AIM: To assess effectiveness of guidelines for referral for elective surgical assessment. METHOD: Systematic review with descriptive synthesis. DATA SOURCES: Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites. SELECTION OF STUDIES: Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults. OUTCOME MEASURES: Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs. RESULTS: 24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex ("one-stop shops") to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change. CONCLUSIONS: Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.