Joint guidance on the use of the NHS e-Referral Service 2018

Initiated in 2015, following a refresh and redesign of the old Choose and Book system, the NHS e-Referral Service (e-RS) is now in use across the National Health Service (NHS) in England. When properly implemented, e-RS can provide significant benefits, not only for patients, but also for referrers, providers and for the wider NHS, by delivering choice, certainty, security and reliability.

As well as offering a simplified and fully integrated booking service, e-RS provides a key opportunity to improve the patient experience. It provides reassurance in the secure delivery of the referral information and, in most cases, the ability to book an appointment at the time of referral. It reduces waiting times, compared with traditional referral methods (e.g. fax, email or letter), and puts the patient more in charge of their care pathway, giving them more control and flexibility in the management of their health care at very uncertain times in their lives.

This guidance has been jointly written by GPC (England), along with NHS England and NHS Digital, to help organisations understand the importance of using e-RS as it is intended to be used. It should be noted that the traditional role of the General Practitioner in decision making when referring patients to hospital (where appropriate), has not changed - just the mode through which they do it. It is hoped that the guidance provided here will be recognised and implemented by GPs and others using the e-Referral System to refer patients, so that all patients, wherever they are in England, will experience the same high-quality of referrals into NHS care.

Dr Nikita Kanani
Acting Director of Primary Care
NHS England

Dr Farah Jameel 
England Executive Team
GPC England
[email protected]

Dr Stephen C Miller 
National Medical Director and Service Owner
NHS e-Referral Service (NHS Digital)

The NHS e-Referral Service (e-RS) is an electronic referral-support tool, designed to make it easy for GPs to manage patients who may need referral for onward care. It is being used by GP practices in England, with referrals into both consultant-led out-patient clinics and non-consultant-led services, such as community, diagnostic, assessment and GPwSI services. The service aims to:

• improve efficiency of referrals from primary to secondary care
• enhance clinical communication channels
• deliver choice, certainty and control for patients, who increasingly expect to interact with healthcare through digital channels

This guidance has been prepared to help General Practitioners and their staff understand the most effective way of using e-RS and thereby support them in the management of their patients. It is recognised that referral processes often vary between individual General Practices, so flexibility in how e-RS is implemented and used on a day-to-day basis will be demonstrated throughout this guidance. This is key to realising the benefits of the service.  

The NHS e-Referral Service application is undergoing constant technical development and enhancements, focused on user-driven needs and requirements. These include an extensive programme of work to develop Application Programming Interface (API) technology, that will allow current integration with GP clinical systems to become much more seamless, further enhancing users’ experiences and enabling them to benefit from high quality referral management tools from within their GP clinical system.

The NHS e-Referral Service has several advantages over other referral methods, including paper and email. It is:

• a national asset, freely available to all NHS organisations in England
• a digital, paperless platform for professionals that, unlike emails, extends from the point of referral in primary care all the way through to the patient attending an appointment in a provider organisation
• supported by stable and resilient technology, with over 99.9% system availability
• fully auditable and secure, with referral and booking history easily available to professional users from within the application (that is - it shows who did what, and when) 
• a method of supporting different referral pathways, including those resulting in the direct booking of an appointment and those providing an initial online assessment of clinical referral information
• a portal that allows patients to select and book their own appointment (where bookable services have been chosen and are available)

The NHS e-Referral service is an online referral and booking tool that is made up of two parts: 

1. A professional application, used by referrers (such as GPs) to create and send an electronic referral to provider clinicians (such as Consultants) in secondary care, or to community providers.

2. A patient-facing website (called 'Manage Your Referral'), that allows a patient to book an appointment on-line, once the electronic referral has been initiated by their referrer into a bookable service.  A telephone number (at local call rates) is provided for patients who are unable to use the on-line booking service.

Professional access to the NHS e-Referral Service currently requires a smartcard, with appropriate roles having been added and authorised by a local NHS Registration Authority.

An e-RS referral can be made into either a bookable service (in which case the patient needs to book an appointment before the referral can be processed further), or sent to a triage/assessment service, where the referral information is assessed first, without an appointment being pre-booked.  Referral outcomes vary, depending on whether the referral is into a Bookable service or an Assessment service (see Section 6 below on Referral Outcomes).

3.1 What is the difference between a bookable and an assessment/triage service?

When referred to a bookable service, the patient is required to book an appointment before the clinical referral information can be seen by the provider. The provider clinician should then view the referral information as soon as possible and make a judgment as to whether the patient has been booked into the correct service, with the correct urgency, or whether the timing of the appointment needs to change in light of the condition being referred. The provider clinician can choose to Accept, re-Direct or change the date/time of the appointment, using functions within the e-RS application (see more details in Section 6 below).  

