HSSIB interim report: Electronic patient record systems – electronic referrals for ongoing care: advice and guidance (18 August 2026)

Summary

This report is an interim publication as part of the Health Services Safety Investigation Body (HSSIB)’s focus on electronic patient record systems – electronic referrals for ongoing care.

This report examines the patient safety risks associated with advice and guidance (A&G) services between general practice and secondary specialist care. A&G services enable clinicians in general practice to seek specialist advice about a patient’s care, either before or instead of referring them to hospital for specialist assessment. A&G is often undertaken via the NHS electronic referral service (e-RS), a digital platform also used for referring patients to NHS hospitals.

The use of A&G services has increased significantly in recent years. Concerns were raised with HSSIB that further plans for expansion and prioritisation of A&G, including as part of single point of access (SPoA), created risks to patient safety. SPoA is a model where all A&G requests and elective referrals (other than those for urgent suspected cancer) are directed into a single digital entry point at specialty level within secondary care

Content

Findings

• A&G services had positively influenced patient care where they had improved communication between general practice and specialist services, and enabled efficient specialist input into care. There was limited data on outcomes relating to patient safety.

• There was evidence that A&G – due to how it had been implemented, integrated into processes, and/or was monitored – had contributed to near misses and incidents of patient harm, both physical and psychological. Harm had arisen as a result of delayed or missed diagnoses, and delays to care and treatment.

• Evidence demonstrated that A&G services were being used in some pathways where general practice had requested specialist assessment for suspected cancer. Incidents demonstrated that this had contributed to delays in diagnosis.

• The extent of the risk to patient safety of A&G/SPoA processes could not be determined, due in part to limitations in safety data. Incidents identified in general practice were not consistently reported to the Learn from Patient Safety Events service due to technical barriers and limitations in local reporting processes.

• There were gaps between how A&G/SPoA processes had been and were being implemented, and national expectations. Examples included local pathways that required GPs to use A&G instead of making direct referrals, and referrals for specialist assessment being declined despite GPs having persistent concerns.

• There was tension between national timeframes for the implementation of A&G/SPoA processes, and the capability and capacity of providers and ICBs to ensure that implementation and expansion managed risks to patient safety.

• ICBs have a significant role in supporting the co-design, implementation and oversight of A&G/SPoA processes. Challenges facing ICBs, and the effectiveness of some of their interface groups (or equivalent), affected their ability to provide this support.

• While most specialist responses to A&G requests occurred within expected timeframes, there were repeated examples of delays ranging from weeks to more than 6 months. The quality of requests and responses also varied, with limited standardisation in the structure of information shared.

• Issues with the functionality and usability of the e-RS, and its interoperability with other health IT systems, affected users’ ability to consistently share high-quality information, and monitor and track patients through pathways. Planned upgrades to the e-RS had been delayed at the time of writing.

• Providers deploying e-RS were unable to provide evidence that compliance with digital clinical risk management standards (DCB0160) had been achieved. Deployment of e-RS into local pathways, and the associated risks, had not been assessed.

• Further concerns relating to the implementation of A&G/SPoA processes had not been fully addressed by national stakeholders or through local co-design. These included clarification of what constitutes a ‘clinically appropriate’ referral, concerns about medicolegal accountability, addressing resource and training needs, and ensuring that GPs retain the right to refer.

HSSIB recommendations

Safety recommendation R/2026/095:

HSSIB recommends that NHS England/Department of Health and Social Care undertakes a rapid evaluation of advice and guidance processes, including as part of single point of access. This is in order to address the varying risks to patient safety created by the:

1. resource and capacity limitations of integrated care boards and providers, and their ability to support implementation and oversight of processes

2. varying effectiveness of interface groups, and their ability to support collaboration between general practice and secondary care

3. training needs of the multidisciplinary workforce to undertake safe and effective asynchronous consultations

4. limitations in risk identification and mitigation associated with the deployment of the electronic referral service into local pathways, in line with standards

5. gaps in reporting of patient safety incidents by general practice to inform understanding of patient harms and risks to patient safety.

