The letter backlog: why it grows, and how to clear it

A letter backlog is almost never a writing problem. It is a queue with no fixed slot in the week, so it only gets touched once everything else is done, which is never. Clearing it takes three fairly boring things: a standing slot, a small set of templates, and a decision about which letters need writing at all.

The short version

• Letters slide because nothing in the clinic day forces them to happen.
• Notes have a same-day standard. Letters do not, so they queue.
• Split the pile into three kinds. Only one is genuinely urgent.
• Templates and placeholders remove most of the repeat typing.
• Clear the old pile oldest first, then keep the slot permanently.

Why the pile grows

Notes get written because the day forces them. There is a next patient, there is an end to the clinic, and the professional standards are explicit about timing. The Chartered Society of Physiotherapy's record keeping guidance sets the bar at notes written "immediately after the contact with the service user or before the end of that working day". Nothing pushes a letter like that.

So letters wait for a gap, and a clinic day does not reliably produce gaps. They get done on a late cancellation, or at nine in the evening, or when somebody chases.

The second reason is that they arrive from four different directions and land in the same undifferentiated pile. A GP asks a question. An insurer wants a report. A patient needs something for work. A solicitor writes in. Those are four different jobs carrying four different levels of urgency, and once they are stacked together the stack itself becomes the thing you avoid.

The third reason is that the pile is usually invisible. It lives in your head, on a sticky note, or as a flag inside the practice software that only you can see. A queue you cannot count is a queue you cannot plan, and it always feels bigger than it turns out to be.

Three kinds of letter, and only one of them is urgent

Before writing anything, split the pile. Most of what looks like one large job is three smaller ones with different deadlines.

Clinical correspondence that affects someone's care. A referral onward, a letter to a GP about something you found, a reply to a clinician who asked you a direct question. This is the only category that is genuinely time-critical, and in most clinics I have seen it is also the smallest. The CSP guidance is clear that you must share information with other health professionals directly involved in the patient's care, and adds that while you do not need written permission to do so, you "should always seek to ensure that your patient is aware of the communication".

Routine updates. A discharge summary back to a referrer, a courtesy note at the end of an episode. Useful, good practice, and rarely urgent. This is where most of the pile actually lives.

Chargeable requests. Insurance reports, medico-legal letters, letters for an employer. These carry a fee and usually a deadline set by whoever asked for them. Letting these drift costs money twice, once in the fee and once in the chasing.

It is worth remembering that correspondence sits at the front of the professional standards rather than off to one side. Communication and patient partnership is the first of the four themes in the General Osteopathic Council's Osteopathic Practice Standards. A letter is part of the care, and the standards treat it that way.

Templates do most of the work

Almost every letter a clinic sends is one of roughly eight letters. Same structure, same opening, same closing paragraph, different patient and different findings. Retyping that structure from memory each time is where the evenings go.

Cliniko keeps these under Settings, then Letter templates, and lets you drop in placeholders that pull the patient's name, the date and your clinic details into the letter as you write it. PPS, TM3, WriteUpp and Semble all do a version of the same thing under their own names, so none of this depends on which system you run. If Cliniko is what you use day to day, the letters and templates side of it is worth setting up properly once.

The way to build them is backwards. Take the last ten letters you sent, put them side by side, and mark the sentences that appear in all ten. Those sentences are your template. Do not write templates from scratch, and do not write more of them than you need, because a template you have to hunt through is slower than typing.

How to clear a backlog that already exists

Making the pile visible comes first. Get every outstanding letter into one list with a patient name, a date, and which of the three kinds it is. The count is nearly always lower than the dread suggests.

Then work it in this order.

1. Anything clinically time-critical goes today, outside the slot. That is care, not backlog.
2. Chargeable requests next, oldest first, because they carry a fee and somebody else's deadline.
3. Routine updates in batches, oldest first, inside a fixed slot rather than whenever a gap appears.

Batching matters more than people expect. In most clinics I have seen, six discharge letters written together go faster than six written across six different days, because you are not reloading the format and the tone each time.

Some of the letters at the bottom of the pile no longer need writing. The episode closed months ago, the patient has moved on, the referrer never chased. Decide that deliberately, write a line in the notes recording that you decided it, and take it off the list. An item left open forever is worse than an item closed with a reason.

Then keep the slot. The slot is the entire reason the backlog does not rebuild. Put it where the writing is easiest, which for most people is the same day as the clinic rather than the end of the week, and protect it in the diary the way you would protect an appointment.

Getting the letter out of the building safely

A clinical letter is patient-identifiable information, and how it leaves the building matters as much as what it says. Sending from inside the practice software, as an attached PDF to a named recipient, is usually cleaner than pasting a letter into a personal email account, because the send gets logged against the patient record and the next person can see it happened.

Beyond that, the route is a data protection question rather than an admin one. The ICO publishes guidance on encryption, including sections on encrypting data in transit and on encrypted email, and it is worth reading before you settle on how correspondence leaves your clinic. If you are unsure whether your current setup is appropriate, that is a conversation for whoever supports your IT rather than something to settle from a blog post.

When it is worth handing over

Sometimes it is not, and it is fair to say so. If you write two letters a week and they go out on time, you do not have a backlog, you have a system that works. Leave it alone.

It becomes worth handing over when three things are true at once: the pile never reaches zero, chargeable reports are going out late or not being billed at all, and the writing has moved permanently into your evenings. At that point the queue needs an owner rather than more of your evenings.

Dictation to finished letter is one of the easiest jobs to hand over, because the split is clean. Clinical judgement and the content of the letter stay with the clinician. The typing, the formatting, the chasing of missing details, the sending and the filing do not have to.