Working with colleagues

• You must communicate effectively with colleagues and work with them in ways that best serve your patients’ interests.
• You must act quickly to protect patients from risks posed by colleagues.
• You must treat colleagues fairly.
• If you are the practice owner or manager, you should make it clear to patients that offensive behaviour will not be tolerated and they will not be seen for a consultation if they exhibit such behaviour.
• You should only delegate patient care to appropriately skilled and experienced practitioners.
• You should keep the patient informed when you delegate aspects of their care to a colleague.
• You should write clear referral letters that contain relevant information about the condition, reason for referral and level of urgency.
• You should give patients written information, or a copy of the referral letter and tell them what to expect.
• Use your professional judgement about the urgency of a referral, taking into account College guidance or local protocols.
• If you delegate patient care, or supervise others, you are still responsible for the patient and the clinical findings.
• The protected functions of sight testing or contact lens fitting can only be undertaken by someone who is registered to perform those functions.
• For good continuity of care you must keep good records and provide necessary patient information to practitioners to whom you refer, delegate or are supervising.

C168

This Guidance does not change what you must do under the law.

C169

You must communicate effectively with colleagues and work with them in ways that best serve your patients’ interests.²⁷⁷

C170

You must ensure your conduct, whether or not connected to your professional practice, does not damage public confidence in you or your profession.

C171

You are encouraged to contribute to the professional development of your colleagues.   

C172

You must not make any patient doubt the knowledge or skills of colleagues or other health professionals by making unnecessary or unfounded comments about them, either privately or publicly, for example through social media.

C173

The safety of patients must come first. You must act quickly to protect patients from risks posed by colleagues or the environment in which services are provided. If you have a serious concern about any practitioner’s fitness to practise, you should raise this with them first, if you feel able to. If necessary, you should escalate your concerns to an appropriate person. This could be the colleague’s line manager, employer, or person in a primary care organisation or hospital. If you remain concerned, you should consult the relevant professional, representative or regulatory body (refer to COVID-19 guidance).

C174

Raising a concern is different from making a complaint. See section on Raising concerns. If you make a complaint, you might be asked for evidence to prove your case. When you raise a concern, you should not be expected to prove the issue you are concerned about. If you are not sure whether you should act, ask yourself:

1. what might the outcome be in the short- or longer-term if I do not raise my concern? 
2. how could I justify not raising the concern?

C175

If you receive a prescription for dispensing from another practitioner, and there is an anomaly or a complaint of non-tolerance after dispensing, you should, with the patient’s consent, contact the prescribing practitioner. You should agree a course of action with them and the patient. The Optical Confederation has produced guidance on this.²⁷⁸

C176

You must treat your colleagues fairly. You must not allow your personal views to adversely affect your relationship with them. You must not discriminate against colleagues on the grounds of one or more of the protected characteristics. These are:

• age
• disability
• gender reassignment
• marriage and civil partnership
• pregnancy and maternity
• race
• religion or belief
• sex
• sexual orientation.

C177

Where possible, patients should be given a choice of which optometrist they wish to see.²⁷⁹  Patients may wish to see an optometrist of their own gender, or who speaks their first language. The reason for a patient’s choice is private to them and they should not feel pressured into disclosing it if they do not wish to. However, if it is apparent or disclosed that their choice derives from a discriminatory approach to any of the protected characteristics (listed in C171) you should exercise your professional judgement on what to do next. This could include informing the patient that choices made on the grounds they have expressed are not acceptable, and explaining how their eye health needs will need to be met elsewhere. See paragraph C173. In England, GOS contractors must keep a written record of a refusal to see a patient and the reason for the refusal.²⁸⁰

C178

You will not be expected to examine a patient who makes an offensive or inappropriate comment about you or a member of staff, especially if it relates to a protected characteristic. If a patient makes such a comment before the consultation begins you may refuse to see them. If the comment is made during the consultation you may stop the examination and bring this to the attention of an appropriate person, such as your practice manager. If you are concerned about the patient’s eye health, you should direct them to an alternative source of care. You should make a note in the patient record of why you refused to see the patient or stopped the examination.

C179

If you are the practice owner or manager, you should make it clear to patients that offensive behaviour will not be tolerated and they will not be seen for a consultation if they exhibit such behaviour. This can be done by displaying notices in the practice. If you witness instances where offensive behaviour is tolerated within the practice, you should raise this with an appropriate person and escalate as necessary. See section on Raising Concerns (paragraphs B97 – B105).

