Introduction
Learning how to make an effective referral nhs is arguably one of the most high-stakes, high-frequency skills you will master as a junior doctor. This single task sits at the crossroads of clinical acumen, communication, and professionalism. When done well, it is a seamless handover of care that ensures patient safety. When done poorly, it can lead to clinical errors, delays in treatment, and significant patient harm.
For UKMLA candidates, this is not just a theoretical exercise. The referral process is a common theme in both the AKT (testing your clinical reasoning) and the CPSA (assessing your communication and professionalism in a simulated station). This comprehensive 7-step guide provides a robust, repeatable framework to ensure every referral you make—both in your exams and on the wards—is safe, professional, and effective.
Key Takeaways
Referral is a Process: An effective referral is not just a letter; it’s a multi-step process that begins with patient assessment and ends with “closing the loop.”
Safety First: Your primary duty is to assess and stabilise the patient before initiating a referral. You cannot safely refer an unstable patient without first managing their immediate needs.
Clarity is King: The single most important part of any referral is a clear “clinical question.” The receiving team must understand exactly what you are asking them to do and why.
SBAR is Mandatory: The SBAR framework is the gold standard for all urgent verbal handovers. It is non-negotiable for safe practice.
CPSA Scripts are Key: Knowing what to say in a high-pressure phone call or when facing a rejection is a testable skill. We provide scripts for both.
Escalate, Don’t Abdicate: If your referral is rejected and you still have concerns for patient safety, you have a professional duty to escalate to your senior.
The 7-Step Framework for Effective NHS Referrals
This framework provides a robust, repeatable process for every referral.
Step 1: The Pre-Referral Decision (Assess, Justify, and Stabilise)
Before you pick up the phone, your first action is to think. A referral is a request for another clinician to use their resources and expertise. You must ensure this request is appropriate, justified, and, most importantly, safe.
Is this Referral Necessary? Ask yourself: “Have I done everything I can for this patient within my own competence?” Have you taken a full history, performed a thorough examination, and reviewed the initial investigations?
Identifying Urgency: You must correctly identify the urgency. This will dictate the entire referral pathway—whether it’s a verbal-plus-written referral or a simple electronic letter.
Table 1: Referral Urgency Levels Explained
| Referral Type | Timeframe | Action Required | Example |
|---|---|---|---|
| Emergency (Crash Call) | Immediate | Dial 2222. Requires immediate, life-saving intervention. | Patient in cardiac arrest. Anaphylaxis. |
| Urgent (Hot Referral) | Within 0-4 hours | Verbal (SBAR) + Written. Needs same-day assessment/intervention. | Acute appendicitis. Septic patient. Acutely ischaemic limb. |
| Routine (Cold Referral) | Days to Weeks | Written letter only (e.g., e-RS). For outpatient assessment. | Chronic joint pain for orthopaedics. Stable skin lesion for dermatology. |
Your Duty of Care: This is a critical safety point. You cannot refer an unstable patient without initiating management. Always apply an A-B-C-D-E approach. You are referring for specialist input, not abdicating your own responsibility.
Step 2: Gathering Your Information (The “Casefile”)
You cannot make a good referral without good data. Have all relevant information at your fingertips.
Patient Demographics: Full Name, Date of Birth, NHS Number, Location (e.g., “Ward 12, Bed 4”).
Key Observations: Most recent NEWS2 score. Are they febrile? In pain?
Key Results: “FBC shows a white count of 18. The CRP is 220, and the venous lactate is 3.1.”
Key History & Meds: “He is an insulin-dependent diabetic on Apixaban. Allergies: Penicillin.”
Key Interventions: “We have given 1L of Hartmann’s and the first dose of IV co-amoxiclav.”
Step 3: Identifying the Correct Specialty, Team, and Pathway
Referring to the wrong team is a common mistake that delays patient care.
Using Local Guidelines: Every NHS Trust has its own intranet with specific referral pathways. Before you bleep, check the intranet “On-Call” page.
Seeking Senior Advice: You will encounter patients who don’t fit neatly into a box (e.g., an elderly patient with a fall, delirium, and an AKI). Do not guess. Escalate to your senior (Registrar or Consultant). A quick, “I’m not sure who this referral is for, can I run the case by you?” is a sign of a safe doctor.
