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Mental health best practice guidelines and the NHS e-Referral Service

This guidance aims to demonstrate the benefits of using an electronic referral and booking tool for mental health services and explain how the system should be used in day-to-day clinical practice.

Introduction

The NHS e-Referral Service (e-RS) is now well established as an effective means of referral to outpatient services that is both safe and convenient for patients and following the success of the Paper Switch Off Programme, is now used for all GP to consultant-led outpatient referrals. It is being used more and more for referrals to mental health services.

This guidance aims to build on that previously issued (in 2009) to demonstrate the benefits of using an electronic referral and booking tool for mental health services and explain how the system should be used in day-to-day clinical practice. The guidance:

  • supports providers using an electronic system (e-RS) to replace existing manual processes
  • draws on feedback from clinicians and managers who have highlighted a number of key issues that need to be addressed during implementation
  • should help to ensure that processes are fully optimised to support referrers and patients in choosing a provider and in booking an appointment using e-RS

Mental health services

The NHS e-Referral Service (e-RS) supports referral and booking from GPs and referrers for adults, and children and adolescents. Referrals and bookings can be made into a preliminary mental health clinical assessment service where required, or straight through to an outpatient appointment. Below are the two mental health specialities and their associated clinic types.

Speciality: Mental Health - Adults of all ages

Adult mental health clinic types include:

  • anxiety/depression/stress - moderate or mild
  • anxiety/depression/stress - severe
  • drug/alcohol problems
  • eating disorders
  • memory problems
  • not otherwise specified
  • peri and post natal issues
  • psychological disorders/difficulties
  • psychotic disorders
  • self harm
  • sexual issues

Speciality: Mental Health - Child and Adolescent

Child and adolescent mental health clinics types include:

  • anxiety/depression/stress - moderate or mild
  • anxiety/depression/stress - severe
  • behavioural problem 
  • drug/alcohol problems
  • eating disorders
  • emotional problems
  • not otherwise specified
  • psychotic disorders 
  • school refusal
  • self harm 
  • sleep problems

Providers will need to decide which of their services are appropriate to load onto the NHS e-Referral Service. As a minimum, routine consultant-led services should be made available on the NHS e-Referral Service, plus routine services led by other healthcare professionals and and in other settings e.g. community services. Providers will need to consider whether urgent services are also appropriate and whether having them on the NHS e-Referral Service may facilitate a more efficient process for urgent referrals.

Services such as crisis resolution services and assertive outreach team services are inappropriate to have on NHS e-Referral Service due to their particularly urgent nature. Providers will need to ensure that the referring practices and other healthcare professionals are clear as to how to access these types of services or any other services that are not appropriate for the NHS e-Referral Service.


Models of care for mental health services

The referral, assessment and treatment pathway for mental health services may not be as straightforward as a referral to an acute hospital consultant. Therefore it is essential for referrers and providers to be involved in designing and agreeing the referrals process which will best suit the need of the local pathway.

Direct to service

  • referrer refers directly to the service
  • the appointment is booked and the service provider personnel can view the clinical referral information
  • if the referral is appropriate then the provider can accept the referral
  • if the referral is not appropriate then the referral can either be redirected to the correct service or rejected back to the referrer

This is appropriate where referrers are clear on what service they require for that patient.

Service providers will need to ensure that the supporting information they provide to referrers through the Directory of Service information supports their decision making.

Example a patient who requires a referral to a drug or alcohol service.

Patient

Benefit

  • immediate access to the correct service
  • can be supported in the booking process by the referrer at the time of referral if needed
  • reassurance that they are ‘in the system’ before leaving the referring practice

Referrer

Benefit

  • immediate visibility of available services at a local and national level
  • supporting service information at the time of referral such as referral criteria and required investigations
  • ability to book appointments immediately to support vulnerable patients
  • knowledge at all times as to where patients are in the system
  • ccess to advice and guidance. 

Consideration 

Complex cases where a referrer may not have sufficient knowledge to accurately identify the correct service and advice and guidance is not available to support the decision. 

Provider

Benefit

  • almost zero admin overhead for the service booking the appointment
  • referral letter immediately available at the service
  • no internal transfer of paper referrals
  • referrals can be redirected to other services electronically if needed
  • worklist provision gives immediate access to referrals that require processing
  • ability to provide the referrer with referral and service information at the time of referral e.g. referral criteria and required investigations
  • fewer inappropriate referrals resulting in a potential significant cost saving
  • can provide advice and guidance to help reduce inappropriate referrals
  • fewer inappropriate referrals resulting in a potential significant cost saving
  • can provide advice and guidance to help reduce inappropriate referrals. 

Consideration

It may be difficult to define services where it could not be reasonably expected that a referrer could correctly identify the appropriate service.


Clinical/telephone/referral assessment service (CAS/TAS/RAS)

  • the referrer refers to the Assessment Service which can ‘onward refer’ to the appropriate service
  • referrals can be redirected to different services within the organisation or outside of the organisation
  • feedback can be sent directly to the referrer on the appropriateness of a referral, or the referral returned to the referring clinician with advice on how to manage the patient, if the referral to another service is not needed.

