Referrals on the right path
What constitutes a good referral or a good reason not to refer? Dr Scott Mackie explores his experience of the realities and pitfalls
What constitutes a poor referral? Apart from the obvious, such as poor legibility, use of unknown acronyms, no differential diagnosis suggested or an incorrect pathway chosen, the overarching issue of over-referral is the most common reason for frustrations between ophthalmology and optometry.
An example of a poor referral might be referring a patient complaining of reduced vision with a small degree of cataract and advancing dry age-related macular degeneration (AMD). Referral will not provide a treatment and, unless rehabilitation using low vision aids is the desired outcome, the patient should remain in primary care with advice given regarding worsening symptoms such as sudden visual loss or metamorphopsia.
A discussion on reducing risk factors such as smoking, UV exposure and the use of supplements as per AREDS2 guidelines should be considered, and this should be recorded to evidence your professional judgement as to why you did not refer the patient. If the patient consents, you may inform their GP, but this is a recommendation rather than a requirement. The patient should then sign a declaration, or you should note on the record card that they do not wish to be referred.
Conversely, for a good referral into secondary care, you should use all your clinical skills and acumen to determine if the referral is warranted and consider what degree of urgency is required. For example, a diagnosis of wet AMD from history and symptoms, dilated Volk, optical coherence tomography (OCT) and fundus changes (bleeding, gray membrane, pigment changes and/or loss of the foveal reflex) should warrant a fast-track referral within the two-week NICE guidelines for anti-VEGF injections (such as Lucentis, Eyelea or Avastin according to the recent NHS England ruling).
A good referral is vital for patient safety, but is also crucial to maintain good relations with other healthcare professions
Providing additional literature, such as the AOP’s ‘for patient’ leaflets, the College of Optometrists’ leaflets on the specific disease, or additional information, such as what drops you administered, is good practice. You should also outline the urgency of the referral and what to do if symptoms get worse before they are seen. It may be appropriate to e-refer or give the patient additional documentation, such as copies of visual fields or OCT.
It is important to give the patient clear advice and involve them in decisions about their care. If the patient is happy for you to do so, it may be appropriate to discuss their care with a family member. This is especially the case for vulnerable patients who may have a reduced capacity to consent – the General Optical Council’s (GOC) consent guidance can help you here.
A significant number of fitness to practise cases at the GOC reveal deficiencies in record keeping and it would be a good refresher to read the GOC’s Standards of Practice – the majority of which are relevant to referrals. It is also a mandatory requirement to be candid when referrals go wrong – the GOC has specific guidance in this area.
Copies of the referral should be sent to the receiving centre, such as secondary care, directly for fast track or via e-referrals. However, a copy should also be sent to the patient’s GP.
Confusion can arise as to whether you should give the patient a copy of the referral. If you feel the patient can understand the reason for the referral and has the capacity to consent, it may be appropriate to give a copy of the referral if it will not induce stress or disclose details of a third party. However, the majority of referrals to a doctor are simply noted on a copy of the prescription.
A good referral is vital for patient safety, but also crucial to maintain good relations with other healthcare professions, which is becoming particularly important as the professions work more closely together.
The GOC’s Standards of Practice for Optometrists and Dispensing Opticians April 2016 is available on the regulator’s website.
Dr Scott Mackie is a therapeutic prescribing optometrist and a GOC council member