Referrals to complementary therapists

Background
This guidance has been produced in response to evidence of a growing interest amongst patients in the use of complementary therapies, whether by self referral or GP referral, and amongst GPs and other health care professionals in offering such treatment. Several private health care providers now offer cover for various complementary therapies, on condition that the patient is referred to the therapist by their GP. GPs might therefore expect an increasing number of patients to request referral to a complementary therapist. A study published in 2000 estimated that up to 5 million people may have consulted a practitioner specialising in complementary and alternative medicine (CAM) in the previous year.

The BMA’s policy on this issue emphasises the need for increased awareness amongst medical students, the value of post graduate education for the health care professions, and the need for all practitioners providing treatment in the discrete clinical disciplines of acupuncture, osteopathy, chiropractic, homeopathy and herbalism to attain high levels of education and competence. The aim of this guidance is to clarify the legal and ethical obligations of GPs in responding to requests for such treatment. The BMA welcomes the greater use of the range of specialist skills within the health service, but has some concerns about the implications for GPs, in terms of legal liability, if patients are to be referred to non-medically qualified practitioners.

GPs are obliged under their contracts or agreements with primary care organisations (PCOs) to refer patients for services available under the NHS, and referral to complementary therapists should not therefore be considered a contractual requirement. However, referral to NHS doctors at one of the five NHS homeopathic hospitals or NHS homeopathic clinics in cases where GPs and their patients think such treatment is appropriate would fulfil the contractual responsibility. GPs may prefer to suggest that patients visit a particular type of therapist without actually making a formal referral, and may then offer to recommend a suitable individual. In doing so, however, they must satisfy themselves that the individual is competent in the therapy concerned.

Many GPs will not wish or feel able to advise a patient to consult a complementary therapist and will therefore not wish either to delegate or refer. In those cases, the GP should make it clear that they have no objection to the patient consulting whomsoever they wish, and will not criticise or victimise the patient should they choose to do so.

Delegation and referral
The General Medical Council (GMC) distinguishes between delegation and referral in paragraphs 46 and 47 of Good Medical Practice (3rd Edition, 2001):

“Delegation involves asking a nurse, doctor, medical student or other health care worker to provide treatment or care on your behalf. When you delegate care or treatment you must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved. You must always pass on enough information about the patient and the treatment needed. You will still be responsible for the overall management of the patient.

Referral involves transferring some or all of the responsibility for the patient’s care, usually temporarily and for a particular purpose, such as additional investigation, care or treatment, which falls outside your competence. Usually you will refer patients to another registered medical practitioner. If this is not the case, you must be satisfied that such health care workers are accountable to a statutory regulatory body, and that a registered medical practitioner, usually a general practitioner, retains overall responsibility for the management of the patient.”

Since 1990, GPs have been able to employ complementary therapists, but must check that the person employed is suitably qualified and competent to perform the duties for which they are employed.

Referral to registered professionals
GPs can safely refer patients to complementary therapists who are registered as doctors or nurses with the GMC or Nursing and Midwifery Council (NMC) respectively, because the therapists would be fully accountable to the GMC or NMC for their actions and the patient could seek legal redress against them in the event of an accident. This principle also applies where practising doctors or nurses offer complementary treatment as a supplement to their normal services. Although the GP remains responsible for the overall management of the patient’s care, he or she is not responsible for the detail of the treatment given.

There is also no problem with GPs referring patients to practitioners in osteopathy and chiropractic who are registered with the relevant statutory regulatory bodies, as a similar means of redress is available to the patient. Before doing so, they have an obligation to check that the therapist is registered with the appropriate body. These are currently the only complementary therapists subject to statutory regulation, although several others operate under voluntary registering bodies and may be subject to statutory regulation in the future.

In either case, the GP must first be satisfied that the patient will benefit from the type of treatment involved. This presupposes that the GP has some knowledge of the basic principles of the therapy, and some belief in its efficacy.

If the patient suffers any harm as a result of the treatment, the referring GP could retain some liability and would need to demonstrate that they had reasonable grounds for believing the therapist to be competent. Registration with a statutory regulatory body would be regarded as reasonable grounds.

Delegation to other practitioners
GPs can delegate treatment to complementary therapists who are not registered with a statutory regulatory body. In doing so, they remain responsible for the treatment given and would bear some liability should the patient come to any harm. Whether GPs are prepared to delegate treatment in these circumstances would therefore depend principally upon their knowledge of, and belief in the efficacy of, the therapy and their personal knowledge of the competence of the individual therapist.

The BMA advises (Medical Ethics Today, 2004) that:
For other therapists [not subject to a statutory regulatory body], the GP is considered to have delegated care and so retains responsibility for the overall management of the patient. When GPs employ CAM therapists who are not subject to a statutory regulatory body, they need to be satisfied that the individual is suitably qualified and experienced to undertake the role. GPs should also be aware that, in such circumstances, they may be held liable for any harm arising to their patients.

In delegating to complementary therapists, GPs must
  • ensure that tasks are delegated only to those who are competent to fulfill them, even though the person to whom care is delegated need not be medically qualified or subject to a statutory regulatory body.
  • satisfy themselves that the treatment seems appropriate to the patient’s needs and is likely to benefit the patient. As above, this presupposes some knowledge of, and belief in the efficacy of, the therapy.
  • pass on enough information about the patient and the treatment needed (as stated by the GMC). The GP will need to exercise a degree of professional judgement in identifying the information that the therapist needs, and must ensure that they have the patient’s clear consent to the disclosure of this information, particularly if it is likely to be of a sensitive nature.
  • retain responsibility for managing the patient’s care (as stated by the GMC). This might best be done by asking the patient to visit the GP again shortly after the treatment to review its effects. The GP must also ensure the patient has access to any conventional treatment they require. If the patient remains insistent upon seeing a complementary therapist rather than following the GP’s advice that conventional treatment is required, the GP should record this matter clearly in the patient’s notes and would also be well advised to confirm their advice to the patient in writing.
Further reading and information
  1. University of Exeter, Professional Organisation of Complementary and Alternative Medicine in the United Kingdom 2000 – A Second report to the Department of Health, 2000.
  2. GMC, Good Medical Practice 3 Edition (2001), GMC.
  3. BMA, Medical Ethics Today, The BMA's Handbook of Ethics and Law: 2 Edition (2004) BMJ.
  4. Stone & Matthews, Complementary Medicine and the Law, 1996, OUP.

    © British Medical Association 2008

Log in to your BMA here



Download the guidance in PDF format (40k)

  • Adobe PDF iconTo view and print PDF files, you must have Adobe® Acrobat® Reader installed.

    Download Adobe here