NHS e-referral Service

Transcription

1 NHS e-referral Service Vision and Key messages Making paperless referrals a reality Version 1.0 June 2013

2 Contents Foreword... 4 Background... 5 Document Purpose... 5 Vision Principles... 5 Strategic drivers The NHS Constitution The NHS Mandate The new NHS Provider Licence Liberating the NHS no decision about me without me The 2013/2014 NHS Standard Contract Choose and Book Best Practice Guidelines Putting Patients First... 8 The Benefits Case Patients Referrers Providers Commissioners... 9 What we have heard... 9 The Challenges From patients: From referrers From provider organisations General What might a future Service look like? Integration and Usability Referral Management Support Any-to-Any Referrals Linked Appointments Follow-Up Appointments Self-referrals... 14

3 7. Reporting Electronic Communications Delivery Roadmap Next Steps Consultation Business change support for implementation Appendix 1: Summary of Consultation Questions Appendix 2: Benefits map by stakeholder Patient benefits Referrer benefits Commissioner benefits Provider Benefits Appendix 3: Clinical Storyboards... 25

4 Foreword Since 2004, more than 40 million referrals from GP to first outpatient appointments have been made using the electronic booking system, Choose and Book. Despite being used to refer up to 40,000 patients per working day, this still only represents half of all possible GP to first outpatient referrals. The current contract for Choose and Book comes to an end very soon, which provides the perfect opportunity for it to evolve into something even better. The time is now right for a new, reinvigorated Vision for an NHS e- Referral Service, which supports a paperless NHS being in place by This future Service needs to put an end to the current mixed economy of paper and electronic referrals. We must have a single approach that will ensure that the NHS is patient-centred, customer-focused and easy for patients to do business with. We know that Choose and Book works well for many patients and professionals but not for everyone all of the time. The same patients and professionals living and working in different localities can have vastly different experiences of the system. Very often, however, these difference exist even within the same local health communities. Over the years, much anecdotal feedback has been received on what appears to work and what doesn t. We have added to this by holding discussions with key stakeholders, including workshops with Clinical Commissioning Groups and patients. Old issues have resurfaced, but we ve also heard lots of new and exciting ideas that will allow us to build on both the successes and learn from the failures of Choose and Book. So far, we have taken those ideas and developed patient and user journeys that help illustrate some of the suggested functionality and new ways of doing things. Some of these are reproduced later in this document and demonstrate how the Vision might be transformed into reality and into pathways that benefit patients, referrers, service providers and commissioners. This document will help launch the Vision of the new service. We will ensure that all those who have a view on what electronic referrals should look like are given every opportunity to let us have their comments. I do hope that you will consider the ideas and suggestions that have been put forward so far and let us have your own. This is all about listening and learning and we very much want to listen and learn from you. With best wishes Beverley Bryant Director of Strategic Systems and Technology NHS England Page 4

5 Background Choose and Book is a national service that combines electronic booking with a choice of place, date and time for first hospital or clinic appointments. It revolutionised the old booking system, by allowing patients to choose their initial hospital or clinic appointment, and book it themselves. A new NHS e-referral Service will succeed the current Choose and Book service over the coming years. It will be developed based on feedback from patients and NHS professionals. The future service will use enhanced technology to expand on current benefits and improve the quality of the referral experience for patients. It will better support current and future business processes for clinicians and administrative staff. In so doing, it will help create a more patient-centred, people-powered NHS, making the NHS much easier to do business with. Document Purpose This document will: Outline the Vision for the new NHS e-referral Service Facilitate discussion, debate and consultation Support on-going business change processes, leading to a paperless NHS by 2018 Summarise strategic drivers and benefits associated with electronic referral and booking. Vision Principles 1. The new NHS e-referral Service will improve patient outcomes, user experiences and support the drive to a future paperless NHS referral system. 2. The new service will build upon the benefits and successes of the Choose and Book system, acknowledging its failures (both real and perceived) and lessons learned. 3. There will no longer be a mixed economy of paper and electronic referrals. 4. The needs of patients and professionals will be foremost in designing the new service, which will include support for enhanced functionality and usability. Strategic drivers There are a number of recent policies and strategic drivers that contain statements relevant to the development of a new NHS e-referral Service. This section highlights key elements of those policies/documents and shows the way in which the Vision can respond to these strategic drivers. Page 5

