1. NHS e-Referral Service
Introduction to e-RS – Service Definer
Presenter:
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2. Housekeeping

3. Objectives – during today’s session you will:
Understand the background of the NHS e-Referral Service
Look at the different types of referral models that are used within the NHS
Know the different functionalities within NHS e-Referral Service
Learn how to set up and manage a Directory of Services (DOS)
Appreciate local processes and expectations of the organisation for the way you will use e-RS

4. First thing’s first
For every UBRN, there is a referral For every referral there is a patient!

5. First thing’s first For every referring organisation there are:
Doctors
Nurses
Medical Secretaries
Receptionists
Practice Managers, and
Patients!

6. First thing’s first For every provider organisation there are:
Consultants
Nurses
Medical Secretaries
Booking/Outpatient staff
Directorate managers
a Patient Access team; and
of course patients!

7. Who is going to be involved and what for?
Patient
IT Department
Registration Authority Team
Local CCG
Training Department
Directorate Management
Patient Access Team
IT Department
Link e-RS to a booking system (PAS)
Testing
Setting up desktops for users
To report issues to and either resolve or report to HSCIC
Continued support
Registration Authority Agent/Manager
Issue Smartcards
Add/remove/manage roles
Local CCG
Promote new services
Support with queries
Deal with complaints
Training Department
Train new staff
Keep up to date with new functionality
Produce materials
Directorate Management
Setting up services
Planning clinics
Capacity & Demand
Patient Access Teams
Rearranging clinics
Prepping clinics
Booking/rebooking appointments

8. What does a Service Definer do?
Sets services up on the DOS, completing all relevant information.
Liaises with clinicians to ensure the right information is included, especially Snomed terms
Works with the electronic booking system manager (PAS) to make the service directly bookable (a DBS)
Requests services be commissioned (if on the primary care menu)
Updates DOS information to ensure referrers and patients have the latest information

9. Overview of the NHS e-Referral Service (e-RS)
e-RS (previously Choose and Book) is an electronic referral and management system, using Spine information, that can integrate with other systems
e-RS is able to be dynamic and responsive to patient, clinician and NHS England requirements
Background
getting the patient to the right place, first time and without undue delay
provides a secure environment to send patient information between referrers and providers
enables on-line booking/management of appointments
integrates with other systems, eg GP clinical systems and provider appointment booking systems
What is e-RS about?

10. Overview of the NHS e-Referral Service (e-RS)
Everyone! GPs, nurses, hospitals, admin staff, diagnostic and community services
As it supports different pathway models, it can be used by a variety of providers
Who uses e-RS?
As long as the referral is kept in e-RS:
Better patient care
Paperless
Secure
Instant
Choice
Simple to use
What are the benefits?
Better patient care:
You can use the system to refer patients to the right service more easily and in real time
- You can monitor their referral at any time, using the system worklists or Patient Activity List
- Patient knows they are in the system and have the ability to either be supported in their appointment booking, or have an appointment booked whilst they are with the GP, or book it themselves in their own time
- Patient can see exactly what is happening to their referral through their on-line portal (Patient Web Application)
Instant
A referral can be made, an appointment can be booked and referral information sent over to the provider during the doctor/patient consultation
A provider can immediately see the referral to triage it (as long as all the above is completed)
Appointment booking/cancellations/rejections etc are all completed in real time
Paperless (or Paperlite)
Referral sent by GP and triaged (by provider) electronically
Rejections, DNA and CAS messages can be sent on-line
Referrals can be moved internaly, on-line
Choice
Patients and clinicians can choose where the patient is referred to, based on the information given at the time of the referral, eg waiting times, location etc
Service information is available to see on-line
Secure
- Smartcard access only allows those given permission to access the referral

11. What facilities does e-RS give me?
The DOS can be set up and managed by every organisation with an NHS contract and N3 connection.
A Directory of Services (DOS)
The on-line Directory of Services (DOS) shows users what services are available and all their service details
Directory of Services
The ability to refer and book appointments on line, especially useful for vulnerable patients
Capability to manage referrals via worklists and enquiries
On-Line Referral Management
Knowledge that you can still refer patients to a service with no appointments
Referral Deferral
An on-line capability to ask a provider clinician a question, instead of (or before) sending the patient for an outpatient appointment.
Advice & Guidance
Reports and extracts that give you information about your referral patterns
Reporting

12. How does NHS e-Referral Service support different referral models?
Within the NHS referral pathways depend on a number of elements, for example:
If the patient is being referred to a community, secondary care or tertiary service
Where diagnostics are required before an appointment
If a referral management service is in place
When it is for a patient with mental health issues
2WW referrals
e-rs can support these pathway models by being using direct to service or assessment service functionality.
How does NHS e-Referral Service support different referral models?

