Version 1.2, 8 November 2023

This guidance is part of the Patient record and information systems’ functionality section of the Good practice guidelines for GP electronic patient records.

NHS e-Referral Service (e-RS)

The NHS e-Referral Service (e-RS) is an electronic, web-based, advice and referral support tool, designed to make it easy for general practice in England to manage patients who may need referral for onward care.  The system (known as Choose and Book in its previous iteration) is designed to enable patients and clinicians to book real-time appointments with a provider of choice.

e-RS overview

Through e-RS, referrals can be made into both consultant-led outpatient clinics and non-consultant-led services such as community, diagnostic, assessment, and GP with special interest (GPwSI) services.  It is also used widely at the interface between primary and secondary care for advice and guidance (A&G) and referral triage services (see below). 

From a patient perspective, it provides a way to make appointments at a time and place of their choice, which comes with several benefits for general practice and the wider NHS.  It should be noted, however, that demand for services, staff shortages, etc., can impact on clinic and appointment availability and, therefore, patient choice.  This sometimes means that the patient may decide to book the first available appointment rather than a preferred provider and/or location.

e-RS aims to:

  • improve efficiency of referrals from primary to secondary care
  • enhance clinical communication channels between primary and secondary care
  • deliver choice, certainty, and control to patients, who increasingly expect to interact with healthcare through digital channels

Patients who have an NHS login account are now able to receive information via email – their first outpatient appointment request (instead of, or as well as, the traditional letter), referrals requiring booking, referrals waiting to be triaged by the chosen provider, referrals waiting for an appointment to be booked by the chosen provider and referral information on booked appointments.

These emails will come from e-RS, not the GP practice email system.

The service has been designed to be implemented flexibly, reflecting the fact that referrals are handled differently in different practices.  It undergoes regular development and improvement according to user needs and feedback.

Some features of the application have been designed to be used by clinicians, and other functionality is more for administrative staff.  Practices can choose who undertakes the various tasks associated with referring patients.

The different models of use are explained in detail in the NHS Digital guide. NHS Digital became part of NHS England in February 2023.

You can keep up to date with the e-Referral service by checking out the e-RS pages on the NHS Digital website including helpful, current and detailed user guides for each step of the process.

Key features of e-RS

The e-RS contains a range of features to support referrers:

  • Directory of services (DoS) maintained by the service providers, that acts as a ‘shop window’ for what is available. It lists the name and location of the service, including, in some instances, a named clinician, conditions treated, treatments offered and exclusions.  It can include links to referral protocols and specific alerts for referrers.  Contractually, providers must add all their consultant-led services to the DoS, so that referrers in primary care know that all the information needed is available in one place.  Providers must also ensure that this information is current.
  • Advice and guidance function (A&G) which allows a clinician to seek advice from another, providing digital communication between two clinicians, i.e. the ‘requesting’ clinician and the provider of the service, the ‘responding’ clinician. A&G aims to provide a rapid turn-around of advice and guidance responses to encourage GPs to use this route before considering referral.  Recent changes to e-RS now allow a referrer to authorise a provider to convert the A&G into a referral, if clinically appropriate, reducing the need for this to be returned to the GP/referrer for them to have to make the referral. 

The advice and guidance function aims to reduce inappropriate referrals, offer interim management advice, and ensure the patient is directed to the most appropriate clinician / service, should further treatment be required. Advice and guidance is not exclusive to e-RS.  Localities may have alternative commissioned services.

  • Referral assessment/triage services (RAS) (such as musculoskeletal or MSK, paediatrics, dermatology etc., assessment services) for triage of referrals, or clinical assessment of the patient’s needs.  These services are able to refer patients onwards to other appropriate, or more specialist clinics, to which GPs may not have direct access. 

This service also aims to filter out inappropriate referrals, saving time and resources. For example, locally commissioned services such as tele-dermatology, where queries, which must include dermatoscope images, are initially sent for screening, ensuring that onward referral to the most appropriate secondary care service is made by the practice.

  • Near real-time data on appointment and treatment waiting times, to help manage patients’ expectations.
  • Visible alerts, showing a provider’s capacity to see and treat patients, and suggestions of alternative services where provider capacity may be limited.
  • Access to bookable appointments for consultant-led services, diagnostics, therapy services, community services and appliances (such as hearing aids and orthotics).
  • Integration with all accredited GP clinical systems, allowing clinical information from the GP record to be converted easily into a structured referral ‘letter’ and attached electronically. Medication, investigations, past medical history, lifestyle information etc., can all be electronically attached to the referral.
  • Worklists, with dashboards designed to help the referring organisation manage the referrals. They act like a mailbox and are, in effect, a single point of access to check for outstanding actions and updates. The dashboard shows the current state of a referral and ensures that any actions needed are obvious to the referrer and easily remedied. They have the following lists which can be filtered in the system to show information for individual referrers or organisations:
    • Rejected / triage response
    • Letter outstanding
    • Incomplete
    • Advice and guidance
    • Assessment returned / cancelled / DNA
    • Awaiting booking

Further information on the e-RS worklists can be found on the NHS Digital website.

