Objective To identify discrepancies and explanatory variables in grading referrals sent from primary care physicians to the neurology service.

Methods We asked eighteen neurologists in our centre to grade twelve different referrals made by primary care physicians. The directorate operates subspecialty triage within the neurology service, including epilepsy, ataxia, movement disorders, neuro-ophthalmolog, sleep etc. The letters were sent to neurologists to grade on two different occasions, 4 weeks apart without prior warning that they will receive them twice. We asked for the letters to be graded as urgent (<2 weeks), soon (<6 weeks) or routine (up to 14 weeks). We have also asked for referrals to be channelled into the appropriate clinic including the option of general neurology clinic.

Results We note marked variations between consultants in the grading of the degree of urgency to see patients and triaging them to the appropriate clinic based on the information provided in the referral letters. However, the consultants mostly were consistent when they graded the letters twice. We also note that general clinic was the most preferred choice of first contact.

Conclusion There is a lack of consensus about an appropriate grading system for referral letters and little evidence about long-term outcomes for patients following grading. It is clear that variations do exist and that a large proportion cannot be explained easily. It is likely that patient flow and long term care would be better should they be seen by an appropriate subspecialty clinic from the first visit.