NHS e-Referral Service
Maximising the Benefits and Functionality of the
NHS e-Referral Service
Presented by Sue Allan, Mike Harris & Michal Kus
Aims of Session
1. Introductions
2. Background
3. Why use e-RS?
1. Drivers
2. Benefits
4. Case studies – real life examples
5. Support available
6. Future changes
7. Discussion / Q&A
2
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
3
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
4
Why use e-RS?
5
Drivers
6
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.
7
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
8
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
9
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
10
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’
11
Supporting CQUIN Delivery - Guidance
http://content.digital.nhs.uk/referrals/future
12
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
13
Benefits by stakeholder group
14
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
20
2WW Referrals through e-RS
Oxford University Hospital Trust &
Oxford CCG
21
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
23
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
24
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
25
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
26
Improving Appointment Slot Issues in e-RS
Cambridge University Hospitals Trust
27
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
29
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
30
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
31
Key Issues
• The 2 main issues identified when e-RS polling matches manual
booking:
1. The need to identify additional capacity for rescheduled
appointments
2. 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………
32
ASI Programme Outcome
ASIs Performance at CUH - May 2015 to May 2016
0.45
9000
8000
0.4
7000
0.35
6000
0.3
5000
0.25
4000
0.2
3000
0.15
ASIs per booking
No. of UBRNs
0.42
Total ASIs
0.15
0.1
2000
0.08
1000
0
DBS
Bookings
0.05
0
ASIs Per DBS
Booking
33
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
34
Using e-RS Advice & Guidance
Calderdale & Huddersfield NHS
Foundation Trust
35
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.
36
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
37
Future Support
38
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 - shortterm project
• Trust @c20%, focus on business process change, services on eRS, engagement – longer term project
40
Future Plans
41
Future – Functional Enhancements
Future Roadmap – 5 Key Components of Paperless 2020
1.
2.
3.
4.
5.
Enhanced Referral Management
Any-to-Any Referrals
Enhanced Reporting
Pathway Management
Follow Ups
42
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
43
www.digital.nhs.uk
@nhsdigital
[email protected]
0300 303 5678