Development of referral pathway standard operating procedure

RefHelp - NHS Ayrshire and Arran
NHS Ayrshire and Arran

This SOP (also available in PDF format) outlines the step-by-step process for developing referral pathways. The aim is to ensure a standardised, collaborative, and efficient method for creating, reviewing, and approving pathways that meet clinical and governance standards.

NHS Ayrshire and Arran Acute Services Planned Care have been commissioned by the Medical Director to develop a referral pathway portal using Right Decisions as a host platform.

What is a referral pathway? 

‘A referral pathway provides guidance to a clinician to aid decision making on if and when to refer a patient to another service for treatment and management of their condition’

Quick link to RefHelp on Right Decisions content template

Process:-

Initial review of existing referral pathways

  1. Identify the referral pathway requiring development or update.
  2. Collect relevant referral pathway from other Boards or established sources.
  3. Analyse the existing referral pathways to determine:
    • their applicability to NHSAA settings.
    • key elements to retain or adapt.
    • gaps or inconsistencies needing resolution.
  4. Document findings and recommendations for the pathway’s structure.

Content transfer and template application

  1. Use the Right Decisions Referral Pathway Template as the standardised format.
  2. Populate the template with content:
    • Adapt and transfer relevant information from existing referral pathways.
    • Create new content where gaps exist, ensuring consistency and clarity, citing sources of evidence where applicable.
    • Obtain copyright permissions where required for copyrighted material included (Ask for help from  aa.RightDecisions@aact.scot.nhs.uk if unsure)
  3. Ensure content complies with NHSAA clinical policies and priorities.

Collaboration with Primary Care colleagues

  1. Share the draft pathway with identified primary care colleagues for input.
  2. Incorporate feedback to ensure practical relevance and usability in primary care settings.
  3. Maintain a record of all feedback and responses.

Identification of a Clinical Lead and review timescale

  1. Assign a Clinical Lead for each pathway to:
    • validate clinical accuracy.
    • coordinate feedback and updates.
    • endorse the pathway before submission.
  2. Determine and document an appropriate review timescale based on:
    • clinical urgency.
    • expected changes in guidelines or practices.
    • historical data or prior review intervals.

Inclusion of medication

  1. Where medications are included in the referral pathway review must be made by appropriate pharmacist.
  2. Where possible provide a link to the local formulary or BNF. This ensures the information is up to date.

Submission to Clinical Governance Group

  1. Present the completed pathway draft to the relevant Clinical Governance Group (e.g. Surgical, Medical, Women & Children), if not already passed by Governance.
  2. Ensure group members review and provide feedback.
  3. Address all feedback and document changes made.

Submission to AARefHelp Steering Group

  1. Submit the revised pathway to aa.RightDecisions@aapct.scot.nhs.uk The document will be passed on to the next AARefHelp Steering Group meeting for final review and sign-off.
  2. Record any additional amendments requested by the Steering Group and ensure completion.
  3. Obtain documented approval from the Steering Group.

Submission for upload

  1. Complete the Right Decisions Referral Pathway Template, ensuring all relevant sections are completed. Email completed document to aa.RightDecisions@aapct.scot.nhs.uk.
  2. Library & Knowledge Services staff inform clinical lead when the pathway has been published to RDS.
  3. Confirm the pathway’s accuracy and accessibility on the RefHelp platform.
  4. Communicate the pathway’s publication to relevant stakeholders. Library & Knowledge Services staff will publicise on eNews and Daily Digest.

Monitoring and updates

  • Clinical Leads must ensure pathways are reviewed as per the documented timescale.
  • Updates to pathways must follow the same process outlined in this SOP to ensure consistency and quality.

Records and documentation

  • Maintain all versions of the pathway and feedback records for audit purposes.
  • Ensure all approvals are documented and stored securely.

Responsibilities

  • Clinical Leads: Provide expert input and oversee clinical accuracy.
  • Primary Care Colleagues: Participate in content development and provide practical insights.
  • Clinical Governance Groups: Ensure the pathway aligns with clinical standards.
  • RefHelp Steering Group: Provide final approval for implementation.
  • Library & Knowledge Services staff: Manage uploading and publication of the approved pathway.

Editorial Information

Last reviewed: 28/02/2025

Next review date: 28/02/2028

Author(s): Kerr A.

Version: v0.3

Approved By: RefHelp Steering Group

Reviewer name(s): aa.RightDecisions@aapct.scot.nhs.uk.