Maximising the Benefits and Functionality of the NHS e-Referral Service Presented by Sue Allan, Mike Harris & Michal Kus

Aims of Session Introductions Background Why use e-RS? Drivers Benefits Case studies – real life examples Support available Future changes Discussion / Q&A

NHS Digital Team Sue Allan – e-RS Programme Manager Mike Harris - Senior Implementation and Business Change Manager Michal Kus – Senior Implementation and Business Change Manager

NHS e-Referral Service (2015) History + Milestones Current utilisation 55% (GP to 1st consultant-led OP) Choose and Book (2004) Initially GP  1st OPA Expanded Provider Base: AHPs, Diagnostics, GPwSI, Assessment Services Choice of 4/5 providers (including ISP)  ‘Free’ Choice Advice & Guidance Named Clinician Functionality Ability to search by SNOMED clinical terms NHS e-Referral Service (2015) Any to Any Enhanced A&G

Why use e-RS?

Drivers

Standard Contract – Service Conditions New Clause – Service Condition 6.2A With effect from 1 October 2018, and as provided for in NHS e-Referral Guidance and/or any subsequent guidance published by NHS England and/or NHS Digital, the Provider need not accept (and will not be paid for any first outpatient attendance resulting from) Referrals by GPs to Consultant-led acute outpatient Services made other than through the NHS e-Referral Service.

Standard Contract – Technical Guidance A new national CQUIN indicator will provide a financial incentive in 2017/18 for providers to do their part to promote the systematic adoption of the NHS e-Referral Service for GP referrals. From 1 October 2018, however, new arrangements are mandated through the NHS Standard Contract. From that date, providers need not accept any GP referral into a consultant-led outpatient service unless it is made through e-RS As currently, providers must use all reasonable endeavours to ensure that sufficient slots are available to enable direct booking of appointments via e-RS Providers must also ensure that they accept all referrals made through e-RS via the “appointment slot issues” route (that is, where a GP or patient is unable to book an appropriate slot, but still wishes to make the referral). The provider is able to return any non-e-RS referral to the GP and will not be paid for any first outpatient attendance which results from a non-eRS GP referral.

NHS e-Referrals – CQUIN Description Relates to GP referrals to consultant-led 1st outpatient services only and the availability of services and appointments on the NHS e-Referral Service. It is not looking at percentage utilisation of the system All providers to publish ALL such services and make ALL of their First Outpatient Appointment slots available on NHS e-Referral Service (e-RS) by 31 March 2018 following the required trajectory Undertake required work on their Directory of Services to publish ALL services on the NHS e-Referral Service

NHS e-Referrals – Measurement Q1 - Submit a baseline plan to deliver: Q2 (80%), Q3 (90%) and Q4 (100%) targets for service availability, measured by referral volume A reduction in ASIs to 4% Q2 – Q4 Services published as listed on EBSX05 extract, measured against baseline plan ASI rate reducing to 4% or less, in line with baseline plan

NHS e-Referrals – Guidance This CQUIN has been introduced to: support Providers with the transition to receiving all GP referrals through the NHS e-Referral Service, in line with the expectations of the NHS Standard Contract reduce the number of patients that experience an ‘Appointment Slot Issue’

Supporting CQUIN Delivery - Guidance http://content.digital.nhs.uk/referrals/future

Operational Drivers Amongst others… Cancer Waiting Times – 2WW on e-RS, more efficient start to the pathway – case study to follow Referral to Treatment Time – use of A&G plus new functionality – Referral Assessment Services – more detail to follow Demand and Capacity - prospective access to referral information, Enhanced Referral Management Financial pressures – NAO report, benefits, cost savings when comparing paper to electronic

Benefits by stakeholder group

Patient Benefits

Referrer Benefits

Service Provider Benefits

Service Provider Benefits NAO report 2014, based on completed Outpatient Pathway Modelling Tool by providers Reduced cost to process referrals Savings of £27,500 per 10,000 referrals Reduction in Did Not Attend rates Savings of £76,500 per 10,000 referrals

Commissioner Benefits

Case studies

2WW Referrals through e-RS Oxford University Hospital Trust & Oxford CCG

2WW Referrals through e-RSC Joint trust and CCG project to implement 2WW services, started Oct 2016 Background Oxford CCG use e-RS for approx 85% of all 1st OP referrals OUH Currently receive approx 70% of all 1st OP referrals via e-RS 2WW services were not provided via e-RS Most 2WW referrals were e-mailed in Several processing steps required which allow for human error in transferring emails at the central 2WW bureau either into appointments or, in 50% of cases, passing the referrals on to departments to carry out their own processing adding another step.

