Electronic Eyecare Referral Systems in England

Electronic Eyecare Referral Systems in England (EeRS) - Frequently Asked Questions

Prepared by the Optical Sector Information and IT Committee in partnership with NHSX and NHS England. Issued 8 November 2021.

These FAQs are for the information of practice owners, practitioners and systems suppliers in England. They will be updated as implementation progresses.

EeRS in brief

1. What is EeRS?

EeRS stands for Electronic eyecare Referral System. This is shorthand for a secure, electronic system for the two-way transfer of patient and clinical data (including images) between eye care services (and with GPs).

2. Why and how is EeRS being commissioned?

The NHS Long Term Plan made it a clear priority to reduce avoidable outpatient attendances in specialities like ophthalmology. NHS England’s National Eye Care Recovery and Transformation Programme (NECRTP), which includes EeRS, is intended to deliver this and other goals in the NHS Long Term Plan.

A reliable and efficient IT connectivity system is the key enabler if the NHS is to achieve its goals. NHSX worked with NHS regions to commission EeRS using a Dynamic Purchasing System (DPS – see ‘Background’ section at the end of this document) in late 2020-21.

EeRS has now also been added to the NHS England’s 2021-22 planning guidance as a key deliverable.

3. How will EeRS benefit patients, the NHS, practitioners and practices?

Optical practices have long championed the introduction of electronic referrals to secondary care to improve patient safety and facilitate other improvements in the way optometrists and dispensing opticians work with hospital colleagues. These include supporting the development of advice and guidance (both real-time and phased), feedback, shared care, discharge to primary care and supporting extended primary eye care services.

The goal of EeRS is to support patients being treated in the right place, by the right service, at the right time in line with Right Care, Getting It Right First Time (GIRFT) and Optometry First principles (see ‘Background’ section at the end of this document). This will ensure that:

• patients will only have to visit a hospital when clinically necessary, with more care being provided closer to home
• the NHS will be able to deliver eye care more efficiently and effectively, maximising use of all available capacity and sharing large data files such as OCT for the benefit of patients
• communications between primary and secondary care will improve, potentially including building multidisciplinary networks, greater collaboration between colleagues, enhancing skills, and extending primary eye care services for patients

Technical aspects/funding

4. What referrals are covered?

Local EeRS system may vary but, ideally, EeRS should cover all eye care referrals made within the NHS:

• following a sight test (GOS or self-funded)
  • from an extended primary eye care service such as CUES, glaucoma enhanced case finding and so on
  • from a triage or diagnostic hub system
  • from the hospital eye service (HES) to an optical practice
  • to or from a GP.

5. How is EeRS being funded?

Initial funding of £8.5m was provided by NHSX via NHS England regions to fund the DPS contracts.

6. What is being funded and for how long?

The initial project consists of one year’s transformation funding from NHSX. Subsequent funding will depend on the success of the implementation and the impact on patient care and eye care services. The initial funding was made up of £7m revenue (running costs) and £1.5m capital (physical facilities and hardware) which was passed to NHS England regions to fund contracts for EeRS from the DPS list of approved suppliers.

The funding was made available in the financial year 2020-21 but the DPS will run from January 2021 to November 2024.

Suppliers which meet the criteria can join the suppliers list at any time and bid to NHS England regions for EeRS contracts.

7. Who will receive the funding?

Suppliers who are awarded contracts will receive the funding depending on what they have been contracted to provide, for what period and the contract price.

8. Is any other funding being negotiated?

The Optometric Fees Negotiating Committee (OFNC) has raised with NHS England how the mobilisation and ongoing costs of EeRS are to be funded, with discussions ongoing.

9. Why are there seven regional systems rather than a single national EeRS system?

Attempts at procuring national NHS IT systems in England have been unsuccessful in the past, so current NHS thinking is that IT systems procured and managed regionally are more likely to meet local needs and hence more likely to succeed. This means that each of the seven NHS England regions’ ‘proof of concept’ sites may have slightly different local requirements on top of the core functionality required from all suppliers to be on the DPS-approved list.

The potential disadvantage of this model is increased development and ongoing costs of running multiple systems, especially for primary care providers who often have patients who live and work across traditional NHS boundaries. To mitigate this, NHSX has worked with the sector to develop a common first stage application programming interface (API) solution (see FAQ 19).

