About advice and guidance and points to consider

The information below is intended to support local health systems to successfully mobilise NHS e-Referral Service (e-RS) advice and guidance services.

Advice and guidance is a two-way dialogue channel in the e-RS which allows GPs/referrers to seek specialist input into a patient’s care. Advice and guidance services provide a secure rapid digital communication channel between two clinicians:

1. the ‘requesting’ clinician and the provider of a service (the ‘responding’ clinician).
2. enabling a patient’s care to be managed in the most appropriate setting.

There may be a number of reasons why a clinician may wish to seek advice and guidance including:  

• asking another clinician or specialist for their advice on a treatment plan and/or the ongoing management of a patient
• clarification (or advice) regarding a patient’s test results
• seeking advice on the appropriateness of a referral for their patient (e.g. whether to refer, or what the most appropriate alternative care pathway might be)
• identifying the most clinically appropriate service to refer a patient in to

The referrer can attach documents to the advice request, which may include diagnostic results, clinical photos, scanned images, or previous correspondence relating to the patient. The referrer can also authorise for the request to be converted to a referral by the provider.

Since February 2021 e-RS advice and guidance allows GPs/referrers to preauthorise the specialist to convert the advice and guidance to a referral, if appropriate. This functionality now allows advice and guidance to be used as a referral channel, to reduce the burden on GPs/referrers and streamline patient care. Find out more about the enhancements which were introduced on February 2021.

The provider is then able to review the request (along with any attachments) and either:

• convert the advice and guidance to a referral (if authorised to do so); at the point of conversion they can provide advice to help the GP/referrer support the patient while they wait for their appointment, noting that ongoing two-way dialogue between referrer and provider is not possible once the patient is accepted onto the waiting list
• return the advice and guidance request with advice only, adding their own attachments (for example, a proposed treatment plan or links to external documents and websites), if required
• return the advice and guidance request asking for further information
• return the advice and guidance request advising the referrer to send the patient to a particular service

The referrer is then able to either:

• convert the advice request into a referral or appointment request, linking the advice information (and any attachments) to the referral; ensuring that the receiving provider has all the relevant referral information and negates the need for a new referral being created
• respond to the provider if they do not feel able to manage the patient in primary care and would like further information or the advice and guidance request converted to a referral by the provider
• remove the request from the worklist if confirmation is received that the request has been converted meaning the referrer can save the full advice conversation (using the ‘Print’ button) and close the request from their worklist

Note: The implementation of advice and guidance should complement other referral pathways, including Referral Assessment Services (RAS).

Advice and guidance has an easy to follow screen, which shows the discussion between clinicians, and any attachments as a link. It has an easy to read flow, with a 'text message' like format.  

We have included an example of what a conversation looks like, starting with a question from the referring clinician and with a response from a provider consultant. 

e-RS provides the following pathways for referrers to communicate with providers:

Advice and guidance – an advice service which allows a referrer to request advice from a provider (for example, a consultant) before or instead of making a referral. As part of the changes introduced in January 2021, a referrer may authorise a consultant to convert an advice and guidance request into a referral where appropriate, or a provider clinician may recommend that a referral is required. In either case, the responsibility to refer remains with the referrer/GP.

Bookable services – a referral service where the patient selects an appointment and books before the specialist provider reviews the clinical referral information. Directly bookable services are the most economical way of referring a patient into an outpatient appointment using e-RS.

Referral assessment services (RAS) - a Referral Assessment Service (RAS) can be used by providers to assess the clinical referral information in order to make sure that the patient sees the most appropriate clinician, attends the correct clinic or receives required diagnostic tests while avoiding unnecessary hospital attendance. Referrals may be returned with advice only, similar to advice and guidance. However, RAS differs from advice and guidance in that;

• a RAS does not support two-way dialogue between referrer and provider clinical teams
• a RAS does not allow specialists to provide interim clinical advice at the same time as accepting the referral
• a RAS does not allow the GP/referrer to respond in e-RS if the referral has been returned with advice only, as the referral is closed by the provider
• the historical RAS advice and comments cannot be accessed under the ‘Enquiries’ tab, unlike advice and guidance responses
• Where a RAS is part of a consultant-led pathway, a referral into a RAS service will generate a referral-to-treatment clock start

Review supporting clinical referral pathway for further information.

