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

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

3. 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

4. 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

5. Why use e-RS?

6. Drivers

7. 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.

8. 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.

9. 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

10. 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

11. 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’

12. Supporting CQUIN Delivery - Guidance

13. 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

14. Benefits by stakeholder group

15. Patient Benefits

16. Referrer Benefits

17. Service Provider Benefits

18. 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

19. Commissioner Benefits

20. Case studies

21. 2WW Referrals through e-RS
Oxford University Hospital Trust & Oxford CCG

22. 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 ed in
Several processing steps required which allow for human error in transferring s 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.

23. 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

24. 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

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. 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………

33. ASI Programme Outcome

34. 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

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

36. 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.

37. 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

38. Future Support

39. 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

40. 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 main focus on data quality and accuracy, exceptions and communications - short-term project
focus on business process change, services on e-RS, engagement – longer term project

41. Future Plans

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

43. 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