Writing to a GP About Your Patient

How to Undertake the Best Referral 

 

Writing a letter to your GP about your patient is not just a skill but a requirement. An effective referral letter from you to the GP can open doors for both the patient and yourself. I set out to discuss the process with clinical colleagues.

Writing for Permission!

Less Acceptable 

‘Dear Dr Abc,
I saw your patient today who had an ingrown toenail and think they should have nail surgery. Are there any medical concerns that would prevent me from proceeding…’

Many reading this sample may feel this is both reasonable and sensible. But reflect more carefully on the content and presentation. A podiatrist is trained to undertake nail surgery as part of their standard education. A GP refers a patient to a service expecting that all due care is taken to provide such a service. Today, this also includes providing drugs that avoid tapping into the GP’s budget. Because the topic of prescribing will complicate the theme of letter writing, this will be left for another article. Taking a medical history precludes all risks in connection with nail surgery. If the podiatrist cannot offer this service, the letter should recommend deferment elsewhere. In all other cases, assess the patient and get on with providing the treatment you were trained for and expected within your role as an independent practitioner.

More Acceptable 

Of course, there are exceptions to the rule, and it would be churlish of me to say there were times when I felt there were no risks and needed advice. Through years of practice, my confidence and experience changed to reflect my learning. However, a professional needs to write a letter in such a way that it looks competent, professional, ethical and helpful. If you seek advice, there are ways to achieve this and certainly ways to avoid looking as if you were poorly informed. Like many, I learned the hard way, made mistakes, and almost certainly wrote the type of letter my colleague had when first qualifying. Today, the above example falls fair and square to the rule ‘avoid!’

‘Dear Dr Abc,
I saw your patient today. I recommended nail surgery and covered all the important risks, including healing, regrowth, potential pain, and infection, and he wished me to proceed. From the history and examination, he appears healthy without medical concerns. An information sheet has been provided to support the planned treatment. I will keep you informed of the progress.

The second letter is more professional and tells the GP that you are a competent professional. Of course, more could be added as a diagnosis. Make headings and provide a list of medical issues and drugs used. You can add more about your assessment, including vascular flow analysis (doppler). Your clinical notes will carry all the details showing that you took detailed care. It is good practice to copy the letter to your patient. Communication is enhanced and there is an opportunity to correct any misunderstandings.  Never write anything you would not wish the patient to read, and be aware that GPs copy letters are copied to patients. Never make any judgment in a letter that could later lead to embarrassment. 

Writing to a Doctor about your Concerns

A patient presented with an ingrown toenail and was having chemotherapy. In this case, an oncologist was involved. The protocol requires you to write to the consultant and copy the GP. The patient’s doctor needs to be aware of any treatment they may wish to perform. Chemotherapy lowers the blood cells, particularly white cells, so fighting off infection immediately becomes a problem. The GP is the wrong person to write to for advice because should something arise through any misunderstanding, the GP will rightly turn around and say that you were the professional performing that treatment, not me. With modern MDT practices, management is better coordinated than it was once when shared as teams. An oncologist will rant if you try to undertake a phenolisation during the height of cancer management. I am not making this stuff up, as I had one oncologist write back and say.

‘DON’T DO ANYTHING – YOU WILL KILL THE PATIENT!’

You never forget this type of response. But how do you manage a letter? Again, it is important to be cognizant of the medicine. 

‘Dear Dr Xyz
Your patient has an ingrown nail. I am managing this conservatively to avoid any healing or infection issues. Still, at some stage, I would advise that she is referred/managed by non-phenolisation to remove the chronic inflammation by surgical excision. If she continues to have repeat infections this will pose additional risks when she has her next course of chemotherapy. We can minimise any risk with antibiotics until she has healed. However, it is unclear when you wish to start the next treatment cycle. If you could liaise with me on this matter, that would be of considerable help. etc…’

This letter is informative, confirms that you know what you are talking about, and begs for a liaison so the patient has collaborative support.

Writing to a GP Requesting Medication

There is a strong advocation to persuade all podiatrists to consider independent prescribing. Whether in the NHS or independent practice, management comes under the podiatrist’s control. If a GP provides a drug, he or she is doing this by proxy and many doctors are no longer happy at taking such risks. Over-the-counter medicines will help most but baseline drugs like antibiotics should be part and parcel of modern podiatry practice. There are drugs that are not covered. So how do you proceed?

Again, purely through experience, I learned the ideal form of a letter to help a patient. I read a colleague’s letter. He was a consultant anaesthetist and pain specialist. As this was a case of independent non-NHS treatment, he wrote the following lines:

‘Dear Dr Albe-Well
Diagnosis…. etc
Your patient presents with ongoing ankle pain due to XYZ, and I have advised and undertaken ABC investigations today and attached the relevant reports. I would recommend that you consider introducing gabapentin 300mg tds initially. I have arranged to see her in three weeks…’

In the NHS, drug protocols should allow you to provide treatment around your scope. In the independent sector, patients can pay legitimately as part of their non-NHS management. Your letter may have a rider that indicates that the medication you recommend is not listed for sale or access and you appreciate following the recommendation. These concerns are only included to highlight some of the issues podiatrists may face. Please refer to The Royal College of Podiatry or Institute of Chiropodists & Podiatrists for information about the use of independent prescribing and access to drugs and medicines. Courses such as webinars and branch talks on prescribing are constantly run at conferences.

Writing to a GP for a Referral Onwards

In all probability, this aspect of letter writing is the most vexing. Both from Facebook and from interviews over the years, some podiatrists have found that their letters have fallen on deaf ears! The question must be, why? The first thing anyone must do is to ask if the letter is clear enough. Here are a few things you need to know about doctors.

• Doctors are busy, meaning they have a mass of correspondence to get through daily.
• Scan reading means it is easy to miss actions, and actions are what you want to happen.
• Long letters and those on A4 paper have been the GP’s least favourite missives. A4 has to be folded if the system uses Lloyd George-style envelopes. Today, we are more likely to see information generated via e-mail and computer systems. However, these systems lie in the domain of the NHS. Links to the independent podiatry practice are unlikely unless the practice dovetails with the GP centre.

Call to action

1. The heading must clearly state what is needed so that the action can fly off the page (virtual or otherwise). 
2. Highlight the history clearly in a logical way.
3. Be clear about what you want the doctor to do.

Follow up

Make sure the patient has a copy and direct them to the GP to consolidate your referral and recommendations. This should be noted in your records. Follow this up after the patient has attended. If you do not develop feedback, you cannot hope to reflect upon your success or shortfalls.

David was a former podiatric surgeon consultant, clinical tutor, and lead clinician working in the NHS and independent sector until 2018. He has 43 years of experience in podiatry and is now a full-time author.

Thanks for reading ‘Writing to a GP about your patient’ by David R Tollafield

Published by Busypencilcase Reflective Communications Est. 2015
First released 1 June 2021 in longer form. Updated 23 January 2025.