on copying letters to patients. Participants mostly preferred a simple letter about their care rather than a copy of the letter sent to their general practitioner. Harris & Boaden (Reference Harris and Boaden2003) reported that carers would like a copy of their dependant’s consultation letter and that a large proportion of older adults also wanted their carer to have a copy. Around half the users of mental health services found copy letters difficult to understand and many reported that they contained too much jargon. Most users wanted copies of letters, but found it difficult to contact professionals when they had questions about the letters. Interestingly, professionals were more likely to think there was too much jargon in the letters. Murray et al (Reference Murray, Nandhra and Hymas2003) and Nandhra et al (Reference Nandhra, Murray and Hymas2004) found that psychiatrists omit information from letters when they know patients will be sent copies. The draft template for consultation letters in the Department of Health Good Practice Guidelines (2002) is a useful starting point but is more suitable for surgical and medical settings. A consensus needs to be reached on the extent of the information and content of letters sent to patients, particularly psychiatric patients. The aim of this study was to assess the views of patients and mental health professionals on patients receiving copies of letters from psychiatric clinics.
Method
After a review of the literature and discussion with members of community mental health teams and patients, a 20-item questionnaire was designed to evaluate the views of patients and staff members on copying letters to patients. Questions explored views on disclosure of various aspects of a psychiatric assessment and a management plan. A question was asked to assess whether it was a good idea to send copies of clinic letters to patients. This questionnaire also explored respondents’ views on patients wanting to discuss or read letters before they were sent to other professionals. Responses were obtained using a Likert scale. Additional openended questions were asked on the advantages and disadvantages of sending copies of letters to patients. Staff members were also asked to name specific diagnoses that they considered unsuitable for this practice.
Questionnaires for staff members were mailed to their team leader for distribution. Over a period of 1 week, reception staff requested patients attending out-patient clinics staffed by eight local community mental health teams to participate in this study.
The Statistical Package for the Social Sciences software was used for data entry and analysis (SPSS, 2001).
Results
In total 104 questionnaires were completed (63 patients, 41 staff members). Receptionists from all eight community mental health teams invited all the patients attending clinics to participate. Hence it was not possible to ascertain the total number of patients who were requested to complete these questionnaires or patients’ reasons for refusing to participate. Out of a total of 64 members of staff, 41 (64%) returned completed questionnaires.
Out of the 63 patients, 33 (52.4%) were female. The mean age of the patients was 44 (range 21-71) years. Forty-six (72%) reported that they had been diagnosed with depression, five (8%) schizophrenia, five (8%) bipolar affective disorder and two (3%) eating disorder.
Among the staff, 18 (44%) were female and the mean age was 40 (range 26-60) years. Twenty (50%) were community psychiatric nurses, 16 (39%) doctors, 3 (7%) social workers and 2 (5%) psychologists.
Table 1 details the responses of the patients and staff. Significantly more patients (83%) than staff (37%) thought that copying letters to patients was a good idea (OR=14.56, 95% CI 4.674-45.158). There were significant differences between the two groups for the majority of questions. Patients favoured disclosure but staff members were more reluctant to disclose information. The majority of patients and staff agreed that the content of letters should be discussed (55% and 66% respectively, OR=1.061, 95% CI 0.385-2.924). In comparison, 75% of patients wanted to read letters before they were sent whereas only 17% of staff wanted that to happen (OR=18.8, 95% CI 6.428-54.987).
Table 1. Responses of patients and staff members to the questionnaire1
| Questions | Patients agreeing n (%) | Patients disagreeing n (%) | Staff members agreeing n (%) | Staff members disagreeing n (%) | OR (95% Cl) for agreement |
|---|---|---|---|---|---|
| 1 Copying clinic letters to patients/clients is a good idea | 52 (83) | 5 (8) | 15 (37) | 21 (51) | 14.56 (4.694-45.158)* |
| 2 Letters about mental health should be copied to the patients | 51 (81) | 3 (5) | 19 (46) | 13 (32) | 11.632 (2.981-45.384)* |
| 3 I would like to discuss contents of the letter before the letter is written | 35 (55) | 11 (17) | 27 (66) | 6 (15) | 1.061 (0.385-2.924) |
| 4 Letters should be read by patients/clients before they are sent to other professionals | 47 (75) | 10 (16) | 7 (17) | 28 (68) | 18.8 (6.428-54.987)* |
| 5 Patient’s/client’s carer should receive a copy of this letter | 35 (56) | 14 (22) | 12 (29) | 24 (59) | 5 (1.973-12.669)* |
| 6 Letter should include comprehensive information | 43 (68) | 4 (6) | 17 (42) | 18 (44) | 11.382 (3.359-38.565)* |
| Patients/clients should know what is written about… | |||||
| 7… them | 60 (95) | 2 (3) | 23 (56) | 13 (32) | 16.957 (3.548-81.047)* |