Step 4: The Verbal Handover (Mastering the SBAR)
For any urgent referral, a verbal handover is mandatory. It is a formal transfer of responsibility, and SBAR is the gold-standard script. This structured communication is central to learning how to make an effective referral nhs.
What to Say: The Perfect SBAR Verbal Referral
(Before you speak): “Hi, is this the [e.g., surgical registrar]?” (Wait for confirmation). “Is now an okay time to discuss a referral?”
S (Situation): “My name is [Your Name], I’m the [FY1] on [Ward]. I’m calling to make an urgent referral for [Patient Name, DOB, NHS Number] in [Location]. The primary problem is [e.g., an acute abdomen with suspected appendicitis].”
B (Background): “He was admitted with [complaint]. His relevant history is [e.g., T2DM]. So far, we have [intervention, e.g., given IV fluids and co-amoxiclav].”
A (Assessment): “My assessment is that he has a surgical abdomen. His observations are unstable [e.g., Tachycardic at 110, BP 100/60, NEWS2 of 6]. His key results are [e.g., WCC 18, CRP 220, Lactate 3.1]. He is tender with guarding in the right iliac fossa.”
R (Recommendation): “My recommendation is that he needs an urgent surgical review. The clinical question is: could you please come and assess this patient for a likely appendicitis? I am concerned he is septic and may need theatre.”
This is a core CPSA skill. For more, read our expert guide on how to manage a phone consultation and our guide on CPSA communication skills for IMGs.
Step 5: Writing the Letter: The Core of an Effective Referral
The written referral is a medical-legal document and a key part of how to make an effective referral nhs. It must be clear and concise, even if you have already done a verbal handover.
Table 2: Anatomy of a High-Quality Referral Letter
| Section | Purpose | Gold-Standard Example |
|---|---|---|
| Patient & Referrer Details | Who and where. | Patient: Name, DOB, NHS No., Location. Referrer: Your Name, Grade, Bleep, Consultant. |
| The “Ask” (Clinical Question) | State your reason for referral at the *top*. | “Dear [Specialty] team, thank you for seeing this [Age]-year-old [Man/Woman] for assessment of…” |
| Clinical Synopsis | The story: relevant history, exam findings, and investigation results. | “Presented with… On examination… Key results include… We have commenced…” |
| Past Medical History | Bulleted list of *relevant* history. | – IHD (Stents 2019) – T2DM – On Apixaban for AF |
| Allergies & Key Medications | A non-negotiable safety step. | Allergies: Penicillin (Anaphylaxis) Medications: List key ones (e.g., anticoagulants, insulin, steroids). |
| Final “Ask” and Urgency | Reiterate the plan. | “I would be grateful for your urgent review. I have discussed this with [Name/Grade].” |
Quick Checklist: Referral Letter Dos and Don’ts
✓ Do: State the clinical question clearly at the start.
✓ Do: Include the patient’s location, your name, and your bleep number.
✓ Do: List all allergies and key medications like anticoagulants.
✓ Do: Use bullet points for history and medications.
✗ Don’t: Write a long, chronological essay.
✗ Don’t: Use accusatory or demanding language (“Please sort this patient”).
✗ Don’t: Forget to state the urgency (e.g., “for urgent review today”).
Step 6: Upholding GMC Standards and Clinical Governance
Your referral is a professional and ethical action, governed by the GMC Good Medical Practice guidance.
“You must contribute to the safe transfer of patients between healthcare providers or settings… You must share all relevant information with colleagues in a timely way…”
— GMC, Good Medical Practice
Patient Consent: You must inform the patient: “To get you the best care, I need to speak to the [surgical] team and ask them to come and see you. Is that okay with you?” Document this consent.
Safety Netting: This is a classic UKMLA ethical dilemma and a common CPSA scenario. If you genuinely believe the patient is at risk, you must not simply accept a rejection.
What to Say: Handling a Rejected Referral (CPSA Script)
You: “Thank you for your advice. Can I just clarify my main concern? I have a patient with a lactate of 3.1 and guarding on examination. I remain very concerned that he has a surgical abdomen and is at risk of deteriorating.”
(If they still reject):
You: “I understand your reasoning, but given my clinical concern, I don’t feel it is safe to wait. I am going to escalate this to my registrar, as I feel the patient needs a senior review for safety.”
