Introduction As economic pressures increase, many primary care providers are restricting referrals to hospital. Evidence based guidance for such restrictions are difficult to find and there is a risk that patients with significant disease may have their diagnoses delayed or missed. We have worked with colleagues in primary care to produce a single page guidance sheet for doctors seeing children with common (and occasionally important) symptoms.

Methods We started with a common problem - the coughing child. Most children can be managed in the community, but some have important underlying diseases that need more specialised investigation and treatment. We developed three tools

1. an evidenced algorithm for referral, clarifying which features of the history and examination indicated significant or worrying disease,

2. recently published reviews that allowed professionals to read more on the subject,

3. good patient information that set out the principles of our advice.

These were reviewed and discussed at a joint meeting with primary care doctors and then the amended guidelines were disseminated.

Results The resultant guideline (one page with links to articles and information sheets) has been popular with primary care, and is available through the hospital website. It has been used in training. Involvement of primary care doctors has improved its credibility, and early analysis of referral patterns suggests that practices using the guidelines have a lower referral rate to secondary care than the local average, suggesting it modifies referral behaviour. We hope to employ the methodology in a wide range of common paediatric conditions.