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Independents' Day

How can I manage a patient insisting on an unnecessary referral?

Dr Emma Cuzner on a medicolegal situation your practice could face

Dr Emma Cuzner on a medicolegal situation your practice could face

A patient asked her GP for a referral to an orthopaedic surgeon because she had chronic back pain.

The GP had previously made a referral to another orthopaedic surgeon and to a rheumatologist. Both considered the back pain to be mechanical in origin and that surgery was not indicated.

The patient had also received several courses of physiotherapy but explained that this hadn't helped with the pain.

The GP did not think referral to another orthopaedic surgeon was clinically indicated or likely to be in the patient's best interests, and recommended a referral to a pain clinic, but the patient refused. The GP did not know if he was required to offer a second referral and asked the MDU for advice.


The MDU advised the GP that if he did not think the referral to the orthopaedic consultant was clinically indicated, having checked the details of the history and carried out an appropriate examination, he should take time to explain this carefully to the patient.

The GP could consider discussing the matter with a colleague in the practice to seek their views and could document the discussion in the clinical records.

If the patient still insisted on the referral the GP should bear in the mind the GMC's advice that in providing care doctors must "respect the patient's right to seek a second opinion" (paragraph 3e), "consult and take advice from colleagues, when appropriate" (paragraph 3i) and "make good use of the resources available to you" (paragraph 3j).

The GP was advised that the final decision would be his, taking account of the guidance described below and based on his clinical judgement, discussion with the patient and any advice from colleagues.

The GMC's advice in Good Medical Practice (2006) states that good clinical care must include "referring a patient to another practitioner when this is in the patient's best interests" (paragraph 2c).

The GMC adds that "the investigations or treatment you provide or arrange must be based on the assessment you and the patient make of their needs and priorities, and on your clinical judgement about the likely effectiveness of the treatment options" (paragraph 7).

Patient trust

The RCGP guidance Good Medical Practice for GPs (2002) states: "Patients need to trust that you will refer them for a specialist opinion when it is necessary. In general, you should respect a patient's request for referral for a second opinion, although there may be circumstances in which you judge it not to be in the patient's best interests to be referred".

Learning points

• It is important that any decision about a referral is arrived at after a discussion with the patient about their clinical needs so that, if possible, an agreement can be reached.

• Such discussions should be noted in the medical records.

• GPs may need to bear in mind relevant clinical guidelines from recognised organisations such as NICE when making referrals.

• Consider discussing the case with a colleague in the practice. This can be done without identifying the patient, to maintain confidentiality. If you do this, make sure there is a note in the patient's records.

• Ethical guidance, for example from the GMC, should be borne in mind and any decisions made must be consistent with the principle of acting in the patient's best interests.

Dr Emma Cuzner is a medico-legal adviser with the MDU

The case mentioned is based on cases from the MDU's files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.© copyright MDU 2008

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