The following advice on managing elective referrals during the coronavirus response has been circulated by NHS England and NHS Improvement to their regional teams:
The recent letter NHS letter, 'Second phase of NHS response to COVID-19' dated 29 April, sets out the need for all NHS local systems and organisations to step up non coronavirus urgent services, as soon as possible over the next six weeks, including primary care to “make two-week wait cancer, urgent and routine referrals to secondary care as normal”. This note provides supplementary information and guidance to enable referrals to be made.
GPs and other healthcare professionals must continue to make referrals using the NHS e-Referral Service (e-RS). To allow this, secondary care providers must ensure that services remain available on e-RS to refer into. This will enable referrals to remain visible, ensure patient safety, and enable providers to book patients into appointment slots when appropriate. As per existing practice, this will also enable the transfer of clinical responsibility from primary to secondary care and allow patient clock starts to be recorded for the purposes of referral to treatment (RTT) and cancer performance monitoring.
Acknowledging that providers will be managing referrals in different ways, NHS Digital has produced the following guidance which details various features of the NHS e-Referral Service (e-RS) that can help referrals to be managed safely, triaged and processed according to clinical priority.
Secondary care providers should review this guidance and ensure that the most appropriate features within e-RS to allow Primary Care / GPs to make referrals, are enabled as soon as possible.
Accepting that providers will be managing referrals in different ways, this page identifies various features of the NHS e-Referral Service (e-RS) that can help referrals to be managed safely and according to clinical priority.
Allowing routine referrals to continue to be made
In February 2020, new functionality - the patient booking window - was introduced in e-RS to allow providers to set a ‘booking window’ for each clinical priority that a service supports.
As part of the management of routine and urgent capacity, providers can ensure patients are able to book a future outpatient appointment within a specified booking window, for the priority of the referral.
This new functionality can help providers manage which referrals they will accept with a booked appointment (for example, urgent and two week wait) and which they would prefer to manage from the ‘Appointment Slot Issues’ (ASI) worklist (for example, routine), allowing them to book the appointment when ready to do so.
As an example, providers could make their urgent priority appointment slots available within the required timescale (to allow urgent referrals to still be booked, if required) and set their ‘Routine Booking Window’ to start after the end of the polling range. This would ensure that the service is still visible to referrers for any routine referrals that still have to be made, but that they would all come to the provider as ASIs, to be recorded and then managed at a future date.
Below is a diagram showing slots available in e-RS only:
Using the patient booking window is the preferable solution to reducing the e-RS slot polling range to zero.
Important points to note when setting polling range to zero.
- setting a polling range to zero will remove ALL appointments of every priority from each service this change was applied to
- some patient administration systems (PAS) do not behave as expected when the polling range is reduced to zero, meaning that slots are still showing as available to be booked into
- even when reducing slot polling to zero days, if an appointment is cancelled in either e-RS or PAS (and not the actual clinic slot in the clinic template on PAS), and an appointment is cancelled ‘today’ that slot will still be visible to patients (who have already been accepted into that service) to re-book into until the next overnight poll
Remember – if appointments for routine referrals need to be cancelled, then using the patient booking window functionality will ensure that those referrals cannot be rebooked, either by the patient, their GP practice or the appointments line, outside of the routine appointment ‘window’. For example, into appointment slots within the booking window defined for urgent appointments.
However, the provider can rebook, if required (as in this example), any cancelled routine referral into an urgent priority slot
Find out more about the patient booking window.
Advice and guidance
e-RS advice and guidance (A&G) allows referring clinicians to seek advice from provider clinicians, allowing consultants and other hospital clinicians to provide support to GPs in relation to a patient’s condition. Use of A&G helps to reduce unnecessary hospital referrals and minimise the need for face-to-face appointments.
In the current situation, use of A&G should be considered ahead of any referral being made, so that only those referrals that are clinically necessary at the present time are made to providers. Advice back to GPs from provider clinicians should, wherever possible, maximise management of patients in primary care.
Remember – e-RS now allows providers to set-up ‘Advice Only’ services which may help providers to manage the current situation. Setting up these service types at specialty level would support consultants pooling the response process.
Find out more by reviewing the advice and guidance toolkit.
