sharing letters with service users policy…health copying letters to patients good practice...

Document Title Sharing Letters with Service Users Policy

Reference Number

CNTW(O)22

Lead Officer Executive Director of Nursing and Chief Operating

Officer

Authors (name and designation)

Anne Oxley Associate Nurse Director

Ratified By Business Delivery Group

Date ratified Nov 2019

Implementation date Nov 2019

Date of full

implementation Nov 2019

Review date Nov 2022

Version Number V05

Review and

Amendment

Log

Version Type of

change Date Description of change

This policy supersedes

Reference Number Title

NTW(O)22 – V04.3 Sharing Letters with Service Users Policy

CNTW(O)22

2

Sharing Letters with Service Users

Section Content Page

1 Introduction 1

2 Responsibilities - Who the policy and guidelines are for 1

3 Requirements of the policy 1

4 Writing Directly to Service Users 2

5 What constitutes a letter? 2

6 What does not constitute a letter? 2

7 Capacity to consent to receive letters 2

8 Consent to receive letters 3

9 Copying letters to carers 4

10 When letters should not be copied 4

11 Children and Young People 5

12 Procedure for Sharing Letters with Children and Young People

6

13 Administrative Procedure for Sharing Letters Service Users 6

14 Identification of Stakeholders 7

15 Training 7

16 Implementation 7

17 Monitoring Compliance 7

18 Equality and Diversity Impact Assessment 7

19 Fair Blame 8

20 Patient Policy leaflets 8

21 Associated documentation 8

Standard Appendices - attached to policy

Appendix A Equality Analysis screening Tool 9

Appendix B Training Checklist and Needs Analysis 11

Appendix C Audit and Monitoring Tool 13

Appendix D Policy Notification Record Sheet - click here

Appendices attached to policy

Document No: Description

Appendix 1 Sharing Letters with Service Users - Checklist

Appendix 2 Information leaflet – A4, A5, Easy to read versions

link to Patient Information Centre

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

https://www.cntw.nhs.uk/resource-library/sharing-letters-service-users-information-leaflet/

https://www.cntw.nhs.uk/resource-library/sharing-letters-service-users-information-leaflet/

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1 Cumbria, Northumberland Tyne and Wear NHS Foundation Trust CNTW(O)22 Sharing Letters with Service Users Policy V05 Nov 19

1 INTRODUCTION 1.1 The Sharing Letters with Service Users Policy and Guidance sets out how

Cumbria, Northumberland and Wear NHS Foundation Trust (the Trust/NTW) implements the Department of Health policy to copy correspondence to service users which came into effect in April 2004. The National Health Service (NHS) Plan (paragraph 10.3) stated that service users should be able to receive copies of clinicians’ letters about them as of right from April 2004.

1.2 The principles are consistent with established good professional practice

already required within health services. This includes good communication, obtaining consent, record keeping and handling, confidentiality, data protection and the provision to meet legal requirements to prevent discrimination on the grounds of disability or race.

1.3 Staff are required to read this policy in conjunction with the Department of

Health Copying Letters to Patients Good Practice Guidelines (2004). 1.4 The Trust has developed this Policy and Guidance, which outlines what type

of letters should be copied, how the service user’s capacity will be established and how consent will be recorded. The Practice Guidance describes the issues to be taken into account when preparing a letter that will be shared with the service user.

2 RESPONSIBILITIES - WHO THE POLICY AND GUIDELINES ARE FOR 2.1 The policy and accompanying Practice Guidance Notes (PGN) are intended

for use by:

Healthcare professionals

Health records and information staff, including those responsible for commissioning new systems

Medical secretaries and administrative staff

Non NHS staff working into health teams where records are integrated.

3 REQUIREMENTS OF THE POLICY 3.1 As a general rule, and where service users agree, letters written by one health

professional to another about a service user should be copied to the service user. The general principle is that all letters that help a service user’s understanding of their health and the care they are receiving should be copied to them as of a right.

