Referral management standards and ethics
September 2007
The introduction of referral management schemes has raised a number of concerns relating to the standards and ethics that apply to these referral processes and the potential medico-legal implications for clinicians. This guidance has been produced to clarify where the responsibility for patients lies during the referral process, to advise clinicians on circumstances where they feel that they have not been sufficiently involved in the diagnosis and preparation of a patient, and to highlight the requirements for obtaining patient consent.
Clinician responsibility during the referral process
New tiers of care between primary and secondary care mean that the relationship between a referring general practitioner and a consultant is becoming more remote. Intermediary steps, such as referral management centres, make it less clear whether the responsibility for a patient lies with the general practitioner or the consultant during the referral process. It can also be unclear who is clinically responsible for patient care in the referral management system, where elements of care might be managed by non-medically qualified healthcare practitioners.
The General Medical Council (GMC) has advised that ‘general practitioners have overall responsibility for managing a patient’s care, even after making a referral, whether to an individual consultant or to a referral management centre. For example, if a patient’s condition worsens before the patient has been seen by an appropriate specialist, the general practitioner would be expected to take appropriate action in response. However, doctors are not held accountable for by the GMC for decisions taken by others. Neither general practitioners nor consultants would be accountable for decisions taken by referral management centres’. In addition, if there are concerns that a centre is putting patients at risk, either because of a lack of, or inappropriate, clinical input, these issues should be raised, as detailed in the GMC’s Good Medical Practice, paragraph 6.
Involvement of the treating clinician in the diagnosis of patients
There have been reports that some clinicians working in independent sector treatment centres (ISTCs) are pressurised to perform procedures without having been involved in the diagnosis or assessment of patients before operating/treating. This has raised concern about clinicians assuming the responsibility for treating a patient based on another doctor’s assessment and whether a clinician can refuse to treat a patient where they are not satisfied that they have been sufficiently involved in the diagnosis and assessment stages.
The GMC has acknowledged these concerns and has advised that ‘doctors need to judge whether it is safe and appropriate to treat patients without having been involved in diagnosis or previous discussions with the patient concerned. Where doctors are concerned that this may not be safe, they should consider what would be in the patient’s best interest, or what course of action would expose the patient to less risk’. In emergency situations it may be the case that doctors will provide treatment with little prior knowledge of the patient, and this may be appropriate in the circumstances. However, for elective procedures it may be more appropriate for a doctor to defer or delay treating a patient if they believe that they would be putting the patient at unnecessary risk. Where a system has been identified as likely to put patients at risk of harm, doctors should raise the issue with their employing or contracting body.
Obtaining patient consent
In the absence of the treating clinician’s involvement in the diagnosis of his/her patients, the treating clinician is unlikely to be involved in the process of obtaining patient consent. The GMC’s guidance ‘Seeking Patients’ Consent’ states that the doctor providing treatment is responsible for ensuring that the patient has given consent. However, ‘where this is not practicable for the responsible doctor, these tasks can be delegated to a suitably trained and qualified person, provided they have sufficient knowledge of the proposed investigation or treatment and understands the risks involved. The treating doctor however remains responsible for ensuring that the patient has been given sufficient time and information to make an informed decision and for ensuring that the patient has given consent’.
Referral management schemes
The Central Consultants and Specialists Committee and General Practitioners Committee have produced joint guidance on the guiding principles for the establishment, objectives and continuing progress of referral management schemes. Read more on referral management schemes.