6 1. The NHS Constitution 2. The NHS Mandate Response: You have the right to make choices about your NHS care and to information to support these choices The objective is to ensure the NHS becomes dramatically better at involving patients and their careers, and empowering them to manage and make decisions about their own care and treatment. The NHS e-referral service will support patients rights to be involved in discussions about their healthcare and to be given information to enable them to do this. It will provide opportunities to allow them to choose where they would like to be treated, by whom and when. All providers of NHS care will be able to make their services electronically available to patients, fully supporting the referral and booking process. Response: The needs and choices of patients will be at the forefront of driving the improvements that will help shape the future of an NHS e-referral Service. Patients will be given an easy opportunity to express choice of provider for every clinically appropriate referral and empowered to exercise that choice by directly booking an appointment using appropriate and convenient methods. The service will allow patients and referrers to view information in support of choice, such as cancellation rates, waiting times and referral to treatment information, thus allowing informed decisions to be made about care pathways and encouraging providers to improve performance and attract more patients. Functionality will be enhanced to allow for a wider range of services to be booked, including Diagnostics, Selfreferrals and follow-up appointments. Page 6

7 3. The new NHS Provider Licence Choice and Competition: This condition protects patients rights to choose between providers by obliging providers to make information available and act in a fair way where patients have a choice of provider. Response: The NHS e-referral Service will provide access to data that enables comparisons to be made between service options, thus allowing patients to choose services that fit around their needs and commitments. The service will support referrals to local and national services (both community and hospital-based) as well as to diagnostic and tertiary services (if appropriate for choice). 4. Liberating the NHS no decision about me without me We are working to maximise use of Choose and Book so that more referrals are made through it and more patients are given an opportunity to make choices over their care and treatment In future, diagnostic tests which are not carried out as part of a consultant-led first outpatient appointment should be listed on the Choose and Book system and be directly bookable Response: Referrer and service provider organisations will be made fully aware of the benefits and efficiency savings associated with the current Choose and Book service. They will be encouraged to provide input to the development of an enhanced NHS e- Referral Service. The service will have an intuitive user interface and be simple to use. As well as allowing the direct booking of appointments into provider Patient Administration Systems, it will support integration with GP, hospital and other clinical systems, including Radiology Information Systems. Page 7

8 5. The 2013/2014 NHS Standard Contract The Provider and the commissioners shall adhere to Guidance in relation to the use of Choose and Book and ensure service users are fully supported in their use of Choose and Book and are not delayed or inconvenienced by insufficient slots being made available. Commissioners shall use their best endeavours to ensure that all referrals to the Provider are made through the Choose and Book system Response: The NHS e-referral Service Programme will engage with providers and commissioners to support them in maximising their use of the current Choose and Book system and to listen to their requirements for a future NHS e-referral Service. Enhanced reporting and availability of relevant management information will support effective demand and capacity planning by providers, leading to increased availability of appointment slots. Functionality to support patients in booking follow-up appointments electronically will make appointment provision and planning more efficient. 6. Choose and Book Best Practice Guidelines This document is designed to help organisations comply with the requirements of the NHS Standard Contract. 7. Putting Patients First Putting patients at the centre of decision making. Improving patient outcomes Response: The NHS e-referral Service programme team will continue to engage with patient groups to ensure they have a clear understanding of the new service and how it will work. The service will ensure that patients are aware of how the NHS e-referral Service can support their rights to choice and facilitate them in exercising those rights. There should be greater visibility of clinical pathways and greater transparency of outcomes/experiences. Patients will be treated respectfully as customers, with their interests being of paramount importance, enabling them to make more informed choices and be in better control of their care. Page 8

9 Patient outcomes and user experiences will be improved by: supporting customer convenience, by being available 24 hours a day, seven days a week, enabling referrals to be made and appointments to be booked. supporting the concept of any-toany referrals, allowing a wider range of health care professionals to refer patients across technological and organisational boundaries. allowing full visibility of all available services and ensuring sufficient appointment slots are available. providing improved access to information to support choice and selection of services The Benefits Case It is anticipated that the NHS e-referral Service will deliver the following benefits by stakeholder: 1. Patients 1.1. Improved patient confidence and certainty 1.2. Improved patient choice 1.3. Reduced waiting time for first appointment, and a reduction in the overall treatment time 2. Referrers 2.1. Improved confidence in the referral process 2.2. Improved referral management 2.3. Improved patient safety 3. Providers 3.1. Effective and consistent referral and patient management 3.2. Reduced administrative overheads 3.3. Improved patient safety 3.4. Improved integration with hospital clinical systems 4. Commissioners 4.1. Improved reporting and management information 4.2. Improved referral management 4.3. More effective and efficient commissioning What we have heard During 2012/13, extensive consultation took place with a wide range of stakeholders including patients, NHS professionals, Clinical Commissioning Groups (CCGs), Referrers (GPs), and Service Provider organisations about what an ideal e-referral service might look like. In addition, a Request for Assessment (RFA) process has always been in place to enable Choose and Book users to suggest and debate future enhancements to the system. From engagement to date we have heard that: Choose and Book is a good thing when it is implemented well; the underpinning principles of electronic referral are correct Choose and Book needs to evolve to support emerging NHS structure Page 9

