Making and receiving patient referrals are part and parcel of everyday practice. However, the process can and does give rise to patient complaints and claims. Following a few key principles can help manage the risk of problems occurring.

Patients seem to readily accept that their GP will, on occasion, need to refer them on to a colleague for a consultation or treatment, either within the practice or to secondary care. Dental patients, in contrast, often appear to have an expectation that their GDP can and should deliver all of their care, and may be surprised or even suspicious of the suggestion of such a referral.

GDC advice

Good communication and record keeping are, therefore, fundamentally important in managing the situation. The GDC's Standards for the Dental Team makes this clear, saying that, 'You should provide patients with clear information about any referral arrangements related to their treatment' (2.3.11), and that, 'If you refer a patient to another dental professional or other health professional, you must make an accurate record of this referral in the patient's notes and include a written prescription when necessary' (4.1.6).

Patients should be given clear information about the reason for the referral, options including NHS or private, the person or organisation to whom the referral is to be made, any costs involved and a realistic indication of the timeframe.

The GDC's Standards also say that you mustn't mislead patients into thinking that NHS-available treatments can only be provided privately (1.7.3). This is particularly true for purely private practices, where patients should be made aware of this before being treated.

For mixed practices, the Standards are also clear that patients mustn't be pressured into private treatment if it's also available, and they would prefer to have it, under the NHS (1.7.4).

Check and double-check

It is vital, therefore, that you are sure of the currency and accuracy of the information you provide, as a failure to do so may leave you open to allegations of being misleading or even dishonest.

For example, where a patient is to be referred for molar endodontics, it is essential to have up-to-date knowledge of the local referral options. Reliance on anecdotal information or an assumption that there is no NHS provision can be risky, as the commissioning of such services may change from time to time and from area to area.

Practices can double-check their information by contacting their NHS Primary Care organisation and referral centres (such as dental hospitals) for written confirmation about referral options, criteria and protocols, and ask that they be updated when there are any changes. In this way colleagues can be confident that patients are not inadvertently given inaccurate information at the time of referral.

It is important that colleagues and organisations accepting referrals pro-actively provide such information to their referring practices. To do so helps to manage patient expectations, avoid inappropriate referrals and reduce the risk of patients being frustrated at having waited for an appointment only to find that they cannot be seen and treated.

Practice protocols

The GDC requires that colleagues communicate and work effectively as a team in patients' best interests. Practices should have protocols in place so that all team members understand their roles and responsibilities within the referral process. This can help ensure it runs efficiently and, as far as is possible, reduces the risk of a delayed referral, with its potentially serious attendant consequences.

Protocols between practices and other organisations should be clear. For example, where referrals are made for imaging, we would suggest it is the responsibility of both the referring clinician and the professional accepting the referral to be clear on whether the patient is being referred for the radiographic exposure alone, with the images to be reported by referrer, or both the radiographic exposure and a report on the images.

The specialist societies often provide helpful guides for referring clinicians, such as that provided by the British Orthodontic Society.

Fees and charges

The GDC generally takes a dim view of any referral fees changing hands, with the Standards stating that:

• patients' interests must always come before any financial, personal or other gain
• you must not accept gifts, payment or hospitality if they could affect your professional judgment, or appear to do so
• referrals must made in the patients' best interests and not for anyone else's financial gain or benefit.

To help avoid patient complaints, those working in the NHS need to understand and carefully apply the current rules and regulations governing referrals.

For example, when referring a patient for Advance Mandatory Services in England and Wales, the referring practice should collect the full patients' charge for the course of treatment. The appropriate boxes on the claim forms should then be checked by both the referring and treating practices. In this way the patient is charged for a single course of treatment. More information on such issues is available via the NHS Business Services Authority's Knowledge Base.

In summary, as patients' expectations and the ever-increasing range of treatments available continue to grow it is likely that practices will see an increase in the need for both internal and external referrals. Careful attention to detail in terms of communication between clinician and patient, colleague to colleague, record keeping and adherence to up to date protocols will all contribute to risk management of the process.