How Do Doctors Break Bad News in the UK? The SPIKES Approach Explained

CareerPro UK Team

Oct 25

9 min read

Updated: 2 days ago

Breaking bad news is one of the hardest things a doctor does, and in the UK it is also one of the most closely watched. Patients and families remember the words, the room and whether the doctor sat down. This guide explains the SPIKES approach used across the NHS, the cultural differences many international medical graduates (IMGs) notice, and how these conversations are tested at interview.

Quick answer

Most UK doctors break bad news using SPIKES, a six-step structure: Setting (private room, right people, sit down), Perception (what does the person already know?), Invitation (how much do they want to know?), Knowledge (warning shot, then plain words), Emotions (pause and respond with empathy) and Strategy and summary (next steps and support). The patient, if they have capacity, is told first.

What you will learn in our free Communication Skills for Doctors: Bad News, Complaints and Difficult Conversations course

Communication is on every NHS person specification and tested in almost every interview. Learn the structure and words UK panels and patients expect. Our free online Communication Skills for Doctors: Bad News, Complaints and Difficult Conversations course is written for NHS doctors and international medical graduates. You study at your own pace in 6 short modules, with worked examples, interactive exercises and a short quiz at the end. There is no sign-up, and your progress is saved so you can stop and come back.

The 6 modules

Foundations: consultations that work: What the GMC and patients expect, Communication across cultures, A structure for every consultation, Ideas, concerns and expectations (ICE), Listening and empathy
Explaining, risk and shared decisions: Explaining clearly — chunk, check and teach-back, Communicating risk, Consent and shared decision-making
Breaking bad news: Breaking bad news — SPIKES, What to say — and what not to say
When things go wrong: anger, apology and candour: The angry patient or relative, Saying sorry — and the duty of candour, DNACPR and treatment-escalation conversations, Martha's Rule — when families are worried
Complaints, interpreters and remote consultations: Complaints and PALS, Working with interpreters, Telephone and video consultations
Your evidence: interviews, role-plays and portfolio: Communication in interviews and role-plays, Plan your next difficult conversation, Evidence for your CV and portfolio

By the end of the course you will be able to

Structure a consultation and explore ideas, concerns and expectations
Explain information clearly using chunk and check and teach-back, and communicate risk with natural frequencies
Support shared decision-making in line with Montgomery and GMC consent guidance
Break bad news using the SPIKES framework
De-escalate an angry patient or relative and respond with empathy
Apply the professional and statutory duty of candour, and apologise well
Hold DNACPR and treatment-escalation conversations, and explain Martha's Rule
Respond to complaints, work with interpreters and consult safely by phone and video

Why it helps your NHS application

Model phrases for the hardest conversations: bad news, an angry relative, saying sorry, DNACPR
Up to date with UK law and guidance: Montgomery, duty of candour and Martha's Rule
Ready for interview role-plays — and a conversation plan you can download

How to write it on your NHS application

In your CV and on NHS Jobs or Trac: list it under "Courses and CPD" (or in the training and courses section of the form), for example:

Communication Skills for Doctors: Bad News, Complaints and Difficult Conversations, online CPD course, CareerPro UK. Certificate of completion, [month and year]; verifiable online, ID CP-XXXXXXXX.

In your supporting statement: show what you learned and how you use it. For example (adapt it so it is true for you):

"I completed a communication skills course covering breaking bad news with SPIKES, responding to complaints and working with interpreters, and I use this structure when I lead difficult conversations."

At interview: the course also prepares you for questions such as "Tell us about a time you had a difficult conversation with a patient or relative."

Your certificate of completion

When you pass the quiz, you can download a certificate pack:

A verifiable PDF certificate of completion with your name, the course, your CPD time and a QR code that shortlisters and appraisers can scan
An appraisal-ready reflective note, pre-filled with the course learning outcomes
A ready-to-paste line for your NHS Jobs or Trac application and CV, and a one-click "Add to LinkedIn" button
Studying is free. The certificate pack is a one-off £5, and you pay only after you pass

Online course — does not replace face-to-face communication skills training.

