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Supporting clinical referral pathways – NHS e-Referral Service (e-RS)

Find out about the different channels available in e-RS via which a referrer may obtain a clinical opinion and/or refer a patient

An e-RS referral can be made into:

  • either a directly bookable service - in which case the patient needs to book an appointment before the referral can be processed further
  • or a triage/assessment service - where the referral information is assessed first, without an appointment being pre-booked 

In addition, advice can be obtained by a referrer from an advice and guidance service, before (or instead of) making a referral.

More information on the following different referral channels are described on this page:

  • advice and guidance
  • referral assessment service
  • directly bookable service

This function allows a referrer to enter into dialogue with a provider (consultant) around a patient’s care.

If the outcome of the advice dialogue is to refer, the referrer can easily convert the A&G dialogue into a referral.

Process flow
  1. Referrer initiates A&G with the consultant or specialty of their choice and informs the patient they are seeking expert advice.
  2. Referrer asks a question and adds relevant clinical information.
  3. Consultant/specialist reviews the A&G request and responds to the referrer.
  4. Referrer/referrer admin reviews A&G worklist daily:
  •  reads and actions any replies
  •  monitors unanswered queries
  1. Referrer/referrer admin liaises with the patient on the outcome of the advice. If needed converts the A&G to a referral, adding any additional clinical information

Image illustrating the advice and guidance process flow

Key points
  • A&G provides two-way dialogue between the referrer and consultant/specialist
  • worklists keep a record or all open advice and guidance dialogues
  • audit trail available through the unique booking reference number (UBRN)
  • when A&G is converted into a referral the advice and guidance dialogue is attached to the clinical referral information
  • if a referral is needed the referral can be sent to any provider (not just the one from which the advice was requested)
  • referrers and providers can easily add photographs, documents, and web addresses as attachments to the dialogue
User benefits and considerations

Referrer

Benefits

  • treatment may be recommended and started within 48 hours of seeking specialist health (improved health outcomes)
  • one to one dialogue with specialist to optimise complex patients’ care
  • improved knowledge/education for referrer
  • improved confidence that the patient is being managed appropriately

Considerations

  • additional clinical task to raise the A&G request
  • additional clinical/admin task to read and action the reply

Provider clinician

Benefits

  • ability to educate referrers and disseminate knowledge easily regarding latest treatment and care pathways
  • offer care for patients without unnecessary face to face appointments
  • provide reassurance to patients and referrers where a referral is not required
  • attracts a tariff price for each response

Considerations

  • additional clinical task to respond to request

Provider admin

Benefits

  • reduction in the number of patients that require their appointment or service changing

Considerations

  • additional admin task if a clinician does not access e-RS themselves

Patient

Benefits

  • faster treatment closer to home
  • appointment only created after specialist advice is given
  • following receipt of advice, greater confidence in their eventual treatment plan

Review the A&G toolkit for more information.

RAS enables the referrer to send a referral to the provider clinician to enable them to assess the clinical information and/or triage the patient, prior to (or instead of) booking an appointment. Responsibility rests with the provider in booking any subsequent appointments.

Process flow
  1. Referrer searches for the most appropriate services for the patient’s clinical condition. After agreeing the patient’s preferred provider, they send the request to a RAS.
  2. Referrer/referrer admin attaches the relevant clinical information to the referral.
  3. The specialist reviews the clinical information and decides whether the patient needs to be seen or provides advice to the referrer instead.
  4. If the patient needs to be seen, the specialist arranges the right type of care. For example, small operation, specialist test, or an out-patient appointment.
  5. Provider staff contact the patient and agree the service and appointment date and time with the patient, recording the outcome on e-RS.

Image illustrating the RAS process flow

Key points

RAS was designed for the following scenarios:

  • where a service (often oversubscribed) has a high number of referrals that could have been dealt with by advice back to the referrer rather than a face-to-face appointment
  • a service where a number of referrals could be booked straight to test/procedure without the need for a first out-patient appointment (for example, booking straight to endoscopy)
  • where a provider has determined that pathways are complex and that the clinical referral information (CRI) needs reviewing before an appointment is booked - in such cases directly bookable services may be restricted and only available by referring to a RAS.

Note: patients are not registered automatically on the patient administration system (PAS) when being referred to a RAS.

