Restricted services supporting alternative care pathways - NHS e-Referral Service

Specialist services

Provider organisations can now publish their more specialist services on e-Referral Service (e-RS). Previously, these might have been considered ‘tertiary’ services and therefore were not subject to the contractual requirements to list them in the Directory of Services. Such services can now be listed as ‘restricted’ services, with a clearly defined pathway (e.g. via an authorised general service or an authorised Clinical Assessment Service or Referral Assessment Service) being shown to the referrer.

Multiple care pathways

There may be some services where it has been determined that prior clinical assessment is required before gaining access to the service. This might be to ensure that the most appropriate care pathway is selected for the patient. This can be achieved by making such services ‘restricted’ and ensuring that an ‘authorised’ Assessment Service exists that is able to clinically assess the referral and then re-direct or onward refer to the ‘restricted’ service. This applies to services on both the Primary Care and Secondary Care (national) menus. The service should only be restricted if it is in the clinical interest of the patient and must not be used as a means of managing demand.

Locally commissioned services

Where a CCG has locally commissioned services available to its local referrers only, there is no need to use service restriction functionality. The ability to commission services (in e-RS) at referring practice level means that only those practices which have commissioned a service will be able to see and refer into it. This removes the need for such services to be restricted.

Providers must NOT restrict access to services in order to artificially manage demand and capacity. Those delivering services under the terms of an NHS contract must adhere to their contractual obligations and only restrict access to services for a specific reason. Secondary care services should only be restricted when they are not ordinarily accessible as a direct GP referral. Such restrictions must be agreed and monitored by the lead commissioning organisation.

Services on the primary care menu should only be restricted for reasons agreed with the commissioner as part of the commissioning process (e.g. if prior clinical assessment is required or to support local commissioning schemes).

We have provided some diagrams to illustrate models that Restricted Services functionality can support.

Tertiary or Restricted Secondary Care Service Model

In this example, the National Eye Hospital offers specialised tertiary services. These services are published in the Directory of Services (DOS) as restricted services. The DOS entry lists all available, authorised services that referrers can initially access.

Clinicians within the authorised services are able to redirect to or (where they themselves are a clinical assessment service) refer-on to the restricted services, where clinically appropriate.

Clinical assessment model

In this example, the local CCG has commissioned Newtown Hospital to provide an Orthotic Service and The Village Hospital to provide a specialised Podiatric Service, with surgical input. The CCG also provides a Community Physiotherapy Service. All of these services are restricted services and do not accept referrals directly from GPs within the CCG.

The pathway to all these services is via the Newtown Musculoskeletal Assessment Service. This service is an authorised service for the others. Referrals received into this service are triaged and/or treated. Those referrals that are clinically appropriate can be referred-on to the relevant restricted service.

GPs can see the restricted services, but cannot refer to them directly - they will instead be directed to refer via the authorised service, Newtown Musculoskeletal Assessment Service. 

Referral Assessment Service Model

In this example, the local paediatric referral pathways are complex and referrers often refer into an inappropriate service so the service provider has set up a Referral Assessment Service (RAS).

The RAS takes all paediatric referrals into the hospital, triages the referral and, where appropriate passes the referral on to the appropriate clinic. The specialist paediatric clinics are all restricted and the RAS is the only service that is authorised to refer into them.

Authorised Referrer Model

In this example, two GPs at neighbouring practices are looking for an appropriate service for their patient who has a spinal problem. Both GPs can search and see that the National Neurosciences Hospital Spinal Service might be appropriate. This service is however a restricted service and the first GP (Dr Smith) is not an authorised referrer. This GP sees, within the search results, a list of alternative authorised services that he can refer to as part of the pathway:

Authorised Organisation Model

Newtown CCG has commissioned a local vasectomy service for only the practices in a specific location or Federation. This service is therefore defined as a restricted service. The service is an initial referral service but is restricted to authorised organisations - those individual practices which the service is commissioned for.

Practices in Oldtown Locality can see the service but cannot refer to the service.