Start the free Communication Skills course now

What SPIKES is and where it comes from

SPIKES was published in 2000 in The Oncologist as a six-step protocol for giving bad news to people with cancer. It is now taught in UK medical schools and used across specialties, from emergency medicine to psychiatry, because it works for any news that seriously changes how someone sees their future: a cancer diagnosis, a stroke with lasting disability, a pregnancy loss or a death.

Its value is not the acronym itself. It is that it stops you making the most common mistakes under pressure: giving the news before you know what the person understands, using jargon, and filling the silence with treatment plans before the person can take anything in.

The six steps of SPIKES in practice

Setting. Prepare first. Check the results and notes, agree the plan with your senior, book an interpreter if needed, and ask a nurse to come with you. Find a private room, hand your bleep to a colleague, and sit down. Ask the patient who they would like with them.
Perception. Before saying anything new, find out what they already know or suspect: "Can you tell me what you understand about why you had the scan?" Their answer tells you where to start.
Invitation. Ask how much detail they want. Most people want full information; some prefer the outline first. "Would you like me to go through the results in detail?"
Knowledge. Give a warning shot ("I'm afraid the scan has shown something serious"), pause, then give the news in one or two short, plain sentences: "It shows a cancer in the lung, and unfortunately it has spread to the liver." Avoid phrases such as "a lesion suggestive of malignancy".
Emotions. Stop talking. Let the person react, and name what you see: "I can see this is a terrible shock." Ten seconds of silence feels long to you but is what the person needs.
Strategy and summary. When they are ready, explain what happens next, check understanding, offer written information, and make sure they know who to contact and when you will speak again. Then document who was present, what was said and what was agreed.

When someone asks "How long have I got?", be honest but careful: give a range rather than a single number, explain the uncertainty, and involve your senior or the specialist team. If a death has to be shared by telephone, first check who you are speaking to and that they are somewhere safe to talk, and use the words "died" or "dead", because euphemisms such as "we lost him" are easily misunderstood.

Cultural differences IMGs often notice

Many IMGs trained in systems where the doctor decided the treatment, families were told first, and a cancer diagnosis was sometimes kept from the patient. The NHS works differently, and the adjustment takes time.

The patient comes first. An adult with capacity is entitled to information about their own health. Family members are involved with the patient's agreement.
Plain words. UK patients expect "cancer" and "died", said kindly, rather than indirect wording.
Shared decisions. Options are explained and the decision is made with the patient, in line with GMC guidance on decision making and consent.
Time for feelings. Patients expect space to ask questions and show emotion, not a short, task-focused consultation.

A common situation is a relative who says, "If it's cancer, don't tell Dad." The request usually comes from love. A good response acknowledges that, explores their worries, and explains kindly that you will be guided by their father: you will ask him how much he wants to know. A patient may choose not to hear details, but that is the patient's choice, not the family's.

Your own cultural knowledge is still an asset. Some of your patients will share those expectations. The skill is to ask rather than assume: "Some people like their family involved in decisions; others prefer to hear things themselves first. What would you like?"

Handling anger, complaints and saying sorry

Anger in hospital is usually fear or frustration underneath: a worried relative who has waited hours without an update. Keep yourself safe, stay calm, let them speak, and acknowledge the emotion ("I can see how worried you are; let's sit down and I'll tell you everything I know"). Avoid blaming colleagues, agree a clear plan and follow it through. Security is for threats of violence, not for frustration.

When something has gone wrong, the GMC and NMC joint guidance on the professional duty of candour expects you to be open and honest with the patient, apologise, and explain what happened and what will be done. In England, regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 also places a statutory duty of candour on organisations for notifiable safety incidents, including telling the person in person, apologising and following up in writing. Under section 2 of the Compensation Act 2006, an apology does not of itself amount to an admission of negligence.

