Understanding NHS Referrals: Complete Guide & System‑Wise Cheat‑Sheet for PLAB 2

Practice a case with the AI patient 🤖

In the NHS, patient care usually begins with the General Practitioner (GP)—the first point of contact for any health concern. Based on the severity and urgency of the condition, the GP decides whether to manage the case or refer to a specialist.

⚡️ Four Urgency Levels

Type	Target Time	Typical Use
Immediate (Emergency)	Same day (often 999 / ambulance)	Life‑, limb‑ or vision‑threatening situations
Very Urgent	Within 24–48 h	Rapid assessment needed to prevent permanent harmIncludes ALL suspected cancers in children & young adults (0–24 y)
Urgent (2‑Week‑Wait)	≤14 days	Suspected cancers & other critical adult pathologies
Routine	≤18 weeks	Problems with no red flags

🧷 Safety‑net every patient: “If you worsen, new symptoms appear, or you don’t hear from us by the expected time, phone the surgery, 111, or go to A&E.”

🔄 Services You Can Self‑Refer To

Service	What For
A&E / 999	Any life‑threatening emergency
Sexual‑Health / GUM	STIs, contraception, HIV tests (walk‑in / online)
NHS Talking Therapies (IAPT)	Anxiety, depression, stress
Physiotherapy (MSK)	Back, neck, muscle‑joint pain (many areas)
Midwifery	Book your own antenatal care
Podiatry	Diabetic / high‑risk feet (Trust‑dependent)
Stop‑Smoking / Addiction	Walk‑in or phone refer
Abortion clinics	Any abortion before 24 weeks of GA

🗂️ System‑Wise Referral Matrix

👁️ Eye

• Immediate — closed‑angle glaucoma • GCA • keratitis • scleritis • retinal detachment • optic neuritis

• Very Urgent (24–48 h) — wet ARMD • ocular toxoplasmosis

• Urgent (2 ww) — bi‑temporal hemianopia

• Routine — open‑angle glaucoma • cataract • diabetic retinopathy (severity‑based)

👂 ENT

• Immediate — sudden idiopathic hearing loss • malignant otitis externa

• Urgent (2 ww) — acoustic neuroma • cholesteatoma • unilateral tinnitus • unilateral nasal polyp

• Routine — Ménière’s • chronic suppurative OM (stable) • wax resistant to drops • recurrent epistaxis (med‑review) • bilateral nasal polyps

🩸 Anaemia / Fatigue / Confusion

• Immediate — severe hyponatraemia • myeloma with hyper‑Ca²⁺ • MALA • Addisonian crisis • BPH with retention • lithium toxicity

• Very Urgent (24–48 h) — symptomatic leukaemia • any suspected cancer in child/young adult (0‑24 y)

• Urgent (2 ww) — asymptomatic leukaemia (abnormal FBC) • suspected adult colorectal cancer

• Routine — chronic fatigue syndrome • OSA

🤕 Headache / Neuro Red‑Flags

• Immediate — SAH • raised ICP • CO poisoning • GCA

❤️ Cardiovascular

• Immediate — MI • unstable angina • acute heart failure

• Urgent (2 ww) — stable angina

• Routine — palpitations (no red flags) • chronic heart failure

🫁 Chest / Respiratory

• Immediate — PE • severe pneumonia/PCP/Legionella • acute asthma/COPD • active TB

• Urgent (2 ww) — suspected lung cancer • mesothelioma

🧴 Dermatology

• Immediate — severe, systemically‑unwell cellulitis

• Urgent (2 ww) — melanoma • squamous cell carcinoma • high‑risk or aggressive BCC (face, ears, lips, peri‑orbital, immunosuppressed, relapse, >20 mm, morphoeic) • red‑flag seb‑keratosis • genital herpes/warts • vulvar cancer • syphilis

• Routine — low‑risk BCC (small, nodular, trunk/limb) • other benign skin problems without red flags

🦴 Rheumatology / MSK

• Immediate — septic arthritis • cauda equina • acute large‑vessel vasculitis with ischaemia (e.g., aortic dissection, critical limb)

• Very Urgent (24–48 h) — new‑onset rheumatoid arthritis (<3 days) • osteosarcoma (<48 h) in child/young adult (0‑24 y) • suspected giant cell arteritis without visual loss • systemic lupus flare with nephritis

• Urgent (2 ww) — suspected bone/soft‑tissue sarcoma (if not already immediate)

• Routine — ankylosing spondylitis • chronic gout • stable PMR (no visual symptoms)

🧠 Neurology

• Immediate — Guillain–Barré • encephalitis • meningitis • TIA

• Urgent (2 ww) — first seizure • Parkinson’s disease

🍬 Endocrinology / Diabetes

• Immediate — DKA • severe hypoglycaemia • hyper‑Ca²⁺ due to hyper‑parathyroidism

• Routine — hyperthyroidism (stable)

🍽️ Gastro / Acute Abdomen

• Immediate — appendicitis • acute liver decomp • bowel obstruction • cholecystitis / cholangitis • pancreatitis • ectopic pregnancy • acute PID • perforated PUD • red‑flag diarrhoea • malaria

🧒 Paediatrics

• Immediate — intussusception • sick infant (SOB, lethargy, dehydration) • button‑battery ingestion • acute asthma

• Very Urgent (24–48 h) — any suspected cancer

• Routine — ADHD • autism assessment

🍒 Urology / Testicular

• Immediate — testicular torsion • ureteric stone • pyelonephritis

• Urgent (2 ww) — bladder / prostate / testicular cancer • epididymo‑orchitis → GUM

• Routine — epididymal cyst • hydrocele

👩‍⚕️ Obstetrics & Gynaecology

• Immediate — pre‑eclampsia • refractory hyperemesis • postpartum sepsis • toxic shock (retained tampon)

• Urgent (2 ww) — post‑menopausal bleeding

• Routine — PCOS • fibroid • endometriosis • uterine prolapse • ovarian insufficiency • hypertension in pregnancy (on ACE‑i)

🌸 STIs / Sexual Health

• All STIs — self‑refer to walk‑in GUM clinic

🧠 Psychiatry

• Immediate — acute psychosis • severe suicidal depression

🔪 Surgery / Lumps

• Urgent (2 ww) — suspected breast cancer • suspicious neck lump (laryngeal / nasopharyngeal Ca, lymphoma)

• Routine — fibroadenoma • duct‑ectasia nipple discharge

🛡️ Standard Safety‑Netting Phrases

Urgency	What to Say
Immediate	“We’re organising emergency care right now. If anything changes on the way, call 999 or go straight to A&E.”
Very Urgent	“You’ll be seen within 24–48 h. If you don’t hear from the clinic, or symptoms worsen, contact us, 111, or A&E.”
Urgent (2 ww)	“An appointment should reach you in ≤14 days. If nothing arrives in 10 days, or you deteriorate, call us or attend A&E.”
Routine	“You should be seen within 18 weeks. Tell us if you haven’t heard, or if anything changes.”

🎓 Exam Nuggets (PLAB 2 / OSCE)

1. Match urgency to harm.

2. All suspected cancers in 0‑24 y = Very Urgent (seen <48 h).

3. Safety‑net EVERY patient.