C180

You should communicate effectively with team members.

C181

Even if you have your own practice, you should consider yourself as part of the wider eye care team, for example when you refer a patient to a colleague.

C182

You should work constructively in teams, including multi-disciplinary teams, and respect the skills and contributions of colleagues.

C183

You are accountable for your own professional conduct and the care you provide while working as part of a team.

C184

If you are leading a team, you should ensure that (refer to COVID-19 guidance):

1. each team member understands the scope of their role, including what decisions and actions have and have not been delegated to them
2. the team provides care which is safe, effective and efficient
3. the team understands the need to provide a patient-centred service which is polite, responsive and accessible
4. patient information is kept confidential
5. you encourage a culture that allows open, non-judgemental discussion of problems and mistakes which enables constructive feedback and contributes to continuous improvement
6. team members are appropriately supported and undertake professional development that is relevant to their role and level of experience
7. team members are not asked to undertake tasks for which they are not competent
8. you have the necessary leadership skills, or work to develop the skills.

C185

If you are working in a team providing shared care to a patient and you believe a decision taken by the team would harm the patient, you should tell someone who can take action. As a last resort, you should take action yourself to protect the patient’s safety or health.

C186

If you examine a patient who is under the care of the hospital eye service, you:

1. may decide not to conduct tests that would have been done at the hospital and record your reasons in these cases
2. should bear in mind that a patient being assessed for one condition may not have been checked for another unrelated condition
3. should inform hospital eye service colleagues of your findings, if you feel it would influence their management of the patient.

C187

If you participate in a community service or co-management scheme, you should refer patients back to their usual practitioner for their routine eye examination.

C188

You may refer a patient or you may receive a referral from a colleague. If you receive a referral, you should address the reasons for referral and advise the patient to consult their regular practitioner for routine eye care (refer to COVID-19 guidance).

When to refer

C189

If you observe a sign or symptom of injury or disease which you cannot manage within your competence or scope of practice, you should refer the patient to an appropriate practitioner who is registered with a statutory regulator.

C190

You should consider national and local guidance on referrals.

C191

The National Institute for Health and Care Excellence recommends that patients with signs of possible glaucoma or related conditions, identified during  a routine sight test, should have additional tests before they are referred for a diagnosis.²⁸¹ The Scottish Intercollegiate Guidelines Network has published guidance on glaucoma referral and safe discharge.²⁸² 

C192

If, in your professional judgement, you do not need to refer the patient, or it is impractical to do so, you may decide to manage the condition yourself.²⁸³

C193

If you decide not to refer the patient you must record:

1. a sufficient description of the condition
2. the reason for deciding not to refer on this occasion
3. details of advice or treatment given to the patient.

C194

If you decide not to refer the patient you should inform the patient’s GP of any relevant findings, if the patient consents.

C195

The welfare of the patient must not be compromised.

C196

You must refer patients with appropriate urgency. If there are local protocols in place for referrals, including emergency or urgent referrals, you should follow these. If in doubt, you should seek advice from the on-call ophthalmologist to determine the most appropriate pathway for the patient. Where there are no local protocols, guidance on which conditions are considered an emergency and which are considered urgent can be found in Annex 4 Urgency of referrals table.

C197

Patients have a right to be fully involved in decisions about their care.

C198

If the patient does not wish to be referred you should:

1. ensure they understand why the referral is necessary
2. record a full account in the patient records

3. obtain the patient’s signature on a declaration that they do not wish to be referred.

Whom to refer to

C199

You must only refer patients to a practitioner with the appropriate qualifications and registration.²⁸⁴

C200

When you refer a patient, you also transfer responsibility for the relevant part of the patient’s care.

C201

If the patient is not registered with a GP, or wishes to see a doctor privately, you should give them the referral letter and tell them to register with a GP or to arrange a private appointment with an appropriate doctor, for example an ophthalmologist. Alternatively, you can send your advice by recorded delivery to the patient and enclose the referral letter.

Telling the practitioner

C202

You should write a clearly worded referral and include:

1. relevant details from the eye examination
2. the reason for referral, including images where appropriate
3. details of discussions with the patient and any with the practitioner to whom you are referring
4. the level of urgency.

C203

If the patient is already receiving care for the observed sign of injury or disease you should notify the practitioner who is caring for them if you believe your findings might provide additional, useful information.

C204

If you send the referral letter directly to the practitioner to whom you are referring, you should ensure that the patient’s GP is kept informed. This may be relevant in an emergency or where you use a referral centre.

