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AIMS: This article describes a seven-year multifaceted intervention leading to sustained improvement in primary care radiology referral quality and value in Canterbury, New Zealand, and discusses the transferability to other health systems. METHODS: Access criteria were developed with input from general practitioners and hospital-based specialists, and embedded in locally developed clinical pathways. A referral management service was created to streamline referral processes. Systems were developed to enable electronic referral and triage, and to provide visibility of prior imaging. A team of general practitioners was formed to continually review referrals relative to agreed criteria and to provide advice to referrers. Referring general practitioners were provided data and education about their referral patterns relative to their peers. A clinical audit programme was introduced to ensure quality and safety of care. RESULTS: The service achieved sustained improvements in referral quality (referral acceptance rates increased from 78% to 88%, urgent referrals reduced from 59% to 22%) and value (plain film volumes reduced by 40%). CONCLUSIONS: Sustained improvement to primary care radiology referral quality and value is achievable at scale using a multifaceted intervention. The transferability of this outcome is likely to be connected to supporting factors present in the Canterbury health system.