Requesting a second opinion policy

1 Policy summary

This policy sets out the process where a patient or their representative may request a second opinion from another clinician about their care or treatment. This is policy is designed to empower patients and increase their autonomy.

This policy is distinct from the policy covering statutory second opinions under the Mental Health Act and does not cover a change in lead clinician.

2 Introduction

Occasionally patients request a second opinion on their diagnosis or treatment; there is no legal right to a second opinion but where clinically appropriate the trust will support these requests. Any second opinion will be provided by an equivalent specialist within the trust. If a patient requests a second opinion outside the trust this will be considered on a case-by-case basis, it will not stop that patient from accessing trust services.

There are a number of different types of clinicians who may have patients who decide to request a second opinion. For the purpose of this document, they will be referred to as ‘the clinician’

3 Purpose

To describe what should happen when a patient requests a second opinion.

4 Scope

This applies to all clinicians and patients; for patients under 16 years of age who lack competence to make such decisions, this policy will apply to their parent or guardian. A request made under this policy can be in relation to any opinion provided by a clinician in the trust.

The Mental Health Act 1983 (amended 2007) (MHA) sets out circumstances where a second opinion is a statutory (legal) requirement with specific reference to second opinions in relation to treatment of detained patients.

This policy refers to requests for second opinions outside the terms of the MHA, including non-statutory requests for second opinions on detained patients

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure and implementation

5.1 Quick guide

5.1.1 Inform about second opinions

Any colleague to whom a patient raises concern about their care and treatment should be able to inform the patient of how to request a second opinion.

5.1.2 Making the request

Requests can be made either by the patient or representative on their behalf.
Requests may be verbal or in writing.
Where requests are not made by the patient themselves it should be discussed with the patient and their views sought as well as considering their capacity to make a decision.

5.1.3 Advocacy

For any patient who has a request for second opinion made colleagues should ensure they are aware of advocacy.
This may come from a carer, relative, patient advice and liaison service(PALS) or professional advocate.
For patient advice and liaison service (PALS) and advocacy, information should be provided on how to access them

5.1.4 Arranging the second opinion

The clinician should meet the patient and attempt to resolve the matter informally.
If the patient declines to meet the clinician or the matter can’t be resolved informally the clinician will need to determine whether the request for the second opinion is reasonable.
If the request for the second opinion is deemed reasonable this will be passed to the appropriate service manage to arrange the second opinion.

5.1.5 The second opinion

The second opinion will come from a clinician of the same discipline and of equal professional ability to the original clinician.
The location of the second opinion will be decided by agreement between the individual providing the second opinion and the patient.

5.1.6 When a request is declined

If it is felt that a request for a second opinion is not appropriate or reasonable the clinician should meet the patient and explain this decision and document this in the patients notes.
If they remain dissatisfied they should be directed to the service manager or their GP to discuss the matter or make a formal complaint to the trust.

5.2 Inform patients of how to request a second opinion

Any colleague to whom a patient raises concern about their care and treatment should be able to inform the patient of how to request a second opinion; this should be via awareness of this policy and direction of the patient to its content where necessary.

5.3 Making the request

Most requests are made verbally or in writing and in this case, the colleague to whom the request is made should notify their Team Manager who in turn should notify ‘the clinician’. ‘The clinician’ should then arrange to meet with the patient and discuss the reasons for their request and attempt to resolve the matter.

5.4 Requests for a second opinion made on the patient’s behalf

For adult patients these can only be made with their consent, any colleague to whom the request is made must explain that consent is needed and without it the request will be refused. They should pass details of the request to ‘the clinician’ who should contact the patient to ask their views. If the patient consents the person who originally made the request should be informed of the outcome.

If the patient lacks capacity to consent to the request being made and has appointed someone to act on their behalf under a registered lasting power of attorney for health and welfare or a deputy for health and welfare has been appointed by the court of protection then they may make a request for a second opinion.

Any requests from interested parties not appointed in a legal capacity should be considered as part of the Mental Capacity Act (2005) best interests process. The best interest decision-making process should take into account the provisions of the Mental Capacity Act (2005) and its associated Code of Practice (2007). Patients should be enabled to participate as much as possible in the decision-making process and colleagues should follow the trust’s Mental Capacity Act (2005) policy.

5.5 Advocacy for the patient

Anyone receiving a request for a second opinion should tell the patient that support can be provided by a carer, relative, patient advice and liaison service (PALS) or professional Advocate. For patient advice and liaison service (PALS) and advocacy, information should be provided on how to access them.

5.6 Patients with language or communication difficulties

Appropriate arrangements should be made to have an interpreter or other support with the patient at all meetings, in line with the trust interpreters policy (provision, access and use of, for patients, service users and carers).

