Standard operating procedure

Referral Management Procedure

The step-by-step procedure for making, sending, tracking and safety-netting routine, urgent and urgent suspected cancer (two-week-wait) referrals through the electronic referral service at [Organisation Name].

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  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Procedure
  • 6. Records
  • 7. Audit
  • 8. Related documents
  • 9. Review and version control
  • 10. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance)
  • Care Quality Commission (Registration) Regulations 2009 - Regulation 18 (Notification of other incidents)
  • National Institute for Health and Care Excellence, Suspected cancer: recognition and referral (NICE guideline NG12, 2015, updated)
  • Data Protection Act 2018 and the UK General Data Protection Regulation
  • General Medical Council, Good medical practice (2024)
  • The national electronic referral service (e-Referral Service / e-RS): national operating standards and guidance

Who it applies to

All GP partners, salaried and locum GPs, advanced nurse and pharmacist practitioners and other referring clinicians, together with the referrals coordinator, secretarial, administrative and reception staff at [Organisation Name] who make, process, send, track or action referrals on behalf of patients.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Appointment Slot Issue (ASI)
A referral that could not be booked straight away because no suitable appointment slot was available, so the receiving service has to deal with it.
Blood-borne virus (BBV)
An infection such as hepatitis B, hepatitis C or HIV that can be passed on through blood.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Data Protection Act 2018
The UK law that sets the rules for collecting, storing and using people's personal information.
Did not attend (DNA)
When a patient does not turn up for a booked appointment and did not cancel beforehand.
Direct-access investigation
A test, such as a scan or endoscopy, that a GP can order directly without first referring the patient to a specialist.
Duty of candour
The legal duty to be open and honest with a person and their family when something goes wrong with their care.
e-Referral Service (e-RS)
The national electronic system used to refer patients from general practice to hospital and other services and to book or change their appointments.
Failsafe
A backup check that makes sure an urgent referral is not missed, by confirming it has been received, accepted and booked.
Faster Diagnosis Standard (FDS)
The national standard that people referred urgently with suspected cancer should have cancer confirmed or ruled out within a set number of days.
General Medical Council (GMC)
The body that registers doctors in the UK and sets the standards they must follow.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards of safety and quality that care providers must meet, enforced by the Care Quality Commission.
Informed consent
Agreement to treatment or referral given freely after the risks, benefits and alternatives have been clearly explained.
Integrated Care Board
The local statutory body responsible for planning and arranging health services for its area.
National Institute for Health and Care Excellence (NICE)
The national body that produces evidence-based guidance on treatments and care.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
NICE guideline NG12
National guidance from the National Institute for Health and Care Excellence setting out the symptoms and signs that should prompt an urgent referral for suspected cancer.
Proforma
A standard referral form with set fields that must be completed for a particular service or condition.
Referral to Treatment (RTT)
The pathway and clock that measure how long it takes from a patient being referred to the start of their treatment.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Safety-netting
A clear plan telling the patient what to expect, which symptoms should make them seek help, and what the practice will do if the referral does not progress.
Standard Operating Procedure (SOP)
A written, step-by-step instruction describing how a particular task should be carried out consistently and safely.
Triage
Sorting referrals or patients by clinical priority so that the most urgent are dealt with first.
Two-week-wait (2WW)
An urgent referral for suspected cancer, where the patient should be seen by a specialist within two weeks.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.
Unique Booking Reference Number (UBRN)
The reference number created by the e-Referral Service that identifies a particular referral and lets the patient book their appointment.
Unique patient identifier
The single number used to identify a patient correctly across health services.
Urgent suspected cancer (USC) referral
The current name for a two-week-wait referral, made when a patient's symptoms meet the criteria for suspected cancer.

How it works

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  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

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