All the letters I get from businesses are clear, concise and useful. I just got a letter confirming a hotel booking. It was all these things. I feel confident that when I arrive I will be welcomed and cared for. The letter told me implicitly and explicitly that I was important.
For patients, the communications they receive are practically and symbolically important. An appointment letter may be the first time they come into contact with the health service. Unlike hotel customers, they may need reassurance. Being in pain, vulnerable and uncertain, the NHS must send a letter that is extra careful with content, structure and language.
I recently got an almost incomprehensible hospital appointment letter that barked: ‘make sure you attend’ in bold letters surrounded by a red-outlined box. There was no map, no mention of how to prepare (was I going to have to undress? What sort of questions might I think about?). I felt infantilised before I even arrived.
Why can’t the NHS write good appointment letters?
Two reasons why hospital letters are, on the whole, so poor: Firstly its nobody’s job corporately to take the work in hand. In turn this is because few see its contribution to high quality care and a better experience for patients.
Alf Collins, an inspirational doctor and supporter of shared decision-making, shared his colleague’s, thoughts on this issue. Andrew Rix, an organisational psychologist, googled ‘GP appointment’ and asked of the first 20 practices mentioned:
1. How many mention a ten minute appointment? Nearly all.
2. How many mention a ‘one problem per consultation’ policy? Over half.
3. How many tell you how to make a complaint? Nearly all.
4. How many mention the cost to the practice of DNAs? Well over half.
5. How many mention the amount of time you will have to wait? Very few.
6. How many mention other restrictions, like Fridays for emergencies only? About half.
7. How many offer a choice of GP? Most, but not today.
8. How many give advice on how to use your time with the doctor? A few.
9. How many offer an alternative e.g. telephone consultation/practice nurse? Under half.
10. How many tell you how to make a suggestion for improvement? Not many.
This suggests that the patient needs to fit the system rather than vice-versa. Andrew says: “Did your last communication from an outpatient clinic give you a choice/invite you to discuss dates or was it a take it or leave it offer, with a warning that Did Not Attends would be deleted from the waiting list? Did it engage you in making the appointment or tell you what was going to happen? Is it more about how you are expected to behave?… Patient behaviour is a response to the values of the system that patients encounter”. (10 minutes for patient-centred care. https://www.linkedin.com/in/andrew-rix-955b4a21)
Bringing it all together
As Patient Director I oversee work on patient experience, patient and public engagement, patient communication and self-management support and can thus co-ordinate work usually farmed out to others in silos and often left to junior staff.
In the Sussex MSK Partnership (Central), we receive referrals from GPs across three CCG areas, concerning musculoskeletal problems, such as shoulder, back and neck pain, foot and ankle injuries and rheumatological and arthritic conditions. Our ‘triage’ service decides on the next stage and may refer people to our community clinics to see a specialist in their condition.
We offer a patient an appointment, and send them a letter, a two page A4 information sheet about the particular clinic they will go to and a map. I decided to check out how good it all was. Not very, I’m afraid.
We also know that our administrative systems to ensure access, co-ordination and continuity of care need improving and are the subject of justifiable complaints. Improving appointment letters is one of several improvements we are trying to make.
We re-wrote the short letter and made it more user-friendly. We made sure that we did not have web-links to dud pages and that all phone numbers were correct. We took out the red boxes, structured it better and re-did the grammar.
We stopped barking at patients. Instead of ‘due to very high demand, please make sure you can attend the appointment’, we wrote: ‘We hope the appointment is suitable, please let us know if you cannot make it’. Subtle but important. And when I tweeted that we were doing this, I got many supportive responses.
A few members of staff were wary: ‘They do need to know how busy we are’ one said. ‘I reckon most of them do’ I said. ‘And I’m not sure that hectoring people helps’.
Then we did a few additional things:
• Brought the information – the booking letter and the clinic information sheet – together in one letter for patients.
• Created one generic MSK appointment letter, rather than having one for people with foot and ankle problems, one for hand and wrist, one for shoulder, etc…
• Added more information about how patients can prepare for the appointment, what they need to think about in order to get the most out of their care and treatment and to be involved in decisions about treatment choices.
Simple isn’t easy
A simple idea had grown in ambition. But as it did so, the challenges to implementation became more tricky, and the number of fingers in the pie grew.
The Performance and Information Team, responsible for the IT systems and templates, needed to be involved. We will have to make sure that other sorts of letters, such as those after an appointment from specialists to patients and GPs, are also patient-friendly and aligned with the appointment letter’s content and structure.
I have to check things out with the Integrated Quality and Service Management Committee (yes, we have our bureaucracy too). A senior operational manager pointed out that we should tell people our policy on what happens when people don’t turn up three times (the ‘DNA’ or do not attends). We need sign off from the clinical leads (three of them covering different conditions) and from the operational team. Of course I had to test drafts with patients. And think about how to get letters available in different languages.
Some of the obstacles illustrate how barmy a system can be when trying to change things. Or maybe that’s life – what can seem simple to change is hard: How are the ‘simple’ new year’s resolutions to do more exercise going?!
One friend said this was all a “massive waste of effort”. But, yet again, patients kept me going: “carry on with the good work. Staff don’t realise how important this is for patients” said one.
Having a Patient Director role doesn’t mean that things will change quickly or easily. On the other hand, if nobody has oversight of patient-facing work, little will change at all. if work on improving patient experience is disconnected from patient communication, patients will continue to receive information that speaks volumes about how little the NHS truly cares.
If you liked this blog, see all 40 of my previous blogs at http://www.inhealthassociates.co.uk