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Referring Patients: Responsibilities of General Practitioners
A General Practitioner’s decision to refer a patient to a specialist service is a key part of any patient’s care.
Referral rates between practitioners, and across specialities, are known to vary considerably (1) and this has
important implications, especially in terms of deciding which services should be commissioned and the cost
of providing such services. Reviewing referral rates are now also part of the 2011/12 QOF domain and have
also occurred as part of the operation of Referral Management Schemes. This LMC guidance considers
GPs’ professional and contractual responsibilities when making patient referrals.
Professional Responsibilities
The GMC ‘Good Medical Practice’ (GMC GMP) contains several references to the appropriateness of patient
referral: under ‘Providing Good Clinical Care’ GPs should (Para 2c) refer a patient to another practitioner,
when this is in the best interest of the patient. By reflecting on their own skills and competences, GPs
should therefore (Para 3a) be able to recognise and work within the limits of their competence, and also
(Para 3i) consult and take advice from colleagues, where this is appropriate. GPs are also expected (Para
3e) to respect a patient’s right to seek a second opinion, which may require a referral.
Paras. 7 and 9 emphasise the requirement for GPs to arrange and provide care on the basis of a patient’s
clinical need; and not discriminate in terms of the nature of the patient’s illness or other characteristics of
the patient themselves. Local referral mechanisms normally provide GPs with a method of prioritising
referrals, such as under the 2 week rule, if this is appropriate, but GPs must (Para 3j) also make good use of
the (limited) NHS resources available.
All referrals should provide appropriate patient information (Para 5i) including their medical history and
current condition; in some cases GPs may be expected to make referrals within a template which requires
the completion of certain questions: this may be appropriate and may in part be delegated to others, but the
GP remains responsible for the referral itself.
Contractual Responsibilities
Within the NHS (GMS) Contract Regulations 2004, Part 5 Para 15 defines the essential services General
Practitioners are expected to provide. Equivalent clauses are also found within PMS and APMS Contracts.
GPs are expected (Para 15, 4b) to make available such treatment or further investigations as are necessary
and appropriate, including the referral of patients for other services under the National Health Service Act
1977, which relates to other NHS services that may be provided, such as hospitals and community clinics.
There is no contractual obligation to make a private referral, but GPs have a professional responsibility to
ensure they provide colleagues who may see patients’ appropriate information about their clinical
condition, including pre-existing medical problems and current medications (as in GMC ‘Good Medical
Practice’ above).
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Documentation and Audit
GMC ‘Good Medical Practice’ emphasises (Para 3 f&g) the importance of keeping appropriate and
contemporaneous medical records which note the key decisions that have been made at the time. Although
some General Practitioners arrange a referral at the time of consultation, many do not and it is important to
have robust in-practice procedures to ensure:
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agreed referrals are made, and in an appropriately timely way
DNA information is noted and if appropriate acted upon
the outcome of a referral is noted, and any treatment or other management advice or
requests are actioned.
Although many professional fitness to practice and clinical negligence cases relate to a failure to diagnose
and thereby provide or arrange appropriate treatment, a significant subsection relate to a delay, or failure,
to refer, or because the outcome of a referral was not acted upon. As an example see Good Medical
Practice Case 2.32 (available via the GMC website) or various examples from the indemnifying
organisations publications.
Patient Entitlements
General Practitioners are expected (GMC GMP Para. 3c) to respect a patient’s right to a second opinion,
which may require a referral. Under the NHS Constitution (7), patients now have a legal right to make
choices about their NHS care. This interlinks completely with the expectation in the Royal College of
General Practitioners “Good Medical Practice for General Practitioners” Good Clinical Care (8) that in all but
exceptional circumstances, patient care will be the outcome of a collaborative and mutually agreed
approach.
The NHS Constitution also offers patients, in most circumstances and subject to availability, the right to a
choice in terms of the organisation which provides care when they are referred to a consultant-led service for
a first out-patient appointment.
Balancing Resources
All NHS resources are limited and therefore as each patient receives care so, at least theoretically, the
resources available for the next patient reduce. GMC GMP guidance (Para 3j) requires all doctors to make
good use of the resources available, although this is a very broad statement.
There are few examples of contractual mechanisms which relate to resource allocation; one is Annex 8 of
the 2006/07 GMS Contract, which specifically refers to prescribing, allowing commissioning PCTs to
investigate possible instances of excessive prescribing.
As demographic change affects the population, and pharmaceutical and medical technologies advance, the
underlying cost of providing NHS care continues to rise; this represents ‘NHS-inflation’ and represents the
amount necessary to provide the equivalent level of NHS care as has been provided the year before. It has
consistently increased in recent years. Economic and political pressures mean General Practitioners are
facing unprecedented demands to justify and review the costs of their decisions. Although not yet enacted,
Section 24 of the Health and Social Care Bill 2011 would, if passed, require all primary care contractors to
be a member of a [commissioning] consortium and to act with a view to enabling their consortium to
discharge its functions, one of which will be to maintain financial balance.
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The Quality and Outcome Framework (QOF) 2011/12, whilst voluntary, also includes indicators designed to
ensure General Practitioners conduct an internal practice review of data on secondary care outpatient
referrals (QP6) and develop pathways to improve the management of patients in primary care and avoid
inappropriate and/or unnecessary outpatient referrals (QP8).
Further guidance (9) provides a description of an unnecessary referral: this is described as being one where
the GP could reasonably and effectively have met the patient’s needs, in a timely fashion, without referring
them for an outpatient appointment.
Referral or Delegation
GMC ‘Good Medical Practice’ is careful to distinguish (Para 54 and 55) between the two processes of
delegation and referral, since these have significantly different implications in terms of a GP’s continuing
clinical and legal responsibilities for the patient and their care.
