These frequently asked questions are to support NHS organisations implementing changes to deliver electronic referrals (e-referrals) to first out-patient appointments across the NHS.
The 1 October cut-off date relates to the date of the referral, not the attendance. Therefore, if your Trust accepts a paper referral on 30 September 2018, the CCG must pay for the activity relating to that outpatient attendance in, for example, November 2018.
Whereas if the paper referral is made on 1 October 2018, and in line with any agreed referral return processes, the CCG is able to withhold payment for that attendance, whenever it takes place, in accordance with service condition 6.2A.
The approach to starting the RTT clock should remain unchanged and be applied from the point at which the provider receives a referral. From October 2018, and in accordance with Service Condition 6.2A of the NHS Standard Contract, all referrals must be made through e-RS and the clock start should therefore automatically be applied through e-RS.
In the event that a non-e-RS referral is received the RTT clock start should be applied from initial receipt of the referral at the provider organisation, as per paper referral RTT rules. The provider should then follow their agreed process for communicating with the GP practice to request an e-RS referral in line national guidance.
In all circumstances once the provider has transitioned to the exclusive use of e-RS, the return of a “paper” referral should be an exceptional event. Any delay in referring the patient through e-RS should be minimised by the provider and CCG, in accordance with their responsibilities outlined in Service Condition 6.2A, and supported by a robust and agreed paper referral return process. In the very exceptional event where a routine referral does not get re-issued through e-RS within the agreed timescales (as defined locally and in line with e-RS guidance), the original paper referral will be rejected in accordance with Service Condition 6.2A and escalated to the CCG. In these cases a new referral pathway will need to be initiated.
SC6.2A applies to acute providers only, not to mental health providers. This is a reflection of the relative higher level of adoption in acute settings and to incentivise rapid improvements to deliver full use of e-RS by October 2018. The lower rates of e-RS utilisation in mental health providers at this time mean it would not be feasible to expect mental health providers to deliver full use in the timescales required by SC6.2A.
The national programme team will continue to support e-RS uptake across mental health providers and offer the necessary advice, guidance and tools to support mental health providers to increase e-RS utilisation in line with the expectations set out in the NHS Standard Contract.
No. SC6.2A affects GP referrals to consultant-led services only. Therefore SC6.2A does not apply to tertiary referrals.
NHS Digital is currently working to understand the associated business requirements relating to processing tertiary referrals through e-RS with a view to developing this capability. Further communications will confirm the availability of this feature in e-RS for those providers wishing to make use of it.
No. SC6.2A affects GP referrals to consultant-led services only. Therefore SC6.2A does not apply to referrals originating from other primary care clinicians such as dentists and optometrists.
No. Currently the referrals from prison GPs into first outpatient appointments are excluded from SC6.2A.
No. Referrals for Defence Medical Services patients based outside England (such as military personnel and dependents, associated civilians and others) are exempt from SC6.2A.
Yes. SC6.2A applies to these patients who are based in England.
Yes. SC6.2A applies to all acute service providers under NHS contract.
No. Referrals made by private GPs or for private patients are exempt from SC6.2A
No. Referrals made by Out of Hour GPs or GPs based at Urgent Care Centres are exempt from SC6.2A.
Referrals to consultant-led teams or named healthcare professional are covered by Service Condition 6.2 of the NHS Standard Contract which states that “The Provider must describe and publish all Primary Care Referred Services in the NHS e-Referral Service through a Directory of Service, offering choice of any clinically appropriate team led by a named Consultant or Healthcare Professional, as applicable.”
No. SC6.2A applies to referrals from GPs for first outpatient appointment only.
Yes. There will be a number of locally-agreed contracting arrangements within the terms of the Standard Contract. SC6.2A applies to any relevant activity and it is expected that the use of e-RS will determine what is qualifying activity in support of local discussion.
At present, SC6.2A does not apply to referrals to same-day services or services which are accessed through self-referrals. In many cases these would be the two main referral routes for patients requiring TOP services. SC6.2A also only applies to acute services, so if TOP contracts are commissioned as community services, they will be excluded on that basis.
Decisions about whether or not to exclude TOP services should be agreed between commissioners and providers and, if there is agreement to exclude them, this should be documented and communicated to GP practices and other referrers as part of the paper switch-off process.
Indirectly booked GP referrals (where the referral is deferred to the provider using e-RS but providers book the appointment directly on their patient administration system (PAS) and then update e-RS) are acceptable under SC6.2A; they need not be returned and commissioners must pay for the resulting first outpatient attendance.
In these instances, and as described in the guidance document, the referral will need to be manually input to the PAS and the unique booking reference number (UBRN) manually recorded into to patient pathway identifier (PPI) field. This will ensure that the e-RS record can be reconciled to the commissioning dataset (CDS) and payment can be made.
SC6.2A does not apply to any referrals received for Scottish or Welsh registered patients into English Providers.
Providers are responsible for making their appointments available through e-RS so that sufficient appointment slots are made accessible for booking.
Where a referral is made through e-RS and no appointment slot is available for the chosen service(s), the referral can still be deferred to the provider who has a responsibility to contact the patient directly to arrange an appointment.
Each time a referral is deferred it will appear on the service providers ‘Appointment Slot Issues’ (‘ASI’) worklist. Providers must ensure that their ASI worklist is actively managed so that appointments are booked for patients in a timely way.
