Membership information 1800 932 916
Medicolegal advice 1800 936 077

From the advice line

15 July 2019
Dr James Lucas, medicolegal consultant at Medical Protection,shares a recent case where a member sought advice about across-border referral.

Dr D, a GP, telephoned Medical Protection’s medicolegal advice line to discuss an unusual request from a patient. The patient in question required a knee replacement and was considering having the surgery in a hospital in Spain through the (EU/EEA) Cross-Border Directive scheme. Dr D had already referred the patient to a consultant orthopaedic surgeon at a hospital controlled by the HSE. However, due to long waiting lists, Dr D was coming under pressure from the patient to make a referral to the surgeon in Spain. Dr D was worried about the potential medicolegal risks associated with a referral to a medical practitioner outside the Irish jurisdiction.


Dr D spoke to Dr P, an expert medicolegal consultant with a specialist interest in the Irish jurisdiction.

Dr P referred to the HSE’s guidance on the Cross Border Directive (CBD)1 which explains that CBD treatment is only available to Irish residents who qualify for public healthcare.The patient must pay for any CBD treatment abroad and then apply to the HSE to claim the cost of the treatment after the patient returns to Ireland. The patient must get a referral by their GP or consultant to get most types of CBD treatment, and they must get prior authorisation if it is required for the particular treatment.

Dr P advised that a GP can refer the patient for healthcare abroad under the CBD in the same way that they would refer the patient for the same treatment in Ireland.

Turning to address Dr D’s specific concerns, Dr P emphasised that the HSE itself has indicated that a GP may refuse to refer a patient if they are:

(i) unfamiliar with the service abroad;

(ii) concerned about the quality of the service abroad;

(iii) concerned as to whether the service will fully meet the patient’s medical needs.

Dr P reminded Dr D that the referring GP in Ireland can advise the patient if their healthcare is covered by the CBD, but if the patient is in any doubt, they are advised to contact the National Contact Point. Dr D was advised to check that the patient is  well-versed in the details of the CBD scheme and to remind the patient that GPs are not involved in the financial aspects of the scheme (such as pre-approving funding for treatment, which is a matter for the HSE alone).

Dr P also made reference to the Medical Council’s guidance in the Guide to Professional Conduct & Ethics,2 which defines ‘referral’ as sending a patient to another doctor or healthcare professional to get an opinion or treatment. The Medical Council states that referral usually involves the transfer (in part) of responsibility for the patient’s care, usually for a set time and a particular purpose,such as care that is outside the doctor’s area of expertise. Dr P read out a paragraph of the Medical Council’s guidance that seemed to be particularly relevant in the context of the query:

“When you delegate or refer you must give sufficient information about the patient and their treatment to the clinicians continuing the care of the patient. You should take reasonable steps to make sure that the person to whom you delegate or refer has the qualifications, experience, knowledge and skills to give the care needed.”

Dr P advised that in circumstances where Dr D declined to make such a referral, it would be important to explain the rationale for the refusal to the patient. The discussion should be documented carefully in the patient’s medical records.

Dr P also pointed out that the HSE’s guidance indicated that where a patient has a ‘waiting list letter’, a GP referral did not appear to be required under the scheme.


2. Medical Council. Paragraph 22. Guide to Professional Conduct and Ethics for RegisteredMedical Practitioners. 8th Edition, 2016.