How to Redesign a Referral Pathway in the NHS

Why this topic matters

NHS services continually face pressure to manage rising demand with finite resources. Inefficient referral pathways exacerbate these challenges by:

• Increasing waiting lists: Patients often face long waits to be seen in specialist services due to unclear referral criteria, inappropriate referrals, or fragmented processes.
• Duplication of effort: Patients may undergo repeated investigations or consultations as they navigate different services, leading to wasted resources and a poorer patient experience.
• Delayed diagnosis and treatment: Complex or circuitous pathways can delay access to critical interventions, potentially impacting clinical outcomes.
• Staff frustration and burnout: Clinicians at both ends of a pathway (referring and receiving) can become demoralised by inefficient processes, contributing to workload pressure and moral injury.
• Financial inefficiency: Every unnecessary step, delayed decision, or duplicated investigation carries a cost, impacting the financial sustainability of services.

Redesigning referral pathways is not merely an operational task; it's a strategic imperative for delivering higher quality, more sustainable healthcare. It requires multidisciplinary collaboration and a patient-centred perspective to ensure the changes genuinely improve care delivery.

Practical explanation: What does ‘redesign’ entail?

Referral pathway redesign is a structured approach to evaluating, optimising, and implementing changes to how patients are referred from one service or care setting to another. It typically involves:

• Mapping the current state: Understanding the existing pathway, including all steps, decision points, stakeholders, and data flows.
• Identifying pain points and opportunities: Pinpointing where the pathway breaks down, causes delays, or leads to suboptimal outcomes.
• Benchmarking and best practice review: Looking at how other organisations or national guidelines (e.g., NICE) manage similar patient journeys.
• Co-designing a future state: Developing a new, more efficient pathway with input from all key stakeholders, including patients.
• Piloting and implementing changes: Testing the new pathway on a smaller scale before wider rollout.
• Monitoring and evaluating: Continuously assessing the impact of changes against defined metrics.

Key principles guiding pathway redesign include:

• Patient-centred care: The patient's journey and experience should be at the forefront of all decisions.
• Evidence-based practice: Utilising national guidance, clinical evidence, and local data to inform decisions.
• Multidisciplinary collaboration: Engaging primary care, secondary care, allied health professionals, social care, and patient representatives.
• Digital enablement: Exploring how technology can streamline processes, improve communication, and support clinical decision-making.
• Equity: Ensuring the redesigned pathway addresses health inequalities and provides fair access for all patient groups.

Common pitfalls to avoid

Undertaking pathway redesign can be complex. Be mindful of these common challenges:

• Lack of clear scope and objectives: Starting without a defined problem or desired outcome can lead to scope creep and ineffective solutions.
• Insufficient stakeholder engagement: Failing to involve all relevant groups (especially primary care and patients) can lead to resistance and non-adoption.
• "Solutioneering" too early: Jumping straight to solutions (e.g., "we need a new IT system") without fully understanding the root causes of the problem.
• Ignoring data: Relying on anecdote rather than data to identify issues or measure impact.
• Underestimating change management: Not planning for the human side of change, including communication, training, and support.
• Overlooking interdependencies: Changes in one pathway can have unintended consequences on others if not carefully considered.
• Lack of sustained leadership buy-in: Pathway redesign requires consistent support and sponsorship from senior management.
• One-off project mentality: Viewing redesign as a finite project rather than an ongoing process of continuous improvement.

Step-by-step approach to pathway redesign

Step 1: Define the problem and scope

• Identify the specific pathway: Which referral pathway are you focusing on (e.g., suspected lower GI cancer, chronic pain, cardiology outpatient referral)?
• Articulate the problem: What specific issues are you trying to address? (e.g., "average wait time for routine cardiology assessment is 26 weeks, exceeding target," "30% of dermatology referrals are deemed inappropriate by specialists"). Use data to support this.
• Set clear objectives: What are the measurable outcomes you aim to achieve? (e.g., "reduce average wait time by 50%," "decrease inappropriate referrals by 25%").
• Define scope: What are the start and end points of the pathway under review? Which services and patient groups are included/excluded?
• Form a multidisciplinary team: Ensure representation from all key stages of the pathway, including primary care, secondary care specialists, nursing, allied health, operational managers, and ideally, a patient representative.

Step 2: Map the current state

• Visualise the existing pathway: Use flowcharts or swimlane diagrams to map every step, decision point, handover, and information flow. Include patient and carer journeys.
• Collect data: Gather quantitative data (e.g., referral volumes, waiting times, conversion rates, investigation rates, re-referral rates) and qualitative data (e.g., staff and patient interviews, feedback).
• Identify pain points: Where are the bottlenecks, delays, communication failures, and inefficiencies? What are the biggest sources of frustration?
• Review current guidelines and evidence: Compare your current pathway against national guidelines (e.g., NICE, Royal Colleges) and best practice examples.