2WW Referrals through e-RS Allowing 2WW referrals to be sent by e-RS removes a lot of the processing problems for the trust, thereby reducing admin errors Common method of referral for routine urgent and 2WW simplifying referral pathways for GPs and provider processes Appointments can be booked directly, improved certainty for patients, reduced admin for provider Full audit trail for the referral available

2WW Referrals through e-RS Challenges Capacity management and service redesign Updating process for current 2WW tracking and reporting to work with e-RS, some manual work required Other competing priorities for trust

2WW Referrals through e-RS – OUH Project Phased approach to 2WW service deployment 2WW referral clinical templates available to referrers within integrated systems Each service required Service redesign for e-RS workflow to remove paper Clinic build on PAS Service build on e-RS Some services also required Demand and Capacity review User training, consultant online review Updated 2WW proforma deployed to referrer systems

2WW Referrals through e-RS - Progress The trust currently is live with 2WW services on e-RS for the following specialties: Breast Dermatology Thyroid/Endocrine In total 11 2WW services live to date Rollout to all specialties due to complete July 2017

Improving Appointment Slot Issues in e-RS Cambridge University Hospitals Trust

Note for the following slides These slides have been created by the NHS e-Referral Service (e-RS) team on behalf of Cambridge University Hospitals All of the information used in the slides has been obtained from: e-RS/ASI questionnaire completed in June 2016 Regular meetings and discussions between CUH and e-RS team CQC inspection reports (2015 and 2016) e-RS/ASI Case Study - now available

Cambridge Hospitals - ASI Position in 2015 ASI rate peaked at 0.42 during 2015 Circa.1000 referrals on the trust’s ASI worklist CQC inspection in April 2015 rated Outpatients as Requires Improvement “Significant numbers of patients awaiting appointments who have not been clinically assessed or received treatment in line with their clinical needs” As part of an ASI turnaround programme, new outpatient management team brought in All e-RS improvements driven by trust exec team, supported by lead CCG

Proactive Approach to ASI Management Weekly Report is circulated to Service Delivery Managers highlighting: ASIs received during week ASIs waiting to be booked from worklist Referrals still waiting to be booked Appointments booked into Services Future available e-RS appointment slots e-RS Reports & Extracts are used to build overall picture of Demand & Capacity Regular meetings take place between central team and specialities Slot polling is managed at Service, Speciality and Location level

Responding to Increasing ASIs If increasing number of ASIs are a trend, it is important to understand: The driving factor behind the increase What plans are in place to manage ASIs received Options to increase the e-RS polling range Current clinic template (New vs. follow-up appointments) Options to create an Ad-Hoc clinic & book ASIs asap Always a joint discussion between the central and speciality teams

Key Issues The 2 main issues identified when e-RS polling matches manual booking: The need to identify additional capacity for rescheduled appointments The time required to contact patients in order to re-book into alternate appointments To ‘stop the flow’ of ASIs, polling ranges MUST BE extended beyond ‘manual booking’ window Services will always attempt to cover clinics rather than cancel appointments Cancelled/rescheduled patients are always prioritised CCGs key to addressing demand – Community Services, referral criteria, use of e-RS/A&G………

ASI Programme Outcome

Lessons Learned & Summary e-RS is only one part of the overall Demand & Capacity process e-RS Reports and Extracts are just as important as e-RS functions such as ‘Poll Now’ and ‘Slot Reservation’ Success will only happen with Provider and CCG Exec-level ownership, this being the driver for change ‘On its own it (e-RS) cannot solve the issue within Outpatients, but used as an integral part of a comprehensive operational grip process it can really help shape services to meet patient demand’ Sian Freeman. Outpatients Service Manager Cambridge University Hospitals NHS Digital / Cambridge Hospitals-ASI Case Study now available

Using e-RS Advice & Guidance Calderdale & Huddersfield NHS Foundation Trust

Advice and Guidance – Case Study Using Advice & Guidance (A&G)not only improves patient satisfaction and referral to treatment times, but it can also lead to savings on the overall cost of health care provision. A&G introduced by Calderdale & Huddersfield NHS Foundation Trust in 2011 In 2015 the Trust received 2,384 A&G requests. The specialties receiving the highest number of A&G requests are Cardiology and Haematology CCG and trust have agreed a tariff of £25 per A&G response The Trust aims to respond to requests within three working days.

Advice and Guidance – Case Study The graph below demonstrates the Advice and Guidance outcomes:- 26% advised to refer to secondary care 57% advised no further treatment or management was needed 13% advised to manage the condition locally

Future Support

NHS Paper Switch Off Programme Supporting Acute Providers to accelerate progress to the October 2018 contractual position NHS England writing to CEOs and CIOs to introduce the programme Brings together co-ordinated support from NHS England, NHS Digital and NHS Improvement NHS Digital will: Support initial diagnostics and project planning Provide Subject Matter Expertise to support delivery of project

Scope of Projects Focus on GP to first consultant outpatient referrals only Banded according to use of e-RS Timescales vary from c3 months to c12 months Level of detail and support vary accordingly Early pioneers, e.g. Sherwood Forest @97% main focus on data quality and accuracy, exceptions and communications - short-term project Trust @c20%, focus on business process change, services on e-RS, engagement – longer term project

Future Plans

Future – Functional Enhancements Future Roadmap – 5 Key Components of Paperless 2020 Enhanced Referral Management Any-to-Any Referrals Enhanced Reporting Pathway Management Follow Ups

Enhanced Referral Management - 2017 Verification of Referral Criteria Enhanced Advice and Guidance Advice only services Multi-way dialogue Simpler conversion for referrers Advice worklist for referrers Referral Assessment Services Ability to triage a referral without the need for an appointment Access to clinical referral information from the ASI worklist Delivered Delivered  Delivered Delivered