Autism referral
22. Ms E says the Practice did not appropriately support her to complete an autism assessment referral. Specifically, she says it did not arrange an appointment to explain the different services available to her, referred her to a service with a long waiting list, and did not go into enough detail about her needs on the referral form. She says, had the Practice discussed the options available to her, she would not have chosen to be referred to Surrey and Borders and would have chosen SAAS as it had a shorter waiting list.
23. Additionally, Ms E says when she raised these concerns with Practice staff, they ‘dismissed her’ and did not take her seriously. She explains this made her feel ‘not worthy’ of support for her referral.
24. It is clear Ms E has found this process upsetting and frustrating. We recognise this referral was very important to her and had a big impact on her life. We are sorry to hear the referral process and her communication with staff has left her feeling unheard and unsupported.
25. The NHS ‘right to choose’ guidance explains an NHS patient ‘should always be offered a choice at the point of referral to a mental health service’. It says NHS patients should also be given the opportunity to ‘discuss the options with the person referring them’. In doing so, this will give a patient better control over their care which ‘best suits their circumstances’. Finally, this guidance explains if an NHS patient feels they do not have enough information to decide their preferred service, they should ‘speak to the person who is referring them’ to raise this concern.
26. GMC ‘Good Medical Practice’ guidance explains clinicians have a duty to record their work ‘clearly, accurately and legibly’ and medical records should include ‘relevant clinical findings’.
27. In this case, the records indicate Practice staff did not discuss Ms E’s autism referral options with her at the point it submitted the referral on 3 April 2023. Instead, it submitted her referral form to Surrey and Borders without exploring any other options with her. This meant, she did not have enough information to make an informed choice about which service to go to.
28. Further, the original referral form did not include all relevant information or contain enough details about Ms E’s symptoms for it to be accepted.
29. On 1 February 2024, Ms E contacted the Practice because she felt she had not been given relevant information about the referral process or offered a choice on which service she wanted to be referred to. The Practice apologised to Ms E. It submitted a new referral to SAAS in March 2024.
30. Sadly, it appears the Practice did not correctly follow the NHS ‘right to choose’ guidance. It did not arrange a discussion with Ms E to establish which service she would like to be referred to ‘best suit’ her circumstances before submitting her referral. It also did not include all relevant information or put in enough detail when it submitted the referral. This is not in line with GMC guidance, which explains the ‘relevant clinical findings’ should be clearly recorded in a patient’s records. This indicates its service fell short of what is expected.
31. Ms E says because all her information was not included in the first referral form, this delayed the assessment process. We recognise it would have been frustrating for Ms E to find out the form was not fully completed with all relevant and detailed information. That said, we do not think the lack of detailed information in the first form caused a delay in the Surrey and Borders referral process.
32. Nevertheless, we recognise the Practice originally sent Ms E’s referral form to Surrey and Borders without discussing this with her first. Ms E told us she wanted a referral to SAAS as it had a shorter waiting list. We can see she was rereferred to this service in March 2024 (approximately eleven months after the first referral). On balance, we consider this delay could have been avoided, had the Practice correctly discussed her referral options with her in April 2023. We next consider what the Practice has done to put things right.
33. Our NHS ‘Complaints standards’ (December 2022) says organisations should ‘openly identify instances when things have gone wrong’ and ‘look at what action will be taken to learn from the experience to improve services’. It also says organisations should ‘welcome complaints in a positive way’ and be ‘responsive to the needs of each individual’. Finally, it says staff should ‘actively listen and demonstrate a clear understanding of what the main issues are for the person who has made the complaint, and the outcomes they seek’.
34. As part of this process, we contacted the Practice and explained we had seen indications it had not followed the NHS ‘right to choose’ and GMC guidance when processing Ms E’s referral. We also explained its communication with Ms E, had left her feeling unsupported and that it had ‘dismissed her complaint’.
35. The Practice acknowledged its service and communication had fallen below the standard expected. It agreed to write to Ms E, to apologise for the impact this had on her. It also asked us to ask Ms E for valuable feedback on how she felt it could improve its service for patients in the future. This was done and sent to the Practice.
36. It explained this feedback will help them decide and put in place service improvements to prevent similar mistakes happening in the future. It has agreed to review its current service, to ensure appropriate support is made available to patients with Autism, ADHD, and other neurological divergences. This includes support with referrals. The Practice has committed to begin putting these changes in place by December 2024 and will write to Ms E directly to share these findings.
37. Additionally, the Practice recognised Ms E had been left feeling unsupported. To resolve this, it has agreed to offer her individual support through an allocated care coordinator. The Practice hopes this will improve the service and accessibility for her. The Practice Manager has committed to sharing details about her care coordinator by the end of December 2024.