  • Referral summary screen. All referrals have a unique booking reference number (UBRN).  Referring organisations/staff can follow the referral progress/status.  The screen contains and consolidates all relevant information about the referral (such as referral letter, advice and guidance conversations, other clinical comments/dialogues such as rejection comments and the referral history).  It:
  • ensures important updates/responses to referrals are not missed
  • indicates progress or work on a referral

The defining state of the referral can be any of the following:

  • booked
  • not booked
  • incomplete
  • deferred to provider
  • rejected
  • did not attend
  • triage – provider to action
  • cancelled by provider
  • cancelled by patient
  • assessment result
  • awaiting triage
  • triage response
  • cancelled referral

How does the service work?

The e-RS comprises two elements:

  • the professional application, used by professionals with referral rights (such as GPs, registrars, locums with referral rights, advanced clinical practitioners, and nurses) or administrators acting on behalf of those referrers, to create and send an electronic request for advice or a referral to other provider clinicians or services
  • the patient-facing service that allows a patient to book an appointment on-line.

Demand affects capacity and sometimes there may be no scheduled clinics/ appointments available to book into.  In this case, responsibility for booking the appointment lies with the service provider rather than the patient, and the referral status will be recorded as ‘deferred to provider’. A telephone number (at local call rates) is available for patients who are unable to use the on-line booking.

Professional access to the e-RS needs a smartcard (or other method of authenticated access such as NHS CIS2) with appropriate roles having been added and authorised by a local NHS Registration Authority.  Instructions on how to access the e-RS can be found on the NHS Digital website.

Referrals may be to one of the following:

  • a bookable service, in which case the patient or the general practice administrator needs to book an appointment before the referral can be processed further
  • triage assessment, where the referral information is assessed first, without an appointment being pre-booked; the provider is then responsible for any subsequent appointment or diagnostic test.

Urgent appointments

As a best practice principle, administrators or referrers should liaise with patients to book two-week wait (urgent) appointments at the time of referral creation.

The ‘two-week wait’ or ‘urgent’ appointment was introduced so that a specialist would see any patient with symptoms that might indicate cancer as quickly as possible. Referrals into this service are made on a standard referral form specific to the local commissioning group. 

Practices should monitor these referrals and ensure patients have been provided with information about the service at point of referral, as well as monitoring outcomes to ensure that patients have attended their appointments. Provision of patient information about this service is a contractual requirement with a current target of 95%.

Steps in a bookable service referral

The following four steps need to be followed when referring into a bookable service:

  • Step 1| Check the directory of services (DoS) using the built-in search tools for clinics suitable for the patient’s condition.
  • Step 2| Shortlist clinics from which the patient can choose their preferred provider. Referrers are asked to ensure they shortlist on average 5 choices from which the patient may choose, where this is practicable, clinically appropriate, and preferred by the patient.   For example, a patient living in the North of England but working in the South of England, may choose treatment in a service based in the South of England, which may better suit their own circumstances.
  • Step 3| Provide the patient with instructions on how to select a clinic and, if required, book their appointment. This can be by email if patient is registered with an NHS login or printed, by simple print button, and given to the patient (or posted) if not.
  • Step 4| Attach clinical referral information (such as a referral letter or locally agreed pro-forma) to the electronic referral.

Once the referral to a bookable service has been created, patients (or others acting on their behalf) can book an appointment with one of the services shortlisted.

If no appointments are available at the first-choice provider, the patient can try one of the other providers.

If no appointments are available at all, the patient can ‘defer’ their referral to a provider and then wait to be contacted by that provider with an appointment date.

Appointment slot issues (ASIs)

Where providers are struggling to manage their capacity, there may be no appointments on e-RS when patients try to book.  These are known as appointment slot issues.

Referrals can still be sent to services with ASIs (via a process known as ‘deferring’) and the referral will then appear on a worklist for the service provider to contact the patient and arrange an appointment.  There will be an end date shown for this contact.

Using the e-RS waiting time information and capacity alerts reduces the chance of an ASI.

