Directory of Services (creating and maintaining services) on the NHS e-Referral Service

The Directory of Services (DOS) is the core of the NHS e-Referral Service (e-RS) application and:

• holds information that describes the services that organisations offer
• enables referring clinicians to search for appropriate services to which they can refer patients
• provides a window through which providers can display their services

Service providers build and publish their services on the DOS within e-RS. This in turn enables referrers to search for and list appropriate services for their patients. In the case of primary care services, commissioners need to specifically choose (commission) which services they wish to appear to their referring organisations.

Services are built by service definers, using the service definition tool. They are categorised by specialty, which is then broken down into clinic types. Once a service is defined and built, it can be published. Services published on the secondary care menu, including those services belonging to acute and foundation trusts as well as many independent sector providers, are available to referrers throughout the country. Services published on the primary care menu are commissioned within e-RS and only appear to those referrers for whom the e-RS commissioning organisation is responsible.

Information published in the DOS should contain enough detail to enable the referring clinician to select appropriate services for their patients and ensure that the service provider clinician receives clinically appropriate referrals.

A well-constructed DOS will ensure that referring clinicians are able to shortlist and refer to the correct service(s) first time, resulting in:

• fewer referral redirections and rejections
• fewer patients being inconvenienced by delays to their care
• less administration work for providers and referrers
• provider clinicians receive clinically appropriate referrals and information

Additionally, they will ensure that patients are given appropriate and helpful instructions prior to arriving for their appointment.

There are two key activities which need to be completed before being able to load services onto the DOS:

1. smartcard allocation - those responsible for inputting the services (service definers) need to be registered with smartcards and trained. In addition, those who will process referrals will also need to be registered and issued with smartcards and then allocated to each relevant service’s workgroup
2. Organisational Data Service (ODS) - Service definers should ensure that all service locations have been defined by the ODS

To enter data onto e-RS, service definers need to obtain Smartcards from their local registration authority. More information is available from the registration authority.

Service provider clinicians and support staff also need to be allocated to particular services so they can view and process information relating to the bookings and referrals received into that service. In order to do this, they must be added to a workgroup (N3/HSCN connection required to access this link) that is associated with the service. Prior to a workgroup going live, all staff allocated to it will need to be issued with smartcards.

e-RS enables service definers to create, update and deactivate workgroups.

The location of a service defined on the DOS is one of the key factors to be taken into consideration when defining services. For example, where an organisation provides the same service from two different sites this must be set up as two separate services. This enables referrers and patients to choose the most appropriate and convenient place to be seen.

Locations are loaded into e-RS from the Spine Directory Services (SDS), which in turn takes information from the Organisational Data Service (ODS). For NHS trusts, there is a nightly upload to the SDS from the ODS. For the Independent Sector this upload is made on an adhoc basis. There is a daily upload from the SDS to e-RS.

• trusts can check which locations have been identified for their organisation from the ODS Portal (N3 access required)
• trusts should submit new locations or any changes to existing locations to ODS, via their ODS lead

Supporting information for service definers is available within the e-RS online help (N3 connection is required).  The following information covers each section related to creating a new service, giving guidance for the key fields that support the creation of an effective service description. Guidance is available for all fields from the e-RS online help (N3 connection required).

The three key elements of creating a service in the DOS are:

1. listing the conditions treated, procedures performed, main exclusions for each service and necessary pre-requisite tests/investigations
2. listing SNOMED CT and specialty and clinic type, enabling referrers to search for services effectively
3. providing administrative and other service information helpful to patients and referrers, for example location and parking facilities

To describe services effectively, providers need to ensure that each service on the DOS:

• follows the service naming convention to enable referrers to compare like for like and identify the most appropriate service
• is mapped to appropriate SNOMED CT and specialty and clinic type so that referrers can easily search and find appropriate services for their patients
• contains other service information, for example inclusions/exclusions or pre-requisite tests, that is accurate and up to date

Remember, before creating a service, discussions must be undertaken to clearly define information about the service. This includes the type of service being offered. For example, will the service be a referral assessment service, clinical assessment service and/or offer advice and guidance? Find out more about how e-RS supports clinical referral pathways.

Service details, clinic types

Service name

However, a service can only be mapped to one specialty. If more than one specialty is appropriate the provider will need to consider creating an instance of the service under each specialty. 

This Specialty and clinic type video (duration 6 minutes) explains the terms as used within e-RS and demonstrates how specialty and clinic type are used to locate a suitable service for patient referral.