Delegation (Para 54) involves asking a colleague to provide treatment or care on your behalf, thus making
that individual accountable for their decisions and actions, but leaving you responsible for the overall
management of the patient and accountable for your decision to delegate.
Referral (Para 55) involves transferring some or all responsibility for a patient’s care, or more usually for
General Practitioners a particular aspect of that care, to allow for the patient to receive further investigation,
care, or treatment that is outside your competence. The referral should be made to a healthcare
professional who is accountable to a statutory regulatory body (3); if it is not, it will be considered
delegation and GPs will remain responsible for the overall management of the patient.
Referral Processes
I
Referral Management and similar schemes
The BMA has advised (4) that GPs should not refuse to refer via referral management schemes if these are
created locally; there may be elements of such schemes, such as tracking referrals, appropriate redirection
of some referrals, and gathering data on individual and area referral patterns, which are beneficial for
patients and GPs, particularly those with commissioning responsibilities. There are also significant risks,
including lost or unactioned referrals, clinically inappropriate triaging to services or clinicians other than
those requested, and delays. The DH also described referral management as “a key lever to manage the risk
of ‘supply-induced demand’” in the acute sector. This has undermined General Practitioners’ confidence in
such schemes.
General Practitioners are not accountable for decisions made by a referral management scheme; however,
they remain responsible for the continuing care of their patients. It is therefore important for GPs to have
procedures in place to identify returned referrals and DNA appointment notices. Although GPs may not be
responsible for individual lost and/or unactioned referrals, they should alert a referral management centre
and those responsible for managing or commissioning it if they become aware of such examples. By doing
so, they should be reducing the likelihood of this becoming a recurring problem.
II
Choose and Book
The Choose and Book system is an optional system under which General Practitioners (as Referring
Clinicians) can search for services commissioned nationally or locally and shortlist those appropriate for the
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referred patient. They may then book an appointment directly, or create an Appointment Request, which
may later be fulfilled by another person on behalf of the GP using the ‘Referring Clinician Admin’ function.
This represents delegation, and the GP would remain responsible for the management of the patient and the
decision to delegate.
Users within a service provider organisation (to which patients are referred) can use the Service Provider
Clinician or, on a clinician’s behalf, Service Provider Clinician Admin function to accept, redirect, change the
prioritisation or reject new referrals. This is a process for which the provider organisations’ clinicians are
responsible and accountable, not the original referrer.
GPs should, however, have a procedure in place to ensure that, if told, they are aware of rejected referrals.
Inadequate Resources
Most General Practitioners do not have a direct influence on the resources available for patients who require
referral, but GPs involved in local clinical commissioning will do so. Under GMC GMP Para 9, GPs have a
responsibility to alert the responsible organisation if they believe inadequate resources prevent the
appropriate treatment or investigation patients require, including the prioritisation according to clinical
need. GPs have a similar responsibility (Para 6) if they believe inadequate resources or other infrastructure
off procedures is or may be seriously compromising patient safety.
For GPs in this situation, this may be most appropriately done by raising such concerns with the local PCT or
Acute Trust Medical Director. It may also be helpful to discuss your concerns with the BMA, LMC or your
Defence Organisation.
Summary
 GPs have a professional and contractual duty to refer if this is clinically appropriate.
 GPs should demonstrate they have reviewed the advice or requests resulting from a referral.
 GPs should have practice systems in place to ensure referrals are made in a timely way, and to identify
patient DNAs.
 Numerical or financial caps on referrals are not appropriate, but GPs should be willing to peer review
referrals, as for any other professional activity.
 GPs should draw commissioners’ attention when inadequate funding or resources limit referral access,
but recognise that as NHS resources are finite commissioners may choose to prioritise the availability of
NHS treatment.
Dr Julius Parker
Chief Executive
July 2011
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Appendix
Colleagues may find the further information available in the following documents helpful.
1
See the BMA’s Health Policy and Economic Research Unit (HPERU) Guidance May 2009 entitled
‘Factors Capable of Influencing an Increase in GP Referral Rates to Secondary Care’
www.bma.org.uk/images/refrates_tcm41-186413.pdf
Colleagues may find this document helpful when reviewing Practice referral rates for example, as
required in QOF QP6 to 10.
2
GMC ‘Good Medical Practice’. This is available via the GMC website www.gmc.co.uk and the basic
document refers to other supplementary guidance.
3
See the Council for Healthcare Regulation Excellence (www.chre.org.uk) which lists the Statutory
Regulators within the UK as being the: General Chiropractic Council, General Dental Council,
General Medical Council, General Optical Council, General Osteopathic Council, General
Pharmaceutical Council, Health Professionals Council, and Nursing and Midwifery Council.
GPC Guidance (March 2006) Referrals to Complimentary Therapists: Guidance for GPs.
4
The BMA Advice Documents (1) Referral Management Principles.
(2) Referral Management Standards and Ethics, both available via the BMA (www.bma.org.uk).
5
See Choose and Book: Clinical Responsibilities when Delegating Actions in Choose and Book,
Version 2, December 2010
(www.chooseandbook.nhs.uk/staff/communications/fact/clinicalrespons.pdf).
6
BMA Advice: patients requesting a second opinion.
www.bma.org.uk/ethics/doctor_relationships/SecondOpinion.jsp
7
See www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution
8
The Royal College of General Practitioner website www.rcgp.org.uk under ‘Good Medical Practice
for General Practitioners’.
9
QOF Quality and Productivity (QP) indicators: Supplementary Guidance and Frequently asked
Questions for PCTs and Practices in England (May 2011).
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