Musculoskeletal (MSK) referral optimisation.
What referral optimisation actually means
In the National Health Service (NHS), MSK referral optimisation means improving what happens before a referral is made. Patients who need a specialist should reach one at the right time. Patients who do not need one now should get a clear plan instead of a queue.
It is not a term invented by suppliers. NHS England defines referral optimisation as the improvement of system-wide pre-referral pathways. These are the routes patients take before a referral, across a whole local health system. Its aim is that people are seen by the right person, at the right time and in the right place. NHS England's musculoskeletal guidance was developed with the British Orthopaedic Association, Getting It Right First Time (GIRFT) and the Chartered Society of Physiotherapy. Groups that speak for people living with these conditions were also involved. This guidance is the document most MSK services now work to. Musculoskeletal means the joints, muscles, bones and soft tissues, and MSK is the standard NHS abbreviation.
This page explains what the term covers, why referral volume is a poor measure of referral quality, and where MSK clinical decision support fits. It is written for first contact clinicians, for the service and clinical leads who design these pathways, and for the commissioners who fund them.
Why the pre-referral decision carries so much weight
Together, these figures show a system under strain. A lot of specialist time goes on patients who are discharged after one visit. The decision behind all of it is made much earlier, by a clinician working at first contact. They usually have ten or fifteen minutes, and usually work alone.
A referral at the wrong time fails in two directions
Referral optimisation is often read as referral reduction. That reading measures half the problem, and it is the half that is easiest to count.
Over-referral
A patient is sent for a specialist opinion they do not currently need. They join a queue, they wait, and the appointment ends in discharge or in advice that could have been given at the start. The cost is not one appointment. It is the appointment, the follow-up behind it, and the place in the queue taken from somebody whose problem was surgical.
Under-referral and late referral
A patient who would benefit from seeing a specialist soon stays in non-surgical care for longer than they should. Nothing visibly goes wrong, because nothing visibly happens. There is no complaint, no missed waiting time target and no data, so this failure is almost never counted. A service can look as though it is improving while it is happening.
Both failures have the same root. The specialist criteria, and what happened afterwards, are not routinely shared with the clinician who makes the decision. The number of referrals rises and falls for good and bad reasons. On its own, it tells a service almost nothing about whether its referral decisions were right.
The decision has moved to first contact
More and more, referral decisions for musculoskeletal problems are made at the start of the pathway, not at the hospital end. The clinicians making them are first contact practitioners in general practice, and GPs (family doctors). Advanced practice physiotherapists make them too, in community MSK services and in interface services between general practice and hospital.
NHS England says clearly that this is where the expertise sits. It names MSK first contact practitioners, advanced practitioners, consultant practitioners and specialist doctors. These are the clinicians referral optimisation should draw on, working closely with consultant orthopaedic surgeons. Not sure how these roles differ? Our companion page explains what a first contact practitioner is and how the MSK roles and pay bands fit together. Another page explains how MSK triage works and where it happens.
Why referral thresholds are hard to see
The difficulty here is not clinical skill. The clinicians making these decisions are experienced. In most cases they are more expert in musculoskeletal assessment than the doctor the patient would otherwise have seen.
The difficulty is information. A clinician working at first contact does not routinely see the threshold a particular surgical team applies. They do not usually see what the surgeon looked for in the referral letter. They are not usually told which of their own referrals ended in an operation and which were sent back. Nor do they usually see how any of that has changed in the last two years. Surgical criteria change as the evidence changes, and nobody sends round the update. Advice does travel, but informally, by email to a consultant the clinician happens to know. So it reaches the clinicians with the right contacts, not the ones with the most difficult cases.
NHS England makes the same point in its own words. It describes formalising specialist advice, where an informal approach may already exist, as enabling safe and timely access to specialist care.