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4. WRITING DIRECTLY TO SERVICE USERS 4.1 In many cases, healthcare professionals already write directly to service

users, copying the letter to the General Practitioner (GP) or others as necessary. This demonstrates good practice and should be encouraged.

5. WHAT CONSTITUTES A LETTER?

5.1 A letter includes communications between different health care professionals.

Different types of letters include:

Letters of communication between different health professionals, for instance those from and to GP’s, hospital doctors, nurses, therapists and other health professionals.

Letters or forms of referral, letters following discharge from hospital or episode of treatment, and letters following outpatient consultations.

Letters from NHS health professionals to other agencies such as social services, housing, etc.

6. WHAT DOES NOT CONSTITUTE A LETTER? 6.1 Other documents, for example, single test results or Mental Health Act

reports, should not normally be sent to service users. In due course, the outcome of such tests should be included in a letter that is shared with the service user.

6.2 Reports written to Mental Health Review Tribunals and Manager’s Hearings

should adhere to the guidance set out in the Mental Health Act. 6.3 For the purpose of this policy ‘letters’ do not include multidisciplinary team

meeting minutes, assessment tool reports and rating scales. Clinicians should have measures in place to communicate this information to service users.

7. CAPACITY TO CONSENT TO RECEIVING LETTERS

7.1 In accordance with Capacity Legislation, mental capacity is presumed unless

there is evidence to the contrary. Where there are concerns in relation to the service users’ capacity to consent, clinicians should consult the Mental Capacity Act 2005 which defines capacity and includes a framework for the assessment of capacity.

7.2 If there is concern regarding capacity, the Trust’s Policy, CNTW(C)34 – Mental Capacity Act (MCA) Policy should be followed

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7.3 If the Health Care Professional concludes that the person lacks the capacity to

make the decision, this should be recorded in the clinical record.

8. CONSENT TO RECEIVE LETTERS 8.1 Having demonstrated capacity, in line with the overall NHS policy of informed

consent, it is for each service user to decide whether or not they wish to receive copies of letters written about them by health care professionals.

8.2 The person who writes the letter is responsible for arranging that a copy is

made and provided to the service user, after capacity to decide has been confirmed and it has been established that the service user has consented to receive copies of their letter.

8.3 Service users should be offered the information set out in the information

leaflet (SL-PGN-01 - Sharing Letters with Service Users, Appendix 1) and routinely asked by the clinician if they wish to receive a copy of their letters; the decision should be recorded on Electronic Patient Record (Electronic Patient Record (RiO)).

8.4 The service user’s consent to receiving any letters should be documented at

the beginning of the clinical episode in RiO and any format needs to be flagged.

The professional should ensure that their consent to receive letters is reviewed with the service user at least every 12 months or more frequently if there is reason to believe that their capacity or consent has changed.

8.5 The service user may decide to opt out of receiving copies of letters, which

can be done at any time. 8.6 Individual departments should make arrangements for recording and acting on

the service user’s wishes about receiving copies of letters.

8.7 Further considerations:-

How the service user prefers to receive the letter e.g. by post, by collection or by viewing letters onscreen in the clinical setting

How the service users wishes to be addressed of note it is important to consider the particular needs of transgender people who may use different names in different contexts. It is advisable to ask how people want to be referred to in correspondence and check whether this differs from how they wish correspondence to be addressed.

Their preferred format:

o Printed copy of the letter

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o Copies in large print o Copies of letters dictated in the presence of the service user

9. COPYING LETTERS TO CARERS 9.1 Some service users have carers, for example partners, friends or family

members, who are actively involved in their care. Carers may need information and support from professionals supporting the person they care for.

9.2 If the service user wants to have information shared with their carers, a copy

of letters can be sent to their carers providing that the service user has given written consent. This should be recorded on Electronic Patient Record (RiO).