13. Introduction
Before setting up a service, it is important to understand the different referral pathways used within the NHS and/or your organisation.
Although Service Providers have to make their clinics fit into e-RS functionality, there are several to pick from
We will look at three different referral pathways:
Direct to Service
Clinical Assessment Service
Referral Management Centre
Trainer Note:
Tailor this section according to your local needs if required

14. Direct to Service - Introduction
Who uses it?
Hospitals, community clinics, independent sector providers
What for?
Mainly first outpatient clinics
Why?
Simplicity

15. Direct to Service GP and patient decide on further treatment
Patient visits GP
GP and patient decide on further treatment
GP creates a referral from their GP clinical system into e-RS
Appointment booked and referral letter attached
Review
A Provider clinician reviews the referral and accepts or rejects it
Patient treated
The patient is seen in an outpatient appointment.
e-RS journey is complete

16. Benefits Significant cost savings possible.
Referral letter immediately available at service. No internal transfer of paper referrals.
Referral can be redirected to other services electronically if needed.
To provide referrers with relevant information at time of referral.
Can provide advice and guidance to help reduce inappropriate referrals.
Providers
Immediate access to correct service
Can be supported in the booking process by referrer at time of referral if needed.
Reassurance that they are ‘in the system’ before leaving the practice.
Patients
Immediate visibility of available services at a local and national level.
Supporting information shows at the time of referral.
Ability to book appointments immediately to support vulnerable patients.
Access to advice and guidance.
Referrers

17. Clinical Assessment Services - Introduction
Who uses them?
Community clinics, hospitals but much less so
What for?
Triaging referrals and treating patients
Why?
Ability to refer on/onward refer

18. Assessment Services Scenario 1 – A locally commissioned CAS
A Clinical Commissioning Group (CCG) sets up a physiotherapy service to see and treat patients in primary care.
Patients are referred into the service and a clinician triages the referral.
Patients could be:
treated in clinic and discharged back to their GP
referred onward to secondary care straight away
treated by a physio but still need secondary care so referred onward

19. Benefits Ability to triage all referrals to a service.
Can ‘Refer On’ to any service either inside or outside the organisation if required.
Provider
Complex cases can be assessed to ascertain the appropriate pathway.
Patient
Single point of access for referrals
Referrer

20. Referral Management Centres - Introduction
Who uses them?
Clinical Commissioning Groups (CCGs)
What for?
Triaging – preventing unnecessary referrals
Why?
Cost cutting (managing referrals to cheaper, local services) or offering advice on local management
Trainer Note:
Please ensure that you localise this as there are many different types of Referral Management Centres/Services, so this may not reflect how it works in your area.
If you do not know how it works in your area, please seek guidance or remove this and/or the following slide/s referring to RMCs.

21. Assessment Services Scenario 2 – A Referral Management Centre (RMC)
A Clinical Commissioning Group (CCG) sets up a Referral Management Centre to manage referrals on behalf of GPs in that area.
Patients are referred into the RMS /RMC and referrals are triaged.
The RMC refers on to another service.
Also known as a Referral Management Service or RMS
Functionally the process is the same

22. Assessment Services Scenario 3 – A Provider CAS
A provider sets up a CAS to manage complex pathways
Patients are referred into the CAS referrals are triaged.
The CAS refers on.
Functionally the process is the same

23. The practicalities of referring a patient

24. Referring a patient Referral is created Appointment booked
Patient seen in practice
Agreement that a referral is needed
GP system and e-RS used to create a referral
Referral letter attached
The referral is reviewed on-line by a clinician
Referral accepted or rejected by clinic provider
Referral is created
Appointment booked
Referral triaged
Patient receives paperwork with all relevant information to book their appointment

25. How do patients get their appointment?
This is dependant on whether the service is set up as directly or indirectly bookable (DBS or IBS).
Directly Bookable Services (DBS)
Patients can book and manage their appointments on-line either at their referrers practice (eg GP surgery), via the Patient Web Application (PWA) or by ringing The Appointments Line (TAL).
Appointments will be booked straight into
the clinic’s Patient Administration System
(PAS), which will also registers new patients.
Any changes made in e-RS will be
automatically updated in PAS.
Trainer Note:
This section can be adjusted to your local needs. For example, if you only have directly bookable services you could remove the section on indirectly bookable services. However, it is extremely useful for learners to see the whole picture of how patients book their appointments.

