From Battleships to Chess: Smarter Referrals, Better Outcomes for Primary Care

The NHS elective backlog is often framed as a problem of capacity: too many patients, not enough clinicians, insufficient clinic space. And while these pressures are real, they are not the whole story.

A quieter, but equally important, issue sits upstream in the system — the quality and direction of referrals themselves. When referrals arrive incomplete, misdirected, or lacking the information needed to act, delays multiply. Capacity is wasted. Clinicians on both sides become frustrated. Patients wait longer than they should.

For many GPs, referring a patient still feels less like a strategic clinical decision and more like playing Battleships: a referral is fired off into the system with limited visibility of what happens next, and little confidence that it will land in the right place first time.

Not because clinicians are careless — but because the system gives them no clear view of the board.

A system designed for communication, not quality

The national electronic referral system has transformed how referrals are transmitted, but it was never designed to ensure referral quality or pathway accuracy. It moves information from A to B, but it does not guide clinicians toward the right destination, nor does it validate whether the necessary clinical criteria have been met.

Without clear pathways, real-time decision support, or feedback loops between services, primary care is often left navigating a complex and fragmented landscape alone. Secondary care teams, in turn, receive referrals that are difficult to triage, leading to avoidable rework, redirection, and delay.

The result is a system where inefficiency is baked in — not through poor clinical practice, but through poor system design.

From guesswork to strategy: why referrals should feel like Chess

Now imagine something different.

What if referrals were more like a game of Chess — transparent, deliberate, and informed?
What if primary care clinicians could clearly see the options available to them, understand the next best move, and send patients exactly where they need to go, first time, with all the right information?

In Chess, every move is informed by an understanding of the board, the rules, and the likely consequences. In Battleships, you fire blind and hope.

Smarter referral systems should behave like Chess.

A dermatology referral: Battleships vs Chess

Let’s walk through a familiar scenario.

A patient presents to their GP with red, scaly, itchy patches on their elbow. The GP takes a history, examines the skin, considers differential diagnoses, advises the patient, and prescribes topical treatment. At review, the symptoms have worsened and are now affecting quality of life. The GP decides to refer to secondary care for specialist input.

In a “Battleships” system

The GP dictates or types a referral quickly before moving on to the next patient. The referral is sent via e‑RS to a dermatology service, often without structured prompts, pathway validation, or clarity on what information is essential.

From the GP’s perspective, the referral has been “done”.

From secondary care’s perspective, the referral may:

• Lack sufficient clinical detail
• Miss required investigations or images
• Be sent to an inappropriate service
• Require further clarification before action

The consequence? Delays, redirection, and additional administrative burden — for both sides.

In a “Chess” system

The referral process is guided, not obstructive.

As the GP makes the referral, the system checks the patient’s record against locally agreed dermatology pathways. Structured prompts ensure the right history, examination findings, and diagnostic criteria are captured. Integrated clinical photography can be included where appropriate. The GP understands exactly where the referral is going and why.

This is no longer guesswork. It is a deliberate, informed move.

Closing the gap: how Gateway supports better decisions

This gap between intention and outcome — between clinical judgement and system response — is exactly what Gateway® was designed to close.

Gateway does not replace clinical expertise. It amplifies it.

By sitting natively within clinical systems, Gateway® supports primary care teams to make high‑quality referrals by:

• Checking patient records against agreed clinical pathways
• Prompting for only the information secondary care actually needs
• Supporting targeted referrals to the right service first time
• Reducing variation without constraining professional judgement

The result is not simply “a referral”, but the right referral — one that secondary care can act on immediately.

Why this matters now

As Integrated Care Systems focus on neighbourhood models, Advice & Guidance, and Single Points of Access, referral quality becomes a shared, system‑wide responsibility.

Primary care cannot be expected to shoulder this complexity alone. If we want better decisions upstream, the system must provide better tools, clearer pathways, and stronger feedback loops.

Moving from Battleships to Chess is not about technology for its own sake. It is about designing referral pathways that are transparent, intentional, and patient‑centred — pathways that respect clinical time, protect secondary care capacity, and reduce avoidable delays.

When clinicians can see the board clearly, every move becomes more effective — and patients get the care they need, sooner.