Introduction The 31-day target in urgent suspicion of cancer (USOC) referrals fast-tracks patients through the cancer pathway. Local anaesthetic (LA) biopsy can be performed during an outpatient clinic and may improve pathway times. The aim of this study was to compare LA biopsy in head and neck USOC referrals with the traditional general anaesthetic (GA) pathway. Methods This was a retrospective cohort study of USOC referrals to the NHS Greater Glasgow and Clyde head and neck multidisciplinary team between 1 June 2018 and 28 December 2000, and compared pathway times in LA and GA biopsies. Results The mean number of days from clinic to biopsy was 4.4 in the LA group and 28.0 in the GA group. This was significantly faster in the LA biopsy group (p < 0.05). The overall pathway time in the LA and GA biopsy groups was 35.7 and 61.5 days, respectively, and was significantly faster in LA biopsy group (p < 0.05). Conclusions The LA cohort had significantly faster pathway times compared with GA biopsy. LA biopsy requires careful patient selection, but is an effective alternative to GA biopsy in the appropriate patient group.