Navigating tricky patient management scenarios

In this OT skills guide video, AOP head of clinical and regulatory, Henry Leonard, will guide viewers through three scenarios that optometrists in training and qualified practitioners may find themselves in in practice, and will advise how best to navigate these situations.

The scenarios include: what to do when a patient refuses a referral, the importance of an internal referral process (and what an internal referral is), and safeguarding responsibilities.

What to do if a patient declines a referral for an eye condition

Henry says: “In most situations you cannot refer the patient without their permission. So, even if you disagree with their decision, it’s up to them – if they have got mental capacity to reach that decision. you have to respect that.

“Our general advice in this situation would be to write to the patient to set out your findings your advice and, importantly, what the potential consequences might be if the patient does not follow that advice. You need to provide enough information that the patient can reach an informed decision in their own time.

“It's useful to ring the patient, but you may also need to write to them. Ideally send [the letter] by recording delivery so that you have got a record that not only you gave the advice but that the patient received it as well.”

What is an internal referral?

Henry says: “An internal referral is simply when you refer your patient to another practitioner within the practice. The idea is that you are transferring responsibility for that patient’s care, in much the same way that you would if you refer them to a hospital, for example.

“It’s an important step because we have seen cases in the past where patients have come to harm because it was not clear which practitioner was responsible for that patient’s care.

“Unfortunately we have seen cases where patients have fallen through the cracks and come to harm, so having an internal referral system in place is a really good way of reducing that risk.

“If you receive an internal you are then responsible for managing that patient. If the practitioner has used one of the templates that is available from the AOP, it should make it very clear what you need to do and how you’re expected to manage the patient. If you need to, you can always try and go back to the practitioner who referred them to you, but ultimately you are responsible for that patient’s care.

“Practitioners can download the AOP’s internal referral template from the Managing risk in practice section on the AOP’s website. The internal referral template has been drafted in such a way that it should make it quick and easy for you to make the referral.”  

Safeguarding: a child fails to attend for a follow-up appointment, what should you do?

Henry says: “With a scenario where parents are not bringing a child back for something like a cycloplegic refraction, it’s important to try and explain why that’s important. Some parents may not appreciate that you are concerned about their child’s welfare, and they may not understand that if the child does not have their vision corrected properly, they could end up with permanently reduced vision. Once you explain that, most parents will realise why you’re giving them that advice and what they need to do.

“There may be situations where parents do not take that on board and they still do not bring the child back. In those situations, you might need to consider raising concerns more formally in the best interests of the child.”

When might this become a safeguarding issue?

Henry says: “It can vary. As optometrists we only have access to part of the picture. You may want to contact the patient’s GP to see if they have similar concerns. It may be a case of contacting the local safeguarding team to raise a formal concern. The safeguarding team may have received other concerns from healthcare professionals and others involved in the child’s care, so they are in a better place sometimes to assess whether there is an issue that needs to be looked at.

“Your duty as a professional is towards your patient, which is the child in this case. The difficulty is, even if you refer the patient, there’s no guarantee that the parents are going to respond to that – if the hospital get in touch with them to arrange an appointment, they may not respond to that either.”

Should I be cautious about raising a safeguarding concern? What if I am not sure?

Henry says: “Practitioners should not be too concerned about raising a concern with the safeguarding team because they are not saying there is definitely something going wrong, they just saying this is what I have experienced in my capacity as an optometrist.

“It can be difficult to decide when something is genuinely a safeguarding concern, so I think it is  important for practitioners to take advice. If any practitioners are not sure what to do, contact the AOP’s clinical and regulation team for advice. We are very happy to talk through these sorts of scenarios on a case-by-case basis.