38. We asked Ms E if she was happy with the Practice’s proposed service changes and apology letter. She confirmed she was, and this would successfully resolve her complaint.
39. Taking all this into account, we are satisfied the Practice has acted in line with our NHS complaints standards. It has welcomed this complaint in a positive way and been open and accountable for its mistakes. It has also taken steps to understand Ms E’s individual needs and considered her personal feedback as part of its process to make service improvements. As both parties are satisfied with this outcome, we have decided not to take any further action regarding this complaint. We would like to thank the Practice and Ms E for their time, cooperation, and effort to reach this position.
Orthopaedic referral
40. Ms E says the Practice should have put in an orthopaedic referral earlier for her knee pain. She says the Practice has ‘used her BMI against her’ and this delayed her receiving the specialist care and treatment she needed.
41. It must be very difficult for Ms E to experience ongoing, long term knee pain. We recognise this has impacted her quality of life and we are sorry to hear how distressing this had been for her.
42. GMC ‘Good Medical Practice’ guidance says doctors must provide a ‘good standard of practice and care’. If they assess, diagnose, or treat patients, they must ‘adequately assess the patient’s conditions’, ‘promptly provide or arrange suitable advice, investigations, or treatment where necessary’ and ‘refer a patient to another practitioner when this serves the patient’s needs’.
43. NICE ‘Osteoarthritis care and management’ guidance says when a patient has OA a clinician should first recommend non-surgical treatment options. This includes recommending ‘activity and exercises’ and ‘interventions to achieve weight loss if the person is overweight or obese’. This guidance also says healthcare professionals should consider offering paracetamol and/or NSAIDs for pain relief.
44. The records show Ms E first attended the Practice with right knee pain in March 2022. The GP assessed her pain and symptoms during appointments she attended between 11 March to 31 August 2022. The GP documented her BMI as 43 (this is classed as ‘morbidly obese’) and contacted a physiotherapist to give her musculoskeletal physiotherapy. They also referred her to a weight loss management programme. The GP also prescribed naproxen (an NSAID medication) to manage her pain.
45. Ms E went back to the Practice on 16 August and 13 September 2023 for her knee pain. She had completed her weight loss management programme but did not feel she was able to lose any more weight or be more active. The Practice recorded her BMI as 42 (this is classed as ‘morbidly obese’) and told her she was young, and conservative (non-surgical) management is the first option before an orthopaedic referral. Ms E was reluctant to take stronger medication, so the Practice put her on the waiting list for a steroid injection.
46. The Practice gave Ms E the steroid injection on 5 October. Sadly, she was still in pain, so the GP referred her to orthopaedics for consideration for a knee replacement on 17 October.
47. This evidence indicates the Practice acted in line with GMC and NICE guidance when treating Ms E’s knee pain. The records indicate the GP ‘promptly’ referred Ms E to a physiotherapist, who was a ‘suitable practitioner’ to help manage her knee pain. They also gave ‘appropriate advice’ about her treatment options and correctly referred her for weight loss support as recommended in NICE guidance. It appears the Practice also prescribed appropriate NSAID pain relief medication to manage Ms E’s pain in line with NICE guidance. The records indicate the Practice correctly made sure Ms E had been offered the core (non-surgical) treatment options before putting in an orthopaedic referral for consideration of joint surgery.
48. NICE ‘Osteoarthritis care and management’ guidance (October 2022) says clinicians should not exclude a patient from a referral for joint replacement based on BMI measurements alone. Instead, they should consider the patient’s weight, alongside a number of other risk factors for surgery, including ‘age, sex or gender, smoking, comorbidities’ and discuss this with the patient. It also explains surgery should be considered after ‘non-surgical management (for example, therapeutic exercise, weight loss, pain relief) is ineffective or unsuitable’.
49. We recognise Ms E feels the Practice treated her unfairly and would not refer her for a knee replacement based on her weight alone. We want to reassure her this was not the case. The records indicate the Practice correctly discussed Ms E’s weight and age with her and explained this increased the risk of successful surgery. However, it is clear the basis of its treatment plan was to exhaust non-surgical options first before referring her for surgery. This is in line with NICE guidance. For this reason, we have seen no indications of failings for this part of the complaint.
50. In conclusion, we recognise the hard work Ms E put in to manage her weight and attend physiotherapy. We do not wish to diminish in any way the time and effort she has taken to engage with the Practice to help her knee pain. We understand the Practice’s reference to her weight and BMI made her feel hopeless and upset. We are sorry to hear this was so stressful for her. Whilst we cannot take away these feelings, we hope to reassure her the Practice did not refer her for surgery earlier, as it wanted to try non-surgical treatment options first. We would like to thank Ms E for bringing her complaint to us and we wish her well for her future health.