Referral letter: what it carries and the no-commission rule Regulations 3.1 and 3.2 on consultation, 6.4 on referral fees, and 7.14 on what may be shared.

A referral letter is the note a treating doctor writes when requesting consultation with another physician or facility, which under regulation 3.1.1 of the 2002 conduct regulations "should be justifiable and in the interest of the patient only and not for any other consideration", and for which regulation 6.4.1 forbids any commission or fee split. The regulations use the word "consultation" for what clinics call a referral; Chapter 3 is headed "Duties of Physician in Consultation" and regulation 3.2 opens with "In every consultation, the benefit to the patient is of foremost importance."

When is a referral proper?

Regulation 3.1 starts from restraint: "Unnecessary consultations should be avoided." Regulation 3.1.1 then says that "in case of serious illness and in doubtful or difficult conditions, the physician should request consultation, but under any circumstances such consultation should be justifiable and in the interest of the patient only and not for any other consideration". Regulation 3.1.2 adds that laboratory and imaging referrals "should be done judiciously and not in a routine manner". The clinical judgment about whom to refer is the doctor's; this entry only states the rule.

What does a referral letter carry?

The regulations do not prescribe a form. In practice a referral letter is the treating doctor's letterhead, which under regulations 1.4.1 and 3.7.2 already carries the doctor's name, designation and registration particulars, addressed to the receiving doctor or facility, with the patient's name and age, the reason for the consultation, the relevant findings and current treatment, and the doctor's signature and date. Regulation 3.4.1 expects the physicians "engaged in the case" to be frank with the patient, so the letter is normally handed to the patient. A layout is in our referral letter format.

Can a doctor take a referral fee?

No. Regulation 6.4.1 says a physician "shall not give, solicit, or receive nor shall he offer to give solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment", and shall not be party to any "division, transference, assignment, subordination, rebating, splitting or refunding of any fee". This applies in both directions and to referrals to laboratories and hospitals as much as to other doctors. The NMC's 23 August 2023 notification confirms the 2002 regulations are the conduct rules in force; a clinic-level reading is in the NMC professional conduct regulations guide.

What may the letter disclose?

Regulation 7.14 says a practitioner "shall not disclose the secrets of a patient that have been learnt in the exercise of his / her profession" except in the listed cases. A referral is made for the patient's care and with the patient's knowledge, so the letter carries what the receiving doctor needs and no more. Sending it by WhatsApp or email raises its own questions, covered in WhatsApp for clinics.

How does a small OPD handle referrals?

A general physician writes the letter on the clinic letterhead, notes in the patient's record that a referral was given and to whom, and hands the sealed letter to the patient with the reports. No list of "preferred" labs or hospitals with a cut attached exists at the desk. When the specialist's reply comes back with the patient, it is filed in the same record. The record side is explained in case sheet.