The NHS e-Referral Service programme team has had conversations with a number of providers that consistently keep their level of appointment slot issues low. There are number of key lessons that can be learned from the processes that these providers have in place:
Ensure that e-RS capacity management is embedded in existing capacity management review processes, supported by strong escalation processes.
Royal Devon and Exeter NHS Foundation Trust: “We send an ASI report to all specialties 3 times a week, and ASIs are discussed in fortnightly Access meetings”
Bolton NHS Foundation Trust: “Weekly meeting is chaired by Divisional Director of Operations, with specialty Business Managers in attendance. Figures are supplied each week showing e-RS polling ranges and capacity and demand figures”
Cambridge University Hospitals NHS Foundation Trust: “We produce and circulate a daily report to the service delivery managers which highlights how many ASIs were received for that day and any overdue ASIs not currently booked. Services continually receiving a high volume of ASIs will be contacted by the Outpatient Service team to discuss the on-going issues and produce a management plan to provide additional capacity.
Bolton NHS Foundation Trust: “issues are passed to the relevant business manager, who will contact the doctors to discuss capacity issues and how to resolve”
Liverpool Women’s NHS Foundation Trust: “escalation to divisional business support managers who will raise with service manager”
Ensure that slot poll ranges align with or exceed waits for patients referred by other means
Keeping slot poll ranges shorter than the actual waiting time for a service only results in patients being unable to book their appointment directly.
There are no RTT benefits to providers in keeping polling ranges artificially low, as the patient’s waiting time starts at the point that they appear on the appointment slot issues worklist (or earlier, if they have been through a primary care interface service or referral management centre).
Allowing the patient to book directly also has additional benefits; the provider has immediate access to referral information, the patient is automatically registered on the provider’s patient administration system (PAS) and the patient will also feature on the provider’s patient tracking list (PTL), highlighting RTT pressures and minimising the size of the appointment slot issues worklist, which can sometimes act as a hidden waiting list (as the patients are not on the PTL).
Keeping polling ranges long enough to enable patients to book while supporting organisations in their delivery of RTT requires good management of capacity and demand. Models for analysing outpatient capacity and demand have been made available by NHS Improvement.
Longer polling ranges can present challenges, particularly around the issue of consultant leave notification. The quotations below demonstrate how some providers manage this challenge:
Nottingham University Hospitals NHS Trust: “Most of our polling ranges go over six weeks. This does present a challenge in terms of the consultant leave policy. Most leave is booked well in advance by consultants but if leave is requested within the policy then if we cannot get another clinician to see the patients, then [patients] will be moved to the next available slot. Not an ideal solution but we are balancing two demands here”
Bolton NHS Foundation Trust: “The 6 week leave rule does on occasions cause us problems. We would use our firebreak clinics first, once used up we would ask for extra clinics. As a last resort we would do rolling moves.”
Royal Devon and Exeter NHS Foundation Trust: “Our wish is to move back to polling ranges of 6 weeks, but this is a gradual process as we resolve our capacity issues. We use our Registrars, SHOs etc. to cover consultant cancellations – where we can’t we will tend to shift all patients’ appointments back. However, this is rare”.
Allocate all new slots to the NHS e-Referral Service
If you regularly hold back slots in order to meet your ASI demands, you are effectively compiling tomorrow’s ASI list. As far as possible, align your booking processes and timings for paper etc. referrals with e-RS to prevent the notion of e-RS patients queue jumping.
Audit appropriateness of referrals and regularly feedback to referrers and consultants
If you regularly receive inappropriate referrals into a service then review your directory of services (DOS) entry in consultation with referrers to find out why and minimise reoccurrences.
You may also want to consider using the review referral action to assess the appropriateness of referrals before the patient has an appointment booked. This can allow services with complex care pathways to reduce the number of slots that are taken up by inappropriate referrals.
Enable referrers to request advice and guidance through e-RS
Detailed guidance and case studies are available from NHS Digital. However, there are examples of advice and guidance significantly reducing demand for outpatient appointments.
Consider creating additional capacity by offering non consultant led services on e-RS
Where there are genuine demand and capacity issues in particular services, providers and commissioners should work together to look at making alternative options available, potentially through more community type services.