The NHS e-Referral service (e-RS) is a referral management and electronic appointment booking system which allows for the booking and managing of appointments by professionals and patients in England.

It is currently used for most referrals by GP practices into consultant-led first outpatient appointments but, until 2019, its full use was not required by the NHS Standard Contract.

The e-RS offers a variety of benefits to patients as well as professionals and the wider NHS, particularly regarding the clarity and security of information. 

Advice and guidance function

There are financial incentives for trusts to make use of the advice and guidance function (A&G).

However, most hospital departments already have informal arrangements with practices for rapid advice, which generally work well by including this work as part of on-call duty. 

What should be in place

• Turnaround times for responses through the A&G function are realistic and appropriate for the level of staffing.
• Where departments replace existing informal channels with the A&G function, care must be taken to ensure a smooth transition. Where any additional workload is created, departments should look for quick resolutions by:
  
  i) reviewing work scheduling 
  ii) categorising advice and guidance as DCC (direct clinical care) work for consultants and SAS doctors 
  iii) identifying where residents may be losing out on education and training opportunities.
• If implementation of e-RS does lead to increased workload, clinicians must include this in their job plans/work schedules. 

Clinical liability for DNAs

8-10% of hospital outpatient appointments result in a DNA (did not attend) outcome or are cancelled by the patient. 

Where the original referral and booking was made using the e-RS, the provider’s patient administration system (PAS) will send a message to e-RS if the patient does not attend the appointment.

e-RS potentially adds complexity to the transfer of clinical responsibility between care settings and there is currently no answer as to when clinical responsibility should transfer. It generally mimics clinical responsibility when making a paper referral.

What should be in place

• The level of follow-up should not be over-burdensome and be in-line with the trust’s policy for DNA discharge.
• When a patient does not wish to re-book, the provider would usually discharge them to their GP and clinical responsibility would also return to the GP.
• Where a cancellation is from a vulnerable patient, the trust’s safeguarding policy should be followed.

Training

Effective training for clinicians and administrative staff is essential to ensure there is no additional burden on clinical staff due to e-RS.

What should be in place

• All trusts should run training courses for administrative staff responsible for scheduling clinics on e-RS.
• Training for secondary care doctors of all grades should be in line with that provided to primary care doctors. 

Rejected referrals

What should be in place

• Comments should include advice on managing the patient, as well as any other useful information to assist future referrals into that service.
• While some providers will notify patients that their booking has been cancelled, as with traditional referral methods, responsibility for acting on the rejection advice rests with the referrer.
• Where the receiving clinician assesses that a different secondary care service would be clinically more appropriate, that clinician should re-direct the referral within the e-RS system to the appropriate department.

Referrals from non-medical professionals

Referrals from non-medical professionals - for example, dentists, physiotherapists and optometrists - to secondary care settings cannot currently be made using e-RS.

What should be in place

• Existing referral processes should remain in place for all referrals that cannot be made via e-RS.
• Patients should not be adversely affected because their referral has not been made through e-RS. This could mean blocking out a portion of outpatient appointments for non-e-RS referrals.
• The use of e-RS, if not already, will be extended to all allied health professionals who regularly refer patients to specialist services. 

RMCs (referral management centres)

While RMCs are designed to reduce referrals to secondary care, the BMA has argued against their use due to concerns about their accountability and the transparency of the clinical decision-making process.

With the introduction of e-RS, the purpose of RMCs is increasingly unclear. We believe that they should be phased out completely. e-RS provides clinician to clinician referral, and for guidance to be provided between clinicians through a convenient process.

RAS (referral assessment services)

As part of the e-RS programme, NHS England has introduced referral assessment services (RAS).

This new facility supports complex care pathways, such as gastroenterology and cardiology, where it is not always clear whether a patient needs a consultant appointment or a diagnostic test. A RAS set up by the provider will ensure referrals are triaged correctly.

However, it is likely to take up a reasonable amount of time for some consultants and SAS doctors and this should be included as part of their job plan.

Integrated care pathways

As new models of care are implemented, it will be essential that e-RS is reviewed and adapted to ensure that the system is ready to work with new care pathways. This is preferable to local workarounds, which risk upsetting pathways that are proven to be beneficial to patient outcomes.

If clinicians experience e-RS to be an obstruction to the management of patient care, please contact the BMA so that this can be investigated.