Telling the patient

C205

If you are referring the patient to a doctor, the law says you must give the patient a written statement of the reasons for referral, immediately following the sight test.^{285, 286} If you cannot write the referral letter immediately following the sight test, you can write the reason for referral elsewhere, for example on the patient’s prescription.

C206

You should ensure that the patient understands the urgency of the referral.

C207

You should tell the patient when they should expect to hear about their referral and what to do if they do not hear within that timescale. 

C208

You should tell the patient what to do if their symptoms get worse before they are seen.

C209

You should give patients copies of any correspondence relating to them so that they are clear about their condition and the care they are receiving. This can also be useful in case the original correspondence goes astray.

C210

If the patient is not legally responsible for their own care, you should copy the letter to the person who is legally responsible.

C211

You should provide copies of correspondence in an accessible format.

C212

You should ask young people who have the capacity to consent to treatment whether they would like to receive copies of information about themselves, and how they would like to receive this.

C213

You should not copy a letter to a patient if:

1. they decline a copy
2. the letter contains information about another person who has not given their consent for you to disclose this information (other than if the patient originally provided this information or if you remove this information from the copy letter)
3. you feel it may cause harm to the patient. Giving bad news is an insufficient reason for withholding a copy of the letter.

 
Sending the referral

C214

If you post the copy of the referral letter to the patient:

1. find out where they would like it to be sent
2. use the patient’s full name in the address and check with them if they share the same name as someone else at that address, and how to avoid confusion with other family members.

C215

When you send a referral, make sure it is sent by a secure method or the patient has given consent for it to be sent by an alternative method.

Recording the referral

C216

You should keep copies of all referral letters and a note of the discussions held with the patient, including the advice you gave.

C217

Delegation is different from referral. See section on Working with colleagues. Referral is when you arrange for another practitioner to provide a service that falls outside your scope of practice, contract or professional competence, such as referring a patient to a contact lens optician for contact lens care. Delegation is when you ask a colleague to provide care or undertake a procedure on your behalf.

C218

When you delegate care, you are still responsible for: 

1. the overall management of the patient, and must ensure that your patient receives the same standard of care that you would provide
2. the work of the person to whom you have delegated the procedure and any clinical findings.²⁸⁷

C219

When you delegate, you should be satisfied that the person to whom you delegate has the skills and experience to provide the relevant care or undertake the procedure. If harm can result from the procedure, such as instilling eye drops or inserting and removing a contact lens, you must remain on the premises so you can intervene if necessary.²⁸⁸ 

C220

You should not ask someone who is not suitably qualified to interpret any clinical findings.

C221

You should explain to the patient that you are delegating a particular part of their care to your colleague and that you will discuss any clinical findings with the patient.

C222

You must not delegate any part of the protected functions of sight testing or contact lens fitting, including any part that would be regarded as assessing the patient or exercising professional judgement, other than to someone who is registered to perform the protected functions. 

C223

This section covers general principles of supervision. If you supervise pre-registration optometrists you should follow the relevant guidance on the College website.

C224

If you are in a practice where colleagues need supervising, you must ensure that a named practitioner is responsible for supervising them each day and that everyone is clear who the supervising practitioner is.

C225

If you supervise colleagues, you should:

1. ensure that you have the necessary skills to supervise them
2. observe their work
3. give them regular constructive feedback on their performance.

C226

You remain responsible for the patients under the care of anyone you supervise.

C227

You must be in a position to give advice and support or delegate supervision to someone who can do so.

C228

You must supervise dispensing to patients under the age of 16 or to those who are registered sight impaired, unless this is done by another optometrist, dispensing optician or doctor.

C229

You must supervise a trainee optometrist, student dispensing optician, medical student, or a dispensing optician training to be a contact lens optician when they are performing restricted functions, unless they are being supervised by another optometrist, dispensing optician, doctor or a contact lens optician, as appropriate. You must make a judgement about their capability and how closely they need to be supervised. At the very least you must be on the premises when the restricted function is taking place so you are in a position to intervene if necessary.

C230

If you supervise a colleague, for example, someone who is returning to work or is undergoing additional training, you must assess their capability so that you can tailor their supervision to their level of competence.

C231

When referring, delegating or supervising, you must keep good records and ensure that your colleagues have all the information they need to care for your patient. See section on Working with colleagues for the information you should include when making a referral.

C232

If you care for another clinician’s patient you must keep good records.