Finding no appointment slots available for a chosen service(s) may influence a GP/patient’s choice of provider and they may instead choose a provider with booking slots available. However, where the GP/patient choose a provider and service with no appointment slots, the referral must still be sent through e-RS and not by any other means.
Further information about managing ASIs can be found in the ‘Managing and Minimising Appointment Slot Issues’ guidance.
Yes. These referrals will still be sent to the provider using e-RS and processed in the usual way. Because they remain GP referrals, SC6.2A will continue to apply.
In preparation for paper switch-off, providers will be expected to include processes for managing referrals in the event of an e-RS system failure (for example, as a result of a cyber-attack) in their IT system management procedures and referral standard operating procedures. This documentation should clearly set out arrangements for the management of referrals not able to be received through e-RS in these circumstances.
In such circumstances, temporary suspension of SC6.2A will be applied by the CCGs until a safe system recovery is made.
If the patient’s NHS Number cannot be determined then the referral will have to be made on paper. The receiving Trust will accept the referral and process it. Local arrangements with commissioners will need to be established for resolving these exceptional conditions.
Where a person has registered with a practice as a ‘Temporary Resident’ (i.e. have completed a Temporary services form GMS3), it is not possible to make an e-RS referral from within the Primary Care clinical system. It is possible to make a referral through the web-version of e-RS and this is the mechanism that should be used in these cases.
The national data opt-out is a new service that allows people to opt out of their confidential patient information being used for research and planning purposes rather than for direct care. As e-RS is a system supporting direct care it is not covered by the national data opt-out programme. e-RS securely uses and protects patient information in the delivery of care and can safely be used to refer patients who have exercised their right to ‘opt out’ under the national data opt-out programme.
NHS England and NHS Digital have agreed the most appropriate and failsafe method to track compliance with service condition SC6.2A will be to transfer e-RS utilisation reporting from the monthly activity report (MAR) dataset to the outpatients Commissioning Data Set (CDS). Payment verification can then be achieved by using the new version of the Secondary User System (SUS+).
The new process will use the unique booking reference number (UBRN) generated by e-RS to track through the hospital’s patient administration system (PAS), into the CDS and SUS+.
A Data Set Change Notice (DSCN) 16/2009, which mandates the use of the patient pathway identifier (PPI) field, has been in existence since 2009. PAS suppliers will need to ensure their systems comply with the DSCN (if they don’t already), to enable triangulation measures to be implemented using MAR, CDS and e-RS data ahead of the contract changes.
The new process will enable reconciliation between data from the e-RS system with SUS+, using the primary UBRN, ensuring that the e-RS activity can be tracked from primary care referral through to an outpatient attendance. In this way, payment for any activity that cannot be reconciled back to the primary UBRN may, legitimately, be withheld by the commissioner.
Further detail on this process will follow shortly and will be published on NHS England and NHS Digital websites.
The e-RS programme has commissioned Referral Assessment Services (RAS) which allow a provider to set services up on e-RS, without the need for an appointment to be booked.
This facility will particularly support more complex care pathways, such as gastroenterology and cardiology, where it is not always clear to the referrer whether the patient needs a consultant appointment or a diagnostic test. A RAS set up by the provider in front of these consultant-led services, will allow triage to take place to ensure the patient is referred to the right person, in the right place, first time.
The first release, which allows providers to set up RAS services, was made available in August 2017 and release 3, the final planned release, was made available in January 2018.
Whether a referral is to be considered as “Urgent” or “Routine” is usually a subjective, clinical decision to be made by the referrer.
Some providers identify appointment slots on their Patient Administration Systems, in addition to their routine slots, that are available for referrals identified as urgent by the referrer.
If the GP/referrer considers a referral to be urgent, they should select this priority in the NHS e-Referral Service (e-RS) application. This will flag the referral as urgent to the provider (on their worklist) and if urgent appointment slots are available, these will show alongside routine slots for the patient to book.
The referrer should add Clinical Referral Information (i.e. in a referral letter) in the usual way, but also indicate the reason for requesting this as an urgent appointment.
In some areas, local pathways have been introduced using Advice and Guidance to seek prior advice on how to manage (potentially) urgent cases.
Referrals will appear on the referrer’s awaiting booking/acceptance worklist once the clinical referral information has been added and will remain there until an appointment has been booked and the referral has been accepted by the provider. A status of “awaiting acceptance” will indicate that the provider has not yet reviewed (and accepted) the referral.
Clinical responsibility for reviewing and assessing a referral lies with the provider clinician responsible for the service into which the patient has been referred. This is no difference for an electronic referral than for a paper referral. Once an appointment has been booked and the clinical referral information has been added, the referral will appear on a provider’s worklist for review.
The Model Access Policy produced by NHS Improvement defines Service Standards (Page 11) that include the vetting and triage of referrals.
In reviewing a referral, the provider should assess the clinical referral information in the context of the appointment that has been booked, along with the urgency indicated by the referrer, and consider whether the patient has been booked into the correct service with the appropriate urgency. If so, it should be accepted. If not, providers should take appropriate action to re-book the patient into a more appropriate appointment. Alternatively, they may decide to reject the appointment and offer advice to the referrer instead, or re-direct the referral, within e-RS, to another, more clinically appropriate service.