If the provider clinician feels that their service is not clinically appropriate for the patient and/or there are more suitable alternative ways of optimising patient care, they may choose to return the referral and advise the referrer accordingly. This is known as a ‘rejection’ but only occurs for about 2% of referrals. Where clinically indicated, it should be seen as a positive outcome, both in terms of professional education and in speeding-up patient care. If referrals are rejected, the provider should give clear information as to why they do not feel that their service is suitable for the patient and suggest an alternative provider or method of managing the patient. The referrer always has the option to resubmit the referral with more information to support the rationale for referral into the same service, if they feel that is more appropriate.

If referring to a triage/assessment service, the receiving clinician still reviews the clinical referral information, but before an appointment is booked, and decides on whether to accept the referral. If accepted, the assessment service (not the GP) must identify suitable onward service(s) for the patient and contact them to offer a choice (where choice rules apply) and facilitate the booking of an appointment. In addition to converting a triage request into an appointment, an assessment service can alternatively provide advice back to the referrer, instead of an appointment. 

3.2 Referral into a bookable service

The following four steps need to be followed when referring into a bookable service:

1. Check the Directory of Services (using the built-in search tools) for clinics suitable for the patient’s condition.

2. Shortlist one or more clinics from which the patient can choose an appointment.

3. Provide the patient with instructions on how to select a clinic and book their appointment (printed instructions are currently provided in the form of a letter, but future enhancements will allow patients to receive electronic instructions if they wish).

4. Attach clinical referral information (such as a referral letter or pro-forma) to the electronic referral.

Once the referral to a bookable service has been initiated, patients (or others acting on their behalf) can book an appointment with one of the services listed. If no appointments are available at the chosen provider, the patient can try an alternative shortlisted provider, or defer the referral request to the hospital or clinic and wait to be contacted with an appointment date (see Section 11 below). Links to video clips showing this process are available in the support section of this document – see Section 18 below.

3.3 Referral into a assessment/triage service

As described above, in addition to bookable services, the NHS e-Referral Service supports referrals into one of three types of assessment/triage service. These services, which are set-up by the provider in addition to, or instead of, a directly bookable service, are especially useful for complex pathways or scenarios where the patient might be booked straight to test or procedure, instead of needing an initial outpatient appointment. In such cases, it is the secondary care clinician who decides on the most appropriate referral pathway for the patient, rather than the referrer (GP).

3.3.1 Referral Assessment Service (RAS)

This type of assessment service allows a provider clinician to review clinical referral information without the need for an appointment to be booked. The patient is then either referred-on to a suitable service, in which case it is the responsibility of the assessment service to contact the patient and arrange an appointment, or advice is returned to the referring clinician.

3.3.2 Telephone Assessment Service (TAS)

A TAS operates by taking referral information and then using a telephone consultation with the patient to gain additional clinical information to help determine the correct onward pathway. The TAS appointment date should be agreed with the patient and the process clearly explained, so that the patient understands whether the TAS will be calling them, or whether they need to call the TAS at the agreed date and time.

3.3.3 Clinical Assessment Service (CAS)

In this model, the patient attends a booked ‘assessment’ appointment and is assessed and/or treated by a clinical specialist. The patient may then be referred to another service (for example - in the community, or in a secondary care setting), or advice may be sent back to the patient’s referring clinician to assist with on-going management.  

4.1 Support for referrers

The NHS e-Referral Service contains a range of features to support referrers, including:

• a Directory of Services (DoS), maintained by the provider of the service, that acts as a ‘shop window’ of what is available. It lists the name and location of the service, conditions treated, treatments offered and exclusions. It has the facility to include hyperlinks to referral protocols and specific alerts for referrers. Providers must add all their consultant-led services to the DoS, so that GPs know that everything is available in one place. Any services that are missing from the DoS should be notified to the e-RS lead in the commissioning organisation (or provider organisation)
• near real-time data on appointment and treatment waiting times, to help manage patients’ expectations and to help commissioners plan service-provision
• visible alerts, showing a provider’s capacity to see and treat patients and suggestions of alternative services, where provider-capacity may be poor
• access to bookable appointments for consultant-led services, diagnostics, therapy services, community services and appliances (such as hearing aids and orthotics)
• access to referral assessment services (such as musculoskeletal assessment services) for triage or clinical assessment of the patient’s needs, with the ability for the assessment service to refer-on patients to other appropriate, or more specialist, clinics, including diagnostic services or for procedures to which GPs may not, ordinarily, have direct access
• the ability to seek Advice and Guidance for complex referrals or to ask for alternative management advice (see Section 16 below)
• integration with all accredited GP Clinical systems, that allows clinical information from the GP record to easily be converted into a structured referral ‘letter’ and attached electronically to the referral