Request Types Supported

Services may be set up to receive:

• appointment requests: referred patients can book an appointment
• advice requests: referrers can request advice to support the management a patient from a clinician at the provider
• triage requests: referrals can be reviewed by the receiving provider before referring to an appropriate service

Services may simultaneously support appointment or triage requests and advice requests, if appropriate.

Service effective date range

Entering a date range for the service indicates when the service will be available from and to. The start date is mandatory and represents the date from when your service will be available. It is initially set using the date on which you first saved your service. You can set the dates by clicking and using the calendar icon.

The end date represents a point in time beyond which referrers cannot add new appointment bookings and requests into the service. If you do not enter an end date the system assumes that there is no end date.

Service transition date

The field only becomes available when an end date has been added to the service definition. It is used to manage the date up to which a referrer will be able to see the service in e-RS. These dates in combination let you manage the end of a service without misplacing referrals by mistake giving you a time period between referrers not being able to refer to the service and the need to book all existing referrals for an appointment or to cancel and reject them as necessary.

Include service on Secondary Care Menu

Including your service on the secondary care menu will ensure that all referring organisations in England are able to find and refer to your service (service restriction details notwithstanding).

If you are setting up a service for use in a local area only, you should select ‘Do Not Include on Secondary Care Menu’. The service will need to be commissioned by a commissioning organisation for it to be visible to referrers in that area. You will need to notify the appropriate commissioning organisations when the service is available for commissioning.

Clinical terms

All providers should ensure that when defining and loading their services, they map these to appropriate Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT). This will allow referrers searching for services to produce more consistent and clinically appropriate results.

Standard subsets of SNOMED CT are available for providers to use when defining their service. These subsets are based on the selected specialty and clinic type(s) for the service. Once a clinic type, and associated terms, has been selected, providers have the option, where clinically appropriate, of adding or removing terms from this subset.

Searching via SNOMED CT should be the preferred method of searching for referrers because it is a common language which eventually will be used by all clinical IT systems throughout the NHS. SNOMED CT allows clinical information to be recorded in a structured form – cutting down the potential for differing interpretation of information and the possibility of errors resulting from unclear or ambiguous terms.

Service restriction

Full information on the use of restricted services is available from the using restricted service.

When it is appropriate to restrict a service, this section is used to record the reason for restriction and identify those services, organisations or people authorised to make referrals to the service.

Service priority, patient booking window and indicative wait time calculation

This section is used to identify the priority of referrals accepted by the service and to set a booking window for each clinical priority that the service supports. Waiting times for services that support appointment requests are automatically calculated by the system based on the following:

• for directly bookable services: third available appointment at last slot poll
• for indirectly bookable services: median waiting time for the last 20 bookings

A polling start date and an end date can be set for each priority individually. These dates can be set starting as little as one hour ahead and there does not have to be an end time/date, although if no end date is set only the appointments up to the end of the polling range end date will be displayed.

Any appointments outside of the patient booking window cannot be seen by the referrer, the patient or the appointment line (TAL). However, the provider could still book the patient into any slot (any priority) even outside the booking window.

Weekend days can be excluded from the total count of days for services that do not run on Saturday and/or Sunday. 

More information can be found in the e-RS system Help (N3/HSCN connection required).

Contact information

This section is used to notify referrers of how to contact the service if they require any further information. If the service is indirectly bookable, it also contains contact booking details.

Service personnel

For clinical and support staff to view and process information relating to the bookings and referrals received by a service, the appropriate workgroups (initially defined within the workgroups tab) will need to be added to the service.

In addition, this section allows services to define which clinicians are available for named clinician referrals and which are also associated with the service.

A NAMED clinician is one who is associated with a service and whose name can be used by a referrer to search for services that have specific, named, slots assigned to them.

An ALLOCATED (but non-named) clinician will still be associated with the service, have an individual worklist assigned (from which to manage referrals), but will not be searchable using the ‘named clinician’ functionality.

Commissioning

Any services where the option “Do Not Include on Secondary Care Menu” was selected in the service details must be commissioned by clinical commissioning groups. Any commissioning arrangements will be shown in this section.

Service Specific Booking Guidance

When a referrer clicks on the service name, information entered in the ‘Service Specific Booking Guidance’, such as the conditions treated, procedures performed and exclusions is displayed on screen.

All providers should ensure that all their services have full and comprehensive service guidance information. This will ensure that referrers short-listing unfamiliar services can review this information and be confident that the service is appropriate for their patient.

Instructions 

Specific information for patients to be aware of should be added to this section. This information will be displayed on screen if the patient books online or in their GP practice, and appears when patients accesses their referrals on the Manage Your Referral (MYR) patient website. If the patient books using the Telephone Appointments Line, information in this section will be read to them.

