Review the benefits section to find out more information on how using advice and guidance, via the NHS e-Referral Service (e-RS), can help consultants and other provider clinicians.
Benefit of using advice and guidance
How advice and guidance is used
A typical patient journey using advice and guidance starts with the patient visiting their GP.
The patient visits their GP and the GP creates an advice and guidance request. Patient images or other attachments can be added as required.
The provider clinician reviews the advice and guidance content and responds, either by:
- giving advice on diagnosis and management based on the information received, and adding attachments as required (such as clinical guidelines, patient information)
- requesting further information from the referrer, in which case the advice and guidance request remains in the providers worklist until a response has been received from the referrer
Watch our short film from Peterborough City Hospital about how they use advice and guidance.
Responding to an advice and guidance request
Below are details of how to respond to an advice and guidance request.
- Log onto e-RS using your smartcard.
- Select the worklist tab and the advice and guidance requests option from the worklist type dropdown menu to open the advice and guidance requests worklist.
- Under the filters section, select show all on the consultant dropdown to show all advice and guidance requests into that service (show all will also be the usual recommended default setting in the service, speciality and location setting – please discuss with your e-RS manager).
- Select the load results button to display the advice and guidance requests.
- Open an appropriate advice and guidance, by selecting the UBRN (unique booking reference number).
- Review advice and guidance information, including any attachments which may be embedded in the advice conversation or attached in the left-hand column under advice request details.
- Left click on the patient name at the top of the screen for quick overview of patient details including address and contact details.
- Reply to the advice and guidance request, including adding attachments if required, by selecting add attachment.
When you select 'Return to referrer with advice', you will be required to select one of the four options, indicating your intent. This is for audit purposes only and the information can be found in the AG01 enquiry.
Note: Each provider response will return the request back to the referrer and appear on their worklist; the referrer can then choose to either close or to continue with the conversation.’
- You can copy and paste from provider systems into an advice and guidance response (and/or vice-versa), by highlighting the text and using Ctrl C (copy) and Ctrl V (Paste).
- If you require further information from the referrer, specify the information required and tick the I require further information box. Note, that the advice and guidance will remain on your worklist if you choose this option.
Searching for a previous advice and guidance response
There are two enquiries in e-RS that allow you to see all the historic advice and guidance requests and responses information, including attachments.
Select the enquiries tab at the top of the screen
From the dropdown list select either:
- patient enquiry – enter the advice and guidance UBRN or NHS number to search for an individual patient
- advice and guidance enquiry
For advice and guidance enquiry:
- select your speciality and time period to search for all advice and guidance responses within a defined time frame (maximum 90 day window)
- click the patient name header to arrange advice and guidance responses into alphabetical order by name if required
For access to historical advice and guidance requests and responses completed over 18 months ago review our guidance on archived referrals.
Your e-RS lead can provide summary reports on advice and guidance activity for individual consultants and clinical teams through the AG01 (advice and guidance activity report).
Reviewing your directory of services (DOS)
The Directory of Services (DOS) tab allows you to review your advice and guidance and appointment clinic specifications, including conditions treated and exclusion criteria. You can also view the DOS for other local and national services for comparison.
The NHS e-RS DOS is the provider’s portfolio of services. To ensure that advice and guidance requests and referrals are appropriate for their service, managers will be working with their clinical colleagues to regularly review and update key areas, such as conditions treated, procedures performed, recommended investigations and any exclusions. Advice and guidance and referral advice should be provided in line with these DOS specifications.
Attachments and image transfer
Attachments for advice and guidance can be added in the same way as they can for referrals. Attachments:
- are a beneficial way of enhancing the information you are sending to the clinician (for example: treatment plans, local or national guidelines, patient information leaflets)
- added using e-RS web-based can be up to a maximum of 5Mb per file and there is no limit to the amount of files for each referral
Important: when reviewing attachments, for example patient images, letters, ECGs, ensure that you have closed the attachment completely before you close the advice and guidance response and move on to the next patient. If the attachment viewing screen is minimized and not closed then the attachment will remain open.
Refer to national guidance regarding attachments from relevant organisations, for example the British Association of Dermatologists dermatology guidance for information about patient images and consent for image storage, transfer and teaching use.
What consultants and provider clinician teams can do
We have created a high level guide to using advice and guidance for consultants and provider clinician teams.
You can read guidance produced by NHS England and NHS Digital including:
- NHS England’s elective care and transformation programme – best practice solutions advice and guidance
- 2017/2019 CQUIN
- an e-RS guide for GPs
- an e-RS guide for secondary care doctors
- look up local and national advice and guidance services available on e-RS, through the directory of services tab within e-RS
Plan and communicate
You may want to work with e-RS leads or service managers to decide how advice and guidance services are going to be set up. For example, will they be:
- tariff based?
- an appointment and advice and guidance service (linked to a directly bookable service)?