10 Building on the current Choose and Book service will help the NHS achieve a paperless future Enabling Choose and Book to be used more widely will support ongoing improvement in quality and efficiency The need to focus on sustainable business change is key There are many changes and developments which could be incorporated into Choose and Book to make it, and electronic referral, more effective and better support patients and professional users. The Challenges In addition to suggestions for future enhancements, we have also heard a strong need to address and learn from historic implementation issues and correct misperceptions. These include: 1. From patients: 1.1. Patients are not always aware of their rights under the NHS Constitution and are not always empowered to ask for an electronic referral to a provider of their choice Patients are often unaware that they can book their own appointments Patients are often confused by local processes, particularly where referral management services may be in use, and the process has not been adequately explained to them. 2. From referrers 2.1. Not all providers have made their services available electronically 2.2. Not all services and appointment slots are available or directly bookable 2.3. A myth exists that the current system does not support referrals and bookings to named clinicians A myth exists that the current system does not support referrals and bookings to Two Week Wait services Past incentive schemes have often focused on rewarding quantity of referrals/bookings, rather than quality of referrals. 3. From provider organisations 3.1. Not all provider systems are fully compliant with the current Choose and Book service 3.2. Sometimes, consultants are unable to accept referrals sent specifically to them as named clinicians 3.3. Concerns exist that patients will be constantly cancelling and changing their appointments 3.4. Concerns exist that the electronic process increases workload 3.5. A misunderstanding exists that in order to manage demand and capacity effectively, providers need to see the referral letter before an appointment can be booked. Page 10

11 4. General 4.1. Insufficient benefits evidence exists to effect significant changes in business processes Perception that the current system is slow and technically un-reliable Concerns that the design and Implementation of the system has not been clinically driven and clinically lead. What might a future Service look like? This section describes how a future service might work, based on new infrastructure along with ideas, suggestions and feedback from stakeholders to date. Each section contains a description of what is proposed for the new service and the anticipated benefits that this will deliver. A series of questions has been devised to support the consultation and obtain feedback on the Vision and these potential future developments. 1. Integration and Usability What is proposed 1.1. Manufacturers of Clinical electronic record systems will be able to develop their own user interfaces ( front-end ) to the NHS e-referral Service and respond to the functional requirements of their userbase The system will be easier to use than the current Choose and Book system and more intuitive with a modern look and feel The system will support the seamless transfer of referral information from GP clinical systems into provider (hospital) systems, in a structured referral message format that complies with agreed professional record standards Enhanced functionality will allow provider clinical systems to send back clinical outcome information (e.g. clinic letters and discharge summaries) using the same electronic route Where existing appointment scheduling systems do not exist, the NHS e-referral Service will allow providers to set up appointment templates enabling patients to directly book appointments. Provider clinicians will receive alerts when appointments are booked and will be able to download referral information. Anticipated benefits Reduction in administrative costs associated with printing referral letters Reduction in transcription errors when clinical information is being copied manually between systems A single electronic system available for the transmission of referral and outcome information between clinicians Page 11

