On 15 June 2015 the NHS e-Referral service went live, replacing the previous “Choose and Book” system that had been in place since 2004. In this feature, Dr Thoreya Swage examines the advantages of this new service and looks at the best practice guidelines that have been issued to users.
At the time of being introduced, Choose and Book, an electronic appointment booking service which enable patients to decided where and when they wished to have their first outpatient appointment, was considered a major step in creating a central appointments service, with up to 40,000 patient referrals being made every day and a total of over 40 million bookings. However, Choose and Book was not without its problems where, despite the electronic facility, some referrers had to resort to the previous paper referral system.
This meant that the mix of managing paper and electronic referrals was a burden to providers and the partial availability of slots made it difficult for primary care practitioners to stop using paper-based systems.
A new electronic referral system was required and, after consultation with users of the Choose and Book system, the new NHS e-Referral system was born.
The new NHS e-Referral service
The new NHS e-Referral service does not involved a fundamentally different process, but aims to build on the Choose and Book system and forms the basis of the commitment by NHS England to making all referrals electronic and the NHS paperless by 2018. The change is being implemented by the Health and Social Care Information Centre (HSCIC).
The NHS e-Referral service was developed in consultation with healthcare professionals and patients to reflect their needs better than the Choose and Book system was able to. Since the development of Choose and Book, advances in technology have enabled greater functionality and flexibility of the IT booking system. The new system now encompasses the following:
a Directory of Services with alternative care pathways
the provision of expert advice and guidance to referrers
clinical assessment services
reporting of referral activity and monitoring of referral patterns
a secure and effective route as an alternative to paper referral processes.
Directory of Services
This function enables the matching of the clinical search criteria to the available services. This means that the most appropriate services are identified for patients and the right referral is made. In order to do this, referrers can view all the suitable services that are available within a geographical area, including community services, services provided by GPs with a Specialist Interest and those provided by Allied Health Professionals. This process helps the referrer to determine where the cost-effective alternatives to hospital-based treatments are located.
In addition, the information held within the Directory of Services helps the referrer to ensure that patients are prepared clinically for their appointment and unnecessary or inappropriate consultations are less likely to be made.
There is a Service Details screen that contains both administrative and clinical information. The latter includes information about the conditions treated, exclusions, investigations that need to be done prior to referral and other alternative services. The screen can also advise as to whether a referral may be unnecessary and provide information on local and national referral guidelines.
Expert advice and guidance
This is a facility whereby a GP can contact the consultant for advice and guidance on a patient. This may lead to a discussion on alternative options for management or treatment and result in fewer and more appropriately directed referrals.
In requesting advice and guidance, the referring clinician can attach documents to the request, including the results of diagnostic tests, scanned images, such as ECGs, or other related correspondence. The receiving consultant will then be able to look at the request together with any documents that have been attached. Once the review of the request has been made, the consultant can then respond to the referrer adding attachments, such as a management plan or links to external websites or documents, if necessary.
If an advice and guidance request then requires a referral, this can be converted into a booking request if this is suggested by the consultant as appropriate.
There are many benefits to using the advice and guidance facility for patients, referrers and providers:
Clinical assessment services
The NHS e-Referral service provides a clinical assessment function to aid clinicians in their management of patients, ensuring that the most appropriate referrals are made. In this service referrals are made to a central point and, following assessment, onward referral to a more appropriate service is permitted, or advice is offered to the referrer on alternative options for management.
The clinical assessment service operates within both primary and secondary care and can be booked directly or indirectly. Booking into the assessment centre will, however, start the clock for the Referral to Treatment time wait for a patient.
Referring organisations can also use the NHS e-Referral service to manage their referrals. However, it is essential that patient is involved in the decision-making process so that their constitutional rights to choice are respected. Referring patients to the clinical assessment services should not cause any delays to the care pathway if these are not clinically justified.
Reports and extracts
order to support the analysis and tracking of referrals, as well as to facilitate referral audit, the NHS e-Referral service utilises a system of enquiries, reports and extracts to provide extensive information to support these functions.
In this way, referral patterns can be monitored and referral behaviour influenced through the identification of referrers or organisations that could benefit from support in changing their referral practices.
Similarly, Clinical Commissioning Groups can look at referral numbers and patterns as part of their role in monitoring contracts and performance of providers.
It is essential that confidential patient information is kept secure. The NHS e-Referral service provides a secure online booking system as well as transfer of clinical information between organisations. Security is enhanced by the use of smart cards by authorised personnel which control access to information. The system ensures that an audit trail exists to record all the users who have had access to the information.
Transition to the new service
The weekend before the new e-Referral service went live, all the referrals that were booked under the Choose and Book system were migrated to the new service, enabling access to all referrals on the first day.
The web address for the NHS e-Referral service is https://nww.ebs.ncrs.nhs.uk, which is the same as for the old Choose and Book system.
As there is little difference to the screens of the new system compared to the Choose and Book service, minimal training is required for most users.
Since going live the service has been hit by some difficulties, including unanticipated technical issues causing the entire service to be taken offline for spells. There have also been some complaints around slow loading times. On 10 July the HSCIC issued a summary of the known issues with the system, including suggestions for workarounds of common problems.
Guidelines for use of the NHS e-Referral service
Although the transition has been planned such that users will require minimal training, the HSCIC has published a number of supporting documents to help referrers, providers, patients and commissioners navigate their way through the process.
The following general points of guidance for use have been made for referrers:
referral organisations are required to ensure that referrers are appropriately qualified, trained and compliant with Information Governance Standards, including:
Information Governance Management (eg clear policies and responsibilities for information governance and appropriate training of staff)
assurance of confidentiality and data protection (eg processes for the secure transfer of personal information, consent for the use of personal information and information to the public about the use and viewing of personal information)
assurance of Information Security (eg ensuring that the smartcard users comply with the terms and conditions of use, prevention of unauthorised access to personal information, policies on the use of mobile systems, plans in the event of power and system failures, information asset register and documented management and reporting procedures for incidents)
doctors are responsible for any decisions to delegate clinical actions to non-clinicians using the e-Referral service, for example, administrative staff can carry out bookings or rescheduling appointments, but clinicians must determine the clinically appropriate services and review the referral information
worklists must be monitored on a daily basis to provide information on the effective management of referrals (training on this is on the e-Referral service website)
the correct equipment, infrastructure and user support must be established to facilitate the best use of the e-Referral service
local access and management policies must reflect the guidelines produced by the e-Referral service.
The following responsibilities apply for referrers:
identifying the clinically appropriate services for patients:
by using the most suitable search process to find services through the SNOWMED clinical term, named clinician or clinic /specialty type
through ensuring that the referral follows the service requirements including exclusions
training on referrals is on the e-Referral service website.
by supporting patients in choosing a provider and booking an appointment including:
discussing the available options
booking the appointment on behalf of the patient where support is required or if the referral is urgent.
for other referrals, these must be initiated by the referrer and either:
make a direct booking with the patient and provide an appointment details letter, or
provide an appointment request letter and password to the patient so that they can book at their convenience (this can be by telephone, internet, or help can be offered by a member of the referring surgery staff).
the referral letter should contain enough detail to provide the receiving clinician with enough information about the patient's condition without being excessive and should follow clinical guidelines, if these exist
all necessary information as required by the receiving service should be provided and, if available, referral pro-formas should be completed and attached
the referrals should make reference to the recommended timescales where these exist, ie:
urgent and two week wait referrals – within one working day
routine referrals – within three working days.
Patients may have difficulty in using the NHS e-Referral service for the following reasons:
Last reviewed 15 July 2015