4.2 Clinical safety features

The NHS e-Referral Service has a number of clinical safety features that enhance the patient’s referral journey and provide reassurance and support for professionals:

• every detail of the referral journey is logged, so any authorised professional can look to see where the patient is within the referral pathway and act on that information
• clinical referral information is attached electronically and is held securely - it cannot be lost, unlike paper referrals
• security features of the system ensure that only professionals with a legitimate relationship with that patient have access to the referral and the attached clinical information
• worklists (See Section 10) make it clear to referrers when there are outstanding actions to complete, helping avoid any delay to care. They also make it easy to track referrals that have been assessed and indicate where alternative management plans have been suggested
• all referrals can have their priority changed, without the need for a new referral being initiated; so, a patient whose clinical condition deteriorates can have their status changed from routine to urgent and be rebooked into an earlier appointment. This can be done by anyone with a referral role within a GP practice (that is - it need not be the original GP) and will result in the hospital being notified via an e-RS worklist, allowing them to act to expedite the appointment
• patients can book (or change) their appointment on-line, or through a national telephone booking service, arranging their appointment on a date and time that suits them and making it more likely that they will attend their appointment and receive their care in a timely way
• patients who don’t book are sent two system-generated reminder letters by the NHS e-Referral service
• occasionally, where a provider cancels an appointment and the referral (such as in the case of ‘rejections’), the patient is also sent a letter advising them to contact their referring practice who will be able to advise on next steps

Although some features of the application have been designed to be used by clinicians and other functionality is more for administrative staff, practices may choose to be flexible as to who undertakes the various tasks associated with referring patients.

The following flow diagrams summarise some of the different referral and booking models that e-RS supports, along with points to be considered for each model: 

GP creates shortlist and patient books the appointment

1. GP and patient agree to referral.
2. GP creates referral and shortlists suitable services in e-RS.
3. Patient leaves with Appointment Request letter.
4. Patient books appointment on-line or by telephoning TAL.

Considerations include:

• GP and patient can be confident that clinically correct options are on the patient’s shortlist
• no postage or administration related costs, for the practice (compared to the other models), as the patient leaves with appointment request details
• improved patient satisfaction – the patient books their own appointment at a place, date and time that suits them
• reduced time spent chasing-up referrals
• GP administrators can monitor worklists to chase the small number of patients who have not booked, despite receiving two system-generated reminder letters (sent by the NHS e-Referral Service) and where it has been deemed clinically necessary for them to attend
• GP can create the clinical referral information (or ask their admin staff to do so) at a later, convenient time

GP passes all referral information to admin team to make the e-RS referral on their behalf

1. GP and patient agree to referral.
2. GP dictates or types-up referral info for admin to pick up, including details of any choice discussion with the patient.
3. GP Admin logs into e-RS and creates the referral on behalf of the GP, based on GP instructions.

And then either:

4a - GP Admin sends the patient the Appointment Request letter - patient books appointment online or by phoning TAL.

4b - GP Admin contacts the patient and has the choice discussion and books the appointment - patient receives the Appointment Confirmation letter by post or picks it up from the surgery later. 

Considerations include:

• this model is a fully admin-based process, so takes less GP time than the other models, but may require more administrative skills and resources
• GP passes information to their admin team to select an appropriate shortlist of clinically appropriate services for the patient
• GP remains responsible for the referral, so must ensure that admin staff have been fully trained to manage this workflow (see Section 9.2 below)
• an increase in admin time can be offset by a reduction in the time previously spent by admin staff in chasing-up referrals, as there is now an electronic record detailing every action in the referral pathway
• if GPs do not monitor worklists themselves, practice administration staff should check them on a regular basis to look for any patients who have not booked, despite receiving two system-generated reminder letters (sent by the NHS e-Referral Service). GPs need to be made aware of these non-booked appointments (processes to be agreed locally) and make a clinical decision as to whether the patient still needs to be seen. In such cases, where appropriate, patients should be contacted to support/encourage them in booking an appointment
• GP admin staff can create the clinical referral information to add to the referral
• GP Admin staff can book the appointment for vulnerable patients or Two Week Wait referrals, where they are not booked in the consultation

GP makes referral and books appointment within the consultation

1. GP and patient agree to referral.
2. GP creates referral and shortlists suitable services in e-RS.
3. GP books appointment in e-RS with patient (for 2WW, for example).
4. Patient leaves with Appointment Confirmation letter.