9.3 The service user may not want a letter copied or shown to the carers. Both the

service user and carer have the right to expect that information provided by either party to the health service will not be shared with other people without their consent. In such circumstances, unless there is an over-riding reason to breach confidentiality, the wishes of the service user must be respected. This should be recorded on Electronic Patient Record (RiO).

9.4 If it has been established that the service user lacks the capacity to decide

whether or not they wish to receive copies of letters, a copy should ideally be offered to the identified carer that is documented as being the person to receive communication on the service user’s behalf. This could be a person with lasting power of attorney or a parent or guardian in cases of children under sixteen receiving services. This should be recorded on Electronic Patient Record (Rio) The decision to copy letters to carers should be taken with the service user’s best interests in mind.

10. WHEN LETTERS SHOULD NOT BE COPIED

10.1 There may be reasons why the general policy of sharing letters with service users should not be followed. These include:

Where the service user does not want a copy

Where the clinician feels that it may cause harm to the service user. Where the letter includes information about a third party who has not given consent

Where special safeguards for confidentiality may be needed, e.g. Safeguarding adult/Child Protection Cases

10.2 “No Surprises” where the letter contains abnormal results or significant

information that has not been discussed with the patient, it will be important for arrangements to be made to give the patient a copy of the letter after its contents have been discussed in a consultation with the receiving professional.

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As a general rule the contents of the copied letters should reflect the

discussion in the consultation with the sending healthcare professional, and there should be no new information in the letter that might surprise or distress the patient.

10.3 Sharing difficult or sensitive information is not in itself enough to justify not

copying a letter.

10.4 When letters are written by non NHS Agencies. Letters from non-NHS

agencies may be written to healthcare professionals and not copied to service users. The healthcare professional may consider it is important to show the letter or give a copy to the service user. However, it is not the responsibility of the healthcare professional who receives the letter to send a copy to the service user.

10.5 When clinicians decide for any of the above reasons not to copy letters to Service Users who have the capacity to make the decision and have consented to receive them, a clear rationale should be documented by the clinician and reviewed regularly.

11. CHILDREN AND YOUNG PEOPLE 11.1 The general principles of this policy apply to children and young people

though certain considerations need to be made when sharing letters with young service users and their families.

11.2 A young person over the age of sixteen would normally be considered as

having the same rights as an adult to receive copies of their letter. Their capacity to do this should be considered as in Section 8 of this policy.

11.3 The Fraser guidelines (formerly known as Gillick Competence) suggest that

young people below the age of 16 have the right to receive treatment from the health service, should they be deemed to be able to understand the implications of the treatment and give informed consent about this. This also means that young people below the age of 16 have the right to receive copies of letters written about them should they be deemed to be able to understand the implications of this and give informed consent.

11.4 Clinicians should consider

11.5. Whether the child/young person has the ability to make the decision regarding whether they want to receive a copy of the letter.

11.6 Whether the child/young person has the ability to read and understand the contents of a letter.

11.7 Whether the parents/carers should be offered a copy of the letter instead of or as well as the child/young person.

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11.8 Whether the letter should be copied to the child/young person but not copied to the parents/carers.

11.9 Whether the letter should be partially copied or not copied at all.

12. Procedure for Sharing Letters with Children and Young People

12.1 Capacity to make the decision should be established as in Section 8 of this policy.

12.2 Where the child is deemed able to understand they should be treated in the same way as other service users as referred to in the main body of this policy and asked to complete the Consent Form on Electronic Patient Record (RiO).

12.3 All letters written by professionals within Children and Young People’s Services to other professionals within or outside service will be copied to the child to whom they refer except if any of the criteria described in Section 11 of this policy apply. The reason should be clearly documented in the notes.

12.4 If the child is deemed able to understand, they should be asked whether or not they wish their parents/ carers to receive a copy of the letter also. Their wishes should be documented on the consent form on Electronic Patient Record (RiO).

