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Paper switch off implementation pack

The paper switch off implementation pack is a step-by-step guide to support the delivery of e-Referral Service (e-RS) Paper Switch Off (PSO) in a local health community.

Standard Contract for 2018/19

The Standard Contract for 2018/19 requires the full use of the e-RS for all consultant led first outpatient appointments.

From 1 October 2018, providers will only be paid for activities resulting from referrals made through e-RS.

The Paper Switch Off programme (PSO) has been launched to provide support for the health communities in readiness for the contract change.

This is a step-by-step guide to support the delivery of Paper Switch Off (PSO) in a local health community.

It gives the recommended approach to the project, from establishing project governance and set-up, to business process change, along with the associated guidance, templates, or sample documents from PSO pioneer trusts gathered to date. Items marked with a * should be considered as essential.

It may be possible to do some of the activities at the same time or in a different order to suit your local project requirements. It may also not be necessary to carry out each activity depending upon your current starting point and level of e-RS utilisation.

If you require further information on any of these projects, then please contact your relevant NHS Digital Implementation Manager (contact details at the end of this pack.) They will then progress your request.


To deliver a successful PSO project, the following stakeholders must be engaged with:

  • Provider Trusts and CCG to lead the PSO project
  • LMC and GP leads, CSU to provide advice

The following documents and webpages will assist you:

Project kick-off

Before your project starts:

  • review PSO pioneer trust lessons learnt report
  • ensure executive level buy-in and ideally appointed as project SRO
  • review and confirm your Paper Switch Off go-live date with all stakeholders, including NHS Digital IBC Lead and NHS England Regional Implementation Manager
  • agree your project governance - the resources below will help

Sample kick-off meeting agenda
Template TOR project board
Sample agenda
Template TOR steering group
Sample TOR
Template risks and issue log
Sample R&I log
Template highlight report
Sample A
Sample B

Develop a PID/project brief:

PID template A
PID template B
PID sample

Develop your local project and action plan.

Note: On the template tabs, Type A is recommended for providers over 80% utilisation, Type B for providers with less than 40% utilisation.

Project plan template
Action plan (provider focus) template
Action plan (primary care focus) template
Sample project plan from County Durham and Darlington
Sample project plan from Sherwood Forrest

CCGs will need to be involved and deliver activities supporting all action plans.

Decide on your PSO approach. Some projects with lower utilisation are implementing PSO specialty by specialty, whereas the ones already at higher e-RS use are tending to do PSO for all services at the same time.

Continue to review management information available locally, on the e-RS website and Power BI reports.

Performance reports
Power BI reports

Develop local reporting approach to monitor progress and monitor paper referrals.

Agree the level of support and way of working with your NHS Digital Implementation and Business Change contact.

Identify any relevant case studies appropriate to your particular status.

Planning and discovery

Identify gaps in your business process compared to best practice guidance.

Produce baseline of services that need to be added to e-RS to support e-RS publishing services CQUIN. 

Identify current Appointment Slot Issue (ASI) position and agree associated actions to improve. Ensure the CCG are aware of the position as they can help with communications and GP expectations.

ASI guidance
NHS Improvement Rapid Improvement Guide - ASIp

Agree whether e-RS Advice and Guidance services need to be implemented - see our A&G guidance.

Identify any further internal and external stakeholders to be involved in your PSO project.

Ensure key CCGs are fully engaged and part of the PSO project. Critical activities they are responsible for and can support are:

  • communications with GP practices
  • engagement with LMCs
  • identifying and providing any training requirements (link with NHS Digital as appropriate)
  • addressing any issues with specific GP practices
  • ongoing monitoring and reporting of PSO, and any support necessary for specific practices not following process
  • support the review of DOS, critical to ensuring minimum re-direction occurs
  • technical readiness and delivery of IT infrastructure
  • awareness of cross-border trust PSO plans and activity
  • agreeing and implementing the payment process in line with the standard contract


Begin to deliver the activities detailed in your PSO project plan.

Make all services available to book on eRS. The following resources may be helpful:

Implement the agreed plan to reduce Appointment Slot Issues.