Considerations include:

• all takes place within the consultation
• GP and patient confident in the process and reassured that referral and booking is now complete
• this model is ideal for when referring vulnerable patients, or making Two Week Wait referrals
• does not allow the patient to discuss the referral with friends/relatives and chose a provider, or select the appointment time before the initial appointment is booked (although patients still have the opportunity to cancel and re-book an appointment at any point in the future, if booked through e-RS) 
• patient has an appointment booked immediately - improved patient satisfaction
• where no appointments are available, the GP can defer the appointment and give the patient the deferred appointment letter that now advises the patient to contact the provider (that is - not the GP practice) if they have not heard anything within two weeks
• no postage costs, compared to some of the other booking models, as patient leaves with appointment details
• reduced time spent monitoring worklists to check that patient has booked their appointment
• GP can create the clinical referral information from their integrated GP system (or ask their admin staff to do so) at a later, more convenient time

GP creates shortlist and admin team books the appointment with the patient

1. GP and patient agree to referral.
2. GP creates referral and shortlists suitable services.
3. GP Admin has the choice discussion and books the appointment with the patient. 
4. Patient leaves with, or is sent, the Appointment Confirmation letter.

Considerations include:

• this model can generate unnecessary work for admin staff and is only necessary for the small number of patients who would not be able to book an appointment online, or by phoning the national booking line
• GP and patient can be confident that clinically correct options are on the patient’s shortlist
• admin staff can help vulnerable patients, or those unable to complete the booking process themselves, to book their appointment at a place, date and time that suits them
• this model is suitable for Two Week Wait appointments, (if the appointment is not booked within the consultation)
• where no appointments are available, GP admin staff can defer the appointment and give the patient the deferred appointment letter that now advises them to contact the provider (that is - not the GP practice) if they have not heard anything within two weeks 
• no postage costs, compared to some other models, if done straight after the GP appointment as the patient leaves with appointment details (although postage and/or telephone costs may be incurred if the practice contacts patient later)
• reduced need to monitor worklists to ensure that the patient books an appointment
• GP can create the clinical referral information (or ask their admin staff to do so) at a later, convenient time

As described in Section 3 above, there are several outcomes to an e-RS referral, depending on whether it is made into a bookable or an assessment/triage service.

Accept

This is the usual outcome if a referral is clinically appropriate for the service to which it has been booked. The referrer needs to take no further action. By checking the Patient Activity List, the referring practice can, at any time, see the status of the appointment.

Re-direct

If, having read the clinical referral information, a provider clinician feels that an alternative service would be clinically more appropriate for a patient, then, rather than rejecting the referral (see below), the preferred course of action would be to re-direct it to a clinically more suitable service. This will be managed by the provider within e-RS and the patient will be contacted to re-book their appointment into the new service. In this case, there is no action required on the part of the GP or referring practice.

Cancel

If a provider (such as a hospital or community trust) is unable to book an appointment for a patient within e-RS, or the booked clinic/appointment subsequently becomes unavailable, then the appointment and/or referral may be cancelled within e-RS. If this happens then the provider organisation will have added a reason in e-RS, which the referring practice will be able to view from their worklists. Responsibility for dealing with a provider cancellation rests with the provider (that is -  the hospital or community trust), who will often manually re-book the patient outside e-RS. This will appear on a referrer’s worklist for information only.

If a provider (or a patient) cancels an appointment, but not the referral, and it is not rebooked, then this will appear on the GP practice’s Awaiting Booking/Acceptance worklist, denoting that an appointment still needs to be booked. This is usually for information only, as e-RS will send reminder letters to the patient, advising them to re-book. It does, however, remain the responsibility of the GP practice to ensure that the patient has booked an appointment, if still clinically appropriate.

Advise referrer

This is one of the options that may result if a triage/assessment request has been made and the provider clinician has sent advice back to the referring practice to support the onward management of the patient. These referrals will appear on the Referrer Action Required worklist, from where the referring practice can see the advice supplied and act accordingly.

Reject

This option should only be used occasionally when, for clinical reasons, and after the receiving clinician has assessed the referral information provided by the GP, it is felt that the patient could be managed more effectively by alternative methods and without a prior ‘face to face’ appointment.

In such cases, the booked appointment will be cancelled electronically in e-RS and the referral will appear back on the ‘Referrer Action Required’ worklist for the practice to contact the patient and take appropriate action. This may include cancelling the referral and managing the patient according to the comments provided, or re-referral to another service (or the same service) with the same (or amended) clinical referral information.

Comments will always be added by the provider clinician to help advise on managing the patient, as well as, potentially, providing useful information to assist future referrals into that service. Although some providers will notify patients that their booking has been cancelled, responsibility for acting on the rejection advice rests with the referrer, in the same way that they have always been responsible for acting on any advice sent to them as a consequence of a written referral.

Where practices do not contact the patient within 21 days (for routine referrals) a letter will be sent to patients advising them that their appointment has been cancelled and asking them to contact their GP practice.

