Last reviewed 24 September 2018

In this feature, Thoreya Swage, healthcare consultant, explains the full implementation of the NHS e-referrals service on 1 October 2018 and the run up to this — the National Paper Switch Off Programme.


Referrals for secondary healthcare made electronically have been on a journey since the establishment of Choose and Book in 2004. Choose and Book was an electronic appointment booking service which enabled patients to decide where and when they wished to have their first outpatient appointment.

Later came the NHS e-referral service (NHS e-RS) replacing Choose and Book in 2015. This is currently used for 62% of all GP referrals into consultant-led first outpatient appointments. The NHS e-RS has been shown to be a very efficient, auditable and safe method in which to send referrals and request appointments. The benefits include:

  • clinical information that is processed securely

  • a clear audit trail for general practice

  • more accurate reporting of data for commissioners

  • a wider choice and control for patients over their care through better information about the availability of services

  • a decrease in the Did Not Attend (DNA) rates for acute services (in some cases up to a 60% decrease)

  • a reduction in the time a referral takes from the GP to secondary care.

In addition, the 2014 National Audit Office report on waiting times for elective care showed that approximately £51 million was saved through the use of e-RS.

So what are the next steps?

For a number of years, the NHS Standard Contract has stipulated that providers ensure that relevant services are published on the system with adequate availability of slots to support e-RS and that Clinical Commissioning Groups (CCGs) ensure that GPs use e-RS for referrals.

The 2018/19 NHS Standard Contract is more precise. It contains a specific provision (Service Condition 6.2A) stating that from 1 October 2018 referrals will only be accepted for secondary care if made through the NHS e-RS, ie electronically.

From then onwards paper referrals will not be accepted by hospitals and CCGs will not be paying for these episodes. Paper referrals from a GP would be returned to the practice. In order to promote this, a National Paper Switch Off Programme has been put in place supported by NHS Improvement and NHS Digital.

National Paper Switch Off Programme

The National Paper Switch Off Programme provides support to NHS trusts to help them implement fully the requirements of the NHS Standard Contract through the provision of access to expertise from NHS England Regional teams and others. The aim is to establish projects that improve the current use of e-RS with a view to full utilisation by 1 October 2018.

What services are required to be compliant with the National Paper Switch Off?

The requirements of Service Condition 6.2A of the NHS Standard Contract only covers GP referrals to acute outpatients consultant-led services. The referrals can be “open” or to named consultants. This also includes referrals to consultant-led teams or to named health care professionals.

In addition, acute hospital independent sector providers that deliver services under the NHS Standard Contract are required to be compliant with this requirement.

The following services are not covered:

  • mental health services

  • consultant to consultant (tertiary) referrals

  • referrals from dentists and optometrists

  • referrals from prison GPs to hospital services

  • referrals for Defence Medical Services patients, specifically those that are based outside of England, for example, military personnel and dependents, and associated civilians

  • referrals made by private GPs or for private patients

  • referrals from GPs working in out-of-hours services or urgent care centres

  • referrals for follow-up appointments

  • referrals for same day services, eg some obstetric services such as early pregnancy services, diagnostic or assessment services, such as deep vein thrombosis clinics, etc

  • services accessed through self-referrals

  • termination of pregnancy (TOP) services if through referrals for same day services or self-referrals or if the TOP contract is commissioned as a community service.

What about locally agreed contracts?

Any locally agreed contracts between CCGs and providers that include referrals to consultant-led outpatient services will be subject to the requirements of e-RS.

What exactly will happen to paper referrals on and after the cut-off date?

The cut-off date of 1 October 2018 relates to the date of referral not the attendance. Paper referrals can be accepted on 30 September 2018 and bookings for outpatient appointments can be made after that date.

However, paper referrals made on 1 October 2018 onwards will be returned to the referrer.

How does the e-RS affect referral to treatment times?

This should not affect the management of referral to treatment times (RTT) and the approach should not change and should continue to be applied from the point at which the referral is received by the provider. The RTT clock should be initiated as usual when the referral is made through e-RS.

For referrals that are not received through e-RS, the RTT clock should be applied from receipt as per the paper referral processes. There should be local agreements in place to obtain e-RS referrals from the GP practices.

How does the e-RS work with clinical assessment services?

In situations where complex pathways require an intervention other than an outpatient appointment, for example cardiology or gastroenterology, providers have been supported in setting up Referral Assessment Services (RAS) by the e-RS programme. The RAS replaces locally set up clinical assessment services and enables providers to:

  • assess the clinical information in the referral from the referrer

  • determine the most appropriate clinical pathway

  • liaise with the patient to discuss their choice (if an elective referral is needed)

  • organise an appointment, as necessary

  • provide advice to the original referrer on the triage request if an onward referral is not required.