10. What exactly have EeRS suppliers been commissioned to provide?

EeRS suppliers have been commissioned specifically to provide an EeRS system which links primary eye care with the hospital ophthalmology and GP systems.

However, the DPS regional procurement means that no two contracts are alike – for instance, some are ‘all to all’ and some are more restricted.

The contract specifications are public documents and can be requested from your Regional Lead.

11. Which system suppliers will provide the services in which areas?

An up-to-date list of the approved EeRS suppliers is available via the NHSX website at Dynamic Purchasing System (DPS) for EeRS. EeRS suppliers who have won contracts for ‘proof of concept’ or wider mobilisation to date are

• Primary Eye Care Services
• Monmedical
• Vantage
• EMMS

12. Who is leading the project and who is responsible for its success?

NHS England and NHS Improvement are responsible for delivering the National Eye Care Recovery and Transformation Programme (NECRTP). This includes EeRS in conjunction with NHSX. NHS England Regions have a leading role in EeRS adoption alongside their Integrated Care Systems and CCGs.

13. Ophthalmology departments have many different IT systems. Will they be able to receive e-communications via EeRS and will ophthalmology colleagues be able to access agreed data and images easily?

This is a challenge as there are over 170 ophthalmology departments with different IT configurations. NHSX has developed best practice models for hospitals including how to import referral data via EeRS and is holding monthly secondary care technical forums to address issues and concerns. At the same time the ‘proof of concept’ sites are working with local Trusts in support of local implementation.

14. Given the inherent complexity of implementing IT projects within the NHS, what reassurance is there that this project will come to fruition according to specified timescales?

There are strong drivers to ensure NHS leadership commits to its promise to deliver IT connectivity, including:

• the acute need to address capacity challenges in hospital eye services
• the growing need for eye care services linked to the ageing population and advances in technology
• impetus through the original National Outpatient Transformation Programme, Getting It Right First Time (GIRFT) and now the National Eye Care Recovery and Transformation Programme (NECRTP)
• political commitment from Government and strong backing from ministers for digital solutions to improving eye care.

To support this programme of work and reduce the risk of non-delivery, NHS regional delivery teams are working with all interested local Patient Management System/Software (PMS) providers in a collaborative way. Contractors are advised to engage with their LOC or national representative body to understand the implementation timetable for their area and whether it is covered by an EeRS contract in the current year.

What contractors/practitioners can do to prepare

15. What is the implementation timetable for each area?

Please contact your NHS England Regional Lead for the latest implementation timetable for your region.

16. What and where are early adopter sites?

The early adopter sites are where CCGs (ICSs from April 2022) have let contracts to DPS suppliers to deliver ‘proof of concept’ EeRS systems working with local optical practices and hospitals. These are currently:

Region                                       Site

London                          Mid Central London

East of England         Mid & South Essex; Cambridge & Peterborough

South East                   Oxford University Hospitals

South West                 Somerset CCG

Two of the three remaining Regions are expected to have concluded procurement and rapid adoption in November 2021. The third region (Midlands) has indicated that procurement with take place during early 2022.

17. What further support is available for local systems?

There are three main areas where EeRS is providing support to ICSs

1. Implementing business change: NHSX has commissioned NHS Digital to provide business change expertise to each NHS England and NHS Improvement region and the associated ICSs. These digital change experts will be actively working with local systems, including Local Optical Committees and Local Eye Health Networks (where they are in place) to ensure EeRS is implemented smoothly, based on local requirements and commissioned pathways. This supplements existing local resources and the capability delivered by the EeRS system suppliers.
2. Technical architecture and standards: NHSX has commissioned NHS Digital to deliver an information standard for referrals in eye care. This will support the routine processing of clinical data between practice management systems used in optical practices and referral management and image sharing systems. As electronic referral management and image sharing mature, NHS Digital will develop and refine the standard to meet any further integration requirements that emerge.
3. Integrated primary care offer: The National Eye Care Recovery and Transformation programme is leading on the definition of an integrated primary care offer which uses an ‘Optometry First’ operating model for eye care. EeRS will deliver two of the core digital capabilities (a national API and secure transfer of referrals and images) required to support this integrated primary care vision. Clinical services require commissioning arrangements to be agreed locally.