26. Indirectly Bookable Services (IBS)
Patients book their appointment by contacting the service/clinic they are referred to.
An appointment must be given to a patient when they ring to book one.
The service has to book the appointment into NHS e-Referral Service (e-RS) and the clinic’s Patient Administration System (PAS) separately.
Clear instructions must be given to the patient on how to book their appointment and the times they can contact you to make their booking. This information should be clearly displayed in the Directory of Services (DOS).
Any changes to appointments must be updated in e-RS and PAS
to ensure that information is kept up to date.

27. The Referral to Treatment (RTT) “clock”
Patients have a right to be seen and treated within 18 weeks of their referral.
The RTT clock starts either when:
an appointment is booked
a patient tries to book an appointment, ie rings into an IBS or is deferred (because there are no appointments on-line)
The clock can be stopped under certain circumstances, eg a diagnostic treatment
This is all recorded in the e-RS history/audit trail

28. Referral Deferral
If a DBS has no appointments, referrers have an option to Defer to Provider, when creating the referral.
This option will create a UBRN in the usual way and forward it to the provider you have chosen to defer to.
This option is not available if the service is IBS or has any appointments (even one!).
Trainers Note:
Keep this slide in, especially if you are a DBS so the Service Definer understands what happens if there are no appointments/slots.

29. Setting up Services on the DOS What do Service Definers need to do to?
Trainer Note:
The following slides are to describe to learners what is required when setting up a DOS and how to prepare.
Feel free to localise as required!
Setting up Services on the DOS What do Service Definers need to do to?

30. NHS e-Referral Service Checklist
Providers must have a contract in place to provide services. This will either be the Standard National contract or a locally commissioned contract.
Contract
e-RS
To have access to NHS e-Referral Service, each provider must have an N3 connection, an ODS code and completed the necessary Information Governance assurance.
Compliance
Providers will connect to NHS e-Referral Service using smartcards.
Connection
If the service is locally commissioned, providers will need to set up and publish each one before they are commissioned and appear on the NHS e-Referral Service Directory of Services.
Commission
GPs will help patients/provider’s customers to make a suitable choice where they want to be referred to. Providers must manage each referral appropriately.
Citizens

31. What do providers need to think about first?
Firstly, to understand what the service will deliver and how the whole pathway will look.
Start by gathering information, such as:
Who will deliver the service and where?
What type of service will you be delivering?
How will patients book their appointment?
Who is going to manage referrals and patients
within the service?
Who is going to be involved/set up/support
this service?
Will patients be treated at their appointment or will they be assessed?
Will it be clinicians or admin?
What will the process be for this?
Is there a compliant PAS to use or will patients need to ring the service directly?
Will it be:
- at one or multiple sites?
- be a GP with special interest (GPwSI)?
- Nurse/phyiso led?

32. How are services set up? 1.
To set up a service on NHS e-Referral Service, it needs to have:
its own unique location code, which must be where the clinic is held
a Service Definer, to set up and publish the service on the NHS e-Referral Service Directory of Services (DOS)
a clinician who supports the information held on the DOS

33. Primary or Secondary Care Menu1.
We mentioned before that services must have a either a local or national contract, which defines if it will go onto either the primary or secondary care menu.
Services on the Primary Care Menu must be commissioned (by one or more CCG) and will only be accessible to GPs within the CCG/s that commissions it.
Services on the Secondary Care Menu will be accessible to all GP practices within England.

34. How will users access the system?1.
Smartcards
As well as an ODS code and N3 connection, a smartcard is required for each user, with relevant roles on it.
A Registration Authority (RA) Sponsor provides smartcards and will add/remove roles as appropriate.
RA is usually be located within a Human Resources department.
Lets have a look at some relevant roles

35. Smartcard roles/codes demystified1.
RA Code
Smartcard Role Name
Log in Role Name and Description
User Examples
B1107
Maintain Service Configurations and Workgroups
Service Definer
Users can set up and maintain services/clinics and workgroups on the NHS e-Referral Service Directory of Services (DOS). Users cannot view patients clinical information.
Providers who want to set up services and make them available on the NHS e-Referral Service DOS.
B1110
Manage Inbound Referrals
Service Provider Clinician
Users can view and review clinical information, manage referrals, change appointments, etc. on-line.
Clinicians who will review referrals.
B1115
Proxy Manage Inbound Referrals
Service Provider Clinician Admin
Users can view clinical information, manage referrals, change appointments, etc. on behalf of a clinician.
Admin staff, Medical Secretaries acting on behalf of clinicians.
B1130
Perform Information Analysis
Information Analyst
Users can access reports and extracts for services that they are linked to. Users cannot view patients clinical information.
Information Analysts, Directorate Management, CCG staff.
Other roles you may hear when working with e-RS:
Referring Clinician and/or Referring Clinician Admin – GPs and Admin staff working at a GP practice
BMS Admin, eg CCG staff, The Appointments Line staff
Trainer Note:
The point here is not to go through each one in much detail, but to demonstrate the different terminology that all of us use.

