Diagnostic services

The NHS e-Referral Service (e-RS) supports referrals for a variety of diagnostic tests. Read more information about the different types of diagnostic tests available on e-RS. (N3/HSCN is required to access this link).

The principles of setting up a diagnostic service are broadly the same as setting up any other service on e-RS. Find out more about setting up services in e-RS.

There are several important points when setting up a service, however, when setting up diagnostic services specific consideration needs to be given to the steps below:

• select the appropriate request type supported
• select the appropriate appointment type
• add links to clinical referral templates and/or external referral guidance (if applicable)

Services may be set up to receive:

• appointment requests: referred patients can book an appointment
• advice requests: referrers can request advice to support the management a patient from a clinician at the provider
• triage requests: referrals can be reviewed by the receiving provider before referring to an appropriate service

Services may simultaneously support appointment or triage requests and advice requests, if appropriate. Diagnostic services can be set up using any of the above three options.

Triage request: referral assessment services (RAS)

This facility supports more complex care pathways, where it's not always clear which type of diagnostic test the patient might need. A RAS set up by the provider will ensure patients' referrals are triaged correctly, before booking any appointment. Providers can:

• assess the clinical referral information from the GP/referrer without the need for an appointment being booked
• decide on the most appropriate onward clinical pathway
• contact the patient to discuss choice (if an elective referral)
• arrange an appointment, where needed
• return the triage request to the original referrer with advice, if an onward referral isn't need

Find out more information about RAS.

When ‘Appointment Request’ is selected as the request type, then the appointment type in the service details shrub will be active as there are booking requirements in the request type selected. Appointments can be set up using either ‘Diagnostic’ or ‘First Outpatient’ appointment type.

Diagnostic appointment type

This should be thought of as the default appointment type for diagnostic services. It allows the service to be configured to support either a ‘direct to test’ or a 'clinical assessment' model. It is therefore important to consider how the service will operate.

Direct to test model

This allows the referral to be accepted straight into the service (or re-directed/rejected as necessary). For example, a Bone Density Scan service would use the ‘Diagnostic’ appointment type, with the service provider clinician simply reviewing the clinical information (rather than clinically assessing the patient) before accepting, re-directing or rejecting the referral.

To enable this option, service definers will need to select ‘No’ for ‘Supports assessment/onward referrals’ option in the assessment capability section of the service definition screen. If this is not done, the full two-stage assessment service functionality will be enabled, as detailed below.

Clinical assessment model

There may be cases where a provider wishes to assess the referral before deciding on an appropriate test or other onward pathway. In such cases the ‘refer on’ functionality, (usually associated with the ‘Assessment Service’ appointment type), can be utilised within the ‘Diagnostic’ appointment type. This will allow the service provider to review the request and refer the patient on to another service. For example, a request to a Colon Imaging Advice service may result in an onward referral to a Colonoscopy, CT Colonography, Barium Enema or a Flexible Sigmoidoscopy service.

The assessment service model can also be used where the diagnostic test forms part of an assessment that will determine the onward referral pathway. In this case, the clinician, after carrying out the test, will decide with the patient what the most clinically appropriate onward pathway would be. For example, the result of a Urodynamics test carried out as part of a diagnostic assessment appointment, could determine an onward referral to either a Urology or a Gynaecology service (or the patient could be referred back to their referring clinician with the results of the test).

In order to utilise the referrals for assessment worklist, service definers will need to select ‘Yes’ for ‘Supports assessment/onward referrals’ option in the ‘Assessment Capability’ section of the service definition screen.

First outpatient appointment type

This should be used for services led by a consultant, carried out in an outpatient setting. It may be that diagnostic tests are carried out as part of this appointment, but the referral is essentially to a consultant-led outpatient service, not to a diagnostic service. For example, a referral to a first outpatient Urology one-stop service may result in the patient having one of several diagnostic tests (e.g. urodynamics or ultrasound) as part of the initial consultation with the consultant.

Telephone/Video appointment type

You can use this for remote services where you provide the consultation online. The patient will have booking details in the patient letter or from their online booking. The service has the duty to contact the patient and agree a phone call or video conference. This follows a review of the referral.

Providers of diagnostic services may wish to recommend that referrers use either nationally or locally agreed referral templates, or follow standard agreed guidance, to ensure that all the necessary clinical information is supplied, and that the referral is appropriate.

The clinical request template (CRT) can either be made available as a hyperlink from a provider’s website, and added to the Administrative Requirements section of the service details, or converted to a suitable format and uploaded to individual referrer clinical systems to be completed by the referrer as a pre-populated template. The second method will reduce the amount of effort required by referrers in adding clinical referral information but will require initial set-up time and resources in converting and uploading the templates.

In a similar way, local guidance may be made available to referrers by adding a link to an external source, for example a provider trust’s website, in the Administrative Requirements section of the Service Specific Booking Guidance.

Providers who add links (to forms or guidance) may also wish to consider using the Referrer Alert functionality to advise referrers of this.

The service provider clinician always maintains responsibility for assessing the clinical appropriateness of any referral. This is particularly important for radiological referrals where adherence to Ionising Radiation (Medical Exposure) Regulations (IRMER) has to be considered.

When e-RS is used to make a referral, the patient must book an appointment before the referral information can be viewed by the provider. However, the receiving clinician, who must justify the examination, always has the opportunity to re-direct or reject the referral, if it is clinically inappropriate. It is important that the patient is involved in any decision about changing their appointment, especially if this may be changing what was a diagnostic investigation to an outpatient appointment or if cancelling/re-booking the appointment for other reasons.

The Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER), require a referrer to be a registered health care professional who is responsible for providing sufficient information to enable the practitioner to justify the medical exposure. Find out more about Ionising radiation (medical exposure) regulations.

When using e-RS for radiological referrals, a clinical referrer will have already been authenticated on the system via their smartcard. This will enable the imaging service to verify that the referral is within the range of referral entitlement specified by the management responsible for the facility.

A 2013 letter from Professor Erika Denton (National Clinical Director for Imaging) confirms that role-based access controls assigned to registered health care professionals serve as an alternative to the signature required on paper-based radiological referral forms.

Where diagnostic services (for example, Diagnostic Physiological Measurement or Endoscopy services) are managed on a provider’s patient administration system (PAS), they should be made directly bookable on e-RS, with all the associated benefits this brings.  These benefits include:

• the certainty given to a patient of being booked straight into an appointment slot
• reduced administrative overhead for the providers
• the visibility for referrers of where their patients are in their treatment pathway

Many radiological diagnostic services are managed through a Radiology Information System (RIS) and, as yet, these systems are not compliant with e-RS. While the e-RS team continue to explore ways in which future RIS integration may be possible, such services will need to be set up as indirectly bookable or RAS on e-RS. This will require the provider of the service to enter the relevant contact details into the directory of services, so that patients are guided to call the booking office to arrange their diagnostic appointment.