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Can a referral be rejected?

If referrals are rejected, the provider should give clear information as to why they do not feel that their service is suitable for the patient and suggest an alternative provider or method of managing the patient.

digital.nhs.uk - Joint guidance on the use of the NHS e-Referral Service 2018

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The NHS e-Referral service is an online referral and booking tool that is made up of two parts: 1. A professional application, used by referrers (such as GPs) to create and send an electronic referral to provider clinicians (such as Consultants) in secondary care, or to community providers. 2. A patient-facing website (called 'Manage Your Referral'), that allows a patient to book an appointment on-line, once the electronic referral has been initiated by their referrer into a bookable service. A telephone number (at local call rates) is provided for patients who are unable to use the on-line booking service. Professional access to the NHS e-Referral Service currently requires a smartcard, with appropriate roles having been added and authorised by a local NHS Registration Authority. An e-RS referral can be made into either a bookable service (in which case the patient needs to book an appointment before the referral can be processed further), or sent to a triage/assessment service, where the referral information is assessed first, without an appointment being pre-booked. Referral outcomes vary, depending on whether the referral is into a Bookable service or an Assessment service (see Section 6 below on Referral Outcomes).

3.1 What is the difference between a bookable and an assessment/triage service?

When referred to a bookable service, the patient is required to book an appointment before the clinical referral information can be seen by the provider. The provider clinician should then view the referral information as soon as possible and make a judgment as to whether the patient has been booked into the correct service, with the correct urgency, or whether the timing of the appointment needs to change in light of the condition being referred. The provider clinician can choose to Accept, re-Direct or change the date/time of the appointment, using functions within the e-RS application (see more details in Section 6 below). If the provider clinician feels that their service is not clinically appropriate for the patient and/or there are more suitable alternative ways of optimising patient care, they may choose to return the referral and advise the referrer accordingly. This is known as a ‘rejection’ but only occurs for about 2% of referrals. Where clinically indicated, it should be seen as a positive outcome, both in terms of professional education and in speeding-up patient care. If referrals are rejected, the provider should give clear information as to why they do not feel that their service is suitable for the patient and suggest an alternative provider or method of managing the patient. The referrer always has the option to resubmit the referral with more information to support the rationale for referral into the same service, if they feel that is more appropriate. If referring to a triage/assessment service, the receiving clinician still reviews the clinical referral information, but before an appointment is booked, and decides on whether to accept the referral. If accepted, the assessment service (not the GP) must identify suitable onward service(s) for the patient and contact them to offer a choice (where choice rules apply) and facilitate the booking of an appointment. In addition to converting a triage request into an appointment, an assessment service can alternatively provide advice back to the referrer, instead of an appointment.

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3.2 Referral into a bookable service

The following four steps need to be followed when referring into a bookable service: 1. Check the Directory of Services (using the built-in search tools) for clinics suitable for the patient’s condition. 2. Shortlist one or more clinics from which the patient can choose an appointment. 3. Provide the patient with instructions on how to select a clinic and book their appointment (printed instructions are currently provided in the form of a letter, but future enhancements will allow patients to receive electronic instructions if they wish). 4. Attach clinical referral information (such as a referral letter or pro-forma) to the electronic referral. Once the referral to a bookable service has been initiated, patients (or others acting on their behalf) can book an appointment with one of the services listed. If no appointments are available at the chosen provider, the patient can try an alternative shortlisted provider, or defer the referral request to the hospital or clinic and wait to be contacted with an appointment date (see Section 11 below). Links to video clips showing this process are available in the support section of this document – see Section 18 below.

3.3 Referral into a assessment/triage service

As described above, in addition to bookable services, the NHS e-Referral Service supports referrals into one of three types of assessment/triage service. These services, which are set-up by the provider in addition to, or instead of, a directly bookable service, are especially useful for complex pathways or scenarios where the patient might be booked straight to test or procedure, instead of needing an initial outpatient appointment. In such cases, it is the secondary care clinician who decides on the most appropriate referral pathway for the patient, rather than the referrer (GP).

3.3.1 Referral Assessment Service (RAS)

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This type of assessment service allows a provider clinician to review clinical referral information without the need for an appointment to be booked. The patient is then either referred-on to a suitable service, in which case it is the responsibility of the assessment service to contact the patient and arrange an appointment, or advice is returned to the referring clinician.

3.3.2 Telephone Assessment Service (TAS)

A TAS operates by taking referral information and then using a telephone consultation with the patient to gain additional clinical information to help determine the correct onward pathway. The TAS appointment date should be agreed with the patient and the process clearly explained, so that the patient understands whether the TAS will be calling them, or whether they need to call the TAS at the agreed date and time.

3.3.3 Clinical Assessment Service (CAS)

In this model, the patient attends a booked ‘assessment’ appointment and is assessed and/or treated by a clinical specialist. The patient may then be referred to another service (for example - in the community, or in a secondary care setting), or advice may be sent back to the patient’s referring clinician to assist with on-going management.

digital.nhs.uk - Joint guidance on the use of the NHS e-Referral Service 2018

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