Referring for an imaging examination is comparable to writing a prescription, as it must comply with legal requirements. The Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2024) detail specific obligations imposed by statutes for the protection of patients from unnecessary or excessive exposure to medical X-rays (Ionising radiation). These regulations provide specific guidance for Employers, Referrers, Practitioners and Operators, outlining their responsibilities as IR(ME)R Duty Holders.
It is crucial to understand the reasons behind these legal requirements. A quick overview of the legislation is described in this section.
The regulations identify distinct categories of Duty Holders, each responsible for ensuring the safety of patients undergoing medical exposures using ionising radiation. The Duty Holders identified in the IR(ME)R legislation are:
The Employer (Ramsay Health Care UK) is responsible for establishing a system of policies and procedures, governing imaging referrals, to ensure that justification of exposures takes place and that a clinical evaluation of all imaging is recorded. The aim is to ensure that radiation doses to patients are kept as low as reasonably practicable.
Medical and Non-Medical Referrers (NMRs) who wish to refer individuals to a Ramsay Hospital are classed as Duty Holders under IR(ME)R and must be entitled in accordance with the employer’s procedures.
Referrers have a legal obligation to provide all necessary clinical information relating to the patient and the examination requested. It is essential that correct patient identification details are provided, along with sufficient clinical and medical data, the date of the Last Menstrual Period (where appropriate), and a provisional diagnosis, or clinical question to be answered.
Referrals for medical exposures should be made in accordance with documented referral criteria. The overarching criteria used by Ramsay Health Care UK are based on those provided in the “ iRefer - Making the best use of clinical radiology” document, published by the Royal College of Radiologists.
Practitioners (usually a Radiologist) and Operators (usually a Radiographer) are responsible for justifying and authorising individual medical exposures based on clinical and other relevant information supplied by the Referrer.
They must consider:
⦁ The specific objectives of the exposure
⦁ Individual characteristics of the patient
⦁ The potential benefits to the patient
⦁ Any potential detriment to the patient
⦁ The necessity of the exposure.
⦁ The efficacy, benefits, and risks of available alternative techniques
Special attention is given to:
⦁ Pregnancy and potential pregnancy
⦁ Exposures of infants and children.
⦁ High dose techniques e.g. CT
⦁ Non-medical exposures being performed, e.g. for legal purposes
If the Practitioner or Operator considers the request non-compliant with its IR(ME)R procedures, they cannot legally justify it and must refuse the imaging request. In such cases, the request will be returned to you to supply further clinical information.
All new Non-Medical Referrers (NMRs) will be required to complete an application enabling their entitlement to refer patients for imaging. Referral scope of practice must be agreed in advance between the Radiology Department and the NMR. The application form must be completed and the Radiology Department contacted for approval before sending a referral form to the hospital.
Requests for examinations involving ionising radiation will require evidence of IR(ME)R training. Requests for MRI examinations will require evidence of MR Safety training to ensure an awareness of the hazards associated with MRI. Additionally, evidence of revalidation of this training is required to be provided every three years.
Please see the Training section on this page.
Medically qualified doctors and dentists can refer patients for imaging, subject to the approval of the performing hospital.
The referrer must be a registered healthcare professional who has been entitled by the employer in accordance with Part 2 of the NHS Service Reform and Health Care Professions Act 2002. They must read and comply with the written procedures set out by the employer relating to IR(ME)R. Please see the Ramsay IR(ME)R Employers procedure documents on this page.
Formal training for medically qualified referrers is not an explicit requirement under IR(ME)R, however, it is considered best practice for a referrer to have an awareness of their professional and legal responsibilities under IR(ME)R, as well as an understanding of the biological effects of radiation.
Further training information is available on this page.
You may be entitled as a non-medical referrer if you:
⦁ Are a registered healthcare professional.
⦁ Have had adequate training.
⦁ Have been entitled by the Employer of the individual exposing the patient to radiation to act in this role.
Non-Medical Referrers must understand their professional accountability arising from their professional code of conduct and any legal issues related to their scope of practice.
It is important to note that NMR entitlement is specific to individual Ramsay Hospitals; entitlement at one hospital does not provide automatic entitlement for another hospital. You must be entitled under each hospital’s Employer's Procedures.
There is a useful Referrer checklist available to assist you when referring a patient for a diagnostic imaging examination. View the checklist here.
The following can be accepted as legitimate methods of referral;
- Approved Ramsay Health Care UK referral form (Paper or Electronic)
- Headed letter (with minimum data set as described)
- Electronic referral via MAXIMS (printed or paperless)
- Electronic referral from named NHS Trust
- Centrally written Corporate agreement for external referrals
Informing the patient of the risks and benefits of medical imaging using ionising radiation is a legal requirement under IR(ME)R 2024:
“Wherever practicable, and prior to an exposure taking place, the patient or their representative is provided with adequate information relating to the benefits and risks associated with the radiation dose from exposure.”
In the first instance, this discussion occurs between the patient and Referrer prior to the referral being submitted. The discussion should include how the imaging will aim to provide a diagnosis or monitor the progress of the patient’s treatment, and how the benefits from having the examination outweigh the extremely low risk involved with the examination itself.
It should be emphasised that the risk of cancer induction is extremely low, and an indication of approximate average UK background equivalent radiation time given.
