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Moving to directly bookable service - NHS e-Referral Service

Although the NHS e-Referral Service (e-RS) supports indirectly bookable services (IBS) it is recommended that service providers who have a compliant patient administration system (PAS) move to directly bookable services (DBS).

Moving to direct bookings

While e-RS supports indirectly bookable services (indirect booking of appointments) which means that the patient can be referred using the system but must contact their preferred provider to arrange their appointment.

Where the service provider has a compliant patient administration system (PAS) they are able to make the move to directly bookable services (direct booking of appointments).

Where direct booking is available, the patient will leave their surgery or their referrer with either:

  • an appointment, booked with their chosen provider on a date and at a time that is convenient to them
  • the information necessary to enable them to make their choice of provider and to book, either via the Internet or through the telephone appointments line (TAL)

Both the patient and the referring clinician have certainty about the next step on their pathway, while providers reduce the time spent arranging appointments. Patients express a very high level of satisfaction with such arrangements, and evidence shows that the level of missed appointments is significantly reduced.

Find out how to change an indirectly bookable service to directly bookable service (N3/HSCN connection required).

Successful implementation of direct booking

Board-level engagement

Where board-level management take a proactive part in the implementation of e-RS and particularly direct booking, it is more likely that the necessary support will be made available to enable the project to succeed.

Clinical engagement

e-RS is a clinical programme, requiring clinician support and co-operation in both primary and secondary care. Clinical input is required for all aspects of the system, but particularly in the following areas:

Design of the directory of services (DoS)

A good DoS is the key to successful implementation, and input from both consultants and referrers is crucial to this success. Consultants need to ensure that the DoS accurately describes the services and clinic types available, and referrers need to help ensure that the descriptions and associated clinical terms enable them to find the appropriate choices for the patient. It is also crucial to ensure that consultants understand exactly what the GPs see on the screen when searching for services, as this will facilitate good design. Find out more about directory of services.

Clinic organisation

A prerequisite to a successful implementation of direct booking is to have good control over waiting lists and waiting times, and to ensure that the capacity available in clinic is used to maximum effect. Failure to review the business processes attached to clinics could result in waiting time breaches and/or lack of available slots for patients to book into.

Providers often have concerns around the publication of all slots to e-RS, which may be seen as ‘losing control’ of the waiting list and the management of waiting time targets. These concerns can be overcome if both commissioners and providers work together to understand the demands on services, and NHS contracts provide for the correct levels of activity.

Organisations need to bear in mind that patients have a choice of provider and are entitled to receive an appointment with their chosen hospital. Provider capacity should not be a barrier; any financial issues that may affect the management of activity levels locally need to be addressed through the contracting process and should not be attributed to the e-RS system.

Slot availability

One of the main barriers to successful implementation of direct booking is the availability of appointment slots. Difficulty often arises because the provider is failing to meet demand or is not allocating enough of the available resources to direct booking. This difficulty may be compounded while running both old manual pathways and new electronic pathways in the transition. But it may be that commissioners are seeking to manage demand by placing constraints on the treatment of patients who have been referred. It is not appropriate for either commissioners or providers to limit referral of patients by restricting the availability of slots or the refusal of referrals other than on clinical grounds. This is reflected in the operating framework and NHS contract.

e-RS will very quickly highlight a genuine imbalance between available capacity and demand, and patients will find that there are no slots available at their chosen provider.

What works?

Clinical engagement

Having referrer and provider clinicians championing the cause and working with managers in the rollout of the system across the local health community (LHC), is a good incentive for other clinicians to get on board.


Good communication with all stakeholders throughout the process is very important, and will continue to be important after implementation, to ensure that all users are comfortable with the system, that processes are constantly reviewed, and that shortcomings and areas for improvement are discussed and addressed on an ongoing basis.

Directory of services

Provider and referring clinicians should work together to design a DoS that makes sense from the point of view of both the referrer and the receiving clinician. If this happens, it is far more likely that the referrers will use the system, as it accurately reflects the referral process, and there is a greater chance of the referral getting to the right place first time.


Where providers have planned the implementation of direct booking as a ‘big bang’ exercise, simultaneously rolling out all slots in all specialties, it has proven very successful.

Such a strategy requires the provider to:

  • have a clear understanding of all available capacity and the current levels of demand for services
  • provide dates for all patients on the current waiting list
  • review clinic templates to ensure that they are working at maximum efficiency
  • publish all slots to e-RS
  • identify capacity bottlenecks in advance, including using the information from e-RS system and the diagnostic tools available
  • resolve any true capacity issues through proactive NHS contract discussions with commissioners

Recognising success with feedback from patients

Where direct booking is in place and working effectively, patients are very impressed with the fact that they can leave the surgery with an appointment booked at a convenient time for them, at a provider of their choice. The patient is in control, and once issued with a Unique Booking Reference Number (UBRN) and access code, they can book, change or cancel their appointment with a minimum of fuss. Referrers using direct booking regularly recognise the benefits both for the patients and for their practice administration as a key motivation.