If a concern becomes a formal complaint in England, the 2009 NHS complaints regulations require the organisation to acknowledge it within three working days. Complaints can usually be made up to 12 months after the event (or after the person became aware of it), and someone still dissatisfied after the local response can go to the Parliamentary and Health Service Ombudsman. Many concerns can be resolved earlier through listening, an apology for the person's experience and help from PALS (the Patient Advice and Liaison Service). If you are asked for a statement, keep it factual, address each point and say what you have learned.

Working with interpreters

Bad news, consent and safeguarding conversations need a professional interpreter, in person, by video or by phone. NHS England's guidance for commissioners on interpreting and translation in primary care says that relying on family, friends or unqualified interpreters is strongly discouraged, and that people under 16 should not interpret except in exceptional circumstances where immediate treatment is needed. Local trust policies follow similar principles.

Brief the interpreter beforehand on the purpose and any sensitive news.
Speak directly to the patient in the first person ("How are you feeling?", not "Ask her how she feels").
Use short sentences, pause for interpretation and check understanding with teach-back.
Record the interpreter's name or ID and the language used.

If a patient insists on a family member interpreting, explain why a professional is safer and document the discussion and the patient's informed choice.

How communication is tested at NHS interview

Communication appears on almost every NHS person specification, and many interviews for specialty training and specialty doctor posts include a role-play with an actor. Panels look for the same things a patient values: an introduction, finding out what the person knows, clear language, responding to emotion, honesty and a plan. Candidates usually struggle by talking too much, rushing to information or avoiding the difficult part.

For a breaking bad news station, use SPIKES out loud. For a question such as "Tell us about a difficult conversation", use a STAR structure (Situation, Task, Action, Result) and finish with what you learned:

"A patient's son was angry that his father had been moved wards three times overnight. I took him to a quiet room, listened, apologised for the moves and the lack of updates, explained the current plan and arranged a call from the day team at 10am. He was reassured, and I learned that giving a specific follow-up time rebuilds trust."

On your written application, give the same evidence in a sentence or two: a real conversation, what you did and what changed. Our guide to writing an NHS supporting statement as an IMG shows how to turn examples like this into scored evidence, and the NHS person specification explained shows where communication criteria usually sit.

Our free Communication Skills for Doctors: Bad News, Complaints and Difficult Conversations course lets you practise these conversations with "what would you say?" exercises and model answers. It is an online study guide and does not replace face-to-face communication skills training or your employer's policies on complaints and candour.

Start the free course

The course is split into short modules covering consultation structure, explaining risk and shared decisions, SPIKES, anger and apology, the duty of candour, DNACPR conversations, Martha's Rule, complaints, interpreters and remote consultations, with a conversation plan you can download. It is free to study, ends with a quiz, and offers an optional verifiable certificate and a reflective note for your appraisal: start Communication Skills for Doctors. If you would like your NHS application reviewed and rewritten (£35), email cvreviewexperts@gmail.com.

Frequently asked questions

What does SPIKES stand for?

SPIKES stands for Setting, Perception, Invitation, Knowledge, Emotions, and Strategy and summary. It is a six-step structure for breaking bad news, first published in 2000 and widely taught in UK medical schools.

Should I tell the family before the patient in the UK?

No, not if the patient has capacity. In the NHS you speak to the patient first and share information with family only with the patient's agreement, although you can ask the patient who they would like to be present.

What is a warning shot when breaking bad news?

A warning shot is a short phrase that prepares the person for difficult information, such as "I'm afraid I have some bad news." You then pause briefly before giving the news in plain words.

Does saying sorry to a patient admit legal liability?

No. Under section 2 of the Compensation Act 2006, an apology does not of itself amount to an admission of negligence, and the professional duty of candour expects doctors to apologise when something goes wrong.

Can a patient's child interpret for them?

Children should not act as interpreters except in exceptional situations where immediate treatment is needed. NHS England guidance strongly discourages relying on family or friends, so use a professional interpreter, especially for bad news, consent or safeguarding.