Chairman and Honorary Professor of Optometry, BBR Optometry Ltd and University of Manchester

If you judge the patient has capacity, you must explore whether this appears to be a measured decision based on a reasonable belief (for example, the patient does not wish to undergo surgery, period) or if there is some underlying concern you aren’t able to tease out. There is also the question of whether there is a risk of a significantly adverse outcome: it’s very different to refuse cataract surgery compared with emergency referral for a retinal tear.

Many of us now bypass the GP and refer directly to hospital. There is therefore always the possibility of suggesting: “Why don’t you just have a chat with your GP about this?”

I can think of only five cases over my career where referral was refused. I only disagreed with one of these: in the other four, I understood the rationality of the decision and agreed with the patient.