12 Reduction in the need for specialist application training, due to a more intuitive and familiar user interface. More seamless integration and data transfer between clinical systems and the core application. Greater provider efficiency and patient convenience by being able to provide direct booking for organisations that do not have compatible patient administration systems. Reduction in staffing costs associated with indirectly booking appointments 2.2. Clinical request templates, generated from within referrer clinical systems will be enhanced to allow decision support questions to guide a referrer as to whether a patient meets the referral criteria for a specific service Commissioners will be able to set up Referral Assessment Services specifically aimed at assessing referral information prior to, or instead of, an appointment being booked. Consultation Questions 1. What benefit can you see in having greater integration and interoperability between the NHS e-referral Service and other clinical systems? 2. How do you see the stand-alone appointment scheduler supporting all providers to use the NHS e- Referral Service? 3. Would the ability to send outcome/discharge information back to the referrer using the same system as was used for the referral be beneficial? 2. Referral Management Support What is proposed 2.1. An enhanced Advice and Guidance functionality will allow backwards and forwards dialogue between clinicians, with the ability to add attachments and other supporting information. It will be possible to convert the advice into a referral and retain the clinical conversation. Anticipated benefits Enhanced communication between GPs, hospital doctors and patients Greater confidence that patients are booked into the right clinic first time- every time. Consultation Questions 4. How would an enhanced Advice and Guidance facility support local referral management priorities? 5. Should the NHS e-referral Service contain clinical templates of its own or should these always be created and held within the referrer clinical systems? 6. Is there a role for an electronic gatekeeper to help enforce locally agreed referral priorities? How might this work? 7. What rules should be put in place to ensure that Referral Assessment Services are used in a cost-effective way for the benefit of patients? Page 12

13 3. Any-to-Any Referrals What is proposed 3.1. The current technical constraints, that prevent many clinicians acting as referrers, will disappear, allowing any clinician to refer to any other Consultants will be able to make tertiary and onward referrals Commissioners will be able to assign referrer rights to groups of clinicians, allowing them to make referrals along predefined pathways. This might, for example, allow a midwife to refer to an obstetrician or an optician to refer to an ophthalmologist Provider administrative support functions to have a provider worklist to support more effective management of electronic referrals and remove need for paper. Anticipated benefits Patients will have all the benefits for electronic referral for future stages in their care pathway Commissioners remain in control of the stages of the care pathway. Consultation Questions 8. Should the NHS e-referral Service allow any clinician to act as a referrer into any speciality subject to Commissioner set controls? If not, then what restrictions should it support? 9. Will allowing any clinician to initiate referrals make the management of care pathways more efficient? If so, how? 4. Linked Appointments What is proposed 4.1. It will be possible for the referrer or provider to link appointments in a care pathway, helping to ensure that one does not take place without the other and that they occur in the correct sequence A provider organisation may specify (for example) that a test has to be done prior to an outpatient appointment. The system will ensure that both appointments can be booked within the correct time frame A referrer may book a series of appointments with a patient and specify that they have to be linked and take place in a pre-determined order, so that if one changes for any reason, the others will be altered accordingly. Anticipated benefits Patients will be more involved in arranging all appointments in their care pathway Reduction in wasted or repeated diagnostic tests Test results always available for outpatient consultation (reduction in wasted outpatient consultations) Page 13

14 Consultation Questions 10. What impact might linked appointments have on the clinical and administrative processes within provider organisations? 11. Do you think linked appointments will make provider organisations more efficient? 5. Follow-Up Appointments What is proposed 5.1. Instead of being given an appointment, or told they will be contacted by the hospital, patients will be able to choose and book their own follow-up appointments electronically, during an authorised period, 5.2. For those patients where a planned follow-up is not clinically indicated, clinicians will be able to offer patients the ability to book their follow-up only if required 5.3. Where the follow-up is considered clinically necessary, patients will receive an alert/reminder advising them to book their appointment. Anticipated benefits Reduction in unnecessary follow-up appointments Patients able to choose date and time of follow-up appointments Automatic system of reminding patients when to book appointments. Consultation Questions 12. How might the ability to book follow-up appointments using the NHS e-referral Service contribute to greater efficiency in provider organisations? 13. What effect might electronic followups have on demand and capacity management within provider organisations? 14. Are there any risks or concerns about enabling patients to book their own follow-ups electronically? 6. Self-referrals What is proposed 6.1. Patients will be able to refer themselves into services that have been commissioned as suitable for self-referral Commissioning organisations will determine which services are appropriate to accept self referrals from patients (e.g. physiotherapy, Stop Smoking, Dietetics and counselling services) and make them visible to patients Patients attending self-referral appointments will decide whether their GP is notified of the self-referral. Anticipated benefits Greater support for patient choice and shared decision making. Improved patient access to healthcare services Reduction in unnecessary GP appointments Page 14

