Referral letters: A guide to making non-urgent referrals

As a GP registrar learning to make referrals is challenging. How do we decide who to refer to and what do we say in the referral letter? It is useful to break down the process of referral into a three-point checklist: priority, purpose and person.

Priority
When the patient's condition is stable, waiting for an appointment is unlikely to cause the patient harm. When composing the referral letter, it is important to mark clearly that the referral is non-urgent.

It is important to inform the patient of the category of the referral and how long they can expect to wait for an appointment.

It is good practice to let the patient know which department they have been referred to and to ask them to let the practice know if they have not received an appointment within an agreed amount of time.

The patient should also be encouraged to contact you if their condition changes or symptoms become troublesome so that the category of referral can be changed if necessary.

Purpose
The purpose of the referral should be outlined in a clear and succinct letter to the clinician or speciality involved. Normally, letters are dictated and then typed.

Before sending the tape to the secretaries, make sure that your voice can be heard and speak slowly, adding punctuation and paragraphs where necessary. When dictating a letter, make sure that you have the right patient and state their name, date of birth and address clearly at the top of the letter.

It is helpful to start the text with a sentence describing the patient's complaint, for example: 'Dear Dr X, I wonder if you would be able to see this 28-year-old lady with right upper quadrant pain.'

Follow this opening with the history of the presenting complaint, for example: 'She has had this for three months and over the past month has had symptoms every day.'

In the next few sentences, detail the history and, in particular for a non-urgent referral, list the components in the history that make a serious cause less likely: 'There has been no weight loss or loss of appetite.' This is good defensive medicine and also helps prioritise the referral correctly.

Referral letters should always include a section about prescribed drugs that the patient is taking and any known allergies. A concise history of serious conditions, operations and chronic illnesses should also be included, as well as social history, with reference to the effect that the condition is having on the patient's life. Family history should be mentioned if relevant.

It is imperative to detail the investigations you have already done and the results.

Attach blood test results and radiology reports to the letter. If the patient has attended the outpatient clinic before, you may want to provide copies of previous clinic letters in case the hospital notes are not immediately to hand.

Finally it is essential to show what you want the clinician receiving the referral to do, for example: 'I think X has this condition. I would be grateful if you could see her and give your opinion.' Or if you want to be more specific: 'This patient has right upper quadrant pain and an ultrasound report that suggests gallstones. I wonder if you think she would be suitable for a cholecystectomy.'

It is good practice to detail in the letter what the patient has been told about the referral, and to provide the patient with a copy.

Person
It is difficult initially to work out who provides referral services for patients and how these are accessed. Many other health professionals take referrals. Urological investigations, such as flow rates, for example, may be performed by a urology specialist nurse. Allied professionals often have shorter waiting lists, and some areas now have NHS treatment centres to reduce waiting lists.

In England, the Choose and Book system is changing the approach to referrals. I would suggest that you first discuss the options for referral with the patient. Are they happy to go to any hospital for their appointment or would they like to go to a specific one? Consider referring to professionals other than doctors, and consider using private providers, such as treatment centres. If a patient wants to see a particular consultant or has seen a particular consultant before, liaise with the consultant's secretary and send a referral letter directly to them.