“I was astounded when I went into the surgery and left with my appointment. What an improvement in service. It’s great, more people should know about this. I really felt I was being considered as a person and not just a number for the convenience of the NHS.”

Sarah Thirkill, Devon

A successful implementation of direct booking could be defined as: ‘the majority of appointments can be booked using the e-RS system easily, quickly and with a minimum of obstacles’.

Other measures of progress include the:

  • number of referrers using the system regularly
  • number of referrals being made via e-RS
  • number of referrals being made using traditional methods
  • number of slots available by specialty at each provider
  • number of referrals rejected/redirected
  • number of unconverted appointment requests
  • level of did not attends (DNAs)
  • number of hospital-generated cancellations of appointments booked
  • future slot availability by specialty at each provider

Reports can be generated from e-RS to provide further information. Find out more about reports and statistics

An implementation checklist

The experience of health communities that have the transition to direct booking through e-RS has been incorporated into the checklist below, which should assist other health communities in making the transition to direct booking.

Stakeholder engagement

Are both senior management and clinicians supportive of the transition, are they aware of the changes necessary and are prepared/in a position to make those changes that will make direct booking successful? The following indicators can be used as a checklist:

  • is there active board-level support across the LHC to move from IBS to DBS
  • is there board-level management support across the LHC to resource the transition
  • do you have a clear understanding of the barriers for change from all your key stakeholders
  • do clinicians understand the implications such as migrating to DBS is a change in the working practices and may require changes to service names, clinic types, capacity planning, etc. to implement successfully
  • do clinicians understand and are they willing to work with business managers in order to make sufficient capacity in services available in e-RS
  • do you have the active support of local medical committees. 


There are financial considerations that have to be made before migrating from IBS to DBS. The indicators listed below can be used as a checklist:

  • do you have sufficient funds to resource the rollout of the e-RS project
  • will e-RS help commissioners to address financial issues, for example, demand management
  • will e-RS help providers to address financial issues, for example, capacity management
  • have you clearly communicated the financial benefits of DBS to your stakeholders

Capacity planning

The key to successfully running a DBS trust is sufficient capacity in services being made available to e-RS. The indicators listed below can be used as a checklist:

  • is there an agreed strategy across the LHC to sustain the access targets for all high volume specialties
  • does the provider have an approach or a plan to deal with capacity-constrained services
  • is e-RS being used to maximise capacity, for example, fewer inappropriate referrals, fewer DNAs, less demand on secondary care services
  • does the provider have a strategy or a plan for managing the change in demand that may result from making services directly bookable

DoS review and strategy

A clinically appropriate and accessible DoS will leads to a reduction in inappropriate/incorrect referrals and acts as a front-of-house marketing tool for trusts. The below indicators can be used as a checklist:

  • if your PAS is not fully compliant, do you have a strategy for dealing with missing messaging functionality, for example, priority, named clinicians, multi-slots IDs
  • is senior management aware of the importance of the DoS and the need to provide sufficient resources to keep it maintained
  • have clinicians been actively engaged with adding appropriate clinical content to DoS entries
  • is there a process for referrers to provide regular feedback on DoS entries


e-RS requires new technology to be utilised. The indicators listed below can be used as a checklist:

  • has the board ensured there is an effective IT infrastructure in place
  • have you assessed the likely impact of e-RS on local IT infrastructure
  • does the IT department have the appropriate capacity and resource in place to drive through technical implementation of e-RS
  • does the IT department understand the business implications of e-RS and can they influence implementation across the organisation

Operational and business process redesign

e-RS changes the way referrals are made and handled. Internal trust processes will have to change to reflect this. The indicators listed below can be used as a checklist:

  • does the organisation have a business process/service strategy in place that takes account of the changes which e-RS makes to booking and referral processes and is this supported by senior management
  • is the organisation actively redesigning business processes to take advantage of the opportunities afforded by e-RS
  • does the organisation have a successful history of previous process redesign work, if not, how does the organisation plan to address this and carry out the necessary process redesign work for e-RS
  • is there a resourced training capacity to support the IBS to DBS transition


Good communication of the migration from IBS to DBS along with the changes required and the benefits to be realised will aid the success of the move to DBS. The below indicators can be used as a checklist:

  • do you have a stakeholder map, this needs to include internal stakeholders and external stakeholders (for example commissioners, GPs, the telephone appointment line, patient, etc)
  • do you have a communications strategy that includes the ability to change your communications plan, as well as receive and act upon feedback

Last edited: 27 January 2020 3:40 pm