By modernising the NHS e-Referral service, BJSS has contributed towards the health service's paper-free vision. All while improving the referral process experience for patients.


    Over 75,000 ‘GP to first outpatient’ referrals are made every day in the NHS. Previously, the referral process was performed by the legacy ‘Choose and Book’ service, which enabled the safe electronic transfer of referrals between secondary care providers.

    However, the NHS encountered several issues with the service. While the system was a significant step forward for the health service, it was still a mixture of paper and electronic referrals, and it did not align with its vision of a paper-free healthcare system. Additionally, the manual nature of the service resulted in usage barely exceeding 50%.

    Choose and Book was developed back in 2003 when Agile, open technologies were not readily available. It was, therefore, difficult to scale, change and integrate with other NHS systems.  Additionally, the system had become expensive to both run and licence.

    Having set out its Paperless 2020 vision, the NHS wanted to develop a new Electronic Referral Service (e-RS) that would eradicate the use of paper referrals and reduce costs. By becoming a paperless organisation, health and care professionals will be able to communicate better, and patients will gain access to the care they need quickly and easily.

    Keen to build on the success of Choose and Book, NHS Digital partnered with BJSS to develop e-RS. The aim of the new service was to deliver greater functionality to provide more choice as well as a user-friendly booking experience to encourage maximum uptake.

    A highly flexible and scalable system, developed using the BJSS Enterprise Agile® approach 

    NHS Digital and BJSS developed e-RS using the BJSS Enterprise Agile® approach.

    The initial development involved removing dependencies on the existing electronic health care records service product by delivering new business logic and data access layers. The user interface was re-developed in collaboration with users while maintaining the look and feel to minimise training. An extensive data migration approach was also designed and implemented to migrate over 25 million patient records to e-RS.

    e-RS was delivered using a lightweight, open-source stack with services delivered using open-standards for reusability and to remove dependencies on proprietary software – significantly reducing licensing and running costs. This approach allowed the team to rapidly develop the new system, as well as create an environment that is flexible and Agile.

    External APIs are built into the service, allowing the NHS to securely integrate e-RS with other healthcare systems. By integrating these services, the NHS has reduced the need to send patient referral letters, which is saving NHS money and reducing its environmental impact. It has also helped to reduce demand on the NHS Telephone Appointment Line by directing patients to the Manage Your Referral website which allows them to book, check, change and cancel their appointments following the receipt of their appointment. As a result, the Telephone Appointment Line is now more accessible to those with sight difficulties and elderly patients with limited digital skills.

    The e-Referral Service was designed to be scalable and has been migrated to a secure public Cloud platform, creating a flexible, secure and cost-effective environment.

    e-RS is generating benefits for referrers, secondary care services and patients 

    Alleviating the Administrative Burden
    For referrers, e-RS is reducing the amount of time spent managing and processing referrals, enabling them to spend more time on patient care. Patients can now manage their referrals online or over the telephone, alleviating the administrative burden for referrers. The service is flexible to the needs of different working conditions in referring practices. It is also improving communication between referrers and secondary care services, ensuring patients have the shortest possible wait time for the most appropriate clinic.

    Faster Referral Processing
    Secondary care services can manage referrals electronically, reducing the processing time per referral by an average of 75% in comparison to paper referrals. e-RS also allows secondary care providers to deliver care advice to referrers, with 57% of advice given, resulting in a patient avoiding an outpatient appointment. With patients managing their own referrals using e-RS, secondary care providers have benefitted from a 50% reduction in missed appointments. These collective benefits have been estimated by the National Audit Office (NAO) to save secondary care providers £50.5m a year.

    Providing Patients with Greater Flexibility
    e-RS puts the referral process into the hands of patients who have benefitted from booking appointments at a location, date and time that is convenient to them. On average, patients receive their appointment time eight days faster when booking through e-RS. This increased level of control has reduced anxiety amongst patients regarding the referral process with 76% of patients being able to visit their preferred provider, 66% gaining earlier visibility of their appointment time and 55% receiving their appointment within two weeks of booking.

    Contributing Towards the NHS' Paper-Free Visions
    This delivery by BJSS and NHS Digital has contributed towards the health service’s paper-free vision, all while enhancing the referral experience for patients, secondary care providers and referrers.

    e-RS Benefits at a Glance 

    • 75% reductions in referral processing times
    • 50% reduction in missed appointments
    • £50.5M annual cost savings for secondary care providers

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