| 8… their past history | 57 (91) | 2 (3) | 24 (59) | 14 (34) | 16.625 (3.506-78.836)* |
| 9… their family history | 54 (86) | 2 (3) | 23 (56) | 14 (34) | 16.435 (3.454-78.202)* |
| 10… their childhood | 55 (87) | 5 (8) | 21 (51) | 13 (32) | 6.81 (2.162-21.450)* |
| 11… the amount of alcohol they drink | 43 (68) | 5 (8) | 23 (56) | 11 (27) | 4.113 (1.273-13.280)* |
| 12… the street drugs they take | 32 (51) | 9 (14) | 22 (54) | 13 (32) | 2.101 (0.766-5.760) |
| 13… their involvement with the law | 34 (54) | 7 (11) | 23 (56) | 14 (34) | 2.957 (1.034-8.451)* |
| 14… the diagnosis of their illness | 57 (91) | 2 (3) | 26 (63) | 12 (29) | 13.154 (2.744-63.047)* |
| 15… their future management | 57 (91) | 2 (3) | 36 (88) | 4 (10) | 3.167 (0.551-18.185) |
| 16… their medication | 58 (92) | 5 (8) | 37 (90) | 2 (5) | 1.045 (0.167-6.555) |
| 17… the deterioration/improvement of their illness | 56 (89) | 2 (3) | 31 (76) | 8 (20) | 7.226 (1.444-36.164)* |
| 18… their mental state | 53 (84) | 2 (3) | 22 (54) | 13 (32) | 15.659 (3.259-75.230)* |
| 19… their risk to themselves or others | 53 (84) | 5 (8) | 24 (59) | 10 (24) | 4.417 (1.361-14.328)* |
| 20… information given by a third person | 55 (87) | 2 (3) | 17 (42) | 21 (51) | 33.971 (7.217-159.895)* |
Ninety-eight per cent of the staff responded to the open-ended questions compared with 60% of the patients. Staff members felt the main advantage of copying letters concerned patient education, improving knowledge of their illness, management and goals of treatment. Increased sense of involvement in care, improvement of trust and development of collaborative relationships were other advantages mentioned by a minority. Seven staff members specifically stated that they could not think of any advantages.
The most common advantages listed by patients were also enhancement of their own understanding of illness and its management, along with the perception of taking a more active role in their own care and inclusion as part of the ‘team’. Evidence of improvement in illness with the consequent confidence boost was felt to be important by a few patients. Some stated that it would help them to have a written copy of their clinician’s opinion of them as an individual and a minority felt that it would provide an opportunity to disagree with their clinician’s opinion. Proof of communication to the general practitioner was considered to be an advantage by only one patient.
The most common concerns were the hindering of communication, and causing distress and anxiety through misinterpretation and use of medical jargon. The latter concern was also shared by the patients. Some staff members were concerned that the patient might not agree with the contents of the letter, which could be damaging for the therapeutic relationship. Confidentiality issues were raised by both groups. Additional work for the secretarial staff was mentioned by staff.
A wide variety of diagnoses were named by staff as not suitable for this practice, the most common being personality disorders and psychosis/schizophrenia. Substance misuse, anxiety, depression, dysthymia, factitious disorder, learning disability, hypochondriasis, paedophilia and no mental disorder were other diagnostic categories mentioned. One staff member commented that his reservations depended more on the characteristics of the patient than the diagnosis.
Discussion
Our study confirms the findings of Nandhra et al (Reference Nandhra, Murray and Hymas2004) that there is a demand from patients for copying letters to them after a consultation. There is a clear difference of views between patients and clinicians. A significant cause of the reluctance of clinicians to send copies of letters to patients is related to their fear of breakdown of the therapeutic relationship causing distress and anxiety.
Harris & Boaden (Reference Harris and Boaden2003) also found that use of jargon and reluctance to disclose information by clinicians was an issue. Our study supports the findings of Murray et al (Reference Murray, Nandhra and Hymas2003) that psychiatrists might conceal some information when copying letters to patients that they would disclose under current practice. Responses to openended questions suggest that for a minority of individuals with certain diagnostic entities it will be inappropriate to provide a full-copy letter. In such instances we believe that it would be appropriate to write a personal letter to the individual outlining their management plan when finalised.
As discussed by Lloyd (Reference Lloyd2004), our findings also suggest that there are significant potential benefits, including improving patients’ understanding of their illnesses and improving therapeutic relationships. We agree with Dale et al (Reference Dale, Tardos and Adams2004) that the majority of patients can receive a copy of their clinic letter to other clinicians in a form that is understandable to them. We believe that patients should be asked whether they would like to receive copies of their letters before they are sent and that the likely contents should be discussed with the patients before sending.
Future research and creation of working groups including users, carers, managers and clinicians working in mental health would facilitate the development of guidelines that specifically address mental health issues.
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