Hosting our closing session at the recent HTN Digital Primary Care 2022 conference, we welcomed Dr Mala Ubhi, a GP in Gloucestershire and Clinical Advisor for Digital Productivity in NHSE/I, and Christopher McLlveen, a Patient and Public Voice partner for the Transformation Directorate at NHSE/I.
In her talk she discussed how digital communication between primary care teams and specialists has the potential to add value for patients and clinicians involved in referral pathways. This included a focus on the NHS electronic Referral System (e-RS) and what it can offer for this transformation.
Since 2018, e-RS has been the mandated channel for referrals, but Dr Ubhi still sees huge variability in the referral and advice process, which can be a lot for clinicians to remember: “There is a mix of digital and non-digital channels, and there isn’t always one front door for each speciality as I’m sure you’ll find,” she explained.
In response to this, Dr Ubhi could still see un-equal access to health and care services without standardised approaches, which can result in very different patient and clinician experiences. However, she explained that there are several different factors primary care teams assess to which referral channel will be selected.
The different routes that was emphasised in her talk was patient, temporal, clinician, and organisational factors. She explained: “Such as internet speed and phone reception, it sounds basic but these can be everyday problems in front-line general practice.”
“Support and guidance from a specialist is a huge positive”
There are lots of benefits of advice and guidance for referrals, Dr Ubhi, said: “Certainly in my own experience, being able to add value to a patient care journey quickly through support and guidance from a specialist is a huge positive. Especially when comparing that to a patient waiting on a waiting list to have a consultation potentially with no value being added to their care journey during those weeks or months.
“Of course there are benefits for the clinicians. Using a digital platform such as e-RS for advice and guidance means they aren’t constrained by opening hours or working patterns.”
Dr Ubhi stressed that in primary care there is still a lot of administrative footfall from patients not knowing who to ask about their appointment: “Moving forward, digital platforms could facilitate improved referrals between other NHS settings, which is critically important when thinking holistically of the diverse health and care service that patients may require.
“Advice and guidance has increased over the pandemic”
Explaining the channels in more detail, Dr Ubhi said there are currently three advice and referral channels in e-RS that have different functionalities. The first is Advice and Guidance (A&G) Referral Channel. “This allows for two-way dialogue, which means as a GP I’m able to have a conversation with a specialist over multiple occasions and this can only be closed by me and my GP team.” she explained.
The second channel is the Referral Assessment Services (RAS) which allows the provider to triage the referral before the patient books an appointment. “So whilst the provider is able to return the referral with advice,” she explained, “I’m not able to as the primary care clinician to respond directly. So further dialogue does need to be served through another route.”
The third channel is the directly booked service, Dr Ubhi said: “It doesn’t have an option for a conversation between clinical colleagues, but does allow patients to ‘choose and book’ their appointment.”
Dr Ubhi noted: “It’s probably no surprise to any of us that advice and guidance has increased over the pandemic and on e-RS it has rapidly increased. Nationally there is consistently over 100,000 digital advice and guidance conversations each month. Plus advice and guidance is increasingly being used as a referral route, and the data shows that about a quarter of those have pre-authorisation to be converted to a referral being done so by provider teams.”
“I do feel that it is a vital part of my every day general practice”
Value can be added to patient care through being auditable, accessible at any time, time sensitive and many more which Dr Ubhi explained. “Many of us have been in phone loops where we have tried to call specialists, specialists have tried to call GP teams, and there’s that unfortunate loop of not being able to contact someone because they are in clinic or dealing with a patient. These non-value added steps potentially could be removed through a digital platform.”
She continued saying how helpful the platform has been: “As a clinician using e-RS Advice and Guidance here in Gloucestershire for many years, I do feel that it is a vital part of my every day general practice. And those relationships between clinician team forges professional closeness that helps us to provide care that is more joined up patient centred. And it really strengthens organisational culture and promotes a culture of learning.”
Joining the conversation was Christopher McLlveen, a PPV partner for the NHSE/I Transformation Directorate, providing his view on e-RS as a patient and a public voice partner.
“It means the patient can get the right care at the right time.”
Christopher believes that e-RS is the solution to long waiting lists as not only will GP’s and specialists be able to exchange advice, but it supports the patient while they wait for treatment and care.
He explained: “One of the reasons for this at the moment is that there is no standard process whereby a GP like Mala can seek advice and guidance from a clinical specialist in order to decide on the best course of action for a patient. Which in many cases, may not need to be an onwards referral for an outpatients appointment.
“From a PPV standpoint, this is very urgently needed. It allows GP’s and specialists to readily exchange digital advice and it means the patient can get the right care at the right time,” he explained.
Providing the talk with quotes from the public, he stressed: “They feel supported, informed, not forgotten, and they know much more about what to expect as they go along the patient journey. This stuff works, patients need it.”
“Currently only a quarter of mental health trusts use e-RS”
Going back to Dr Ubhi, she went on to talk about the future of digital triage, appointments and A&G. The NHS strategy for e-RS can be divided into three areas; Enhance, Extend and Evolve. “The themes for enhancing e-RS include internet first, secure access, enhanced image file sharing, greater supplier interoperability, upgraded architecture and improved user interfaces.”
She continued: “Currently in the ‘extend’ work, I am part of a team who are collecting and analysing data in the discovery phase for extending e-RS to mental health services. Currently only a quarter of mental health trusts use e-RS.
Touching upon the ‘Evolve’ strategy, she said: “The Evolve work focuses on the vision of any-to-any transparent advice and referrals system. To include a patient pathway timeline, universal service finder, universal booking platform, AI referral triage and system wide data flow.”
The systemwide impacts are to limit the rise in waiting lists and therefore improve efficiency, provide infrastructure for PCN’s and health and social collaboration, and improve patient empowerment.
The ambition for the NHS e-Referral Service is to become an any-to-any health sector triage, referral and booking system by 2025, with mental health and other additional services being evaluated for inclusion in 2022/2023. “We have now also mandated targets for advice and guidance to deliver 16 specialist advice requests per 100 outpatient first attendances by March 2023,” she said.
Within the strategy, was ensuring the digital transformation agenda aligns with the NHS ambition to deliver a ‘Net Zero’ National Health Service. Dr Ubhi explained: “Ensuring that patients have consultations at the right time, with the right person, in the right place, using the right modality.”
“The critical success factor is having engagement”
Dr Ubhi ending the talk by noting the steps needed to take to implant Specialist Advice, with the first one being understanding opportunity. “That means understanding the current landscape of existing Specialists Advice.” she said. “How do GP teams seek out advice, is it through phone lines, email, or are you using platforms such as e-RS.
The second step was to mobilise and implement, she said: “There are many ways of doing this that may work for your system, but again the critical success factor is having engagement from referring and providing clinicians throughout the process.”
The last step was about evaluating and monitoring sustainability, to which Dr Ubhi highlighted the importance to value and monitor through audit, learning events and knowledge libraries. “For example, here in Gloucestershire, we have an online directory of resources on our G-care website, which have decision making tools to optimise referrals and advice, and guidance consultations.”
Watch Dr Ubhi and Christopher McLlveen’s full presentation via the video link below:
