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November 1 2012
Trevor Warburton, clinical adviser to AOP legal services, discusses the GOC’s rules for referring
Do you know everything you are supposed to do in relation to referrals? We all know (or should do) the obligation to look for signs of injury, disease or abnormality during a sight test. This is achieved by performing internal and external examinations and any other procedures that appear necessary to detect signs. But then what? The GOC rules require you to refer that patient, except in certain circumstances, but there are rules about how to deal with referrals.
Legislation1 requires you to give the patient a statement immediately following the sight test that you are referring them, together with the reasons. GOC rules require you to advise the patient to consult a medical practitioner, to provide a written report to the medical practitioner wherever practicable and, where the referral is urgent, to take such steps as are open to you to inform a medical practitioner immediately.
Generally speaking, if you send an urgent referral to a GP there is a distinct chance that it will be dealt with as routine and you will find yourself liable for having used an inappropriate referral pathway. Do ensure that you know the urgent referral pathways for the likes of wet AMD and retinal detachments for any location where you work. It is a contractual requirement that GOS contractors know their local referral pathways and pass this information to their performers. LOCs can help here by providing details of all local referral pathways on their websites.
Ideally these would be capable of being viewed on a smart phone, as well as being printed for reference in the practice.
Informing the patient
As mentioned above, you must provide the patient with a written statement of the reason for referral immediately after the sight test. Of course, many of us don’t write the actual referral letter until after the patient has left the premises, so the simplest way to comply with this requirement is to add a short comment in the notes space on the prescription, for example “cataract” or “suspect glaucoma.” All of these requirements are echoed in the GOS contract.
It is considered good practice within the NHS to copy letters to the patient and should probably be done as a matter of course when referring patients, in addition to the short comment on their prescription. Apart from anything else, when the surgery (or HES) loses your referral letter, the patient is less likely to complain that you didn’t send it if they have received their own copy. You should also advise them to take the copy to their appointment at the surgery or hospital in case the original has gone astray.
Referring to non-medical practitioners
You can refer to someone other than a medical practitioner. This could be another optometrist, an orthoptist or, quite commonly, a referral centre. In these cases the GOC requires you to record the date and the fact of the referral, a sufficient description of the condition, the advice given, and that a written report is provided along with the urgency and instructions as to where the patient should go next. This is the only occasion where a statement of urgency is mandatory. Whether urgency is stated or not, your actual referral must always be of appropriate urgency and directed on an appropriate pathway.
Part-time optometrists can often have a problem when they wish to repeat a procedure on another day in order to help them reach a decision, eg visual fields. If the outcome of the sight test hinges on this, then in the case of GOS, the form should not be submitted until the additional procedure has been performed. If the part-time optometrist is not returning to the practice for some time this can be a problem. It is advisable for part-time optometrists to keep a log of such occasions and to follow up and ensure the test was performed with an appropriate outcome. An alternative is to formally refer the patient to another practitioner in the practice. This allows completion of the sight test. The referral should be made in writing, separate to the record but with a note on the record, and with advice to the receiving practitioner as to what you expect to be done with the patient dependent on the result. This could be handed to the receiving optometrist or to the practice manager. Just ensure it doesn’t simply get filed with the record.
There are three situations in which you need not refer. One is when you are acting under the direction of a medical practitioner, but the GOC rules2 then impose an obligation to inform the medical practitioner of any condition of which they may be unaware. Secondly, the GOC rules allow you discretion not to refer where there is no justification or it is impractical to do so. In this case you must record a description of the injury or disease, the reason for not referring, the advice given and, if appropriate and with consent, inform the patient’s GP. Thirdly is if the patient refuses referral, in which case you should record that fact and the reasons given by the patient. AOP advice in this situation is to send a referral letter (recorded delivery) to the patient with a covering letter asking them to take it to their GP if they change their mind.
In a nutshell, if referring:
- Record a description, who you referred to (or the reason why not) and the advice given • Make any referral in writing including following up urgent phone referrals with a written report
- Inform the patient of the reason for referral in writing immediately following the sight test and consider giving/ sending them a copy of your referral letter
- Note the urgency when it’s to a referral centre or non- medical practitioner and say where it should go next
- You have discretion on referral
What about the referral itself?
Make sure you know the local pathways. Ignorance will not be treated as an excuse. Write legibly or, preferably, type. Many referrals are scanned and faxed, so use a dark pen. Be clear, concise and to the point; include necessary, relevant clinical information. Say what you think the problem is and what you think should be done (this is particularly important if the patient has multiple pathologies – eg cataract and suspect glaucoma). If it’s urgent, say so (but don’t necessarily expect a GP to act). If it’s a referral to the GP that is not for onward referral to the eye clinic, eg for suspect blood pressure, then make that fact clear and tell the GP whether the patient will contact them, or whether you would like the GP to contact the patient (ideally the former). Include all relevant information. On a GOS18, if there isn’t enough space, consider whether you are writing too much.
This all sounds obvious, yet audits suggest we aren’t as good at this as we might like to think. In an audit of referrals to ophthalmology (OT August 17, 2012), Susan Parker found that optometry referrals could only be considered complete in 62% of cases. On the bright side, the same audit concluded that “optometrist referrals were usually appropriate and some were excellent.”
1. Sight Testing (Examination and Prescription)(No 2) Regulations 1989
2. Rules Relating to Injury or Disease of the Eye 1999
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