New standard for clinical referral information

NEW STANDARD: Digital clinical referral information will support faster, better patient care

We have published our new standard for sharing clinical referral information, which will help to reduce avoidable referrals, speed up treatment times and make care better and safer for patients.

Referrals to hospital are increasing as more people continue to live longer with a range of complex conditions. As a result, good information sharing is integral to ensuring that patients can receive the ongoing care that they need. Currently there are differences between GP systems and GP practices in the clinical content of referrals, with multiple templates in use.

We have consulted widely with clinicians and other health and care professionals as well as patients and system suppliers before publishing the new standard and implementation guidance for digital referrals from GPs to hospitals. Once implemented, this will improve the exchange of referral information from GPs to hospital consultants and other professionals providing outpatient services. The standard was produced in collaboration with the Royal College of Physicians Health Informatics Unit, with input from the Royal College of General Practitioners.

“From my experience as a clinician, getting timely, accurate information is essential so that patients can get rapid access to the right services, said Dr Gareth Thomas, the PRSB’s clinical advisor to the programme and group chief clinical information officer at Salford Royal NHS Foundation Trust. “A standardised referral process means people can then be triaged appropriately on to the best pathway of care, and as a result this will speed up referrals to specialist services.”

Professor Helen Stokes-Lampard, chair of the Royal College of GPs, added: “The communications that clinicians in different areas of the NHS send to each other are critical as they contain the relevant information necessary to ensure our patients receive the best possible, safe, seamless care. We welcome this new standard from the PRSB that should simplify the process for sending e-referrals and ensure the communications sent are standardised, which is in everyone’s best interests.”

Although appointments can be booked online through the NHS Digital e-referrals service (NHS e-RS), some hospitals are still receiving letters by fax or email.

For further information, please contact info@theprsb.org

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Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.

“If someone’s been working for a period of time, in a form of therapy, for instance, where there’s an agreed plan for the locality when they may present in an emergency situation … then it’s really important for us to be able to see that that information and be able to act appropriately according to that because, you know, there isn’t and there shouldn’t be a stock response to that. These plans are designed to be individualised and personalised.  All services should be giving that personalised approach to care wherever possible. And a standard such as [PCSP standard] definitely moves us closer towards being able to do that. [Not acting on agreed plans] is a key finding in terms of emergency responses over the years where responses have been inappropriate.” – Mental Health Nurse

“Following a particular plan that’s been put into place will result in much better outcomes and prevent the sort of poor outcome which would otherwise be leading to an unplanned hospital admission.” – General Practitioner