As with any IT system, the more users become familiar with e-RS, the easier it will become to use. It is vital, however, that as part of the introduction of the service within a GP practice, time is spent in reviewing existing referral processes and deciding, as a team, on any changes that might need to be made. This may include a decision on the referral model that is used (see Section 5 above) and ensuring that all staff are familiar with their roles and responsibilities within the overall process.

Initially, there will be some additional work in setting-up e-RS as part of the referral processes of the practice and there may be some extra administrative work when using the system, for example in booking Two Week Wait appointments, or in monitoring worklists where patients have failed to book their appointments (see below).  

Once the e-Referral Service has been integrated into the referral management pathways of the practice, it has the potential to free-up time and resources. The workload benefits of using e-RS include the following.

Fewer GP appointments booked to check on the progress of a referral, or to query waiting times

Since e-RS puts patients in control of managing their appointments and gives them the ability to book, change or cancel appointments themselves, and to see waiting times and capacity alerts, it helps them to be more aware of what is and isn’t possible in terms of appointments.  

This means that they have a greater level of confidence in the referral process, with expectations being managed more effectively and a reduced need to check-back with their GP. 

A reduction in admin time spent chasing referrals

For referrals made through e-RS, the patient’s pathway is fully visible.

GPs and their staff can see instantly what is happening to a patient at each stage of the referral, without the need to contact the service provider to answer a patient query.

A reduction in re-referrals

The NHS e-Referral Service reduces DNA rates for hospital appointments by approx. 50% and allows any patients that do not attend to have their booking request submitted again and an appointment re-booked by the provider, without any additional GP work.

7.1 Specific workload issues

Self-referrals

The NHS e-Referral Service does not currently support self-referral pathways and, where these exist, patients will be expected to continue to refer themselves to appropriate services, without the need to be referred by a GP. It is not expected that secondary care providers will cease to offer self-referrals, simply that they are not currently supported through e-RS.

Booking Two Week Wait appointments

It is considered to be clinically safer for Two Week Wait appointments to be booked in the practice, either by GPs in the consultation, or by administrative staff, for example, at reception after the consultation is over. Secondary care providers are encouraged to add all their Two Week Wait services onto e-RS and to make appointments available that are directly bookable. The certainty and reassurance that this brings to both the patient and GP often helps ensure a natural conclusion to the consultation, potentially saving overall time in checking on whether appointments have been booked.

Monitoring patients who Do Not Book appointments

Un-booked referrals are listed on the referrer’s Awaiting Booking/Acceptance Worklist and patients will receive two letters, generated automatically from the system, reminding them to book an appointment. For routine appointments, these letters will be sent after 14 and 28 days and for urgent referrals after three and six days. A patient whose electronic referral remains un-booked after this period will need to have it reviewed to assess whether it is clinically safe to be left un-booked.

Managing referrals that have been returned with advice

On occasions, when advice is returned to the referrer, either after a booked appointment is rejected, or as the outcome of a referral into a triage/assessment service, the patient will appear back on the Referrer Action Required worklist. This requires the GP, or someone acting on their behalf, to review the advice and take appropriate action. This may be to refer the patient elsewhere, or to consider alternative management in primary care (see Section 6 above on referral outcomes).

8.1 Choice and involvement in care-planning

Where patients are being referred to an elective (i.e. non-emergency) consultant-led appointment, they have a legal right to be offered a choice of provider for that referral and, if they wish, to be able to choose a consultant-led team (or healthcare professional), for both physical and mental health referrals.

The NHS e-Referral Service is the only tool that allows GPs to see a full range of available consultant-led outpatient services across England, allowing patients to make an informed choice to attend a local provider, or to elect to go somewhere that, for example, may be closer to where they work, or closer to a relative to support convalescence.

Even for those patients who want to stay with their local provider, or to go with a GP’s recommendation, e-RS often allows them a choice of date and time for their appointment and sometimes multiple locations. Again, this helps improve the referral experience for patients and has been shown to reduce hospital Did Not Attend (DNA) rates.

An improved patient web application has been developed, known as “Manage Your Referral” (see the Spotlight Video Clip on using “Manage Your Referral” in support Section 18 below). This enables patients to book, cancel and rebook their appointments and has several useful features:

• it is smart-phone and tablet friendly 
• it has undergone robust research and testing with patients, including those with disabilities, to ensure that the product is easy to use
• it saves time and expense for General Practices who are using admin staff to book patients’ appointments

Promoting the use of Manage Your Referral, allows patients to choose their appointment at a time and date that suits them and to cancel and rebook their appointment if needed - empowering them to manage their own care.