18. What should I do if I want to be an early adopter?

If you are in an early adopter area, please contact your LOC. If not, please consult your LOC, Regional EeRS lead who will know the regional timetable, national representative body or PMS provider.

19. Will this create extra work/costs for me/my practice?

Yes. That is why OFNC is seeking to agree with NHS England how the costs and benefits at practice level might best be assessed and funded. Please see FAQs 8, and 19.

20. Will the EeRS systems work alongside my existing practice management system (PMS)?

This was a key issue raised by the national optical bodies when the DPS was first announced. NHSX is working hard (including consulting with PMS and EeRS providers) on a national first stage API solution to ensure compatibility with PMSs. PMS providers are encouraged to enable the national API for their users. Practices without a PMS system will still be able to use the EeRS system, provided they have Internet connection, by entering referral information manually.

21. Will I have to re-key key patient information into a separate new system to make a referral?

The sector and NHSX agree we need to avoid this scenario. That is why NHSX has developed and tested an API solution to pull as much data as possible from the practice PMS to auto-populate the EeRS system. PMS providers are encouraged to enable the national API for their users.

22. Will I be able to use the system to refer to another ophthalmic practitioner in primary care?

This is the optimal end goal, allowing unnecessary referrals to hospitals to be avoided and to maximise use of resources. NHSX and the sector will continue to work towards this goal, although the actual specification will depend on which EeRS and extended primary care services are commissioned at local level.

23. Will EeRS systems mean that I need to change my methods or frequency of referral, or place my current referral practice under scrutiny?

No, this new system should not be used for this purpose.

Optometrists, ophthalmic medical practitioners and dispensing opticians have a legal duty to refer if, in their clinical judgement, a referral is appropriate (Opticians Act 1989 as amended). This is no more amenable to NHS ‘performance management’ than professional judgements in any other area of clinical practice.

Every referral is unique and depends on the patient, their history, presenting symptoms, the experience of the practitioner, the availability of advice and guidance and assessment of risk. The patient’s interests, based on the advice and judgement of the clinician, must always come first (see GOC standards and College of Optometrists professional guidance Sections C189 and C2).

On the other hand, clinical governance should apply as it does now. This means that, if reflective practice, audit or professional feedback suggest an area for attention, this should be addressed through education, professional support from clinical colleagues and personal CPD.

24. Will EeRS affect what is commissioned in the future?

EeRS is intended as a key enabler to deliver more eye care in primary care settings and improve communications between primary and secondary care.

In time, as we build data and systems around EeRS and IT connectivity rolls out, it will become clearer which services ought to be commissioned from primary eye care, and which from hospitals, to best meet local eye health needs. Commissioning along the pathway should also facilitate early hospital discharge and patient initiated follow up (PIFU) using electronic communication. There are many public benefits to be gained in terms of better public health outcomes, better services for patients closer to home and more efficient use of NHS capacity.

25. What training will be available and how can I access it?

All EeRS suppliers have been contracted to provide set up training or familiarisation sessions with the technology for each practice for which the NHS has purchased a licence. This training will typically be online and accessed differently depending on where you are based. Please contact your EeRS supplier for details.

26. I work as a locum: will I be able to use the system?

You should have access to EeRS via the system in the practice(s) in which you are working, in the same way as employed optometrists and dispensing opticians. As currently, practices should welcome and facilitate locums including sharing details of local referral protocols and following up on patients they have referred when they were working in the practice, as part of good clinical governance.

27. I work in domiciliary practice: will I be able to use the system?

Yes. Domiciliary providers should have the same access to EeRS as fixed practice providers.

28. What will happen in areas of poor broadband IT connectivity?

Where broadband is non-existent, this will be an issue. However, where there is simply a temporary breakdown, the aim is for all systems to have a ‘holding facility’, which will allow referrals to be stored and sent securely when IT connectivity is restored.

29. How can I keep up to date with what is happening in my area?

Your LOC will be aware of what is happening locally and how you can get involved. Equally, your national representative body or PMS provider will be involved through the Information and IT Committee and will be able to help.