Using the advice and guidance process will require more administrative time and resource to manage.

Advice and guidance can be provided through e-RS by all provider organisations as required. All GPs in England have access to e-RS. Since the Paper Switch Off Programme in October 2018, all GPs and NHS providers in England are required to use e-RS as the only method of making and receiving referrals from GPs to consultant-led first outpatient appointments.

Advice and guidance usually involves direct GP and Consultant communication, although a wider referrer and provider workforce may be appropriate, including non-consultant grade doctors, GPwERs, specialist nurses and allied health professionals (if they have the required skill set, training and governance).

In order to access e-RS, healthcare professionals require an NHS smartcard to provide secure and auditable access to national and local Spine enabled health record systems. Advice and guidance can be provided through e-RS remotely and from home with a secure encrypted connection if required.

If the GP/referrer authorises an advice and guidance to be converted to a referral, they are confirming that the patient has agreed to the service provider. Find out more about converting referrals.

A request for e-RS advice and guidance does not initiate a referral-to-treatment (RTT) clock start. The RTT clock start for a converted referral will capture the date on which the provider converts the referral.

Advice and guidance is recommended at the point that an outpatient referral would otherwise be considered. The service is intended to provide advice and guidance targeted to individual patients, rather than generic advice which should already be available through national or local referral guidelines.

The requesting clinician is usually a GP; however, local arrangements may outline circumstances in which it would be appropriate for other Allied Healthcare Professionals (AHP) to submit an advice and guidance request. Service evaluation should be regularly carried out for AHPs working in this capacity to ensure advice and guidance requests are appropriate and contain sufficient clinical information to support patient care.

Advice and guidance is aimed at providing specialist support for patients who have not yet been referred to hospital services (and may not require referral). Patients under active ongoing hospital follow-up should be supported by their named provider clinician as advice and guidance services are generally provided by a pool of consultants within each department rather than individual named clinicians. Advice and guidance services may allow outpatients to be discharged more confidently by provider teams by allowing rapid digital access to further advice if required.

The advice and guidance function should not be used in place of a two week wait referral. For example, where a patient clearly meets NG12 criteria this should usually result in an urgent suspected cancer referral.

Advice and guidance can be used locally where agreed at a system level. This may vary by pathway depending on what is clinically appropriate and must follow engagement with referrers and providers to develop any new processes. Prior to any implementation systems/commissioners should undertake a local training needs analysis and carry out any training as necessary. There should also be ongoing support available to referrers and providers

Advice and guidance will be converted into two week wait appointments in line with the local referral and commissioning guidelines and must be classed as a suspected cancer/two week wait referral, not a consultant upgrade.

The e-RS pathway start will capture the date on which the provider converts the referral. When making the decision on, if to convert advice and guidance directly into a referral and appointment, the clinician reviewing should take into consideration whether they have the required information, and whether the patient is likely to know there is a suspicion of cancer.

Systems or commissioners should regularly review advice and guidance services and conduct quality assurance analysis to ensure they meet local requirements. Lessons learned should also be reviewed and findings shared across the system. Find out more about the advice and guidance recommendations for cancer pathways.

A record of the advice and guidance communication should be accessible by all relevant provider and referrer clinicians for ongoing management of the patient, service evaluation, audit, and in the event of future clinical incident investigation, complaint or litigation.

In e-RS all historic advice and guidance requests and responses (including images) can be viewed by providers under the  ‘Enquiries’ tab, and can be sorted based on referring or responding clinician (available for 18 months) or using the patients NHS number (available for 6 months). Find out more about searching for a previous advice and guidance response.

GPs/referrers can find previous advice and guidance requests and responses by search for the patients by their NHS number.