Using provider worklists to safely manage referrals
Providers should closely monitor the ‘Appointments for Booking’ worklist which displays all referrals (UBRNs), including those that have had their appointment cancelled, either by the GP practice, the telephone appointments line (TAL) or the patient themselves via the Manage your referral website. Referrals are displayed in order of their clinical priority. For example, two week wait, urgent and routine. In addition to appearing on this worklist, the referral will also be visible on the referring GP practice’s worklist, so they can also see that an appointment has been cancelled and needs to be re-booked.
All referrals that are cancelled will appear on the appointments for booking worklist, so it is important, while many appointments are being cancelled, that providers manage this worklist carefully.
If providers are receiving an increased number of referrals (UBRNs) on the appointments for booking and appointment slot issues (ASI) worklists it is recommended that worklist filters are used to limit the list of referrals (UBRNs) displayed. For example, filtering the worklist by a specific specialty, location and/or service will reduce the number of referrals being returned. Use 'Reset all filters' to return to the original view or select an alternative filter.
on and/or service will reduce the number of referrals being returned. Use 'Reset all filters' to return to the original view or select an alternative filter.
Find out more information about worklist filters (N3/HSCN connection required).
All referrals that are remaining on an e-RS worklist must have been clinically triaged to ensure one of the following.
- they are clinically appropriate for the service they have been referred into
- if possible, advice could be offered back to the GP so that the patient can more appropriately be managed in primary care
- the referral priority does not need to be changed
- the patient’s care will not be adversely impacted by the extended wait
Please note – As previously communicated, the sending of routine reminder letters was temporarily suspended during the current situation. Referral rates are now rising again and so this important safety net is being reinstated, with routine reminder letters being sent again from Monday 6 July. This will affect any new routine referrals created, or routine appointments cancelled, from Monday 15 of June.
This is an important safety net, ensuring that referrals do not get lost or appointments missed.
Clinical referral review and triage
The following quick reference guides have been created to support the switch to clinically triaging referrals online via e-RS.
Additional e-RS features that may help
Telephone assessment service (TAS)
e-RS supports referrals into several different service types; outpatient appointment, assessment or triage services, which could be used to support on-line or telephone consultations. One of these service types is the telephone assessment service (TAS). The TAS appointment date/time should be agreed with the patient and the process clearly explained, so that the patient understands what method the clinic will be using to contact them. For example, via telephone or an online consultation.
Contact firstname.lastname@example.org if you would like more information on how to convert face-to-face appointment types to telephone assessment services.
Use of instructions in the directory of services (DoS)
Within the definition of each service on the DoS, providers can use the ‘Instructions’ section to relay information to patients. These are then displayed on the ‘Appointment Summary’ screen (for referrers) and printed on the appointment confirmation when a patient books their appointment or displayed onscreen in the Manage your referral patient booking website.
Providers should use the instructions section to advise patients of the next steps or how their appointment will be delivered, whether via telephone or online consultation, for example.
The EBSX02 extract is now available daily to support providers with the daily management and planning of outpatient referrals, including appointment slot issues or monitoring cancellations, etc.
Find out more from the reports and extracts pages on our website.
Business as usual requirements and considerations
Referral to treatment reporting
It should be remembered that e-RS is a referral and booking tool; it is not a waiting list and should not replace trusts’ usual recording and monitoring processes with regards to tracking patients’ referral to treatment times (RTT). Where patients are being managed from any e-RS worklist, for example, the ‘Appointment Slot Issues’ (ASI) worklist, they must also be recorded on the trust’s patient administration system (PAS) and reported on monthly RTT returns.
Further guidance is available in the NHS Improvement Rapid Improvement Guide, available from the NHS England website.
Cancelled and un-booked appointments
Where trusts have a backlog of un-booked patient referrals in e-RS, it is likely that they will be on either the appointments slot issue (ASI) worklist (new referrals) or the appointments for booking worklist (previously booked or triaged referrals).
If possible, the appointment booking should be carried out within e-RS as this maintains the full audit trail and allows the GP/referrer to monitor patient referrals and bookings.
All these referrals should already have been captured on the trust’s patient tracking list (PTL) and should therefore be booked in order of clinical priority and date of receipt of referral when the trust is ready to arrange the outpatient appointments again.
Using the ‘Update/Book’ option from either of these worklists, will allow providers to either book/re-book the referral into the same service to which it was originally referred or create a new shortlist if the referral needs to be moved to a different service. At this point the provider can continue and book an appointment for the patient, or create a new appointment request letter and send the details to the patient for them to select and book their own appointment via the online patient website (Manage your referral – MYR) or by calling the assisted digital channel (the appointment line – TAL).
