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Business continuity guidance - NHS e-Referral Service

Read our guidance on system availability and business continuity, including background and purpose, maintaining access to e-RS local infrastructure, responding to loss of access to e-RS and invoking business continuity arrangements.

1. Background and purpose of this guidance

1.1 The joint NHS England and NHS Digital Paper Switch-Off (PSO) programme has delivered full use of the NHS e-Referral Service (e-RS) for GP to consultant-led outpatient referrals from October 2018. This has significantly increased reliance on access to the e-RS application and associated components.

1.2 All organisations delivering health care should have existing business continuity arrangements in place to manage a situation where Information Technology (IT) systems are unavailable for a significant period of time. These arrangements should be developed locally, agreed and shared with all stakeholders, be user-friendly and safe.

1.3 They should be tested on a regular basis as part of disaster recovery planning. The NHS e-Referral Service is highly resilient (with greater than 99% availability in the past year), but there may be rare occasions when it is not available – either in isolation, or as part of a more generalised problem with IT services.

1.4 Where healthcare organisations use the NHS e-Referral Service, access to this service should be specifically considered as part of existing contingency and continuity arrangements.

1.5 This guidance sets out areas that CCGs, providers and referrers should consider as part of a review of the content and implementation of their business continuity arrangements, for e-RS. These arrangements must ensure that patient safety is protected throughout any periods of e-RS being unavailable (or of service degradation).

1.6 As the use and reliance on e-RS increases, it is important for local resilience that business continuity arrangements are reviewed and rehearsed regularly, to ensure that they deal with any temporary loss of access to the service.

1.7 This guidance also provides information for CCGs and providers in relation to the payment authentication processes, in the event that contingency plans are invoked.

2. Maintaining access to e-RS – local infrastructure

2.1 The NHS e-Referral Service became a critical system from October 2018, when all GP to consultant-led outpatient referrals were being made using the system.

2.2 The national application is built on a highly resilient configuration and undergoes periodic reviews, including disaster recovery testing, to consider risks to service delivery and possible improvements. It is vital that local infrastructure is also resilient and delivers consistent access to the NHS e-Referral Service, to the level required by a business-critical application.

2.3 Local access and availability arrangements need to be optimised to ensure that the likelihood of downtime, as a result of local infrastructure problems, is minimised. CCGs, CSUs and providers are therefore advised to review local hardware and networking infrastructure, considering increased and sustained e-RS use, and make any improvements where necessary.

Communication channels

2.4 It is a fundamental requirement that all health-care organisations have robust processes in place (including established cascade mechanisms) to communicate effectively with their users, in the event of any national or local interruption in the service. In order to be informed of any national or regional issues impacting system availability, referrers, providers, Clinical Commissioning Groups (CCGs) and Commissioning Support Units should ensure that key people are subscribed to live service alert information for the NHS e-Referral Service. Email to receive these system alerts.

3. Responding to loss of access to e-RS

3.1 There are several possible causes for being unable to access the NHS e-Referral Service, but the end result is the same - interruption to the availability and use of the system. The response to a loss of access depends on the setting, cause and context of the problem.

3.2 Should there be a national outage of the NHS e-Referral Service, communications will be sent to those who have registered for the national alerts (see 2.4 above to register for alerts). All local service desks responsible for supporting e-RS must be aware of this communication channel and already be registered to receive these alerts/updates so that they can initiate local processes for disseminating this information.

3.3 Where GP practice staff are unable to access e-RS, a referral cannot be initiated or progressed for a patient. If one has already been initiated, then patients may still be able to use the online booking service (Manage Your Referral) or The Appointment Line (TAL) to book their appointments.

3.4 Where a provider organisation cannot access the NHS e-Referral Service, this may affect their ability to review referrals or to retrieve appointment slots and may prevent patients from booking appointments. New referrals into their services may, however, continue to be initiated by referrers.

3.5 In the event of an outage, a clinical risk management approach will need to be adopted and alternative arrangements considered for the sending and receiving of referrals.

