Writing effective referrals and using eRS well

Guidance for GP practices on writing effective referrals to secondary care, including use of local pathways, key clinical information, and practical tips to support safe triage and reduce delays.

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Good referrals help ensure that patients reach the right service with the information specialists need to make safe and timely decisions. Clear referrals can reduce delays, avoid unnecessary back-and-forth, and improve patient experience.

This guidance sets out practical advice for both writing referrals and managing them effectively within the e-Referral Service (eRS). It is intended to support clinical practice, not to prescribe it. Clinical judgement should always take precedence.

Practical tips

• be clear about the clinical question or reason for referral
• include only relevant information, avoid unnecessary detail
• attach key documents directly where possible
• use Advice and Guidance for appropriate non-urgent queries
• monitor eRS worklists regularly
• respond to requests for further information
• ensure cover arrangements are in place during clinician absence
• remember that patients may be able to view communications

Small improvements in local workflows can support safer, more efficient pathways and reduce delays and uncertainty for patients.

Start with the pathway 

Before referring, check whether a local pathway or referral criteria exist. Where pathways exist, they should be clear, accessible and clinically reasonable. 

Local pathways may describe: 

  • referral thresholds 
  • recommended initial investigations 
  • information needed to triage safely 
  • alternative community services that may be appropriate 

Including the information requested in the pathway will usually help the receiving team triage the referral more efficiently and reduce avoidable delays.

Pathways should remain proportionate and should not require investigations or processes that would normally sit within secondary care.

Most specialists are looking for three things:

  • The clinical problem: What is happening with the patient?
  • The reason for referral: What input is being sought? What question do you want the specialist to answer?
  • Relevant clinical information: A concise summary of key findings. Short, focused explanations are usually more helpful than full consultation transcripts.
Common reasons for a referral include:
  • diagnostic advice 
  • management advice 
  • consideration of a specific intervention 
  • assessment for a procedure 

 Although requirements vary by specialty, most referrals benefit from including:

  • reason for referral, a clear clinical question or purpose
  • relevant history, key symptoms, duration, important positives or negatives
  • examination findings where relevant
  • investigations already performed, with results and dates
  • management already tried and response
  • significant past medical history 
  • medication where relevant 
  • allergies if relevant to treatment decisions 
  • functional impact where relevant (for example mobility, work or daily activities)
  • Urgency and risk factors: if the referral is urgent, briefly explain why. 

Where documents are required, attach the relevant information directly. Large volumes of unnecessary records can make triage more difficult and delay decisions.

Local audit work has identified recurring issues that can delay referral outcomes:

  • unclear clinical question or purpose
  • missing or incomplete attachments
  • delays in responding to requests for further information
  • large volumes of documentation where only limited relevant detail is needed

These issues are common causes of avoidable delay. Addressing them can improve patient flow and reduce unnecessary back-and-forth.

Referral templates and forms 

Many services provide referral templates or structured forms. These should normally be developed through appropriate local governance processes, including ICB oversight and engagement with LMCs, to ensure they are clinically appropriate, proportionate and workable in practice.

When forms are helpful

These can be helpful where they clearly set out the information needed to triage referrals safely and efficiently. Practices may therefore find it useful to use these forms where they are well designed and aligned with local pathways. Many forms will also auto-extract relevant coded information to support the referral. 

Referrals are not dependent on forms

It is important to remember that a referral is fundamentally a clinical communication between professionals. A clear and well-structured referral letter that contains the relevant information remains a valid referral even if it is not submitted on a specific template. The quality of the clinical information is therefore more important than the format used. 

Avoid rejecting referrals on format alone

Equally, services should avoid rejecting referrals solely because a particular form has not been used if the referral itself contains the necessary clinical information. 

Using eRS effectively

eRS is the standard route for consultant-led outpatient referrals and advice requests. Using it well supports clinical decision-making and reduces unnecessary delay.

When creating referrals:

  • include a clear clinical question or reason for referral
  • attach relevant investigation results or documents directly where possible
  • avoid relying solely on copied consultation text where this obscures key details

Some practices find it helpful for the initiating clinician to complete the clinical content directly within eRS to improve clarity.

Timely referral submission is only one part of the process. Delays often occur after a referral is sent.

Practices may wish to ensure they have clear processes for managing inbound eRS worklists:

  • monitor worklists regularly for responses or requests for further information
  • ensure requests are reviewed appropriately and in a timely way
  • consider administrative oversight to reduce delay caused by clinician absence

Where further information is requested, prompt review can help avoid delays for patients.

Expectations should remain proportionate to clinical urgency and workload.

Continuity and delegation

Referrals and advice requests may require follow-up after the initiating clinician is unavailable. Practices may find it helpful to have clear processes for:

  • managing eRS queries during annual leave, sickness or locum working
  • ensuring outstanding requests do not remain unanswered

Shared workflows can support continuity and reduce risk.

Advice and Guidance can support clinical decision-making and may, in some cases, avoid the need for referral.

In general:

  • it is best suited to non-urgent clinical queries
  • urgent concerns should continue to use established urgent pathways or direct specialist routes

Advice and Guidance should support clinical care. It should not delay necessary referral where specialist assessment is clearly required.

Further guidance on the use of A&G and evolving contractual expectations is published separately on the SSLMC website. 

Referrals from multidisciplinary teams 

In many practices, referrals may be initiated by clinicians from a range of professional backgrounds. 

Practices should ensure appropriate clinical supervision and governance arrangements are in place for non-medical referrers. 

This helps ensure referrals are clinically appropriate and provides reassurance to secondary care teams who may not be familiar with individual clinicians’ experience.

Communication and patient visibility

Communications within eRS may be visible to patients via the NHS App. Language should therefore be clear, professional and appropriate for patient viewing.

Advice requests, referrals and responses should be recorded within the patient record in line with good record-keeping practice. Practices should use judgement when considering patient access to potentially sensitive information.

Working across the primary–secondary care interface 

Improving referrals is part of a broader effort to strengthen collaboration across the primary–secondary care interface.

National work led by the Getting It Right First Time (GIRFT) programme highlights the importance of clear communication, agreed pathways and shared understanding between services to improve care and reduce delays.

Referral quality is therefore a shared system responsibility, supported by: 

  • clear pathways 
  • accessible diagnostics 
  • timely specialist advice 
  • good communication between clinicians 

Further information

Useful national guidance includes: 

Practices should also refer to local clinical pathways and referral guidance where available.