Sources of information to aid this discussion can be found here:
Exposure to Ionising Radiation from Medical Imaging Safety Advice
Patient Dose Information Guidance
In the unlikely event that a patient undergoes a procedure resulting in unnecessary radiation exposure due to mistaken identification, procedural failure, or receiving an exposure greater than intended, an investigation must be conducted into the circumstances that led to the exposure.
The detailed investigation required by IR(ME)R aims to:
⦁ Establish what happened.
⦁ Identify the process failures
⦁ Decide on the remedial action required to minimise the chance of a similar occurrence
⦁ Estimate the doses involved and determining if the threshold for a significant exposure (as defined by statutory guidance) has been met
⦁ Informing the Referrer and patient (or their representative) of the incident
If an accidental or unintended exposure is judged to be significant, then it is required to be notified externally to the CQC.
The Referrer is required to check the LMP (Last Menstrual Period) date of all patients aged 12 – 55 years before referring them for an imaging examination of the abdominal, pelvic, or upper femoral regions.
Referrers should clearly indicate on the request form if it is known or suspected that a patient is pregnant at the time the request is made, so that the Practitioner can decide whether the clinical necessity of performing the examination outweighs the risk of a radiation exposure to a foetus.
NMRs intending to refer patients known or suspected to be pregnant for X-rays should first seek advice from their Consultant/Clinical Lead in their area of work. If the patient is known to be pregnant, the referral must be made by a Consultant. There must be a discussion regarding the referral request between the Referring Consultant and the Consultant Radiologist before a referral is made.
In October 2024, the government added additional requirements under Schedule 2 of the IR(ME)R legislation, which includes requirements of referrers when amending or cancelling any referrals for exposure.
If you need to amend or cancel an imaging referral then you must contact the Radiology department directly by phone as soon as possible. Please do not send any electronic communications regarding cancellations as these may not be read in a timely manner.
Contact details for our hospitals can be found here.
Although there are no statutory regulations covering referrals for MRI, it is considered best practice to follow the principles set out under IR(ME)R legislation.
As with IR(ME)R referrals, requests for MRI examinations must provide relevant clinical information to ensure the correct examination is performed and sufficient information to identify the patient.
As a referrer, you must consider MRI contraindications specific to Ramsay Hospitals. Unlike larger NHS trusts, Ramsay hospitals are unable to perform some MRI examinations that NHS trusts can, such as a cardiac pacemaker or pacing wire, cerebral aneurysm clip, cochlear implant, neuro/bio stimulators even though these may be classified as MRI Safe or MRI Conditional.
It is essential that any safety questions are answered in full on the referral form and information pertaining to implanted medical devices are detailed to allow time to confirm compatibility of the device.
Pregnant Patients should only be scanned after the risk and benefit of the examination has been explained to them by the Referrer and after consultation with a Radiologist.
Although there are no statutory regulations covering referrals for Ultrasound, it is considered best practice to follow the principles set out under IR(ME)R legislation.
Ultrasound referrals must provide relevant clinical information to ensure the correct examination is performed and sufficient information to identify the patient.
Please note – Ramsay hospitals do not perform obstetric Ultrasound scans
Referrer training should cover the following topics:
⦁ Principles of radiation protection.
⦁ Benefits and risks of x-ray examinations, including radiation dose levels and the use of appropriate low dose, or non-ionising alternative examinations.
⦁ Ionising Radiation Regulations (IRR) 2017 and the Ionising Radiation (Medical Exposures) Regulations (IR(ME)R 2024 regulations.
⦁ Responsibilities of Non-Medical Referrers in relation to patient safety and clinical governance.
⦁ Professional and legislative responsibilities.
⦁ MRI safety / contraindication training (if referring for MRI examinations).
British Institute of Radiology - Referring your patient for imaging: For GPs and medical doctors
British Institute of Radiology - Requesting imaging safely: For Nurses and Allied Health Professionals
If you refer patients for MRI, you will need to demonstrate that you are up to date with ‘MRI Safety Training for Referrers,’
This training is available on the e-LfH platform: https://www.e-lfh.org.uk/programmes/mri-safety/
Or if you cannot access e-LFH:
MRI Safety (only the referrer module is required) https://www.eintegrity.org/healthcare-course/mri-safety/
Employers Procedure 1 - Correctly identify individuals exposed to Ionising Radiation - view here
Employers Procedure 2 - Referral Criteria - view here
Employers Procedure 2b - Making, amending and cancellation of referrals for exposure - view here
Employers Procedure 3a - Identification, Responsibilities and Training of IR(ME)R Referrers - view here
Employers Procedure 3d - Justification and Authorisation of a medical exposure - view here
Employers Procedure 4 - Enquiries of individuals of child-bearing potential, pregnancy and breast feeding - view here
Employers Procedure 4 Appendix - Pregnancy Flowchart - view here
Employers Procedure 10 - Provision of information on Radiation Benefits & Risks to patients - view here
Employers Procedure 14 - Non-Medical Imaging - view here
Employers Procedure 15 - Co-operation of Employers - view here
Ionising (Medical Exposures) Regulations 2017 Statutory Instruments 2017 No 1322 - view here
The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2024 - view here
MHRA - Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use - view here
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