12.5 Where the child is deemed unable to understand, the parents/carers should be offered a copy instead and asked to complete the Consent Form on Electronic Patient Record (RiO). In this case, all letters written by professionals within Children and Young People’s Services to other professionals within or outside the will be copied to the parents/carers except if any of the criteria described in Section 11 of this policy apply. The reason should be clearly documented on Electronic Patient Record (RiO).

12.6 The child/young person/carer should be provided with the information leaflet that accompanies this policy.

12.7 The recording of consent should be explicit within RiO via the consent screen. This should be revisited12 monthly as a minimum

12.8 Each copy letter should clearly identify whether it is the child’s copy, parent’s copy or professional’s copy.

13 ADMINISTRATIVE PROCEDURE FOR SHARING LETTERS SERVICE

USERS

13.1 It is the professional’s responsibility to ensure that all letters to service users are written in the format that is preferable to the service user and distributed to them as requested.

13.2 Professionals may choose to write directly to the service users and send a copy to the relevant professional / carers

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13.3 Where administrative staff/medical secretaries are responsible for processing and sending the letters, it is advisable that the professional initially prepares the letter in draft, with clear instruction to administrative staff regarding the service users wishes in relation to formats, address, distribution etc.

14 IDENTIFICATION OF STAKEHOLDERS

14.1 This is an existing policy which has only minor changes that do not relate to operational and/or clinical practice therefore did not require a full Trust wide consultation process

North Locality Care Group

Central Locality Care Group

North Cumbria Locality Care Group

South Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

15 TRAINING

15.1 There is no specific training requirement for this policy.

16 IMPLEMENTATION

16.1 This will be monitored by the Locality Care Groups during the review process.

17 MONITORING COMPLIANCE

17.1 See Appendix C

18 EQUALITY AND DIVERSITY ASSESSMENT

18.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment (Appendix A) which has taken into account all human rights in relation to disability, ethnicity, age

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and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

19 FAIR BLAME

19.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who fail to implement the principles of this policy, although there may be clearly defined occasions where disciplinary action will be taken.

20 POLICY LEAFLETS 20.1 Any information given to patients needs to be in an accessible format,

accurate and ‘branded’ correctly. Cumbria, Northumberland and Wear NHS Foundation Trust (the Trust/CNTW) follows the process around production of this information as outline in the Trust’s CNTW(O)03 – Accessible Information for Patients, Carers and Public Policy.

21 ASSOCIATED DOCUMENTATION

Copying Letters to Patients Good Practice Guidelines (2004). DoH

CNTW (O) 01 - Policy on Policy Development

CNTW(O)03 - Accessible Information for Patients, Carers and Public

CNTW(O)09 – Records Management Policy and practice guidance notes

CNTW(C)20 – Care Programme Approach Policy

CNTW(C)34 – Mental Capacity Act (MCA) Policy

Interpreting Services – thebigword

22 REFERENCES

Department of Health Copying Letters to Patients Good Practice Guidelines (2004)

Mental Capacity Act 2005

General Data Protection Regulation 2018

The Equality Act 2018

NHS Plan 2000

http://www.plainenglish.co.uk/ Guidance on how the plain English approach

can make notices, letters and medical information clearer.

http://www.plainenglish.co.uk/

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals

involved in Review

Date of Initial

Screening

Review Date Service Area / Locality

Judith Hope Anne Oxley

Nov 2019 Nov 2022 Trust Wide

Policy to be analysed Is this policy new or existing?