- an advice and guidance only service, which is not linked to a bookable service, for example, at speciality level rather than individual service level?
- available locally (on the primary care menu) or nationally (secondary care menu)?
Work with e-RS leads or service managers on future planning to ensure consultants and clinical teams agree that:
- processes are in place to ensure that advice and guidance requests are reviewed and responded to in a timely manner
- processes are in place to adapt to fluctuations in volume of advice and guidance requests, and potential for gradual increase in advice and guidance demand from primary care
- there is sufficient clinical cover to respond to advice and guidance e.g. consider a rota system during periods of absence
- there is sufficient consultant workforce to balance advice and guidance workload against face-to-face clinical activity
Work with service leads to ensure that:
- smartcard/computer access is provided, and training is delivered
- new advice and guidance services with CCG or referring GPs are communicated
- service definers work with clinicians on new/existing advice and guidance services to review the directory of services (DOS) and service information
- work is undertaken with commissioners and providers on the roles and responsibilities of using advice and guidance and any applicable tariffs
- the NHS England benchmark prices for advice and guidance services, found in the Non-mandatory prices 2019-20 spreadsheet (Benchmark-advice and guidance tab), in the National tariff payment system: supporting documents is reviewed
- a process is set up within the speciality so everyone is clear about who monitors and manages the advice and guidance worklist, in a timely way
- the e-RS training resources are reviewed
Work with consultants and clinical teams to ensure:
- advice and guidance requests worklists are regularly monitored
- advice and guidance requests are responded to in an agreed timescale
Analysis and audit
Clinicians and service leads should analyse data by establishing regular 6-12 monthly internal audit/service evaluations. Suitable standards include:
- activity per clinician, including response times
- the percentage advice and guidance requests where referral only is recommended
- conversion rates to referrals – consider establishing systems to cross check referrals within a defined period, for example: 6 months using NHS numbers rather than UBRN
- qualitative review of 20-30 advice and guidance responses as a team across all reporting consultants
This data can be used by clinicians in the:
- advice and guidance responses enquiry for qualitative reviewing as this shows advice and guidance response content - that is, the communication text between referrer and provider clinician
- AG01 (advice and guidance activity report) or extracts within e-RS
- your e-RS lead or service manager can access this data, through an information analyst (B1130) role
Find out more information about business roles.
Advice and guidance should be:
- delivered either by the consultant or by another senior clinician (including specialist registrars and specialist nurses) where the consultant retains responsibility for the service and the advice provided
If the implementation of e-RS advice and guidance does lead to increased workload burden, clinicians should be allowed to incorporate this into their job plans/work schedules as appropriate, based on the average time taken to provide an advice and guidance response compared to face to face clinical activity.
Advice and guidance will not be applicable to all elective pathways, and specialties need to be agreed at a regional/local level.
Service managers and e-RS leads should work with consultants and clinical teams to agree that:
- processes are in place to ensure that advice and guidance requests are reviewed and responded to in a timely manner, as it is essential that turnaround times for responses through the advice and guidance function are realistic and appropriate for the level of staffing
- processes are in place to adapt to fluctuations in the volume of advice and guidance requests, and the potential for increasing advice and guidance demand from primary care
- there is sufficient clinical cover to respond to advice and guidance, e.g. consider a rota system during periods of absence
- there is sufficient consultant workforce to balance advice and guidance workload against face-to-face clinical activity
The BMA has published a guide for e-RS advice and guidance - e-RS guide for secondary care doctors. It is essential that any new services are carefully planned and properly resourced as failure to do so may make them burdensome and difficult to deliver. Where departments replace existing informal channels with the advice and guidance function, care must be taken to ensure a smooth transition. Where any additional workload burden is created, departments should look for quick resolutions by:
- reviewing work scheduling
- categorising advice and guidance as DCC (direct clinical care) work for consultants and SAS (staff grade, associate specialist and speciality) doctors
- identifying where juniors may be losing out on education and training opportunities in face to face clinics
- identifying where juniors may benefit from education and training opportunities in advice and guidance
NHS England benchmark prices for advice and guidance services, found in the Non-mandatory prices 2019-20 spreadsheet (Benchmark-advice and guidance tab) have been introduced, in the National tariff payment system to reduce the mixed provision of advice and guidance.
Three tiers of prices have been proposed for 2019/20, based on an agreed quality standard:
- £30 – tariff with two working day quality standard met
- £20 – tariff where two working day quality standard is missed, but is within seven working days
- £10 – tariff where a response does arrive but not within seven working days
- £0 if there is no response received
These proposed prices were based on feedback from providers on current local prices and the reported cost of providing advice and guidance services.
These tariffs are a guide for local negotiation for all specialities. Where advice and guidance services involve the review of several attachments. For example: clinical photographs, ECGs, higher tariffs may be negotiated depending on the average time taken for reporting compared to face-to-face consultation.