Step 3: Design the future state

• Brainstorm solutions: Facilitate creative workshops with your multidisciplinary team. Encourage thinking outside the box, challenging assumptions about how things "must" be done.
• Develop clear referral criteria: Standardise criteria for referrals and ensure they are accessible and understood by referring clinicians.
• Optimise communication and information sharing: Explore secure digital platforms, shared care records, or standardised referral templates.
• Consider new models of care: Could virtual clinics, 'Advice & Guidance' services, shared decision-making, or enhanced primary care roles improve the pathway?
• Define key performance indicators (KPIs): What will you measure to track success? (e.g., reduced waiting times, increased appropriate referrals, improved patient satisfaction).
• Create a future state map: Document the proposed new pathway, highlighting changes from the current state.

Step 4: Plan for implementation

• Develop an action plan: Detail who will do what, by when, and with what resources.
• Identify potential barriers and enablers: Proactively address challenges such as IT system limitations, staff resistance, or resource constraints.
• Plan communication and training: How will you inform and train all affected staff (both referring and receiving) on the new pathway?
• Pilot the new pathway: Start with a small-scale pilot if feasible to test the changes, identify unforeseen issues, and refine the process before full rollout.
• Secure necessary approvals: Ensure the redesigned pathway aligns with local governance, clinical safety, and information governance requirements.

Step 5: Implement, monitor, and evaluate

• Roll out the new pathway: Implement the changes systematically.
• Collect data against KPIs: Regularly monitor the defined metrics to assess the impact of the redesign. This is crucial for demonstrating success and identifying areas for further refinement.
• Gather feedback: Continuously collect feedback from patients, staff, and referrers.
• Iterate and refine: Pathway redesign is rarely a 'one and done' process. Be prepared to make adjustments based on monitoring data and feedback.
• Sustain the change: Embed the new pathway into routine practice, updating policies, training, and audits as necessary.

Example in clinical practice: Optimising an MSK referral pathway

Current State: A medium-sized DGH identified long waiting lists for Musculoskeletal (MSK) physiotherapy and orthopaedic clinics. Referrals from GPs often lacked sufficient detail, leading to many inappropriate referrals or first appointments where only triage occurred.

Redesign Intervention:

1. Multi-disciplinary team: Included GPs, MSK physiotherapists, orthopaedic consultants, and a patient representative.
2. Referral triage hub: Established a single point of access where all MSK referrals were triaged by specialist physiotherapists.
3. Enhanced Advice & Guidance: The triage physiotherapists provided direct 'Advice & Guidance' back to GPs for less complex cases, offering management strategies or suggesting alternative community services.
4. Standardised referral form: Developed a mandatory electronic referral form with specific fields for clinical history, examination findings, and red flag screening.
5. Direct booking: Appropriate referrals were directly booked into the most suitable clinic (e.g., physio, orthopaedics, pain clinic) based on triage outcomes.
6. Patient education: Developed resources for GPs to share with patients, explaining different MSK services.

Outcomes:

• Reduced orthopaedic waiting list: Average wait time for a first orthopaedic appointment decreased by 35%.
• Improved appropriateness of referrals: Over 20% of referrals were managed via Advice & Guidance or directed to physiotherapy, avoiding unnecessary consultant appointments.
• Enhanced patient experience: Patients received more timely and appropriate care, often bypassing long waits for specialist assessment when not required.
• Increased staff satisfaction: GPs felt more supported, and specialist teams received higher quality referrals, improving efficiency in clinics.

How Lazomis can help

Lazomis provides robust tools that can support each stage of referral pathway redesign:

• Project Management: Use Lazomis to set up your redesign project, define objectives, assign tasks, and track progress, ensuring accountability across your multidisciplinary team.
• Data Collection & Analysis: Utilise Lazomis's features to systematically collect both quantitative (e.g., waiting times, referral volumes) and qualitative (e.g., staff feedback) data. Our analytics dashboards can help you visualise pain points and track improvements over time.
• Mapping & Documentation: Document your current and future state pathways within Lazomis, creating a clear, shared understanding for all stakeholders.
• Impact Measurement: Lazomis helps you monitor key performance indicators (KPIs) post-implementation, providing clear data to evaluate the success of your redesigned pathway and support continuous improvement cycles.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.

Key takeaways