It is likely that providers will have a mix of referrals waiting to be booked, both on their PTL and on e-RS. Once these have all been booked, they will be opening up their services again for GPs and patients to book directly into through e-RS.
Returning to business as usual
At this point, the need to understand the length and make-up of the backlog becomes important and this is also where use of the patient booking window may be helpful.
All routine referrals waiting to be booked should be reviewed to ensure that they are still valid, and the appointments are still needed so that these patients can then have an appointment arranged. It is important to do this first to be able to accurately understand when you will be able to make new appointments available for new referrals.
At this point providers can set a routine patient booking window to start form this future date so that all new referrals can have an appointment booked directly through e-RS by either the patient or referrer.
Where virtual appointments may have been used during the current situation, providers may wish to continue with some of these as a means of maximising outpatient capacity and reducing unnecessary patient visits to hospitals.
Actions that providers may have taken and advice on re-setting
Slot polling range reduced to zero days
Where this action has been taken, providers will need to open the polling range for each service again, so that new referrals can be made and booked. Use of the patient booking window feature will help ensure that referrals can only be booked within timescales that meet the needs of the provider. Find out more information about this in the Allowing routine referrals to continue to be made section.
Routine priority removed from services
Some providers have taken the step of removing the routine priority from the service details, so that when referrers search on this priority, their services are not returned. This could be confusing for referrers who will then refer to other providers or potentially not refer at all, which may be against the best clinical interests of the patient. It may also be an adverse incentive to use a higher clinical priority than would be appropriate, just to get the referral to the provider.
When providers are ready to accept routine referrals again, this priority will have to be ‘re-selected’ against each service from which it was removed.
An alternative means of managing routine demand would be via use of the patient booking window. Find out more information about this in the Allowing routine referrals to continue to be made section.
Services removed from e-RS
Some providers have taken the step of un-publishing services from e-RS in order to prevent referrals from being made to them. This has several impacts.
- any patients with an unpublished service on their shortlist will not be able to progress their referral in any way
- any patients with an appointment already booked into a service which is then unpublished will not be able to change or cancel it if needed
- providers will also be unable to manage any referrals that had been made into services that they have since unpublished
- referrers will not be able to see or make any referrals into unpublished services, so these referrals could add to the demand in neighbouring trusts.
Services removed by putting into ‘transition’
This is an alternative way of closing a service down, with the advantage that referrals already created can continue to be managed, but no new referrals can be made once the transition date has started.
Please note - for services removed from e-RS, and those put into ‘transition’, the patient booking window provides a more sustainable means of managing demand. This allows referrers to have the confidence that they have referred their patient to the correct service, which can then manage the referrals at the appropriate time in the future.
Re-publishing an un-published service will make it visible again to referrers. Doing this in conjunction with the patient booking window, will help manage when referrals can be booked and allow time for the management of any backlog of referrals.
Referral assessment services and service restriction
There has been an increase in the number of referral assessment services (RAS) set up on e-RS since the current situation started. Some providers have used the service restriction functionality to limit who can refer into their services, for example only allowing a triage service to make the onward referrals once the referral information has been clinically reviewed. Using the patient booking window and appointment slot issues, as described above, will give providers the same triage functionality as a referral assessment service and will be easier to change back when returning to a more normal situation.
Introducing RASs and service restriction may be a useful means of ensuring that only clinically appropriate referrals are made into a provider’s services. When returning to a more normal situation, providers will need to consider whether the additional administrative work involved in triaging ALL referrals from primary care, is worth the potential improved referral quality. A mixed economy may be best, with the more clinically complex services remaining behind a RAS, but others being opened again to GPs / referrers.
Advice and guidance and advice only services
An increase in advice only services has been noticed and these form an effective means of supporting GPs to get clinical advice on whether a referral is necessary. They also provide a way for providers to ‘pool’ the advice review and response process across a specialty – as an example.
Advice and guidance in e-RS, whether at service or specialty level, provides a critical referral management tool, particularly at the current time. Where a service has been expanded, providers should consider using this going forward as an effective means of both managing demand and supporting GPs to manage their patients in primary care. Further information on this can be found in the Advice and guidance section.