With a 30% increase in the incidence of head and neck cancer since 1999 in the UK, it is important that the two-week wait referral guidelines safely encompass all risk factors but also render these urgent referrals based on signs and symptoms to be reasonably predictable of cancer. In this retrospective study comprising 984 consecutive referrals, 37 had cancer. The clinical risk was stratified as: low risk – not requiring further investigations and discharged (36.8%); medium risk – investigations requested (36.3%); and high risk – biopsy followed by investigations (21.9%). This stratification varied with the experience of the clinician. Of the 37 cancers diagnosed, 25 were in the high risk and 12 in the medium risk categories. The commonest symptoms were persistent hoarseness in individuals over 40 years of age, neck lump and persistent unilateral throat pain. Current or ex-smoker, history of human papilloma virus infection and previous irradiation were risk factors statistically associated with cancer. Nine of the 23 symptoms had a predictive value of over 3%. The only symptoms highly predictive of cancer were neck lump with suspicious clinical features, a suspicious oral cavity lump and a patch of erythroplakia or leucoplakia in the oral cavity. The present referral guidelines had a diagnostic yield of only 3.7%, much lower than the 10-15% yield reported in literature. The authors suggest a review of these guidelines and a suggestion for modification is presented.