Background FAQs

What is NHSX?

NHSX is a joint unit of NHS England and the Department of Health and Social Care set up in 2019 to support local NHS and care organisations digitise services – the ‘X’ stands for ‘user experience’. It has powers to negotiate national contracts, design technical architectures across health and social care and to set national policy to deliver change. (Source NHSX)

What is the difference in roles between NHSX and NHS Digital, NHS England and NHS Improvement?

NHS Digital is the working name of the Health and Social Care Information Centre set up in 2013 as the national provider of information, data and IT systems for the NHS and care system in England. It can be commissioned to deliver various services by NHSX.

NHS England is the working name (since 2013) of the NHS Commissioning Board set up to run NHS commissioning under the Health and Social Care Act 2012 (the so-called ‘Lansley Reforms’ which also established CCGs).

NHS Improvement is the parallel body (originally set up as Monitor in 2004) to oversee the financial functioning of NHS Foundation Trusts and NHS Trusts.

NHS England and NHS Improvement have worked together as a single organisation since 2019 and are planned to merge under new legislation in the Health and Care Bill 2021 currently going through Parliament.

What does DPS mean?

A Dynamic Purchasing System (DPS) is an ‘open market’ system, recently embraced by government, for contracting for works, services and goods. It offers buyers access to a pool of pre-qualified suppliers from whom they can contract for works, services and goods. Unlike a traditional supplies framework, it is dynamic in that any supplier, which meets the qualification criteria, can join at any time. (Source Crowncommercial.gov.uk)

What is an API?

API stands for Application Programming Interface. This software allows applications to ‘talk to each other’ – for example your practice management system would be able to ‘talk to’ the EeRS system and the EeRS system could then ‘talk to’ the HES IT system, all allowing agreed data to be transferred between primary and secondary care without double keying.

What is the National Eye Care Recovery and Transformation Programme (NECRTP)?

The National Eye Care Recovery and Transformation Programme (NECRTP) is part of the wider NHS pathway improvement programme which brings together Getting It Right First Time (GIRFT) and National Outpatient Transformation (NOPT), along with other improvement programmes (see below), including digital transformation, to concentrate improvement resources on three specialties

• eye care/ophthalmology
• cardiology/cardiac services
• MSK/orthopaedics

The NECRTP works with the following national improvement programmes:

National Outpatient Transformation Programme which is tasked with transforming outpatient services. As part of the NHS Long Term Plan, up to a third of the face to face appointments delivered in outpatient care will be avoided by embracing technology and arranging services around patients’ lives. This work also plays a significant role in supporting the recovery of hospital services in response to the COVID-19 pandemic.

Getting It Right First Time (GIRFT) which is designed to improve medical care within the NHS by reducing unwarranted variations. GIRFT’s focus is within hospitals, where clinically-led reviews of specialties, including ophthalmology, combine data analysis with the senior clinical input to examine how things are currently done and how they could be improved.

RightCare which is about patients seeing the right clinician, in the right place at the right time to optimise outcomes and use of NHS resources. NHS RightCare focuses on systems and, using a data-driven evidence base, reviews indicative data to identify opportunities to reduce unwarranted variation and improve population healthcare. The RightCare team consider information from across patient pathways to identify the greatest potential improvements in outcomes and spend.

What is Optometry First?

Optometry First is an innovative ‘first contact’ primary care service model, building on established pathways, which delivers a wide spectrum of care in optical practices, from ‘first contact’ to long-term management of eye condition, for the benefit of patients and communities without the need for hospital visits. The aims are to optimise use of the existing primary eye care workforce, equipment and facilities to improve the efficiency and accuracy of case-finding, reduce hospital attendances and improve the patient experience.

What is the Information and IT Committee?

The Information and IT Committee is a joint committee of the national optical representative bodies, providing an inclusive forum for anyone in the UK optical sector who has an interest in IT, information, uses of information, data ownership, data security, data standards and systems. It helps the national bodies and the sector in its collective parts formulate strategy and policy. It is currently chaired jointly by Max Halford (ABDO) and Peter Hampson (AOP) with FODO providing the secretariat (David Hewlett, Alan Tinger, Damian Testa, Sue Silvester).