Completing this evaluation and addressing findings before further expansion of advice and guidance processes, including as part of single point of access, would ensure risks to patient safety have been identified, assessed and managed.

Safety recommendation R/2026/096:

HSSIB recommends that NHS England/Department of Health and Social Care, in collaboration with relevant Royal Colleges:

• commissions the development of advice and guidance request and response templates for specialties where these do not exist, including general practice

• supports effective implementation of template use in practice.

This is to support greater standardisation in the electronic clinical information provided when advice is sought from and provided by specialists.

HSSIB safety observations

Safety observation O/2026/091:

Organisations involved in the design and provision of healthcare education can improve patient safety by addressing gaps in knowledge and skill across the multidisciplinary workforce for the undertaking of asynchronous clinical consultation tasks, such as those undertaken through advice and guidance services.

Safety observation O/2026/092:

Organisations can improve patient safety by ensuring the mandated requirements for digital clinical risk management (under DCB0160) for the deployment of the electronic referral service (e-RS) are achieved. For general practices and integrated care boards this includes agreeing responsibilities for the digital clinical risk management of e-RS. This is to enable identification and mitigation of risks to patient safety associated with e-RS when implemented into care pathways.

Safety learning for integrated care boards

HSSIB suggests that integrated care boards (ICBs) – through co-design with general practice, secondary care and people with lived experience – ensure that the following are considered as part of advice and guidance (A&G) and single point of access (SPoA) processes:

1. alignment with national expectations, including ensuring that suspected cancer referrals are managed appropriately, and that formalised pathways are established for referral where general practice remains concerned that specialist assessment is clinically appropriate despite a referral being declined.

2. clarification of the concept of ‘clinically appropriate’ within local referral pathways, including the establishment of mechanisms by which clinicians can resolve differences in clinical opinion to support collaborative care planning.

3. clarification of the roles and responsibilities of different providers along patient care pathways where care is transferred, shared or informed by specialist advice.

4. ICB role in digital clinical risk management of deployed systems for A&G/SPoA, including support to general practice to understand local implementation risks.

5. clinical information sharing through interoperable health IT systems, alongside the use of standardised templates where appropriate.

6. oversight of the quality and safety of A&G/SPoA processes, including monitoring of patient safety incidents, the quality and timeliness of A&G responses, and redirection rates where referrals are responded to with advice.

Local level learning

For providers involved in advice and guidance (A&G) or single point of access (SPoA) processes:

• How does your organisation ensure that the design and implementation of processes between providers are informed by effective co-production and engagement with providers, the multidisciplinary workforce and patients?

• Does your organisation have clarity on roles and responsibilities within A&G/SPoA processes, including who is responsible for undertaking clinical investigations, interpreting results and prescribing following specialist advice?

• How could your organisation improve interoperability between health IT systems to support access to, and the flow of, patient information, for example between the electronic referral service and an electronic patient record?

• Has the deployment of the electronic referral service in your organisation been assessed against digital clinical risk management standards (DCB0160) to identify and manage potential risks to patient safety?

• How does your organisation monitor the quality and timeliness of A&G requests and responses, and ensure that they are received and acted on?

For general practices:

• How does your organisation ensure that requests for A&G are structured appropriately and clearly articulate the ‘ask’ (clinical question) to support specialists in understanding the purpose of the request?

• How does your organisation ensure that patient safety incidents involving A&G/SPoA processes or the electronic referral service are reported and escalated, including through the Learn from Patient Safety Events service?

• How does your organisation escalate concerns to the specialist teams when there are delays or questions about the advice received?

For secondary care organisations and specialists:

• Does your organisation use A&G/SPoA processes outside of stated national expectations and does your organisation ensure cancer care is not impacted?

• How does your organisation ensure that responses to A&G requests are structured to support ongoing patient care, including with the provision of safety-netting information?

• How does your organisation ensure that A&G requests are responded to by staff with appropriate training and supervision, in line with national expectations?

• Does your organisation provide protected time within job plans for reviewing and responding to A&G requests, including consultant supervision of staff undertaking this work?

• How does your organisation monitor the responsiveness of specialties to A&G requests and the quality of information shared to provide oversight of the safety and effectiveness of these processes?