User benefits and considerations

Referrer

Benefits

  • improved knowledge/education based on RAS advice

Considerations

  • uncertainty – unable to see who would deliver the fastest appointment or treatment for the patient
  • cannot give the patient reassurance of an appointment date, so patient may come back to see the referrer

Provider clinician

Benefits

  • able to support complex pathways, for example, by arranging investigations followed by the initial specialist appointment
  • ability to arrange straight to test or to procedure (reduce unnecessary initial appointments)
  • reduces unnecessary redirections to the correct service, where the initial service referred to is incorrect

Considerations

  • additional time and resources to manage the patient’s referral, including embedding patient choice where appropriate
  • additional time and resources sending advice back to the referrer

Provider admin

Benefits

  • a reduction in the number of patients who need to be moved, as referrals are all directed to the right service first time 

Considerations

  • patients need to be manually registered on the patient administration system (PAS) if providers want to record the outcome of an assessment on their own clinical systems
  • additional time and resource required to contact every patient to book them into a suitable appointment and register on PAS, if not booked through e-RS.

Patient

Benefits

  • reduction in unnecessary appointments as tests can be booked before an out-appointment making each appointment more worthwhile

Considerations

  • lack of certainty of where their referral is in the process
  • no ability to pick a service based on waiting times
  • potentially lack of choice of booking date and time (if provider books appointment and sends to patient)

Find out more about RASs.

A provider can set up a service that directly links to their appointments system. This allows the patient to select an appointment and book it.

Process flow
  1. Referrer with the patient searches for the most appropriate services for the patient’s clinical needs and shortlists one or more clinics from which the patient can choose an appointment.
  2. Referrer provides the patient with instructions* on how to select a clinic and book their appointment. For vulnerable patients or two week wait patients the appointment is booked and the appointment details given to the patient.
  3. Referrer/referrer admin attach clinical referral information. For example, a referral letter or pro-forma to the electronic referral.
  4. For the majority of patients the patient books their own appointment either online through the patient website (Manage your referral- MYR) or over the telephone via the telephone appointment line.
  5. Consultant/specialist reviews the clinical information and accepts the patient into their service (or re-directs to another more suitable service).

Image illustrating the directly bookable service process flow*Instructions can provided in the form of a printed letter and in some cases, electronically.

Key points
  • ideally suits referral pathways or criteria which are well-established, and the chance of re-direction or rejection is likely to be low
  • availability of appointment and waiting times are clearly displayed for the different services using red/green colour code for services that are struggling with capacity/services with excellent capacity to manage patients
  • the patient books their own appointment and can change their appointment without the need to contact the GP, clinic, or referrer
  • this is the most economical way of referring a patient into an out-patient appointment using e-RS
User benefits and considerations

Referrer

Benefits

  • Referrers can access information from the provider to help ensure the patient is referred to the most clinically appropriate service
  • patients are in control of their appointment meaning reduced numbers return to the referrer with queries
  • ability to track the patient’s referral and manage the patient’s needs proactively during the referral pathway

Considerations

  • Referrer must learn how to shortlist services within the consultation
  • practice admin time increased if patients are not encouraged to book appointments themselves, either online or using the national telephone appointment line

Provider clinician

Benefits

  • reduction in patients who do not attend (DNA) as the patient has booked their appointment at a time to suit them

Considerations

  • referral still needs to be clinically assessed
  • following review of the clinical information, a small number of patients may need to be moved to a more appropriate service

Provider admin

Benefits

  • reduction in admin resources as the system registers all patients on the patient administration system (PAS) and the appointment is booked electronically without the need for manual booking processes
  • improved ability to capacity manage clinics

Considerations

  • some patients may require a change of service resulting in the admin staff having to contact the patient to rebook their appointment

Patient

Benefits

  • improved patient experience: patients can book, cancel and change appointments themselves
  • patients have the provider’s number to chase deferred appointment

Considerations

  • if appointments are not available, referral may be deferred to provider, so the patient is not able to directly book appointment therefore less certainty

Advice and guidance model

Clinical presentation - Referrer receives an abnormal set of blood results for a patient, and is considering a referral, but unsure if this is needed.

Outcome - Advice given on the interpretation of results and referrer advised on alternatives to referral.

Referral assessment service model

Clinical presentation - Referrer wants to refer a patient to their local cardiology service, with symptoms of exacerbation of their heart failure condition.

Outcome - Specialist triages referral and patient sent direct for an echocardiogram, prior to review in an outpatient appointment. Admin team contact patient and book their echo appointment and outpatient appointment.

Directly bookable service model

Clinical presentation - Referrer examines a patient who has a inguinal hernia and the patient and referrer agree that a referral is required, as it is causing pain

Outcome - Referrer finds general surgical clinics that deal with inguinal hernias and patient is offered a choice of providers from which they can book directly into the hospital with the shortest waiting times

Last edited: 24 June 2020 3:25 pm