For those who cannot use the on-line option, a national telephone service is available that is included as an option in the booking instructions to patients. 

Once introduced, improved patient instructions generated from within the e-RS application, along with new ways of communicating these instructions to patients (for example by email) will make it easier for patients to understand the process and to complete their booking electronically. Research is also underway into how patients could, in future, track their referral and book their own follow-up appointments via the Manage Your Referral application.

Informing the patient

With all the above service models, it is important that the patient is fully informed and involved in both understanding the process and agreeing the onward pathway and any appointment bookings. Where an assessment results in an onward referral to secondary care, choice of provider should be offered, in line with patients’ rights under the NHS Constitution, and the patient should be informed by the assessment service of how to book their appointment. Where an assessment service decides that the patient is best managed by the original referrer, they will provide a clinical response to the referrer, who will decide the most appropriate way of informing and managing the patient.

8.2 Patient responsibilities

So long as patients have been involved in the decision to refer, have been informed of the NHS e-Referral Service booking process and have been provided with appropriate instructions (generated from within the e-RS system), they are expected to follow the instructions and to book an appointment with a chosen provider. If patients subsequently decide that they do not wish to be referred, they can cancel their referral on e-RS which will inform their referring practice, via the e-RS worklist. Patients who do not book an appointment are sent reminder letters (at two weeks and four weeks for routine referrals) and remain on a referrer’s worklist for six months or until they book.

If referrers feel that a patient is vulnerable or not capable of following the booking instructions (for example, due to illness or disability), then they should ensure that another suitable adult is able to book the appointment on behalf of the patient. This may be the GP, an administrator in the GP practice or the patient’s carer. 

8.3 Managing patients who Do Not Attend (DNA) appointments

The NHS e-Referral Service has been shown to halve the rate at which patients Do Not Attend (DNA) appointments for elective referrals into secondary care. There will, however, always be times when patients forget to attend their booked appointments. The NHS e-Referral Service supports amendments to the standard contract, introduced in 2016, that require provider trusts to contact patients directly if they do not attend an appointment and offer them another, without discharging the patient back to the GP.

Where the original referral and booking was made via e-RS, the provider’s patient administration system (PAS) will send a message to e-RS if the patient does not attend the appointment. This will add the patient to an e-RS worklist in the provider organisation and enable their booking staff to contact the patient and re-book them back into the same service through e-RS.

If the patient decides that they do not want to be seen, the referral can be cancelled with the reason recorded in e-RS and the referrer informed. There is, in addition, a third option within e-RS that allows the referral to be returned to the GP, appearing on a worklist for them to decide how to manage the DNA. In line with NHS England Standard Contract guidance, this option should only be used by providers after they have contacted the patient to offer a new appointment.

Clinical responsibility when using the NHS e-Referral service generally mimics clinical responsibility when making a paper referral.

A summary is outlined in the table below:

9.1 Clinical liability

Whilst the NHS Constitution promotes the concept of patients being involved and responsible for their own healthcare, the current GMC guidance puts the responsibility for ensuring a patient receives their care very much in the hands of clinicians.

The General Medical Council and the various medical defence organisations do not define where clinical liability starts and ends within the referral process. e-RS does not define clinical liability either, although worklists allow the referring organisation to review the status of a referral and take action, if necessary. Clinical liability depends on the individual circumstances of each referral.

As described in Section 13 below, it is important to define the GP responsible for a referral and to have established processes in place for dealing with referrals made by locums, or from regular doctors who subsequently leave the practice.

9.2 Delegating referral actions

Many parts of the referral process may be delegated to named and adequately trained administrative staff, working within the same referring organisation, usually where direct contractual and supervisory arrangements are in place. If referrers delegate the short-listing of services in this way, then they still retain overall responsibility for the referral and are responsible for ensuring that staff to whom they delegate are adequately trained and have sufficient clinical knowledge of the patient and their condition to make the referral and/or short-list appropriate services.

9.2.1 Delegating actions to external organisations

If an external organisation manages referrals on behalf of clinicians and ‘referring clinician administration’ roles are added to the smartcard profiles of their administrative staff, the following points should be noted:

• the external staff member becomes a ‘proxy’ for the referring clinician
• the proxy-referrer, who is unlikely to have been involved in the clinical management of the patient, may not fully understand the reasons for the referral and be unable to offer effective choice of suitable services
• a proxy-referrer may not have an obvious legitimate relationship with the patient, which could result in potential concerns arising under data protection legislation
• referring clinicians are unlikely to have a direct contractual relationship with the proxy-referrer and therefore may have little opportunity for redress against that person, if inappropriate or incorrect actions are undertaken on their behalf

For these reasons, if referring roles are delegated to staff outside a referrer’s own organisation, it is recommended that, in addition to the Registration Authority processes and authorisation that needs to take place when roles are added to smartcards, a written agreement is also in place between the referring organisation and the named external proxy-referrer. This agreement should clearly outline:

• the circumstances under which the proxy acts on behalf of individual referrers
• the training and qualifications which enable the proxy-referrer to fulfil this role
• who is responsible for any errors or complaints that may arise out of this proxy relationship

GPs and their practice teams have access to four work lists within the e-RS application, which can be used to check on any outstanding actions, monitor the progress of patients’ referrals and responses to advice and guidance queries.