This is appropriate when complex cases need to be assessed to ascertain the appropriate pathway prior to offering an outpatient or equivalent appointment. However, it may introduce delay in the patient receiving definitive care. It may also introduce an additional cost due to each referral having to be triaged, so careful consideration should be made prior to deciding on this model. Any of the assessment models should only be used where it helps to streamline the referral pathway and add clinical value to the patient journey.

Example:

  1. a telephone assessment service for access to psychological therapies (TAS)
  2. a community mental health team assessment to agree treatment options with the patient (CAS)
  3. a Referral Assessment Centre (RAS) that acts as a gateway for a cognitive behavioural therapy service. 

Referrals can be redirected to different services within an organisation or outside of the organisation.

Patient 

Benefit

  • complex cases can be assessed to ascertain the appropriate pathway before the patient attends

Consideration

  • additional step in the pathway
  • vulnerable patients may not understand the process

Referrer 

  • single point of access for all referrals

Consideration

  • not as easy to support vulnerable patients, due to more complex processes

Provider

Benefit

  • ability to triage all referrals to a service
  • can "refer on to any service either inside or outside the organisation if required
  • can return the referral to the original referrer with advice

Consideration

  • every referral must be triaged
  • high overhead for triage
  • high overhead for appointment booking as all patients will need to be contacted to arrange an appointment following triage
  • additional time taken in the Referral To Treatment (RTT) timescales while triaging referrals

Mixed access

The referrer can refer into certain services but other services can only be accessed following assessment.

This model may be appropriate where some but not all services can be appropriately selected by the referrer. It may also be appropriate for different services within the same provider.

Example: a referral to a community mental health team is reviewed and discussed by the multi-professional team prior to the patient being given an appointment for a consultant outpatient appointment.

The referrer can refer directly to a service or to the assessment service. Note that the assessment service can "refer on" to any service. 

Patient

Benefit

  • patient will be on an appropriate pathway for their condition

Referrer 

Benefit

  • immediate visibility of available services at a local and national level
  • for cases where there is uncertainty about the correct service the assessment service can provide access and advice for future referrals

Provider

Benefit 

  • almost zero administrative overhead for booking where the referral goes direct to the service
  • complex cases can be easily ‘referred on’ to the correct service where necessary
  • only triaging a proportion of the referrals that require this intervention

Advice and guidance

Advice and guidance is a secure and auditable electronic means of a referring clinician asking for and receiving advice from a particular service provider clinician through the NHS e-Referral Service. Learn more about NHS eRS advice and guidance.


Setting up a mental health service

See the Directory of Service guidance for information on setting up a Mental Health Service.


Referrals to mental health services

Considerations when making a referral:

  • the NHS e-Referral Service should not be used for very urgent referrals to Mental Health Services or where there is a risk of harm; these referrals should be made to the provider according to the locally agreed pathways
  • searching for clinically appropriate services for patients involves the referrer using either a Specialty/Clinic Type combination or SNOMED clinical terms e.g. anxiety disorder
  • using a SNOMED clinical term is recommended as it should most accurately and easily find appropriate Mental Health Services for patients
  • in certain circumstances, entering a named clinician may be used to locate consultant-led services that have been set up in this way
  • under the terms of the NHS Constitution patients in England who need to see a mental health professional as an outpatient can choose which healthcare professional (including consultants) will be in charge of their treatment
  • the referrer should consider whether they should book the appointment whilst the patient is in the practice or allow the patient to leave with an appointment request and book at their own convenience
  • for many patients who are referred to Mental Health Services, especially those that are vulnerable it is appropriate to book their appointment whilst at the practice so that the referrer and the patient know when and where the appointment will be
  • where the service selected is an assessment service (CAS/TAS) the patient should leave with a clear understanding of whether the assessment will be conducted over the telephone or whether they will need to attend an appointment
  • where the service selected is a RAS the patient should leave with a clear idea of what the next steps are in the referral process
  • in the case of a CAS or a RAS the patient should know what  action to take if they do not hear from the provider within a specified time period
  • some providers may wish referrers to use a particular referral template. This can either be embedded in the referrer’s clinical system or be available via a link in the service detail

Reviewing clinical referral information

Once an appointment has been booked and the clinical referral information has been attached by the referrer, a service provider clinician must undertake a review of the clinical information in a timely manner to ensure that the request is appropriate for the patient and that an appointment has been booked within a clinically appropriate timescale. This is best achieved by the service provider accessing the information directly from within the NHS e-Referral Service.

The provider clinician must then either accept the referral, if appropriate; redirect it to an alternative service, or send it back to the referrer if it is considered clinically inappropriate.

Local processes must also be in place to support a change of priority or appointment time/date.


Restricted services

Additional functionality in the NHS e-Referral Service allows service providers to make certain services ‘restricted’ and thereby govern who can refer patients into them.

A service should only be made restricted if doing so is in the best interest of the patient. Restricting services must not be used as a means of managing demand or where referrers are easily able to identify the correct service without the need for a potentially costly and time consuming intermediate service.

When used together with a CAS or a RAS service, this allows more complex pathways to be made available through the NHS e-Referral Service, including referrals to more specialist Mental Health Services, which may previously have been considered tertiary services.

More information can be found on the restricted services guidance web page.

Last edited: 27 January 2020 3:37 pm