After each of the 5 million outpatient clinic appointments that occur every month in the National Health Service (NHS), a letter containing a summary and management plan is written by the clinician and sent to the patient‘s general practitioner (GP); a copy to the patient and to the tertiary care team if the patient is under a shared-care agreement.¹ Outpatient clinic letters remain the primary means of correspondence across the interface between primary, secondary and tertiary specialists and are crucial in ensuring that both patients and clinicians receive up-to-date essential information to ensure continuity of care. However, every so often these letters may not meet the information needs of the recipients.

Our study aims to address the issue of variability in the method of communication between the secondary and tertiary care specialists to improve the quality and standards of care. In the context of paediatric inflammatory bowel disease, we analysed 99 unselected clinic letters of Crohn’s disease patients presenting in the year 2022 in a university paediatric gastroenterology clinic. The sample included clinic letters from the secondary-care hospital and the local tertiary centre that shared the clinical responsibility of these patients. The letters were analysed and the following items were rated as essential information: diagnosis, latest blood results, latest endoscopy and colonoscopy reports current medications with dose, anthropometry, examination findings, current management and the follow-up plan. The most obvious finding to emerge from this study is that although the letters commonly contained details on diagnosis and examination findings, around one-third of the letters lacked information on recent blood results and the latest biopsy reports. Secondly, around 10% of the letters did not contain updated information about the current medication and anthropometry of the child. Taken together, it can be suggested that the inconsistency in the information provided in the outpatient letters can result in confusion and difficulty in understanding the contents of the letter both for the patients and general practitioners.

A reasonable approach to tackle this issue is to introduce a common structured approach to the content of outpatient clinic letters between the secondary and tertiary care units that include the use of headings such as diagnosis, previous investigations, anthropometry, current treatment, recent blood results and forthcoming follow-up plan. We believe that this change has several benefits including improving continuity of care, avoiding the need to check previous letters for important information and enhancing the patient-centredness of clinicians’ communications. Alternatively, a shared-care digital database could be established that provides a common platform for patient records to be accessed by all clinicians involved in patient care. However, the different software systems used by various hospitals and the technical difficulties in setting up a digital database can prove to be quite challenging in implementing the above changes.

Nonetheless, greater efforts are needed to implement targeted interventions ensuring appropriate systems and services for clinicians dictating clinic letters. We conclude that this is likely to improve the quality of communication and the comprehensiveness and value of these letters to both patients and clinicians.

Reference

1. The Lancet. Patient letters: improving an outdated system. The Lancet 2018;392:892.