Application Programme Interfaces (APIs) for e-RS have been released in 2021 to support integration of e-RS advice and guidance with provider Electronic Patient Records so that the e-RS advice and guidance dialogue:

• can be managed within the provider’s own system;
• is added to a patient’s hospital record; and
• can be converted into a referral from within the provider’s own system, avoiding the need to switch between different systems

Attachments (such as images, ECGs) can be:

• added using web-based e-RS to a maximum of 5Mb per file and there is no limit to the number of files for each referral
• added using GP integrated systems to a maximum of 5Mb in total for each referral

Find out more about attaching files as a GP/referrer.

Work is currently underway to enhance e-RS to allow exchange of clinical information from larger files and different file types.

Patients do not have direct access to the e-RS advice and guidance, although the advice and guidance conversation can be made available to patients on request from their GP practice.

In order that advice and guidance services can respond to requests in an effective and timely manner, it is important that the service be resourced appropriately and factored into the wider planning of outpatient activity. Job planning is for local consideration and agreement and should reflect the best use of resource to deliver a robust advice and guidance service. Many specialty organisations have incorporated e-RS advice and guidance and triage into national job planning guidance.

It is important to consider as part of workforce and resourcing planning that advice and guidance may result in a significant shift of work, traditionally carried out by secondary care, to primary (and potentially, community) care teams. Therefore, an emphasis is needed on communication between primary and secondary care teams when establishing advice and guidance services, to determine what is clinically appropriate to be managed outside a secondary care setting and what access to services and diagnostic provision is in place.  This should be supported by appropriate commissioning relevant to the primary care work undertaken which should be considered at a local level. 

Measurement of the impact of e-RS advice and guidance on GP workload requires national, regional and local data collection to guide resourcing in primary care. Dynamic data showing the percentage of advice and guidance converted to referrals by providers, and the percentage of advice and guidance and referrals returned to referrers with advice should be used to guide resource allocation. This information is available in e-RS and collected nationally.

The National Specialist Advice Activity Dashboard shows the commissioner and provider view of e-RS advice and guidance activity, with functionality to filter the data by region, STP, local commissioner, provider, specialty and metric. 

The National Specialist Advice Activity Dashboard is accessed via the Future NHS platform, anyone with an email address ending in @nhs.net / @nhs.uk / @nhs.scot / @phe.gov.uk can self-register to use the platform by clicking on the link.

Utilisation and outcome data for all models of specialist advice including e-RS advice and guidance services is collated through the System Elective Recovery Outpatient Collection and can be found on the Future NHS Outpatient Transformation platform.

The EBSX05 extract provides details on all active national e-RS services within a reporting period. These reports do not contain any personal identifiable data and are available on the NHS Digital website

In addition, the following extracts are available to colleagues with an e-RS information analyst role on their smartcard:

• AG01 (activity report) which provides local data including advice and guidance activity, users and outcomes
• EBSX02 which provides a daily and monthly CSV extract of any action on a UBRN within a reporting period

The e-RS advice and guidance toolkit is designed to support all aspects of e-RS advice and guidance and provides information for providers, referrers and commissioners.

Advice and guidance is central to supporting the restoration and recovery of elective services as described in the 2022-23 priorities and operational planning guidance

The National Outpatient Transformation Programme is continuing to support the mobilisation of specialist advice services including e-RS advice and guidance, with a range of resources available on the Future NHS Platform, including information on Specialist Advice (login to the Future NHS platform is required to access this link).

Advice and guidance High Impact Intervention Guides were released in September 2020 to support mobilisation of advice and guidance services in the response to COVID-19.

There are a variety of training resources on the advice and guidance support page to help organisations to implement and use advice and guidance.

Additional resources are detailed below.  

Review a video showing an example of advice and guidance benefits for providers and read organisation case studies on advice and guidance.

Find useful information, for all areas of the system, can be found in the e-RS help which can be accessed either through the e-RS system, or if you're on an N3/HSCN connection you can access it without logging into e-RS

e-RS reports and statistics can provide information on advice and guidance usage.

Accessing the end user training environment can build user confidence using the advice and guidance function.