Add all named clinicians to e-RS - see our named clinician guidance.


Formulate and agree training strategy.

Access the e-RS training environment.

Deliver training to any staff requiring a refresh/new training. Support from NHS Digital, if required. Contact for help.

Access the training section for referrers and providers.

The following sample materials developed by Kings are available:

Develop training protocol for new starters - clinical and administrative.


Develop a joint local communications and engagement plan between provider and CCG to provide regular update on progress to all stakeholders. For example:

  • letter to be sent from Trust Executive Team/Medical Director to advise staff of the upcoming improvement work
  • a section for e-Referrals to be allocated in the organisation's newsletter/communications/extranet
  • communication of updates, such as new services available on e-Referrals and training

The communications toolkit contains advice and sample documentation.

GP communications are essential, and should at minimum cover the following points.

Liaison via CCG to LMC’s advising of e-Referral project prior to direct communication with GP’s*.

This is to ensure their awareness of the project, acknowledge any concerns they may have and work through queries together to ensure their support. It is also opportunity to seek their advice on best mode of communication with Primary Care.

Example letters for GPs are available:
Bromley CCG notification of paper switch off
Frimley specialty waves letter
Hull and East Yorkshire Paper Rejection Proforma

Arrange to have a slot on GP communiques to provide regular updates on new services being piloted and rolled out.
Sample from Sandwell and West Birmingham CCG
Yeovil - sample flyer

Continue to complete and review all project progress reports, delivery against milestones, utilisation and ASI reports.

When utilisation approaches the desired level for PSO (such as when it's feasible to implement a paper returns process), the project will enter the final PSO project stage and prepare for switching off paper.

Complete and continue to review the PSO readiness checklist.

Review and sign off the formal date for implementing Paper Switch Off status ie. all referrals for first consultant OP appointments will not be actioned and returned to the referrer.

Agree any local list of exclusions from this PSO project if necessary, taking the standard contract guidance into account. Sherwood exclusions here.

Refine any SOPs, access policy and contingency plans and ensure sign-off. e-RS Standard Operating Procedures sample.

Agree and ensure exec/clinical sign off of the process to follow for returning paper referrals*. This is a mandatory requirements as defined in the standard contract guidance.

Sample for routine referrals
Sample for 2WW referrals
Sample paper referrals recording form/report
Sample from Warrington

Continue to communicate the PSO switch off date to all GP practices, and support their queries.

Example bulletin
Example bulletin from Kings
Sample FAQs
Sample report for Clinical Exec Committee
Sample mail for practices
Sample auto email reply to go to referrers

Consider, co-ordinate and deliver regional communications with trusts in the same local geographic area, sharing knowledge and your timescales for Speciality Go Lives/Full PSO via CCGs.

Ensure detailed data analysis is completed. See our data quality guidance.

Business as usual

Paper Switch Off status is now in place. The provider will return all paper referrals for first consultant OP appointments to the relevant GP practice.

Implement revised SOPs and ensure ongoing BAU activities carried out, such as continual training, new services added to DOS, addressing any paper referrals that continue to be received.

Ensure the Trust, CCG and practices Business Continuity Plan is updated for PSO and is fully communicated. Download a sample e-RS Standard Operating Procedures and continuity plan.

Subscribe to live e-RS service alert information.

CCGs continue to monitor progress in line with the usual contract management processes and the Improvement and Assessment Framework.

From October 2018, CCG to ensure payment for referrals made in line with the standard contract.

Further information

Every NHS Organisation has an assigned e-RS Subject Matter Expert (SME) to support your e-RS implementation, projects and answer any specific queries.

Contact to find out your e-RS SME. Each NHS England Region has been assigned a Regional Programme Manager to support Paper Switch Off.

To be put in contact with the relevant lead, please email

For up to date news on e-RS, please sign up to the bulletin.

The e-Referral Service roadmap shows:

  • system enhancements
  • when they're being delivered
  • deadlines for the levers and incentives for using the service

Contact us

Contact us at

We'd like to know if this pack has been helpful in delivering your PSO project, and whether you have any suggestions on how it could be improved. 

Last edited: 16 December 2020 11:09 am