Making a decision on whether to refer a patient can be one of the biggest tests of your judgement. You will know the basic rule that you should refer if you do not have the necessary facilities, experience or expertise to provide the particular care that the patient needs. To assess this requires careful judgement on your part.
Explaining the situation to the patient and getting their consent are important. They need to know your diagnosis, the treatment options available and why you feel it is better to refer them. Discuss who you are referring them to, it may be through the NHS to another practitioner or a hospital or it may be to a private practice. And reassure them that the transfer of personal and clinical information that accompanies the referral will be done confidentially.
You should send to the accepting dentist or hospital details of the reason for the referral, the oral condition of the patient, and, if relevant, details of any treatment that has been, or will be, provided by you. Sending information by a secure method, consider using registered post or encrypted email, to ensure patient confidentiality is vital. For NHS referrals details of any NHS fees paid by the patient should also be included. Referring dentists should indicate on the NHS forms those aspects of the treatment that are being carried out on referral.
With NHS referrals you need to take care to submit the appropriate claims and charge the patient the proper fee. This can get complicated, particularly in the English and Welsh system. Some referrals will be considered to be within a course of treatment, for example a minor oral surgical extraction; some are for part of a course of treatment; whereas in cases requiring orthodontic assessment, sedation services or domiciliary services referrals have to be made for the whole course of treatment to be provided by a practice that has a contract or agreement to provide those additional services.
You should be satisfied with the abilities of the dentist to whom the referral is made. They are responsible for the treatment they carry out but you are responsible for referring a patient appropriately. Within the NHS practitioners are sometimes asked to justify their reason for making a referral. This has led to some discussion over the approach taken by the NHS. A referral that is rejected back to the practitioner should not necessarily be seen as inappropriate (and hence potentially an infringement by not providing mandatory services or securing oral health). The key issue is the dentist’s confidence to tackle the patient’s treatment needs; you should not attempt care that is outside your scope of practise. Where referrals are rejected this should not be seen as a contractual issue but as an educational one. It is important that PCOs are clear about their triage system for considering referrals. After all, what is the correct approach to take if an extraction is attempted but becomes more complex when the root breaks?
It should also be noted that electronic referral centres are becoming more common and referrals in one geographic area go into one electronic triage system and that will make sure the referrals go to the right place. It is no different from the other old manual system but means waiting lists are more evenly distributed. The quality of these services can vary however as do the criteria that they use for accepting or rejecting referrals.
Generally, the accepting dentist should provide the patient with details of the dentists who will carry out the care and treatments, the address where it will be provided and contact telephone numbers including the emergency cover arrangements (for the treatment being provided on referral only).
By James Dawson, Head of Advice Publications, BDA