A month from the e-Referrals deadline, is the NHS ready for paper switch-off?

October 1 marks the ‘paper switch-off’ deadline. PublicTechnology looks at the stats to assess whether one of the health service’s flagship digitisation schemes is on track.

Tomorrow is the first day of September.

It is a month that typically brings a lot of ends and beginnings; summer is replaced by autumn, students return to the classroom after the holidays, and festivals mark the annual harvesting of crops to provide food for the cold months ahead.

This year the month will also mark an important act of transition and renewal for GPs and NHS trusts, as September 2018 is due to occasion the long-awaited “paper switch-off” of referrals for outpatient appointments. 

The project to roll out e-referrals has progressed markedly in the last 12 months, and entire portions of the country have already eliminated paper for all initial GP referrals. NHS Digital maintains it is on course to meet the 1 October deadline.

However, the overall percentage utilisation of electronic referrals has stalled in the mid 70s, and the most recent monthly report from NHS Digital shows one in six CCGs with a utilisation of 50% or lower – including some as low as 22%. Meanwhile, some doctors and patients retain complaints about the system’s functionality.

With just a month to go, is the NHS ready for switch-off?

By the time 1 October arrives, the NHS e-Referral Service (eRS) should be the only method through which GPs refer patients for initial appointments for secondary-care consultations. After this date, care providers will not be paid for the services they offer to patients in any appointments booked following a paper, fax, or email referral from a GP.

Other referrals, however, are not mandated to meet the paper switch-off goal. This includes referrals for follow-up appointments with the same consultant, referrals from one consultant to another, and referrals made by dentists, optometrists, and GPs serving prisoners or military personnel.

The current overall utilisation of eRS for all referrals is 75%, according to an NHS Digital weekly report published on 26 August. This figure has risen rapidly in the past year; 12 months ago it stood at just 53% – roughly where it had been for many years, across both eRS and its predecessor, the Choose and Book system.

But it is now at something of an impasse.

After steady and continued progress over a period of months, the rate reached 73% in late April. It grew further, to 78%, by the middle of May.

But it fell back by four points the following week and, in the three months since, utilisation has fluctuated back and forth in the region of 73% to 76%.

However, this rate includes all referrals – including those that are not subject to the mandatory paper switch-off – such as follow-up appointments, and referrals from primary-care professionals other than conventional GPs. Additionally, some of the one in four outpatient referrals still made by non-eRS means are made via email, rather than paper.

It is understood that the percentage solely for initial GP-referred outpatient appointments – which, in a month’s time, must be made via eRS – is not measured.

20 of the 25 CCGs with the lowest eRS utilisation rates are in London or the south-east

The central statistic currently being put out by NHS Digital is that over 90% of trusts are now able to book, amend, or cancel first patients’ first secondary-care consultations. Trusts across the entirety of two regions – the South West and North of England – have already achieved paper switch-off, NHS Digital said, and the rest of the country is on course to do so in time for 1 October.

The most recent monthly eRS utilisation report, which covers the month of June, shows the median overall utilisation rate among England’s 195 clinical commissioning groups is 72%. A total of 12 have 100% – or, more accurately, one has a rate of 100%, and 11 more have rates ranging from 101% up to 139%.

At the other end of the spectrum, about one in six CCGs – 33 out of 195 – have a utilisation rate of 50% or lower. Fourteen have 40% or less, and one CCG has just 22% utilisation. 

Again, those rates include all referrals – not just those made by GPs – and may also include many that are being made digitally, just not through the eRS system. But, even allowing for those factors, CCGs with utilisation of two-thirds or lower surely face a busy month to ensure they are ready for paper switch-off.

Regional variation
It is also clear that, to borrow a phrase often applied to other facets of the NHS, there is something of a postcode lottery when it comes to e-referrals adoption.

In the monthly data for June, the top of the utilisation league table is dominated by commissioning groups in the north-west of England. The top four CCGs are: Heywood, Middleton and Rochdale; Greater Preston; Salford; and Chorley and South Ribble. Others, such as Blackpool, Oldham, Flyde and Wyre, and Wirral, are not far behind.

eRS utilisation rate of Horsham and Mid-Sussex CCG in most recent NHS Digital monthly figures

1 October
Deadline for paper switch-off

One-off provision for driving uptake of e-referrals in most recent annual GP contract

15 June 2015
Date on which eRS went live

One in six
Number of CCGs in England – 33 out of a total of 195 – with eRS utilisation of 50% or lower, according to monthly data

Overall utilisation rate for eRS – including referrals mandated for paper switch-off and others that are exempt, such as follow-up appointments or referrals from dentists, optometrists, and military and prison GPs

At the other end of the spectrum, 20 of the bottom 25 CCGs are drawn from the commissioning regions representing London or the south east – six from the former and 14 from the latter. The bottom two CCGs – with respective eRS utilisation rates of 22% and 25% – are next-door neighbours: Horsham and Mid-Sussex CCG; and Crawley CCG.

Which suggests that GPs and hospitals in parts of West Sussex, at least, still have a lot of work to do before September ends.

Speaking to PublicTechnology late last year, the chair of the British Medical Association’s GP committee Paul Cundy said the 1 October deadline for paper switch-off was “clearly nonsensical”, and criticised the functionality of the eRS system.

A quick perusal of current sentiment on social media paints an expectedly mixed picture, but shows that some of those concerns remain.  

On Twitter, a number of GPs and hospital staff praised eRS and the positive impact it has had for their organisation. One GP, who has been using electronic referrals since the days of Choose and Book, said it “never ceases to amaze me that people wouldn’t use” the system.

But other GPs and patients expressed concerns about downtime and criticised the functionality of a system they felt had been designed with sufficient focus on the needs of patients. 

There are also a wide array of hospital trusts celebrating their move to paper-free GP referrals, and saluting the benefits it will bring to patients.

Deadline looming
By the government’s own estimation, the looming deadline by which all other trusts must follow suit is a challenging one. The recent annual report of the Infrastructure and Projects Authority moved the e-Referrals Project from an amber to an amber/red classification. This means that IPA assessors have conclude that: Successful delivery of the project is in doubt, with major risks or issues apparent in a number of key areas. Urgent action is needed to address these problems and/or assess whether resolution is feasible.”

Data sets released concurrently by the authority revealed that, while the project is technically on track, the stringency and proximity of the deadline is a source of doubt.

Of the 15 CCGs with the highest eRS utilisation rates, eight are in the north-west of England, including the top four. Just one – Cornwall – is located south of Birmingham. 

“Concerns were raised by the review team about the ability to deliver paper-switch off by September 2018, despite the technical development of the programme being to schedule,” said the IPA data sets. “It was recommended that the programme review the hard target of September 2018, in line with provider readiness and resource requirements for paper switch-off.”

A hard target it may be, but it is one that, despite the doubters and naysayers, NHS Digital maintains it will achieve.

By the time September has come and gone, we will know whether it has done so. 

Sam Trendall

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