Triage assessments referrals

In these referrals, it is the receiving clinician that decides on the best pathway for the patient rather than the GP.  There are three types of service:

  • Referral assessment service (RAS) where the assessment service reviews the referral and contacts the patient if an appointment needs to be made.  If the referral is not needed, the GP is informed via the system worklist with an explanation and advice.  Assessment services are commissioned by locality and in some cases must be used as a first point of contact.  Referrals will be rejected if this step is missed.
  • Video/telephone assessment service (TAS) where a video or telephone consultation takes place with the patient to gather more information.  Patients need to be told whether they will be called by the provider or whether they need to call them, and when.  A dummy appointment slot may be used to ‘book’ this service, patients are informed of this when they are sent their booking reference number and password.
  • Clinical assessment service (CAS) where the patient attends a booked appointment and is assessed or treated by a clinical specialist.  The patient may be referred onwards to another service, or back to the GP (with advice about on-going management).

Advice and guidance function in e-RS

e-RS advice and guidance can help GPs to understand the best treatment options for patients and avoid unnecessary referrals to acute services.

Referrers can seek clinical advice from colleagues to:

  • help enhance their knowledge about how to manage a problem
  • diagnose a condition
  • decide whether a referral or follow-up is needed
  • whether other, more suitable, management options may be available in alternative care settings

Like a referral into a triage service, a request for advice and guidance can now be referred into an appropriate service by the service provider team, but only if pre-authorised by the GP/referrer.

The A&G feature supports a multi-way conversation between GPs and consultants that can help strengthen professional relationships, share knowledge, and promote important clinician-to-clinician dialogue around patient care.

Business rules around the use of A&G, including any payments for processing requests, should be agreed as part of local implementation plans in collaboration with local medical committees (LMCs). 

Demand management in some areas dictates that A&G (or other forms of triage) should be sought in every instance prior to referral to some specialties, e.g., orthopaedics, where it is important for the referrer to have tried alternative less invasive management of the patient’s problem in the first instance and have the appropriate imaging and test results in place.

Advice and guidance workflow

A typical advice and guidance workflow has the following steps:

  • Step 1| GP initiates A&G with the consultant/specialty of their choice and informs the patient they are seeking expert advice.  If they are going to authorise the provider to convert the A&G to a referral (if needed) the GP needs to confirm that the patient is happy with this provider for their appointment/treatment.
  • Step 2| GP asks a question and adds relevant clinical information, such as blood test or scan results.  The GP ticks the ‘authorise to convert to referral’ option, if appropriate.
  • Step 3| GP or GP admin reviews A&G worklist daily, actions any replies and monitors unanswered queries (targeted timescales for responses are in place).
  • Step 4| GP or GP admin save a .pdf copy of the dialogue or copy and paste the A&G response into the clinical system.
  • Step 5| If the provider has converted the A&G into a referral, there may be supporting management information for the GP to note and action as appropriate.

An advice and guidance toolkit for referrers, providers and commissioners is available from NHS Digital.

Benefits of e-RS

The NHS e-RS benefits referrers by:

  • providing a safe, secure, and reliable system supporting patients in their choices, available 24 hours a day, 365 days a year
  • providing an easy and reliable way of identifying appropriate and available services
  • providing an advice and guidance tool to support GPs making sure patients are referred into the right services
  • supporting continuous professional development
  • helping to make sure referrals are clinically appropriate and local pathways followed
  • providing a ‘book now, refer later’ option, i.e., complete the paperwork outside of clinic time within a 24-hour period, which allows the referrer to fully involve the patient in the decision about where they wish to be seen during the consultation, particularly but not exclusively, for two-week referrals
  • providing a worklist function which can save time and, therefore, money for the practice and the NHS, by showing the status of the referral, e.g., less chasing of appointments by practice staff and enabling practices to see where a referral is in the system at any one time
  • meaning fewer GP appointments, or GP contacts are made to check on referral progress
  • reducing did not attend (DNA) rates by up to 50% as patients book the appointment at a time and a place convenient to them
  • being auditable and secure, with referral and booking history easily available to professional users from within the application (that is, it shows who did what, and when)
  • supporting professional referral management practice
  • encouraging patients to become more involved in their care and condition management.

The e-RS has many benefits for patients:

  • patients can make decisions about where to go and who to see (unless choice is reduced because of service demand, staffing, etc., issues)
  • information about choices is available online
  • patients can choose the date and time that’s convenient (and therefore are more likely to attend)
  • booking can be made at home in their own time, if this model is agreed with the referrer
  • patients can use the NHS App to manage their e-RS referrals
  • reminders are sent, by the system not the referrer, if no appointment is made within timeframes appropriate to the clinical priority of the referral.

Patients can book appointments online or by telephone. The online booking system:

  • is smart-phone and tablet friendly
  • has undergone robust research and testing with patients, including those with disabilities, to ensure that the product is easy to use
  • is integrated with the NHS App.

If patients do not make an appointment, they remain on the referrer’s worklist for six months or until a booking is made.

Appointments can be made by a carer or another person authorised to act on the behalf of a patient who may be vulnerable or who does not have the capacity to act for themselves.

