Transformation Directorate

Improving the efficiency of referrals by optimising use of advice and guidance to GPs

The COVID-19 pandemic presents a unique opportunity to redesign outpatient services using digital technology.

The NHS e-Referral service (which replaced Choose and Book in 2015) is the standard referral platform for all GP referrals in England. All GP practices in England should now be using the NHS e-Referral Service (e-RS) to refer into consultant-led out-patient clinics (NHS standard contract since October 2018).


There are 3 main channels available in e-RS which consultants can provide or optimise in COVID-19 recovery to streamline patient care:

  1. A&G (advice and guidance): pre-referral 2-way digital dialogue, used to provide advice, direct GPs to local guidelines (for example, fatty liver), recommend pre-referral tests (qFIT, ultrasound, fibrotic markers). Since January 2021, consultants can convert A&G requests directly to referrals (if the GP has pre-authorised), and provide advice to help manage the patient while on the waiting list. A&G now provides a streamlined digital channel between primary and secondary care.
  2. Referral assessment service (RAS): a referral triage service, originally designed for pathways such as gastroenterology, allowing consultants to direct referrals to appropriate clinics or organise straight-to-test (STT) or pre-clinic tests to facilitate initial consultation.
  3. Directly bookable services: this is the traditional Choose and Book (C&B) model where the patient chooses an appointment slot, which means there is minimal opportunity for triage.

A&G provides a secure, rapid-access (usually 48-hour turn-around) digital portal for GPs to communicate with consultants and provider teams to support patient care, improve patient safety, and reduce unnecessary outpatient referrals.

Gastroenterology e-RS A&G use has increased dramatically across England (approximately 6,500 per month in October 2019 and more than 9,800 in December 2020). However, provision and uptake of A&G across England is variable, presenting opportunities for mobilisation.


Optimise pre-referral advice to GPs, either avoiding the need for referral to specialist clinics or advising pre-referral tests to facilitate assessment when the patient is seen.

Appropriate use of A&G could ‘divert’ as many as 20% of GP referrals, while RAS provides an opportunity to streamline the patient pathway by requesting appropriate tests in secondary care.

Solution and impact

The Portsmouth Hospitals University NHS Trust gastroenterology team has extensively supported the use of A&G over the past year. The usage has particularly increased throughout the COVID-19 pandemic.

GPs are encouraged to request A&G on all non-two-week wait patients before considering referral.

The use of A&G has increased by 107% (July to December 2019 compared with July to December 2020).


The hospital has seen a 15% reduction in new-patient clinic appointments against the trend (which has been increasing year-on-year throughout previous years).

The 2-way conversation between the GP and consultant means that sometimes simple tests can close the episode without further work or raising patient expectation. The functionality and benefits of A&G are additionally complemented by the increased use of common pathways, such as straight to test (STT), helping to reduce the requirement to place a referral further.

The team estimates that up to three A&G requests can be completed in the time required to see a new patient in clinic. Essentially this means that as long as half of A&G requests are either providing the GP with advice, or sending a patient STT, it ensures that the service is maximising efficiency against the traditional approach of seeing all patients in clinic.


  • eRS is a secure NHS application portal which is linked to the spine
  • A&G provides the opportunity for primary and secondary care clinicians to communicate in free text with one another through a secure national platform


  • A&G allows GPs to ask free-text questions, upload letters, documents, digital images, test results
  • Secondary care clinicians can request further information or send rapid secure digital advice back to GPs with attachments or links to web-based resources to support patient management in the community. Alternatively secondary care clinicians can convert the A&G to a referral (if the GP has ticked the pre-authorisation) and provide interim advice back at the same time to support the management of the patient while on the waiting list
  • The e-RS A&G data is collected in the national A&G dashboard


This should be used in a clinical setting (that is, clinician to clinician) but the solution can be used remotely by clinicians from home.

Key learning points

To enable an effective A&G system, the GP should be encouraged to pose a clear question and the answering consultant needs to deliver a clear answer and not assume specialist knowledge in the GP.

The request for advice needs to be displayed in one clear text box. It is time consuming if the consultant is being sent attachments which hold little to no useful information. A&G and validation of referrals requires daily job-planned time. In Portsmouth Hospital, the process has required at least four hours a day of consultant time. If it is done in zero-time, effective decisions will not be made, confidence in the process will wane and the value of the service will decline.

Local views from the department are that the process needs to be consultant-led and subdivided into gastroenterology and hepatology.

If the system could facilitate a 3-way conversation with related specialities (for instance, between the GP, medical and surgical gastroenterology team), this would permit seamless redirection and booking to further optimise the referral pathway.

Very clear ownership of test results between primary and secondary care when obtained through STT is of high importance.

Key figures/quotes

“In order to maximise the benefit available from A&G we would encourage referrers to ‘tell a story, and ask a question’.”
Amanda Quine, consultant gastroenterologist, Portsmouth Hospital NHS Trust

Find out more

Find out about the new functionality of NHS e-RS

Key contact

Dr Amanda Quine, care group director for medicine, Portsmouth Hospital NHS Trust

Adam Haycox, business manager for medicine, Portsmouth Hospital NHS Trust