Service providers should ensure, where the use of ‘dummy’ appointments or restricted services exist, that the process is clearly detailed to avoid any confusion for the patient. For example, patients thinking that they have an appointment in the middle of the night, or on Christmas Day, or seeing that they have been referred (and possibly booked) into a restricted service that they may have been unaware of.

This information should be clearly detailed at the start of the patient instructions, to help ensure that patients do not miss reading it.

In addition, providers should consider how they name their services (refer to the 'Service name' section above) to avoid any confusion to patients, bearing in mind that all services will potentially be visible to patients. For example, patients may not understand terms such as ‘ghost’ or ‘dummy’ appointments, which should be avoided.

Slot management

• the provider system which contains appointments
• the frequency with which e-RS checks for available appointments
• the number of days in the future for which appointments are checked
• any period of slot reservation (i.e. the number of days during which newly polled slots are only available for booking by the service provider). Further information on the use of slot reservation is available from the e-RS slot reservation page.

Referral correspondence

This section allows the service provider to identify if a referral letter is required and prevent changes to the referral information within the defined number of days before the appointment - ‘Freeze Time’.

Assessment capability

This section identifies whether a service will make use of assessment functionality. Further information on the use of assessment service models is available from the e-RS website under Clinical Assessment Services overview and Managing clinical assessment services pages.

Providers should consider whether their service should be set up using assessment functionality (the patient books an appointment) or using the ‘Triage Request’ request type.

Making services available for referral and booking

Services will be available for referrers and patients to use when the service has been published and has both a valid ‘Service Effect Start Date’ and either a future or blank ‘Service Effective End Date’ (within the ‘Service Details’ section). Additionally, if the service has not been included on the secondary care menu, it must have valid current commissioning rules.

After creating an initial shortlist of services for a patient, referrers are presented with a pop- up screen showing a subset of fields from the DOS. This enables them to confirm that each of the services is clinically appropriate and that all clinical referral criteria have been met or amend the shortlist accordingly.

Service definers will want to pay particular attention to the information within the fields presented to the referrer at this stage, which are:

• referrer alerts
• exclusions
• conditions treated
• suggested investigations

Once your DOS is live, it needs to be maintained to ensure that it is accurate and reflects the needs of both referrers and providers. As your specialties and clinics change, so should your DOS.

A number of reports are available within e-RS for users with information analyst’ access. These can be used alongside the data contained within the extracts that support a service provider in analysing the effectiveness of their DOS. Feedback from referrers is also a valuable tool for identifying changes that are needed.

The ‘Monthly Activity by Service report (S1)’ will display referral activity. For services which are directly bookable the ‘Past Slot Utilisation Reports (S6)’ and ‘Future Appointment Slot Utilisation (S7)’ will display future and historic slot management information. Analysing the data in these reports will help to establish how best to maintain your services. For example, high rejection and/or redirection rates for a service or group of services suggest that you should review the current set up.

• consider merging services if they have been defined too specifically
• consider adding services if those that have been pooled are too general and make referral management difficult, or if new services are set-up
• refine service specific booking guidance in line with feedback from referrers or provider clinicians by amending descriptive elements of conditions treated and procedures performed
• if you change conditions treated or procedures performed, don't forget to amend exclusions where necessary
• remember to set age limits and gender restrictions where appropriate

Any significant change to service definition, such as merging or creating new services should be discussed with all commissioning organisations in advance of any changes and signed off in accordance with agreed procedures. It is also necessary to agree the mechanisms to manage existing bookings and any potentially outstanding UBRNs.

When a service is defined in e-RS it is associated with the organisation of the user who defined the service, and the location selected by this user for the service. Each organisation and location is uniquely identified by a code defined by the Organisation Data Services team (ODS). Moving a service within an organisation to another location that already has a code can be managed simply within the service details. The service would need to be unpublished briefly and the new service location selected and then the service republished.

Occasionally, it is necessary for a new organisation code to be issued by ODS. For example, when organisations merge, de-merge or change organisation type. When a new organisation is created all the locations for that organisation are assigned new location codes that relate to the new organisation, regardless of whether they existed previously under an old organisation.

Independently of organisation changes, locations can also open and close or change address.

New ODS organisation and location codes in e-RS are treated as separate entities even if they are a direct replacement for an existing organisation or location. e-RS automatically processes changes to ODS codes that are made in the Spine Directory Service (SDS). However, as there is no mapping relationship between old and new ODS codes in SDS, this process does not move services.

There is a script that enables the movement of services between different organisations and locations. In order to move existing services to a new organisation or location using this script, a request must be made at least three weeks in advance.

Further detailed information about transferring services is available from the e-RS service transfers page.