These worklists act like a mailbox and should be considered as a single place to go to check for any outstanding actions in the referral process. Using worklists effectively provides an efficient way for GPs to track the progress of their referrals; however, many practices delegate the task of monitoring worklists to administrative support staff who alert the GP when there are outstanding actions or concerns that the GP needs to address, when an Advice and Guidance response has been received for example, or when patients have failed to book appointments, or a referral has been returned with advice. 

A section on managing worklists is included in the Quick Reference Guide for Referring - see support section 18 below.

Where providers are struggling to manage their capacity, there may be no appointments on e-RS when patients attempt to book. These are known as Appointment Slot Issues (ASIs). Referrals can still be sent to services with ASIs (via a process known as ‘deferring’) and the referral will then appear on a worklist for the service provider to contact the patient and arrange an appointment.

This has long been a major cause of concern for GPs and results in a poor service to patients, particularly when their chosen provider fails to contact them to arrange their appointment or takes the patient’s referral outside e-RS to hold the patient on an out-patient waiting list.

Previously, providers often had to contact GP practices to ask for the clinical referral information to be re-sent (via fax or email) and patients often had no option but to go back to their GP practice to find out what has happened to their referral.

Changes made to e-RS in 2018 mean that providers no longer need to contact the GP practice for the referral information and patients who try to book an appointment and find no slots available will now be given a direct telephone number for that provider, either on the printed instructions given by the GP practice, or in the online instructions, if attempting to book via Manage Your Referral. This will reduce, if not eliminate, the need for repeat visits to the GP.

GPs, or their staff, can help reduce the likelihood of a patient experiencing an ASI by using the e-RS waiting-time information and capacity alerts, described above, to check that appointments are available and by offering multiple options (that is -  different services or locations) on the shortlist, so that, if one or more services do not have appointments, the patient may be able to choose an alternative. 

If constructed with due diligence, templates and pro-forma can play an important role in ensuring concise and appropriate clinical information is exchanged between GPs and specialists. Using an integrated GP system, it is possible for e-RS to easily ‘pull’ data from GP records and quickly construct a referral ‘letter’, which saves time for GPs and/or their admin staff. These templated documents, which should be agreed locally between GPs, providers and commissioning organisation, can be attached to the e-RS referral.

Since patients have the right to choose to be referred to any provider in the country for elective (as opposed to emergency) care and, therefore, may have several providers listed on their e-RS shortlist, referral templates and pro-forma should be as generic as possible and should be ‘owned’ by the referring or commissioning organisation, with the content having been agreed with local providers and endorsed by Local Medical Committees.   

Any provider of NHS services receiving a referral via e-RS, should accept clinical referral information in whatever format has been approved for use by the referring/commissioning organisation and endorsed by the responsible LMC. So long as adequate and appropriate clinical information has been added to the e-RS referral, providers should not refuse to accept a referral simply because it is not on their locally-branded template. 

How and when locums use the NHS e-Referral Service largely depends on local processes and how often the locum works in the practice. For a locum to use e-RS themselves, they need to have a smartcard and a referring role associated with the practice in which they are working. If the locum already has a smartcard, then adding the additional roles is often a simple process, managed by practice administration or IT staff, in collaboration with the local Registration Authority. When using the system themselves to generate referrals, locums will have their own worklists. These will need to be monitored when the locum is not working in the practice. This monitoring process is usually carried out by practice admin staff, who need to be given this as a specific task.

Where locums only work on an ad-hoc (or short-term) basis, it is usual for practices to have a process in place whereby a member of the admin team initiates e-RS referrals in the name of another of the permanent GPs in the practice. This ensures that any e-RS referral activity or outcomes relating to that patient can be followed-up by processes already in place to monitor worklist activity for that doctor.

14.1 Preventing technical failures

Technical problems are often cited as a reason for not using the NHS e-Referral Service. Problems such as speed of access, smartcard activation or integration problems with existing clinical or patient administration systems cause great frustration amongst clinicians and their administrative staff. Many of these issues can be easily identified and resolved using existing guidance and resources.