(Then, immediately escalate):
You (to your senior): “Hi, I’m the FY1 on Ward X. I’ve just referred a patient with a suspected surgical abdomen to the surgical registrar, who has declined to see him. I am still very concerned for the patient’s safety. Could you please give me some advice or speak with them?”
Step 7: Closing the Loop (The Post-Referral Actions)
The referral is not “done” until the handover is complete. This final step is what separates an adequate referral from a truly safe one, completing the process of how to make an effective referral nhs.
Document Everything: “If it’s not written down, it didn’t happen.” After your verbal handover, write a clear entry in the patient’s notes:
Who: “Spoke to [Name], [Grade, e.g., Surgical Registrar].”
When: “[Date] and [Time].”
What: “Discussed via SBAR. Agreed for urgent surgical review.”
Plan: “[Plan, e.g., Team to review within 2 hours. Keep NBM.]”
Inform the Team: Inform the patient, the nurse in charge, and (for outpatient referrals) the GP.
Check Receipt: Ensure the electronic referral is sent and received. For guidance, see the NHS Digital referrer best practice guidelines.
Putting It Into Practice: 2 UKMLA-Style Clinical Scenarios
Scenario 1: The Urgent Surgical Referral
Vignette: A 22-year-old man presents to A&E. He has a 1-day history of peri-umbilical pain that has moved to the right iliac fossa. He is febrile (38.1°C), tachycardic (110 bpm), and has guarding in the RIF. Bloods show WCC of 16.
Applying the Framework:
Decision: Necessary and urgent. The patient is septic with a surgical abdomen.
Gather: You have obs, bloods, and a clear history.
Identify: This is a classic General Surgery referral.
Verbal Handover: You use the SBAR script to call the on-call surgical registrar.
Write Letter: You write a concise letter with the “ask”: “Please review for assessment and management of likely acute appendicitis.”
GMC: You inform the patient, “I’ve spoken to the surgeons, they’re coming to see you.”
Close Loop: You document the SBAR call and plan (“NBM, continue IV fluids, for surgical review”) in the notes.
Scenario 2: The Unclear Medical Referral
Vignette: An 84-year-old woman is admitted after a fall. She is now off her feet, confused, and her bloods show a new AKI stage 2 (creatinine 210, baseline 95). Her medication list is long.
Applying the Framework:
Decision: Necessary and urgent. She needs specialist input.
Gather: You have obs, bloods (U&Es), medication list, and collateral history.
Identify: This is the hard part. Is it for Geriatrics (falls, delirium) or Renal (AKI)? Do not guess. The safest action is to escalate to your own senior.
Verbal Handover: You bleep your medical registrar. “Hi, I have an 84-year-old with a fall, delirium, and AKI 2. I am not sure if this is more appropriate for Geriatrics or Renal. Could you advise?”
Write Letter: Your senior advises a referral to Geriatrics. Your letter reflects this: “Thank you for reviewing this patient for management of fall, delirium, and AKI.”
GMC: You handle the referral professionally, demonstrating an understanding of your limits and prioritising a safe pathway.
Close Loop: You document the discussion with your registrar and the subsequent referral to Geriatrics.
Your Turn: A Self-Assessment Exercise
Scenario: You are the FY1 on call. You are bleeped to review a 68-year-old man with acute central crushing chest pain. His obs are stable (BP 140/80, HR 85, Sats 98%). His ECG, however, shows 3mm ST elevation in leads V2-V5.
Your Task:
What is your single most urgent action?
Write down the A (Assessment) and R (Recommendation) components of your SBAR call to the on-call Cardiology registrar.
What is your one-sentence “Clinical Question” for the written referral?
Model Answer
Urgent Action: Call 2222 and activate the hospital’s “STEMI pathway” (or equivalent) for an emergency cardiology review.
SBAR Components:
A (Assessment): “My assessment is that this patient is having an acute anterior ST-elevation myocardial infarction (STEMI).”
R (Recommendation): “My recommendation is that he needs emergency review for consideration of primary PCI. The STEMI call has been activated. I have given Aspirin 300mg.”
Clinical Question: “Dear Cardiology, thank you for your emergency review of this 68-year-old man with an acute anterior STEMI, for primary PCI.”