15 Reduction in administrative overhead costs in GP practice Consultation Questions 15. What controls should commissioners have over selfreferrals? 16. Would self referral reduce unnecessary appointments in GP Practice? If so, what would you estimate this to be? 17. Should patients be able to decide whether their GP is made aware of attendance at self-referral services? 7. Reporting What is proposed 7.1. The NHS e-referral Service will contain a reporting module that provides easy access to referral and booking data, allowing it to be presented in meaningful formats to support different stakeholder groups A simple reporting user interface will allow intuitive queries to be run without the need for extensive data analysis skills Comprehensive uploads to national reporting systems will allow referral and booking information to be combined with other patient outcome/activity data to provide meaningful trend analysis across systems and health communities Data will be easily available to measure referral outcomes and to compare activity derived from other sources (e.g. rates for patients who did not book, did not attend or had appointments repeatedly cancelled) will be available at different organisation levels. Anticipated benefits Support for Commissioners and Providers in developing better and more efficient services, based on the needs of patients and the public. Allow user-friendly ways of reporting activity and outcomes Support for forward order book (planning and developing services) Provide activity data for personal development plans, appraisal and re-validation etc. Better support for demand and capacity management. Better planning for use of NHS resources. Consultation Questions 18. Would enhanced (better quality and more timely) reporting support more effective commissioning and contract management? 19. What type and level of benefit would there be from enhanced reporting? 20. What areas of reporting would be most useful to you in your role? 21. Who should have access to the enhanced reporting module? 8. Electronic Communications What is proposed 8.1. Modern technology will allow the use of mobile phone Apps, Page 15

16 s, text reminders etc, to support different ways of communicating appointmentrelated information to patients and system alerts to professional users Patients will be able to opt to receive booking information and updates in a number of different formats. Paper copies of referral/booking instructions will still be available, but other electronic media will be used to book, confirm and update appointments and send appointment reminders Professional users will be able to set alerts (e.g. by text or ) to remind them when system events occur (e.g. responses to Advice and Guidance requests or when referrals are rejected) Anticipated benefits More immediate communication - more confidence in the referral pathway. Greater variety of communication channels used. Keeping patients more informed of the progress of the referral and any changes that occur. Consultation Questions 22. Are there any other communication channels that should be considered for providing appointment-related information to patients? If so, which? 23. What Information governance concerns do you have (if any) about using mobile technology to communicate with patients? 24. How might professional users prefer to be alerted, if there is information to be reviewed? Delivery Roadmap The Vision will be developed and delivered incrementally. It will consist of the following stages: 1. Remove reliance on proprietary software within Choose and Book, so creating an open flexible platform, and simplifying integration with other systems. 2. Transition to new NHS e-referral Service. 3. Deliver new functionality in an agile manner through introducing a market-place concept for professional user and patient interfaces and functionality available, enabling IT providers of any size to integrate existing products and services, as well as developing new products and services, using appropriate compliance regimes. 4. Support NHS e-referral Service development through enabling changes in the core NHS e- Referrals Service engine. Page 16

17 Next Steps 1. Consultation During the second half of 2013, a wide ranging consultation will take place on the Vision for a new NHS e-referral Service. There will be several ways in which interested stakeholders will be able to contribute to the development of the new service: Workshops Meetings with stakeholders will be arranged through a series of workshops across England. The aim of these will be to facilitate discussion and debate on how to tackle the challenges and determine the priorities for future functional enhancements. Feedback on this document We would welcome feedback on the contents of this document. This can be by to nhs.ers@hscic.gov.uk or by completing an on-line survey at Review of website materials Materials, including storyboards, animated clinical scenarios and presentations are available on the NHS e-referral Service website Creation of a Design Council A clinically-led Design Council will be created later in 2013, which will bring together professional users from across the NHS, alongside IT suppliers to ensure new functionality and recommended business processes are based on the needs of all users, including those with limited technical skills and experience. Support for this will be confirmed via the consultation process. 2. Business change support for implementation. Whilst a new NHS e-referral Service is being developed, it is important that the NHS continues using Choose and Book. Those referrers and providers not currently doing so will be strongly encouraged to consider moving to the service and will be supported by the national programme team. Developing processes to handle electronic referrals internally now will make the transfer to the future system much easier. Moving from any one system to another necessitates a degree of business change, and this will always be more successful where processes are adapted or re-designed to allow the technology to support efficiencies and associated benefits to be realised. A smooth transition from the current Choose and Book system to a new NHS e-referral Service will be of paramount importance to enable business continuity and to ensure that patient care is not compromised in any way. The NHS e-referral Service Programme Team will work with organisations to support them through this process, both through direct support and the development of online end-user materials. Page 17

