Clinical responsibility when delegating roles - NHS e-Referral Service

Current General Medical Council (GMC) Good Medical Practice (2013) guidelines state that, where there is any delegation by a clinician regarding the care of a patient, the clinician will still be responsible for the overall management of the patient:

Standard number 4 from the health & care professions council Standards of Conduct, Performance and Ethics (January 2016) that:

When logged into the e-Referral Service with the business function of Referring Clinician, a referrer (such as GP, dentist or allied health professional) can:

• search those services available nationally or commissioned by their local commissioning organisation.
• shortlist those that are clinically appropriate for their patient.

They can then either create an appointment request or proceed with booking the appointment themselves.

The business function of Referring Clinician Admin in the e-Referral Service enables a non-clinician (an administrator for example) to log into the e-Referral Service and perform the same activities as the Referring Clinician. The Referring Clinician Admin is therefore able to search for services, shortlist them and complete an appointment request or booking on behalf of a specified clinician.

When using the e-Referral Service, it is the clinical responsibility of the referrer to short-list those services that are appropriate for their patient’s needs.

If the referrer delegates the task of short-listing services and thus completing an appointment request to a non-clinician, they need to be satisfied that those to whom they delegate are:

• competent
• appropriately qualified
• experienced
• provided with sufficient information to undertake the task delegated to them

This applies even if the task is delegated within a standard protocol framework.

The clinician will still be responsible for the overall management of the patient, and accountable for the decision to delegate.

Referral management centres have been established in some areas to monitor, direct and control referrals from primary care. Some also decide on the best treatment route for patients. This may involve redirecting referrals to other health professionals (such as a different hospital specialist, GP with a special interest or nurse specialist) or returning the referral to the GP to deal with in the practice.

Health professionals have a responsibility to ensure the referral management systems they are involved in are appropriate. They should ensure that there are suitable protocols in place for managing referrals, including scope to call for expert advice when it is required. Patients and all members of the healthcare teams involved (both referrers and providers) must be informed of the arrangements.

In the e-Referral Service application, users in a provider organisation with the business function of Service Provider Clinician (such as a consultant or allied health professional) can accept, redirect or reject new referrals sent to their service.

The business function of Service Provider Clinician Admin enables a non-clinician (an administrator for example) to log into the e-Referral Service and perform all the functions of a service provider clinician on behalf of a specified clinician. This includes accepting, redirecting and rejecting new referrals.

When using the NHS e-Referral Service, it is the clinical responsibility of the provider clinician to accept or reject any booking or referral. They may also redirect a referral or change its priority.

If the provider clinician delegates any of these tasks they need to be satisfied that those to whom they delegate are:

• competent
• appropriately qualified
• experienced
• provided with sufficient information to undertake the task delegated to them

This applies even if the task is delegated within a standard protocol framework.

The clinician will still be responsible for the overall management of the patient, and accountable for the decision to delegate.

Doctors, dentists and allied health professionals are responsible for their own decisions and actions. They are responsible for the overall management of patients whose care they delegate to others and for their decision to delegate. They need to be satisfied that those to whom they delegate have the qualifications, experience, knowledge and skills to provide the care or treatment involved and are provided with sufficient information to undertake the task delegated to them.

They are not, however, accountable for the decisions and actions of others - except if the decision to delegate, or the way in which care was delegated, was inappropriate.

Where a clinician feels unable to fulfil his/her responsibilities due to local policies or procedures, it is the responsibility of that clinician to refer the matter to an appropriate body within their organisation (such as medical advisory committee, service/clinical director or local commissioning organisation medical director). This will ensure their concerns are formally recorded.

Examples of such local policies or procedures include where:

• Local Commissioning Organisations do not support GPs in their role as referrers in the e-Referral Service
• hospitals do not make facilities available for provider clinicians to review referrals received via the e-Referral Service

In such circumstances, doctors should seek advice from their defence organisation.

This guidance has been revised following discussions with The General Medical Council (GMC), health & care professions council (HPC), Medical Protection Society and the Medical Defence Union. It is offered in parallel with current legal guidelines, but not as a substitute and must be seen as a pragmatic interpretation.