Consultant England SAS doctor

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NHS e-Referral Service: a guide for secondary care doctors

St Marys/Hammersmith Hospitals 21-12-16
Female hospital doctor looking at screen SMH2016

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 now, its full use was not required by the NHS Standard Contract.

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. 

Find out more about e-RS

View e-RS guidance for primary care

 

The process for change

From 1 October 2018, NHS providers and GP practices, via CCGs, should have:

  • Agreed a switch-over date from paper referrals to e-RS
  • Agreed a process for managing the return of referrals to practices, ensuring patient safety
  • Implemented the switch-over and paper referral return process, making any necessary adjustments 

NHS England has published comprehensive guidance for managing referrals.

 

Read our considerations for doctors in secondary care to take into account when implementing e-RS below.

Download the guidance

 

  • Advice and Guidance and workload

    The Advice and Guidance function (A&G) of e-RS is not mandated but there will be financial incentives for trusts to make use of it.

    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 needs to happen next?

    • It is essential that any new services are carefully planned and properly resourced as failure to do so may make them burdensome and difficult to deliver
    • It is essential that 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 burden 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 juniors may be losing out on education and training opportunities
    • If implementation of e-RS does lead to increased workload burden, clinicians must be allowed to incorporate this into their job plans/work schedules as appropriate. If employers contest this, it should be raised with the BMA either though the local negotiating committee (LNC) or by contacting the BMA.
  • Clinical liability for DNAs

    Eight to 10 per cent of hospital outpatient appointments result in a DNA (did not attend) outcome or are cancelled by the patient. Vulnerable patients may cancel appointments via admin staff who may not query the cause of the cancellation.

    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. This will add the patient to an e-RS work list and enable the hospital booking staff to contact the patient and re-book them back into the same service through e-RS. 

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

     

    What needs to happen next?

    • In our discussions on the compulsory use of e-RS, there has been no agreement with NHS England on how many attempts should be made to contact patients to re-book missed appointments
    • The level of follow-up should, therefore, not be over-burdensome and be in line with the Trust’s policy for DNA discharge
    • When a patient cancels their appointment and the 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

    Vulnerable patients

    Where the provider judges that a cancellation is from a vulnerable patient the Trust’s safeguarding policy should be followed.

    This will be of particular consideration in specialties where there is a high risk of a vulnerable patient being referred, e.g. psychiatry or paediatrics. It would also be good practice to alert the patient’s GP via email/phone. In cases where this is not possible, it is advised that you write to the GP/clinical safeguarding lead to inform them of the course of action taken.

  • Training

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

     

    What needs to happen next?

    • All Trusts should run training courses for administrative staff responsible for organising the scheduling of available clinics on e-RS
    • Training for secondary care doctors of all grades should be in line with that provided to primary care clinicians so that doctors working in all settings have a consistent understanding of how the system should work. This will help to minimise errors arising from misinterpretation and misapplication.
  • Inappropriate referrals

    As with traditional referral methods, there will inevitably be some referrals which secondary care clinicians deem to be inappropriate. 

     

    What needs to happen next?

    The receiving clinician may assess the referral information provided by the GP and decided that the patient could be managed more effectively in primary care without a secondary care 'face to face' appointment. The clinician may reject the referral, making sure that they provide appropriate information on the system.

    The referral will appear back on the worklist for the GP practice to contact the patient and take appropriate action, informed by the comments provided by the secondary care clinician.

    • 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 (e.g. dentists, physiotherapists, optometrists) to secondary care settings cannot currently be made using e-RS. 

     

    What needs to happen next?

    • It is imperative that existing referral processes remain in place for all referrals which 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. Clinicians should consult their line manager or Trust policy as to how this should be managed efficiently
    • The use of e-RS should, as soon as possible, be extended to all allied health professionals who regularly refer patients to specialist services. A single system for all referrals will ensure the best patient experience and help minimise the administrative burden for clinicians.
  • Referral management, assessment and pathways

    Referral management centres (RMCs)

    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, and we believe that they should be phased out completely. e-RS provides the ability for direct clinician to clinician referral, and for advice and guidance to be provided between clinicians through a convenient, transparent and professional process. 

     

    Referral assessment services (RAS)

    As part of the e-RS programme, NHS England has introduced referral assessment services (RAS), which now allow providers to:

    • Assess the clinical referral information from the GP/referrer
    • Decide on the most appropriate onward clinical pathway
    • Contact the patient to discuss choice (if an elective referral)
    • Arrange an appointment, where needed
    • Return the triage request to the original referrer with advice, if an onward referral isn't needed

    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 patients' referrals are triaged correctly.

    However, while the aim of this new facility is to increase direct engagement with the referring clinician and the patient referred, 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 incorporate and work effectively with new care pathways. This is preferable to local workarounds which risk upsetting pathways which are proven to be efficient and 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. 

  • Further information

    NHS England guide to e-RS

    NHS e-RS booking system for patients to use 

     

    Contact the BMA for support and advice

    It is important that any challenges or unintended adverse consequences for secondary care doctors arising from the introduction of e-RS are made known to the BMA, as we continue to monitor its implementation.

    If you or your colleagues are finding the move to electronic referrals problematic, please let us know by getting in touch with our First Point of Contact service either by calling 0300 123 1233 (lines open 8.30am to 6pm weekdays, excluding UK bank holidays) or by email