36. What type of service will be delivered?2.
As you saw before there are different referral models.
Will patients be assessed first or treated at their appointment at your clinics?
For either model, it must be clear to patients how their referral is going to be processed
Assessment Services
Referrals must be assessed by a clinician!
First Outpatient Services
The patient is seen by a clinician on-site

37. How do patients get their appointment?3.
This is dependant on whether the service is set up as directly or indirectly bookable (DBS or IBS).
Directly Bookable Services (DBS)
Patients can book and manage their appointments on-line either at their referrers practice (eg GP surgery), via the Patient Web Application (PWA) or by ringing The Appointments Line (TAL).
Appointments will be booked straight into
the clinic’s Patient Administration System
(PAS), which will also registers new patients.
Any changes made in e-RS will be
automatically updated in PAS.

38. 3. Indirectly Bookable Services (IBS)
Patients book their appointment by contacting the service/clinic they are referred to.
An appointment must be given to a patient when they ring to book one.
The service has to book the appointment into NHS e-Referral Service (e-RS) and the clinic’s Patient Administration System (PAS) separately.
Clear instructions must be given to the patient on how to book their appointment and the times they can contact you to make their booking. This information should be clearly displayed in the Directory of Services (DOS).
Any changes to appointments must be updated in e-RS and PAS
to ensure that information is kept up to date.

39. 3. The Referral to Treatment (RTT) “clock”
Patients have a right to be seen and treated within 18 weeks of their referral.
The RTT clock starts either when:
an appointment is booked
a patient tries to book an appointment
The clock can be stopped under certain circumstances, eg a diagnostic treatment
This is all recorded in the e-RS history/audit trail

40. Who will manage incoming referrals?4.
Appointment booking
If the service is DBS, this is done on-line and into a PAS automatically.
If the service is IBS, booking staff will do this.
Clinical triage
Referrals must be reviewed by an appropriate clinician
Referral suitable?
Referrals that are clinically suitable for a service should be accepted.
Referral not suitable? Unsuitable referrals must be managed, as the patient will have an appointment that needs cancelling.
Appointment/referral management
Appointments might be changed either by the patient or provider. How it is changed is dependant on the service set up (ie DBS or IBS).
Services need to chase referrers where patients have an appointment but the referrer letter has not been attached yet.

41. Setting up services on the DOS The practicalities
Trainer Note:
At this point you should direct learners to the training environment for a practical session.
Setting up services on the DOS The practicalities

42. How referrals are created
Let’s have a look at how referrals are created.
Trainer Note:
It would be ideal if you can show Service Definers how a referral is created. A good way to do this is for learners to create new services during training and then the Trainer can log onto the training environment as a referrer and look up the services the learners have created. It’s gives a better level of undersanding and only takes a few moments.
To do this, you will need to ask learners for the speciality and clinic type they created they service under (or if you direct them which speciality/clinic type to select, this will be even easier).

43. Incoming Referrals
Lets see how referrals look when they are waiting to be managed.
Trainer Note:
Again, briefly showing learners providers worklists gives them a better understanding of the whole picture.

44. Recap session Trainer Note:
Add a slide of recap questions to suit your audience, or use the Service Definer Recap Exercises document, which can be found on our website
Recap session

45. Final points

46. Where can I go for support?
Local issues:
[insert details of GP facilitator/trainer]
Technical issues [insert details of your local IT Helpdesk]
National help:
[insert details of e-RS training pages]
Trainer Note
This should be adjusted to suit you locally

47. NHS e-Referral Service Help Files

48. Help Files NHS e-Referral Service has an “in-system” Help directory.
Everyone can access it, regardless of their role, once they have logged into e-RS.
The Help files contain functional information, screenshots and useful information.
The Help files are updated regularly by the national NHS e-Referral Service team.

49. Help Files
Once a user clicks on the Help text, the Help files open to reveal search options, ie role based subject headings, A-Z, free-text searching.
Role based searches are listed by subjects eg worklists, patient search, enquiries listed by name.

50. Discussion:
Have I achieved the objectives?

51. Trainer Note
Customise to suit your local needs