CNTW(O)22 - Sharing Letters with Service

Users-V05

Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

The Sharing Letters with Patients Policy and Guidance sets out how Cumbria, Northumberland and Wear NHS Foundation Trust implements the Department of Health policy to copy correspondence to service users which came into effect in April 2004. The NHS Plan (paragraph 10.3) stated that service users should be able to receive copies of clinicians’ letters about them as of right from April 2004. The issues are consistent with established good professional practice already required within health services. This includes good communication, obtaining consent, record keeping and handling, confidentiality, data protection and the provision to meet legal requirements to prevent discrimination on the grounds of disability or race. Staff are

required to read this policy in conjunction with the Department of Health Copying Letters to Patients Good

Practice Guidelines (2004). The Trust has developed this Policy and Guidance which outlines what type of letters should be copied, how the patient’s capacity will be established and how consent will be recorded. The guidance describes the issues to be taken into account when preparing a letter that will be shared with the patient.

Who will be affected? e.g. staff, service users, carers, wider public etc

Staff, Service Users and Carers

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Need to ensure that for people with sensory impairments that the information is in an accessible format

Sex

Race

Age

Gender reassignment

(including transgender)

Sexual orientation.

Religion or belief

Marriage and Civil

Partnership

Pregnancy and maternity

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Carers

Other identified groups

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through Policy consultation process

How have you engaged stakeholders in testing the policy or programme proposals?

Through Policy consultation process

For each engagement activity, please state who was involved, how and when they were

engaged, and the key outputs:

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Now consider and detail below how the proposals impact on elimination of discrimination,

harassment and victimisation, advance the equality of opportunity and promote good relations

between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and

victimisation

Ensuring the information is provided in an accessible format will eliminate discrimination.

Advance equality of opportunity

Promote good relations between groups Ensuring the information is provided in an accessible format will eliminate discrimination.

What is the overall impact?

Addressing the impact on equalities

From the outcome of this Screening, have negative impacts been identified for any protected

characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Anne Oxley Date: Nov 2019

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Appendix B

Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or agreeing a

new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Existing policy

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

No new skills identified

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc.

Please identify the risks if training does not occur.

The requirements of DoH Guidance 2004 is described within the policy

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

All professional Clinical and administrative staff

Is there a staff group that should be prioritised for this training / awareness?

No, all staff require an awareness of policy and contractual requirement to implement it

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning

Trust Policy Bulletin Policy will be posted Trust intranet site

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

n/a

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Appendix B – continued

Training Needs Analysis

Staff/Professional Group Type of

training

Duration

of

Training

Frequency of Training

Knowledge of information in Policy and PGN

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Appendix C

Monitoring Tool

Statement

The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

CNTW(O)22 – Sharing Letters with Service Users - Monitoring Framework

Auditable Standard/Key

Performance Indicators

Frequency/Method/Person

Responsible

Where results and any

associated action plan

will be reported to,

implemented and

monitored; (this will usually be via the relevant governance group).

1 There is evidence of completed consent forms in the clinical record

Frequency – annually

Via QMT Audit

Locality Care Group Quality Standards Meetings

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.

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Appendix 1

SHARING LETTERS WITH SERVICE USERS

CHECK LIST This checklist should be used as part of the Trust’s Policy CNTW(O)22 - Sharing Letters with service users.

1. Has the service user’s capacity been established? Y / N

2. Has the service user been offered a copy of the information leaflet? Y / N 3. Has the service user consented to receiving a copy of the

correspondence? Y / N

4. Has the service user requested that their carer receives a copy

of the correspondence? Y / N

5. Has the service user requested a specific means of receiving the correspondence e.g. collect from outpatients, sent to an address

different to home address etc Y / N 6. If the correspondence is to be sent to their home address, has this

address been confirmed with them recently? Y / N 7. Does the service user require the copy in a format other than standard

print, e.g. large print, translated? Y / N 8. Does the correspondence contain any information that has not already

been discussed with the service user? Y / N 9. Is there any information about a third party within the

correspondence? Y / N

10. Does the correspondence exclude subjective statements? Y / N 11. Does the correspondence contain any terms the service user is likely

to be unfamiliar with? Y / N

12. Is there a contact number for the service user to contact if they require

further information? Y / N

sharing letters with service users policy…health copying letters to patients good practice...

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