Recommendations from NICE should benefit those patients who need to be referred and those who do not, says Dr Chris Barclay

I recently overheard a conversation: "My doctor is wonderful. The moment he suspects there is anything wrong he refers you straight to hospital." Although this may please some, in reality it is not good enough. Referring every patient delays treatment, clogs clinics and obstructs access for those in real need.

But when should we refer onward for specialist assistance? The National Institute for Clinical Excellence has published referrals advice covering 11 common clinical situations in general practice (see Box 1, bottom).1

The introduction to each section describes the condition briefly but comprehensively, and is followed by explanations of the roles of both primary care and specialist services. Useful guidance on the indications for referral follows and each is rated for its degree of urgency: a four-star rating should be attended to immediately; three stars within 2 weeks; two stars soon; and one star merits a routine appointment.

For example, in the under 15-year-old presenting with a sore throat, the presence of quinsy or signs of respiratory obstruction are graded as four star, indicating that immediate referral is appropriate. The presence of sleep apnoea or daytime somnolence in such a patient merits two stars. For menorrhagia, no four-star situations are given, but the suspicion of underlying cancer merits three stars.

It is reassuring to have considered and accessible guidance for common clinical conditions for which accumulated therapeutic folklore may be outdated or inadequate.

It is useful to have a nationally agreed definition of best practice. For example, how quickly patients with chronic urinary retention and overflow should be seen.

The star rating system provides me with some leverage when referring patients, either to request 'soon' or 'urgent' treatment or, conversely, to tell a patient with osteoarthritis of the hip that in the absence of sepsis or severe rapid deterioration a routine appointment is appropriate.

Finally, the framework in which the guidance is set is ideal for implementing audit. In fact, NICE encourages it and suggests in a separate section how to carry out audit and which audits you may wish perform.

The advice document states that referral times may need to be 'modified because of local circumstances' and its adoption 'should take place within the context of local strategies for achieving outpatient waiting times'. I am looking forward to discussing and implementing these guidelines with my primary care and consultant colleagues.

The advice should decrease the number of referrals from primary care to specialist services while increasing their quality. It should also improve our management of those patients who are not referred.

Box 1: Conditions covered by NICE referral advice
  • Acne vulgaris
  • Acute low back pain
  • Atopic eczema in children
  • Menorrhagia
  • Osteoarthritis of the hip
  • Osteoarthritis of the knee
  • Glue ear
  • Psoriasis
  • Recurrent sore throat in the under-15s
  • Urinary outflow obstruction in men (prostatism)
  • Varicose veins


  1. Referrals Advice: A Guide to Appropriate Referral from General to Specialist Services. London; NICE, December 2001, can be downloaded from the NICE website:

Guidelines in Practice, February 2002, Volume 5(2)
© 2002 MGP Ltd
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