Clinical safety features of e-RS

The e-RS has several clinical safety features that improve the patient’s referral journey and provide reassurance and support for professionals:

  • every detail of the referral journey is logged, so any authorised professional can see where the patient is within the referral pathway and act on that information
  • clinical referral information is attached electronically, held securely, and cannot be lost, unlike paper referrals
  • security features of the system ensure that only professionals with a legitimate relationship with that patient have access to the referral and the attached clinical information
  • worklists within the system make it clear to referrers when there are outstanding actions to complete, helping avoid any delay to care; make it easy to track referrals that have been assessed; and indicate where alternative management plans have been suggested
  • all referrals can have their priority changed, without the need for a new referral being initiated, by anyone in the practice with a referral role (but there is no guarantee that changing a priority from routine to urgent will offer a patient a sooner appointment)
  • patients can book (or change) their appointment on-line, or through a national, local call rate, telephone booking service making for fewer DNAs
  • patients who don’t book are sent system-generated reminder letters by the service (not the referring practice)
  • where a provider rejects the referral, the patient is sent a letter advising them to contact GP to discuss next steps
  • where a provider cancels an appointment, they must contact the patient to rearrange

Clinical responsibility when using the NHS e-Referral service generally mimics clinical responsibility when making a paper referral. Clinical liability depends on the individual circumstances of each referral.

You can read more about these issues in the NHS Digital guidance.

Referral outcomes

Referral outcomes vary, depending on whether the referral is into a bookable service or an assessment service.  There are several possible outcomes to an e-RS referral:

  • accept
  • redirect
  • cancel
  • advise referrer
  • reject

The outcomes of a referral are described in more detail in the NHS Digital guide.

Managing worklists

GPs have access to several worklists within the e-RS application, which can be used to:

  • check on any outstanding actions
  • monitor responses to advice and guidance queries

They act like a mailbox and are in effect, a single point access to check for outstanding actions and updates. 

Monitoring of worklists is often delegated to members of the admin team.

Patients’ rights and responsibilities

Where patients are being referred to an elective (i.e., non-emergency) consultant-led appointment, they have a legal right to be offered a choice of provider for that referral.  If they wish, they should also be able to choose a consultant-led team (or healthcare professional) for both physical and mental health referrals. 

Information for patients about choices is available online.

Technical basics

e-RS is a web-based application integrated with practice clinical systems.  Nothing is downloaded onto practice computers, although referrals are coded and remain visible in the patient’s record. 

The NHS e-RS service is reliable and constantly exceeds the required availability rate of 99%.  Technical support, if needed, is available from integrated care services (ICSs) and commissioning support unit (CSU) IT departments. 

All organisations should have contingency plans to deal with an unplanned and prolonged outage of IT systems, including the e-RS, that should be user-friendly and safe.

Training and support

Patient guidance and support

NHS Digital has produced a video for patients.

Staff guidance and training

Help files and training materials, including an end-to-end demonstration video of a typical referral pathway, have been developed to train and support users of the system. They are available on NHS Digital’s e-RS web pages.

e-RS national training environment

There is a national training environment (see below) available to users of the service  This mirrors the live e-RS system, allowing training without the risk of accessing or altering real data.  Access to the training environment can be requested by contacting ereferralstraining@nhs.net

You are advised to read the synthetic test data page if you are thinking about using the test patient/services in the live e-RS environment. 

Other sources of training and help

You may find local training available through your Primary Care Network (PCN), Integrated Care Board (ICB) or Commissioning Support Unit (CSU). 

More information, training and support is also available:

Online training sessions

The e-RS programme team provides training sessions using Microsoft Teams.

You can find out more about available training for referring clinicians, service definers and service providers on the NHS Digital website.

national training forum has been established to provide open and regular communication channels between the e-RS national training team and a representative panel of e-RS trainers from the NHS and independent sector. 


  • The NHS e-Referral Service (e-RS) is a web-based service enabling referrers like GPs, on behalf of their patients, to seek specialist advice or book, and manage, appointments with consultant clinicians as well as for triage, assessment, and test appointments online.
  • e-RS brings a range of clinical and management benefits to GPs and practice staff as well as to patients.
  • The service provides near real-time information about available services and available appointments.
  • Referrers can also use the service to get secure and confidential advice and guidance from other clinical professionals to support patient management and referral.
  • Training and support in the use of e-RS is provided in a national as-live training environment, through online courses, videos, and document library.


  • Keep up to date with service news and developments by registering for the regular e-RS bulletin.
  • Promote the use of e-RS to patients and encourage sign-up to the NHS App to enable them to manage their referrals online.
  • Book two-week wait appointments on behalf of patients.
  • Have a contingency plan in place in the very unlikely event of unplanned system downtime.

Other helpful resources