These arrangements will need to consider:

  • What (if any) other systems are ‘down’ within an organisation, in addition to e-RS
  • The urgency of the referrals being sent / received
  • The volume of referrals being sent to or from affected organisation(s)

3.6 Local business continuity arrangements may vary across CCGs, GPs and providers. They must be documented as part of an e-RS contingency policy and must be available to all users of e-RS.

Provider organisations

3.7 Within provider organisations, business continuity arrangements must include protocols that ensure timely messages are issued to relevant internal users and to commissioners for onward communication to referrers. It is important that such protocols include processes for communicating with the range of CCGs from which providers receive referrals.

3.8 Communication channels must be maintained throughout any periods of disruption so that on-going status reports can be issued, including information to confirm the resolution of an incident.

3.9 Protocols should include information on alternative referral channels that are available and the means for accessing these channels (e.g. NHS mail addresses)

Referring organisations

3.10 Within referring organisations, contingency plans should clearly describe all alternative methods via which referrals might be initiated/processed, recognising that circumstances at the time of the outage will determine which, if any, alternative plans are implemented. These might, for example, include information on whether referrals will be sent on paper or via NHS mail.

3.11 Contingency plans should include instructions on how to establish communication channels between referrers experiencing problems with e-RS and their support teams, e.g. in CCGs / CSUs. This may simply be a telephone number (e.g. to an IT help desk) to call in cases of difficulty in using e-RS.

Timings for Invoking alternative plans

3.12 Trigger points for initiating alternative arrangements should be agreed based on the likely length of the disruption and the type of referral required. For example, a 2WW referral may require action to be taken sooner than for a routine referral, although a switch to alternative referral routes too early may actually result in a delay to care for all but lengthy outage periods.

3.13 Best practice would advise that, where e-RS is unavailable for less than 24 hours, all referrals should be held and then added to the system as soon as it is available.

3.14 If referrers are advised that an outage is likely to last for longer than 24 hours, then ‘Rapid Access’ or super-urgent (e.g. next day) referrals will need to be managed by alternative means. These are usually local services and individual arrangements will need to be made for such services and communicated urgently, via established communication channels (see above).

3.15 Routine and urgent referrals can be held for several days (e.g. up to five working days) before resorting to alternative channels and are still likely to be processed faster by waiting for e-RS to become available again than by using alternative means. Alternative referral channels will need to be agreed and communicated at the time of any outage, depending on which systems are unavailable.

3.16 If an outage exceeds 24 hours, then plans should be considered for sending 2WW referrals by alternative means (to be agreed at the time), although even for these referrals, waiting for e-RS to become available again may be more efficient and result in sooner appointments, well within two weeks.

3.17 Any decision to invoke alternative referral mechanisms should be taken jointly by CCGs and providers. In the event of business continuity arrangements being invoked the scope of arrangements will need to be clarified and communicated effectively. For example:

  • Where a single provider is unable to access e-RS using alternative methods for ALL referrals may impact upon providers who were unaffected and are still able to receive referrals through e-RS
  • If a single GP practice or CCG is unable to access e-RS, a provider may still want to receive referrals from other CCGs via e-RS

4. Invoking business continuity arrangements – payment authentication considerations

4.1 The 2017/19 NHS Standard Contract Service Condition 6.2A states that after 1 October 2018, acute providers will no longer be paid for any first outpatient attendances which result from them accepting a referral from a GP practice made other than through e-RS.

4.2 Where business continuity measures are invoked, it may be necessary for providers to receive and process referrals other than through the NHS e-Referral Service, until such contingency measures are switched off and business processes return to normal.

4.3 In such cases, the CCG is required to record the date and time when they authorised the business continuity arrangements and the date and time when the switch back to business as usual was approved. Any referral initiated or received by a provider within the agreed date range should be reimbursed as usual.

4.4 Payment for referrals, based on attendance, may not be requested until long after the date of the initial referral and therefore records of referrals made during a period of outage must be maintained as justification for payment.

4.5 Below is an example of a log that local organisations may wish to use to record instances where they invoke business continuity arrangements.

Example of e-RS Business Continuity Log

Example of e-RS Business Continuity Log

Last edited: 27 May 2021 10:45 am