18 Appendix 1: Summary of Consultation Questions Requirements Section a) Integration and Usability Questions (1) What benefit can you see in having greater integration and interoperability between the NHS e- Referral Service and other clinical systems? (2) How do you see the stand-alone appointment scheduler supporting all providers to use the NHS e- Referral Service? (3) Would the ability to send outcome/discharge information back to the referrer using the same system as was used for the referral be beneficial? b) Referral Management Support (4) How would an enhanced Advice and Guidance facility support local referral management priorities. (5) Should the NHS e-referral Service contain clinical templates of its own or should these always be created and held within the referrer clinical systems? (6) Is there a role for an electronic gatekeeper to help enforce locally agreed referral priorities? How might this work? (7) What rules should be put in place to ensure that Referral Assessment Services are used in a costeffective way for the benefit of patients? c) Any to Any Referrals (8) Should the NHS e-referral Service allow any clinician to act as a referrer into any speciality subject to Commissioner set controls? If not, then what restrictions should it support? (9) Will allowing any clinician to initiate referrals make the management of care pathways more efficient? If so, how? d) Linked Appointments (10) What impact might linked appointments have on the clinical and administrative processes within provider organisations? (11) Do you think linked appointments will make provider organisations more efficient? Page 18

19 Requirements Section e) Follow-up Appointments Questions (12) How might the ability to book follow-up appointments using the NHS e-referral Service contribute to greater efficiency in provider organisations? (13) What effect might electronic follow-ups have on demand and capacity management within provider organisations? (14) Are there any risks or concerns about enabling patients to book their own follow-ups electronically? f) Self-Referrals (15) What controls should commissioners have over selfreferrals? (16) Would self referral reduce unnecessary appointments in GP Practice? If so, what would you estimate this to be? (17) Should patients be able to decide whether their GP is made aware of attendance at self-referral services? g) Reporting (18) Would enhanced (better quality and more timely) reporting support more effective commissioning and contract management? (19) What type and level of benefit would there be from enhanced reporting? (20) What areas of reporting would be most useful to you in your role? (21) Who should have access to the enhanced reporting module? h) Electronic Communications (22) Are there any other communication channels that should be considered for providing appointmentrelated information to patients? If so, which? (23) What Information governance concerns do you have (if any) about using mobile technology to communicate with patients? (24) How might professional users prefer to be alerted, if there is information to be reviewed? Page 19

20 Requirements Section i) General Questions Questions (25) Do you use the current Choose and Book system? If not, can you tell us why you don t use the current service (26) If you do use the current Choose and Book system, what do you consider to be the best elements of this? (27) Do you think the Vision for an NHS e-referral Service is taking electronic referral in the NHS in the right direction? If not what else do you think we should be considering? (28) We are aware that patients are not always fully informed of their rights to access health care, so how do we ensure they are involved and aware of their constitutional rights and the NHS e-referral Service? j) Implementation Questions (29) Would all services and appointment slots being available online influence you to use a future NHS e- Referral Service as the means for referring patients? (30) How would you like to see support for implementing a future NHS e-referral Service provided? Should this be at a national level, local level or support available from both? (31) We would like to understand what support you currently have for Choose and Book within your area, is there still local support that you can call on? (32) What do you think is the main barrier (real or perceived) that has prevented full uptake of Choose and Book in your area and how can we help to address this? (33) Some clinicians have said there was not enough input from them into the development of Choose and Book originally; how can we ensure clinicians views are heard and their ideas incorporated in to a future NHS e-referral Service? (34) Patients did not have a great deal of input into Choose and Book originally, so how can we ensure their views are heard and their ideas incorporated in to a future NHS e-referral Service? Page 20

21 Appendix 2: Benefits map by stakeholder 1. Patient benefits Page 21

22 2. Referrer benefits Page 22

23 3. Commissioner benefits Page 23

24 4. Provider Benefits Page 24

25 Appendix 3: Clinical Storyboards The following story boards have been devised to help describe the Vision of how the new NHS e-referral Service might work based on a series of clinical scenarios. 1. Advice and Guidance 2. Linked appointments 3. Self Referral 4. Redirection and Follow-up Page 25

26 Clinical Scenario (1) Advice and Guidance Page 26

27 Clinical Scenario (2) Linked appointments Page 27

28 Clinical Scenario (3) Self Referral Page 28

29 Clinical Scenario (4) Redirection and Follow-up Page 29

30 Images of official reports are courtesy of NHS England and the Department of Health 2013 Health and Social Care Information Centre Page 30