This model uses Service Restriction to support this process, but the ability to commission services (in e-RS) at referring practice level now means that only those practices which have commissioned a service will be able to see and refer into it. This removes the need for such services to be restricted and may be a more effective model for primary care menu services.

For the purposes of recording waiting times, the clock start is taken from the date when the initial referral is converted into an appointment, or when the Unique Booking Reference Number (UBRN) arrives on the provider’s Appointment Slot Issue worklist.

If the provider has restricted a service and prior clinical assessment is required, then the patient’s waiting time will start when the UBRN is converted into an appointment at the assessment service, or in the case where the assessment service may be a RAS, it will start from the date on which the referral appears on the RAS Referrals for Review worklist. It does not start when the appointment is eventually booked into the restricted service.

Therefore, when restricting a service, careful consideration must be given to any potential detrimental effect this may have on the patient’s total pathway time. For example the receiving provider needs to be aware if the referral has come from an assessment service and that the patient’s waiting time has already started.

Under the NHS Constitution, a patient has the right to choose any clinically appropriate provider for their elective care and, under the terms of the current Standard NHS acute contract, providers must make all of their consultant-led elective outpatient services available on e-RS.

If providers are going to make any of their services restricted, they must ensure that at the point at which a patient moves from Primary Care to Secondary Care they have the opportunity to discuss and exercise their choice options.

Commissioning a service within e-RS means that a referrer belonging to that commissioning organisation (currently, the Clinical Commissioning Group to which their practice belongs) is able to refer to that service. The service will be displayed when the referrer selects both the ‘Search Primary Care’ and ‘Search All’ buttons within the application.

All services on the (national) Secondary Care menu are automatically commissioned for all referrers and there is no longer the requirement, nor the ability, to commission a service on the Secondary Care menu.

Primary Care menu services, however, will still need to be commissioned to allow a referring clinician to access the service. If the service is ‘restricted’, however, then it will be visible to the referrers in the CCG but only authorised users or members of authorised organisations (i.e. practices) will be able to refer to it. The ability to commission services (in e-RS) at referring practice level means that only those practices which have commissioned a service will be able to see and refer into it. This removes the need for such services to be restricted. Unless commissioned at practice level, then the service is only visible to the practices which can refer to it. If commissioning at practice level is used then there would not be a need for the provider to restrict the service.

Within a provider organisation, there will be at least one member of staff (ideally more than one) who ‘defines’ the services for that organisation. This is done by the user having a Service Definer role associated with their smartcard.

To restrict a service, the service definer must first select one of the following reasons from within the application:

• Practice Based Commissioning
• Prior approval service
• Prior assessment required
• Specific pathway required
• Tertiary service
• Other (Comments are then required as a mandatory field)

To enable the restricted service to be published the Service Definer must add one or more of the following to the service:

• Authorised Service
• Authorised Referrer
• Authorised Organisation. 

When a referrer has entered specific search criteria and services are returned:

• they will be able to see, and refer directly into, services that they are authorised to access.
• they will be able to see, but not refer directly into, services that they are not authorised to access.

Where a referrer is unauthorised, services that are ‘restricted’ will be clearly marked as such in the Service Selection screen.  Clicking  onto  the  ‘Restricted’  hyperlink  will  return  one  or  more  services  that  are ‘authorised’ to access the restricted service.  In such cases, the referrer is able to select services from the original short list, as well as the services identified as a possible pathway to the restricted service.

Referrers should be aware that selecting an ‘authorised’ service does not guarantee that the referral will be referred-on to the ‘restricted’ Service. This is a clinical decision that will be made by the receiving, authorised service.

There is a restricted services enquiry within e-RS. This enables commissioners, referrers and provider organisations to display restricted services. This is not limited to their organisation but includes any organisation in the Directory of Services.

The enquiry will return the following information:

• the service ID and the service name of the restricted service, along with the reason the service was restricted
• the restriction date/time - showing the last time the service was restricted (which is updated each time this action is carried out)
• the Restricted Count - showing how many times this has been done.

The number of authorised services, organisations and referrers associated to the restricted service, is displayed.