There is a common set of faults in the mind-set of General Dental Practitioners and I have to admit to being susceptible to these too. It’s like our default programming is to dig ourselves a bigger hole when things go wrong. We find it difficult to know when to give up, and keep struggling on with something, even when we really know that it`s not working. We also find it difficult to admit we were wrong or that we started something we couldn`t actually do. We definitely find it difficult to say ‘I’m sorry, but…!’
Outcome 4 of the CQC Essential Standards covers the Care and Welfare of People Who Use Services. It defines the responsibility to: ‘Ensure effective, safe, appropriate and personalised care, treatment and support through coordinated assessment, planning and delivery. Manage risk through effective procedures. Promote rights and choices.’
This means we have to provide care which is safe within our skill-set of knowledge and ability. When something goes wrong, or when we feel that a task is outwith our capability, or even when it is just more convenient for someone else (such as a hygienist) to do the job, we have a responsibility to refer to a high level of skill and to make any referral in a responsible, timely and effective way. At the very least, we need to give the patient a choice about who can help them and where to go. In the words of the advertisement, we need to find a ‘man who can’.
A ‘timely’ reminder
The Quality Compliance Systems Treatment Policy and Procedure reminds us that: ‘Treatment plans should be within the capability of the practitioner, or include treatment to be referred to a specialist’. We have a duty of care to make any referral within a timeframe that protects the patient from harm. In other words, to make a referral quickly before a condition can worsen. Sometimes there is no urgency about this, but sometimes (such as in the presence of sepsis or suspected malignancy) there is a need to make an urgent referral – perhaps initially by phone. However we achieve this, the goal is to ensure safe, coordinated care and treatment where more than one provider is involved.
All the principles associated with referral apply just as strongly to internal referrals between colleagues or other dental care professionals. When treatment is to be carried out by more than one professional, it should include all the relevant information and be made by a safe and secure means which protects the patient’s confidentiality. A referral should also be made geographically in a way which reflects the patient’s wishes and abilities, which is something that needs talking about! As with all aspects of care, we need to be sensitive to the diverse needs, beliefs and choices of the patient in order to make a referral to an appropriate person or place that reflects these.
Policy and Procedure
The Quality Compliance Systems Referral Policy and Procedure helps with planning referrals by reminding us of the best practice involved. Every member of the team has a role to play in this, from the clinical ‘sharp end’ to the admin support that helps achieve a smooth and quick response to the request. In any referral, internal or external, a named clinical lead is always identified for referring and coordinating care for a patient. This is so that there is a reference back on receiving an answer, and also so that a named person is responsible for sorting out any issues or complications around a referral – even this process can go wrong!
It’s important that all those clinicians involved in care will cooperate with continuing care. You cannot ‘wash your hands’ of a patient just by making a referral! Essential practice includes keeping contemporaneous records of all aspects of decision-making around a patient’s care, including the reasons and verbal discussions around the referral process. Make sure that records are kept complete and up-to-date, so that correct factual information concerning a patient is provided should it be requested.
This might seem a bit obvious, but here’s a list of essential relevant personal and clinical information which should be provided on referral:
- Name
- Gender
- Date of Birth
- Address
- Unique Identifying number where one exists
- Emergency contact details
- Any person acting on behalf of the patient, and their contact details
- Relevant records of care and treatment up to the point of referral
- Assessed need for referral
- Known preferences and any relevant diverse needs
- Previous relevant Medical History and GP`s contact details
- Any known medical condition or medication that might affect treatment
- Any allergies
- Any instructions legally required by the other provider
- Last, but not least, the name of the Lead Clinician responsible for referral
Don’t forget …
Referrals should be made in a form that reflects the need for confidentiality. Make sure that they are addressed correctly to the person they are meant to find. If you need to speak on the phone, be very aware of checking that the person is who they say they are and that they have good reason for knowing any personal details pertaining to the patient.
Referrals are made on evidence-based treatment requirements. Quite simply, this means there is some known advantage to making the referral and that treatment may actually be required.
Referrals are made to an organisation that is compliant with all current legislation. For instance, if you are sending a patient to a laboratory for shade taking – YOU need to be in receipt of evidence that they comply with CQC standards, that they have suitable cross infection procedures etc.
Keep copies of referrals, and make sure patients are aware that they can obtain copies if they wish to.
Back to the beginning
In my medico-legal work I find that so many practitioners are vulnerable because they have not made a timely referral. A common example – if a root treatment goes wrong (you know, the inaccessible canal or the fractured file) it is a responsibility to offer referral to a specialist or practitioner with special interest. We need to be honest with patients; we need to be open with them and we need to give choices.
