Right place, right time - improving imaging referrals across south-east London

The challenge

Imaging plays a vital role in diagnosing and treating patients, but not every scan requested is the most appropriate first step. In south-east London, GPs could directly access a wide range of CT, MRI and ultrasound investigations, but the available referral routes and test catalogue did not always direct patients towards the most appropriate investigation or clinical pathway first time.

This created a risk that some patients could undergo imaging that was unnecessary, unlikely to add clinical value or better requested following specialist assessment. Other patients could receive the wrong investigation and require a further referral or test before reaching the care they needed.

This really matters for patients and services, as an avoidable scan can create inconvenience and anxiety and, in some cases expose a patient to unnecessary radiation or further investigation. It also uses limited imaging and reporting capacity, potentially increasing waits for patients who are most likely to benefit.

In response to this challenge, the South East London Acute Provider Collaborative developed a coordinated programme to optimise demand while protecting timely access to appropriate investigations by improving imaging decisions and ensure patients receive the right test, through the right pathway, for the right clinical reason.

The improvement

Rather than relying on a single intervention, the programme brought together digital decision support, clinical review of referral pathways and implementation of national guidance.

To support better decisions when imaging is requested, clinical decision support software was made available through GP clinical systems across south-east London. The system provides evidence-based advice when an imaging request is being made, drawing on guidance from the Royal College of Radiologists.

If the proposed scan may not be the most appropriate investigation, the system prompts the GP to consider an alternative and it can also indicate when imaging may not be required. This supports the clinician’s decision rather than automatically rejecting or cancelling a request.

In May 2026, the collaborative undertook an evidence-based review of the CT and MRI investigations available for GPs to request directly at Guy’s and St Thomas’ NHS Foundation Trust. The review identified investigations that offered limited value as routine GP direct-access tests, or would ordinarily require assessment by a secondary care team. In response, the collaborative:

> removed CT sinus and CT chest, abdomen and pelvis examinations from routine GP direct access

> removed several specialist musculoskeletal MRI examinations while maintaining access to core scans, including shoulder, hip and knee MRI

> restricted direct-access MRI brain referrals to urgent clinical indications

> routed patients with musculoskeletal problems through the new musculoskeletal single point of access, where clinical assessment could determine whether imaging was required.

The aim was to ensure that patients entered the right clinical pathway first time and that imaging was requested where it was likely to inform their care.

The collaborative also implemented NHS England’s Right Test, Right Time approach, focusing on 12 imaging examinations that could provide limited clinical value in particular circumstances. For example, ultrasound is not routinely required for osteoarthritis where a patient does not have atypical clinical features, so by applying the guidance consistently, such as with ultrasound hands, it helps clinicians avoid low-value investigations while maintaining access where imaging is clinically indicated.

Results

The early results suggest that the combination of decision support and pathway redesign is changing referral behaviour. Between May and July 2026, clinical decision support was used across more than 43,000 imaging requests. Following the evidence-based prompts:

> more than 1,900 requests (4.4 per cent) were changed to a more appropriate investigation

> more than 2,600 requests (6 per cent) were cancelled because imaging was no longer considered necessary

> approximately one in ten imaging requests was changed or cancelled after the clinician received decision support

The wider pathway changes were also associated with:

> 83 fewer GP direct-access MRI head requests at Guy’s and St Thomas’ NHS Foundation Trust

> 467 fewer GP direct-access ultrasound hand requests across South East London

> 454 fewer complex GP direct-access CT and MRI requests at Guy’s and St Thomas’ NHS Foundation Trust.

Analysis comparing activity between June and September 2026 with the same period in 2025 estimated that £102,000 of less appropriate imaging activity was avoided over three months. If sustained at the same rate, this would be equivalent to approximately £408,000 over a year. This should be presented as an estimated value of avoided activity, rather than confirmed cash-releasing savings. The estimate is based on the number of imaging requests made rather than scans actually performed. To account for requests that would ordinarily have been rejected during radiology vetting, a 10 per cent adjustment has been applied to the estimated value.

The work shows that improving elective care is not only about adding capacity, it is also about improving decisions earlier in the pathway. By combining technology with clinical leadership and pathway redesign, South East London is:

> helping patients receive the most appropriate investigation or assessment first time

> avoiding investigations that are unlikely to inform clinical management

> freeing imaging and reporting capacity for patients who need it most

> supporting more consistent, evidence-based referral decisions

> reducing avoidable stages and delays in elective pathways.

The next phase will include expanding the range of appropriate GP direct-access tests delivered through south-east London’s network of community diagnostic centres, supported by clear clinical criteria and effective decision support

Further information

For more detail on this improvement insight, contact:

Dr Chris McGurk GP, Rapid Diagnostic Clinic, Queen Elizabeth Hospital; SEL ICB APC Primary Care Diagnostics Lead christopher.mcgurk@nhs.net

Roberto Barcellona, Programme Manager – Dental, Diagnostics, ENT & Ophthalmology, SEL APC r.barcellona@nhs.net