5.7 Requests made by patients detained under the Mental Health Act

All requests will be considered however requests made by detained patients would only be agreed in exceptional circumstances. When a request is declined this should be discussed with the patient once their mental state has improved.

5.8 Arranging a second opinion

When a patient declines to meet with ’the clinician’ or when they meet, but the matter remains unresolved; if ‘the clinician’ feels that the request for a second opinion is clinically appropriate, it should be arranged in line with this policy and documented. The second opinion should be arranged by the appropriate service manager or director as indicated (section 4) and they should contact the patient to inform them of the outcome within two weeks.

If the request is supported the person arranging it should approach a trust employee of same discipline and of equal professional ability to ‘the clinician’ and ask them to provide a second opinion.

5.9 The second opinion

The location of the second opinion will be decided by agreement between the individual providing the second opinion and the patient. In many circumstances it will be appropriate for the patient to travel to the individual providing the second opinion but where this is not possible, they must be flexible and be prepared to travel to the patient, the patient should also accept that this could contribute to delays.

The individual providing the second opinion should be provided with the relevant clinical records and must communicate the outcome in writing to both the patient and ‘the clinician’.

5.10 Patients who decline or remain dissatisfied following a trust second opinion

The trust will only consider requests for an external second opinion in exceptional circumstance. If the patient declines an internal second opinion or remains dissatisfied after an internal second opinion; or if they have had their request for an opinion outside the trust declined, they should be advised to see their general practitioner (GP) to request a referral to another trust. It should be made clear to the patient that if they do this, they will be responsible for their own transport arrangements and costs. In these circumstances the trust will not be responsible for costs incurred to provide an external second opinion.

5.11 Managing patients who make repeated requests for a second opinion

When patients make repeated requests for a second opinion the clinical team will need to make a decision whether it is in the patient’s best interest for the trust to accommodate such requests. If it is felt not to be, then the request will be passed to the service manager and the care group director who will write to the patient explaining why. If the patient remains dissatisfied, they should be advised to contact their GP about referral to another provider or transfer of care to another locality within the trust; they should also be informed of their right to make a formal complaint.

5.12 Action if a second opinion is not felt to be clinically appropriate

In these circumstances ‘the clinician’ should meet the patient and explain this decision carefully documenting it in the patients clinical records. If they remain dissatisfied, they should be directed to the service manager or their GP to discuss the matter or make a formal complaint to the trust.

6 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

6.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

6.1.1 Indicate how this will be met

No issues have been identified in relation to this policy.

6.2 Mental capacity act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

6.2.1 Indicate how this will be achieved

This policy will be implemented in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1).

7 Associated documents

8 Appendices

8.1 Appendix A Responsibilities, accountabilities and duties

Clinician should initially try to resolve the matter locally but if the issues cannot be resolved, they should inform the patient of the process outlined in this policy. They should then inform their team manager of the request. At this point they should also inform the patient of other support available; including advocacy support or support from the patient advice and liaison service (PALS), details are available via the “have your say” link on the trust website. The clinician should make clear to the patient that requests under this policy are for an opinion only and that if the patient wishes to change clinician that would be a separate process.

Where the request is made via another trust employee who is not ‘the clinician’ then they should inform the team manager and ‘the clinician’ who must then follow this policy.

A reasonable request from a patient for a second opinion should not be refused. What is reasonable should be considered on an individual basis with consideration of the circumstances of the individual case.

Team manager should contact the patient to acknowledge receipt of the request and discuss the request with ‘the clinician’. They should also inform their service manager of the request and if delegated to do so by the service manager make efforts to arrange the second opinion.

Service manager should, when a second opinion is appropriate, lead on arranging the second opinion. For internal audit purposes they should also monitor the number of requests received and response times.

Care group medical director and care group nurse director should become involved to assist in arranging the second opinion only when it has not proven possible for the team manager or service manager to arrange the second opinion.

Care group director should assist in arranging a second opinion when ‘the clinician’ is the care group medical director; they should also coordinate the investigation of any complaints which are received in relation to any aspect of this policy.

8.2 Appendix B Monitoring arrangement

8.2.1 Number of requests per team or ward

How: Exception reporting.
Who by: Service manager.
Reported to: Care group.
Frequency: Quarterly.

8.2.2 Number of formal complaints received in relation to this policy and implementation of resultant action plans

How: Complaints review.
Who by: Service manager.
Reported to: Care group.
Frequency: As and when necessary.

Document control

Version: 4.1.
Unique reference number: 401.
Approved by: Clinical policies review and approval group.
Date approved: 20 February 2024.
Name of originator or author: Deputy medical director.
Name of responsible individual: Executive director of nursing and allied health professionals.
Date issued: 26 February 2024.
Review date: 31 August 2026.
Target audience: Clinical colleagues and patients.

Page last reviewed: October 22, 2024
Next review due: October 22, 2025

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