Working with colleagues

• You must work with colleagues in ways that best serve patients’ interests and communicate effectively with them.
• You must act quickly to protect patients from risks posed by colleagues.
• You must treat colleagues fairly.
• You should only delegate patient care to appropriately skilled and experienced practitioners.
• You should keep the patient informed if 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.

C160

You must work with colleagues in ways that best serve patients’ interests and communicate effectively with them.²⁴⁰

C161

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

C162

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.

C163

You must act quickly to protect patients from risks posed by colleagues or the environment in which services are provided. The safety of patients must come first. If you have serious concerns 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.

C164

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? And,
2. how could I justify why I did not raise the concern?

C165

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:

1. age
2. disability
3. gender reassignment
4. marriage and civil partnership
5. pregnancy and maternity
6. race
7. religion or belief
8. sex, or
9. sexual orientation.

C166

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.²⁴¹

C167

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

C168

You should communicate effectively with team members.

C169

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.

C170

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

C171

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

C172

If you are leading a team you should ensure that:

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, and
8. you have the necessary leadership skills, or work to develop the skills.

C173

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.

C174

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

C175

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.

C176

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.

When to refer

C177

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 patients to an appropriate practitioner who is registered with a statutory regulator.

C178

You should consider national and local guidance on referrals.

C179

The National Institute for Health and Care Excellence has published evidence on the effectiveness of a repeat readings service for patients with suspect high intraocular pressure. The Scottish Intercollegiate Network has published guidance on glaucoma referral and safe discharge.²⁴³

C180

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.²⁴⁴

C181

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, and
3. details of advice or treatment given to the patient.

C182

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

C183

The welfare of the patient must not be compromised.

C184

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 para C205a and C205b.

C185

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

C186

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

1. ensure the patient understands why the referral is necessary
2. record a full account in the patient records, and

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

Whom to refer to

C187

You must only refer patients to a practitioner with the appropriate qualifications and registration.²⁴⁵

C188

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

C189

If the patient is not registered with a GP or wishes to see a doctor privately, you should give the patient 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

C190

You should write a clearly worded letter of referral and include:

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

C191

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

C192

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

C193

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.^{246, 247} 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.

C194

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

C195

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. 

C196

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

C197

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 when the patient sees the clinician to whom they have been referred.

C198

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

C199

You should provide copies of correspondence in large print for patients with visual impairment.

C200

You should ask young people who have the capacity to consent to treatment if they would like to receive copies of letters about them. You should also check if they prefer to collect a copy of any letter containing personal information or have it sent to their home.

C201

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), or
3. you feel it may cause harm to the patient, although giving bad news is an insufficient reason for withholding a copy of the letter.

 
Sending the referral

C202

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

1. check where they would like it to be sent, and
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, to avoid confusion with other family members.

C203

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

C204

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

C205

This list is intended to be guidance about which conditions require emergency or urgent referral. Familiarise yourself with and follow relevant local protocols for referral. If a patient presents with a condition requiring an emergency referral you may wish to seek advice from the on-call ophthalmologist. This list is not exhaustive. You should use your professional judgement and look at the College’s clinical management guidelines for further information.

1. emergency referral (within 24 hours), symptoms or signs suggesting:
   
   • acute glaucoma
   • acute dacryocystitis in children, or in adults if severe
   • cellulitis (preseptal or orbital)
   • corneal foreign body penetrated into stroma, or with presence of a rust ring (unless optometrist is specifically trained in rust ring removal)
   • CRAO
   • endophthalmitis
   • facial palsy, if new or with loss of corneal sensation
   • herpes zoster ophthalmicus with acute skin lesions (emergency referral to GP for systemic anti-viral treatment with urgent referral to ophthalmology if deeper cornea involved)
   • hyphaema
   • hypopyon
   • IOP  40mmHg (independent of cause)
   • microbial keratitis
   • orbital cellulitis
   • papilloedema
   • penetrating injuries
   • pre-retinal haemorrhage, although a pre-retinal haemorrhage in a diabetic patient with known proliferative retinopathy who is already being actively treated in the HES would not need an emergency referral
   • retinal detachment unless this is long-standing and asymptomatic
   • scleritis
   • sudden severe ocular pain
   • suspected temporal arteritis
   • symptomatic retinal breaks and tears
   • third nerve palsy with pain
   • trauma (blunt or chemical), if severe
   • unexplained sudden loss of vision
   • uveitis
   • vitreous detachment symptoms with pigment in the vitreous, or
   • viral conjunctivitis if severe (e.g. presence of pseudomembrane)
2. urgent referral (within one week). We recognise that in some areas there may not be an appropriate pathway for patients to be seen within a week. You should familiarise yourself with local referral pathways to ensure the patient is seen within an appropriate timescale, symptoms or signs suggesting:
   
   • acute dacryoadenitis
   • acute dacryocystitis if mild
   • atopic keratoconjunctivitis with corneal epithelial macro-erosion or plaque
   • unilateral blepharitis if carcinoma suspected
   • chlamydial conjunctivitis (refer to GP)
   • CMV and candida retinitis
   • commotio retinae
   • corneal hydrops if vascularisation present
   • CRVO with elevated IOP ( 40mmHg refer as emergency)
   • herpes zoster ophthalmicus with deeper corneal involvement – urgent referral to ophthalmology, but refer to GP as an emergency for systemic anti-viral treatment
   • IOP>35 mm Hg (and <40mmHg) with visual field loss
   • keratoconjunctivitis sicca if Stevens-Johnson syndrome or ocular cicatricial pemphigoid are suspected
   • retinal detachment if not an emergency, see above
   • retrobulbar/optic neuritis
   • ocular rosacea with severe keratitis
   • rubeosis
   • squamous cell carcinoma
   • steroid induced glaucoma
   • sudden onset diplopia
   • vernal keratoconjunctivitis with active limbal or corneal involvement, or
   • ‘wet’ macular degeneration/choroidal neovascular membrane, according to local fast-track protocol.

C206

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.

C207

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, and
2. the work of the person to whom you have delegated the procedure and any clinical findings.²⁴⁸

C208

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 insertion and removal of a contact lens, you must remain on the premises so you can intervene if necessary.²⁴⁹ 

C209

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

C210

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.

C211

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. 

C212

This section covers general principles of supervision. If you supervise pre-registration optometrists you should follow the guidance in the College’s Scheme for Registration Handbook.

C213

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.

C214

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.

C215

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

C216

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

C217

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.

C218

You must supervise a trainee optometrist, dispensing optician or medical student, or a dispensing optician training to be a contact lens optician if 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.

C219

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.

C220

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.

C221

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