Specialist advice, before or instead of a referral
The main method NHS England recommends for referral optimisation is specialist advice. This is a broad term for ways of working led by specialists. Some let a clinician ask for a specialist's opinion before, or instead of, making a referral. Others let a specialist review a referral, then send it back with guidance or direct it to the right clinic.
That guidance sets two clear limits, and both are worth repeating. Specialist advice must not delay a referral that is in the patient's best interest. And the rare serious conditions that need emergency or urgent care must never go through specialist advice. They are managed as an emergency or an urgent referral under local pathways. This is supported by guidance on urgent and emergency musculoskeletal conditions from the Arthritis and Musculoskeletal Alliance. Any tool that sits in this part of the pathway has to deal with safety before it deals with anything else.
How decision support can help
Specialist advice depends on a specialist being free to give it. That is why it is patchy and hard to provide. Clinical decision support takes a different route to the same place. Instead of taking the question to the specialist, it shows the clinician the specialist's criteria and reasoning at the moment of decision.
It is also not patient self-triage. Patient self-triage asks the patient to answer questions on their own, usually before or instead of an appointment, and produces advice for the patient. Referral decision support for clinicians sits with the clinician while the patient is in front of them. It supports the decision the clinician is already making, and leaves the clinician responsible for it.
Done well, that means four things are true in the room. The safety questions are asked first, and nothing is suggested until they are answered. The suggestion arrives with its reasons, in plain words, with the evidence each reason rests on. The clinician can disagree, and the disagreement is recorded rather than overruled. And the outcome comes back, so the clinician finds out whether the decision was right.
Done badly, it becomes a way to check up on clinicians and grade them on how often they refer. That is bad practice. It also defeats itself, because clinicians can simply stop using it.
What Orwyn contributes to referral optimisation
Orwyn is surgeon-governed clinical decision support for first contact MSK clinicians. It works from rules written and governed by a named consultant orthopaedic surgeon, Dr Arj Imbuldeniya. It carries his criteria into the room he is not in. Each one is written down, linked to the evidence behind it, and open to disagreement.
It is designed to make formal something that already happens informally and unpaid. Today, first contact clinicians get surgical advice by knowing the right consultant. In a service that uses Orwyn, that advice would be open to every clinician, at the point of decision, with the reasoning shown. The clinician assesses the patient and makes every decision. It starts with the knee. The hip comes next, then the rest of the musculoskeletal system.
The full description is on what Orwyn does. How it is built and governed is on safety, and the standards it is held to are on standards.
Measuring referral quality rather than referral volume
If referral optimisation is judged only on how many referrals a service avoided, the safest way to score well is to hold patients back. That is exactly the failure nobody counts.
A measure people can trust has to record what was decided, why it was decided, and what happened next, in both directions. That means three things. The reasoning is written down at the time, not pieced together afterwards. The outcome of the referral goes back to the clinician who made the decision. And the service and its commissioners agree in advance what each figure is measured against. Orwyn is designed to produce that record as part of ordinary use. That way, a service can show what changed, rather than just say so. In the demo, Orwyn records its plan and the clinician’s decision, with the reason for any change. Records for real patients, the outcome coming back to the clinician and the link to the record system are planned. Nothing on this page is a claim about outcomes Orwyn has produced. It has not yet been deployed, and any evaluation will be designed with the service that runs it.
Where to read more
Musculoskeletal orthopaedic approach to referral optimisation, NHS England, publication reference PR2103, published 30 October 2023. Read it here.
An improvement framework to reduce community musculoskeletal waits while delivering best outcomes and experience, NHS England. Read it here.
Adult community musculoskeletal service specification, NHS England. Read it here.
Referral optimisation, NHS England Outpatient Transformation Programme. Read it here.
Urgent and emergency musculoskeletal conditions requiring onward referral, Arthritis and Musculoskeletal Alliance. Read it here.
The State of Musculoskeletal Health 2021, Versus Arthritis. Read it here.
Surgeon-governed decision support for first contact MSK clinicians.
The demo uses draft rules awaiting final sign-off, and example patients only.