Information Technology (IT) departments in both commissioning organisations and provider organisations, should therefore work proactively with their dependent organisations and/or end-users to ensure that mechanisms are in place to:

• proactively assess and optimise existing equipment and resources
• issue and renew smartcards (including for locums and temporary staff)
• ensure smartcards have the correct roles loaded and removed, if no longer required (for leavers or locums, for example)
• monitor and update software, such as the smartcard Identity Agent 
• notify users of local IT technical support that is available to them and how it can be accessed
• respond in a timely way to individual IT problems on a day to day basis

Commissioning organisations should ensure that clear and simple reporting mechanisms exist for all problems relating to the use of e-RS and that GPs and their staff are aware and familiar with these processes.

Further information about the technical requirements necessary to successfully use e-RS can be accessed via the link in the support Section 18 below. 

14.2 Contingency plans

As with any IT system, back-up procedures need to be in place in the event of a system failure or outage. The NHS e-Referral Service has an excellent rate of availability, constantly exceeding its requirement to be available 99% of the time. All planned outages are communicated to users in advance and take place outside office hours.

All organisations should have contingency plans to deal with an unplanned and prolonged outage of IT systems, including the NHS e-Referral Service that should be user-friendly and safe. These should be invoked at the appropriate time, noting that a switch to alternative referral routes too early, may result in a delay to care, for all but lengthy outage periods. Contingency planning guidance is available from the link in the support - Section 18 below.

Currently, the NHS e-Referral Service is used to refer patients from GP practices to hospital outpatient services, with routine, urgent and Two Week Wait priorities.  From October 2018, GPs and hospitals are obliged, via their respective contracts, to ensure that all GP to consultant referrals are made via e-RS. In many parts of the country, referrals can also be made into diagnostic and therapy services, although currently not into A&E or same day services.  

The system can, in addition, support a wide range of other ‘Any-to-Any’ pathways of care, allowing referrals from (and into) services in a community setting. Where local care pathways already allow non-GP referrers to make paper referrals, the aim is for these referrals to be managed in future using e-RS, with the non-GP referrers having access to the system themselves, rather than sending the patient back to the GP to initiate the e-RS referral. 

NHS England envisages that, eventually, all healthcare referrals, whether to or from a hospital or community setting, will be made via the NHS e-Referral Service. This means that, in future, commissioned physiotherapists might use e-RS to refer directly to orthopaedics, opticians to refer to ophthalmologists and counsellors to psychiatrists - all directly and electronically.

Work is also underway to look at new evolving models of primary care and how e-RS can be adapted to support, for example, urgent care centres, federated ‘hubs’ or out of hours services.

Although not strictly part of the core referral and booking functionality, e-RS Advice and Guidance (A&G) is a useful tool in helping GPs to understand the best treatment options for their patients. Referrers can seek clinical advice from colleagues to help enhance their knowledge of how to manage a problem, diagnose a condition, decide whether a referral or follow-up is needed, or whether other, more suitable, management options may be available in alternative care settings. Unlike a referral into a triage service, a request for advice and guidance requires the referrer to act based on the response, which may include the suggestion to refer into a bookable service.

The A&G feature now allows a multi-way conversation to take place between GPs and Consultants that can help strengthen professional relationships, share knowledge and promote important clinician-to-clinician dialogue around patient care. 

Business rules around the use of A&G, including any payments for processing A&G requests, should be agreed as part of local implementation plans in collaboration with LMCs. 

Advice and guidance workflow

1. GP initiates A&G with the consultant/ specialty of their choice and informs the patient they are seeking expert advice.
2. GP asks a question and adds relevant clinical information.
3. GP or GP admin reviews A&G worklist daily, actions any replies and monitors unanswered queries.
4. GP or GP admin copy and paste A&G dialogue into clinical system or save a pdf of the dialogue into the GP system.
5. GP or GP admin converts the A&G to a referral if needed, liaises with the patient over choice of service and adds any additional clinical information. 

Further A&G guidance can be found in the support Section 18 below.

Where peer review of referrals within general practice has been agreed locally, this can be supported in e-RS using the RAS functionality, described above. In simple terms, this would allow a service to be set up in e-RS, to which GPs in a practice, or within a group of practices, could send referrals.

Once reviewed, a decision can be made about the quality and appropriateness of the referral, which can then be onward managed in e-RS. Where appropriate, the referral can be forwarded to a secondary care or community service.

This is a fully transparent and auditable process which supports the need for a quick and easy review of referral need.

Help files and training materials, including an end-to-end demonstration video of a typical referral pathway, have been developed to help learn easily and effectively how best to use the system. They are available on NHS Digital’s e-RS webpages. 

Further information can be obtained from our website, by subscribing to the e-RS bulletin or by sending a question to [email protected].

NHS England gateway reference 08730.