The RAS also works in cases where a local pathway is through a triage service, such as musculoskeletal referrals.

The system will be fully functional from 1 October 2018 to support the service condition 6.2A in the NHS Standard Contract.

Availability of appointment slots

It is the responsibility of providers to ensure that an adequate number of appointment slots are available for booking. If there is no appointment slot available for a chosen service for an e-RS referral, it is then the responsibility of the provider to contact the patient directly to organise an appointment. This must be actively managed by the provider.

Cross border referrals

The terms and conditions of the NHS Standard Contract do not apply to Scottish or Welsh registered patients being referred into English providers.

How does the e-RS system work with patients who have no NHS number?

Where the NHS number of a patient cannot be determined, the referral will have to be made on paper. The receiving trust will be required to accept and process the referral. There will need to be arrangements in place locally to deal with this situation.

What about patients who have opted out from having their personal information transferred electronically?

As for instances where no NHS number can be determined, the referral will have to be made on paper. The receiving trust will be required to accept and process the referral. Again, local arrangements need to be in place to deal with these circumstances.

System failures, eg cyberattacks

As with all IT systems there is a risk that the e-RS will be prone to system failures, for example local or national system failures or cyberattacks. As part of the preparation for Paper Switch Off it is expected that providers will have in place processes to manage these situations and to set up alternative arrangements to receive the referrals.

In these circumstances there will be a temporary suspension of Service Condition 6.2A until a safe recovery is made.

How is the national Paper Switch Off being managed across the country?

The most effective way of implementing the use of electronic referrals is through mutual agreement between the commissioners and providers. The referral system is dependent on the commissioners supporting their GPs to refer to clinically appropriate services and the providers ensuring that there is sufficient capacity as well as publishing the details on the services that are available.

Therefore, the Paper Switch Off projects have been established between local providers, CCGs and Local Medical Committees across England in order to optimise the communication processes that are essential to facilitating the safety and efficacy of the referral pathways.

Immediately prior to Paper Switch Off there will be a transition period during which the electronic referral system will be operating and paper referrals will continue to be accepted. This is agreed locally; however, the end point is 1 October 2018 when all referrals to consultant-led services will only be accepted electronically.

A timetable of Paper Switch Off dates has been drawn up across the different regions of England. Most of the trusts have already achieved Paper Switch Off and a few are in the transition period working up to 1 October 2018.

What happens to paper referrals after 1 October 2018?

After 1 October 2018, any referral not received through the e-RS system will be regarded as a “paper referral”. This includes emails and other electronic communications transmitted outside of the e-RS system.

During the transition period to Paper Switch Off, arrangements will need to be made between commissioners and providers to ensure that e-RS referrals are closely monitored and are directed to the most appropriate care as swiftly as possible. In addition, an efficient paper referral return process must be agreed and established. It is recommended that commissioners and providers are able to manage routine and two-week or urgent referrals separately to minimise any potential harm to patients.

Local response times will need to be agreed between commissioners and providers for the return of paper referrals. These should be set in terms of working days or calendar days, taking into account the plan to move towards seven-day provision. It is essential that the provider communicates without any delay with the patient’s GP, so that the doctor can take appropriate action with the returned paper referral.

The actions will be different for routine and two-week/urgent referrals. For the latter, in the interests of patient safety, a quicker action will be required. Thus, if no response is received from the GP practice the following working day, the provider will contact the patient directly to arrange an appointment whether or not an e-RS has been received from the GP. This matter can then be escalated to an identified contact within the appropriate CCG.

The process for paper routine referrals will be different in that these will be returned to the practice without a communication requesting an e-referral. The recommended timescale for the return of routine referrals received outside of e-RS is the following working day. GPs will be expected to turnaround the referral through e-RS within two working days. This is designed to minimise the delay to patients.

If no response occurs then the provider can repeat the request for an e-RS referral after five days. If this is not resolved the paper referral is rejected by the provider. Weekly paper referral data will be shared with the CCG, including by specialty and practice code. This enables the CCG to follow up the referrals directly with the practices concerned.

It is also recommended that providers conduct an assessment of the routine paper referrals received in order to identify any referrals that should be seen more urgently.

While designing the process of the return of paper referrals, commissioners and providers are expected to agree and document the most effective way of minimising any potential clinical risk and ensure that the safety and quality of the patient’s experience is not compromised.

More information

For further information on the National Paper Switch Off Programme — go to the NHS Digital website.

For further information about the NHS e-RS — go to the NHS Digital website.