Frequently Asked Questions (FAQ) about how to make an effective referral nhs
The biggest mistake is a lack of clarity, specifically not stating the “clinical question.” A referral letter that is just a jumble of history and results without a clear “ask” (e.g., “please assess for theatre,” “please advise on management”) forces the receiving team to do detective work, which wastes time and can lead to the wrong outcome. Always state your request clearly at the top. In a CPSA station, this is a primary failure point.
This is a common real-world problem. Do not guess and refer to the wrong team. Your safest and most professional action is to escalate to a senior colleague—either your ward Registrar or the ward Sister/Charge Nurse, who often have a wealth of practical knowledge about local pathways. From an examiner’s perspective, this demonstrates safety-conscious practice and an understanding of your own limitations.
It’s challenging, but your priority must remain the patient. Do not get into an argument. Remain calm, professional, and stick to your SBAR script. Use the “What to Say: Handling a Rejected Referral” script. If they are still rejecting and you are concerned, escalate to your own senior. The Examiner’s Perspective is that they want to see you handle professional conflict without compromising patient safety.
A referral is not a full medical clerking. The key is relevance. For example, a detailed social history is vital for a safeguarding referral but irrelevant for an acute appendicitis. A good rule of thumb is to ask, “Does this piece of information change the urgency, diagnosis, or management plan for the receiving specialty?” If not, leave it out. Bullet points are your best friend.
This is a test of your understanding of mental capacity and consent. First, you must assess why they are refusing. Do they have a misunderstanding you can correct? Are they in pain or delirious? If the patient has capacity and is making an informed decision, you must respect their autonomy. Your actions would be to clearly explain the risks of refusal (and document this), offer alternatives, and ensure they know how to seek help if they change their mind.
Yes, absolutely—if the referral is urgent. The e-RS is the mechanism for the letter, but it does not replace the verbal handover for urgent/emergency cases. An urgent e-referral sent without a phone call is clinically unsafe as no one may see it for hours. For routine, “cold” referrals (e.g., to an outpatient clinic), a verbal call is not needed, and the e-referral is sufficient.
Your responsibility does not end until you have spoken to someone and handed over care. Try all alternative options: call the hospital switchboard, bleep the on-call consultant for that specialty, or call the main department (e.g., the surgical ward) and ask for the registrar. As a last resort, escalate to your own registrar, who will have other ways of contacting them.
This is common for specialist services (e.g., neurosurgery, plastics). The process is the same, but you must confirm the referral/acceptance before booking transport. You will usually speak to the registrar at the specialist hospital, get their name, and they will agree to accept the patient. You must never send a patient in an ambulance to another hospital without a named accepting consultant and team.
This is about clarifying your “ask.” A “consultation” or “review” is a request for an opinion and a management plan, but the patient remains under your (e.g., the medical) team’s care. Referring for “admission” or “transfer of care” means you are asking for the specialty team to formally take over as the patient’s primary doctors. Be clear about which one you are requesting.
You must correct it. Do not wait for the other team to find it. Call them back and clearly state, “I am calling back about Mr. Smith, who I referred 10 minutes ago. I apologise, but I forgot to mention a critical piece of information: he is on Warfarin.” This honesty demonstrates professionalism and a commitment to patient safety. An examiner would reward this insight and proactive correction.
Conclusion
Mastering the referral process is not just an academic exercise for the UKMLA; it is a fundamental pillar of “Readiness for Safe Practice” as defined by the GMC. Thinking of a referral as a 7-step procedural skill—just like taking blood or suturing—will give you the structure and confidence to do it well every time. This is not paperwork; it is a formal, high-stakes transfer of care.
By following this framework, you move beyond just “sending a referral” and embrace the professional duty of ensuring a safe and effective handover. This protects your patients, supports your colleagues, and demonstrates your competence as a future Foundation Year 1 doctor.
Your Next Steps
Practice the Scripts: Role-play the “SBAR” and “Handling Rejection” scripts with a colleague. Saying them out loud build’s confidence.
Apply the Framework: The next time you are on the ward, shadow a referral. Mentally run through these 7 steps.
Prepare for the Real World: A core part of your FY1 year will be handling referrals while holding the on-call bleep. To understand what that’s like, read our essential guide on navigating your first on-call shift as an FY1.
