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At first glance, the NHS system used by patients to book hospital appointments - the e-Referral Service - is just a small part of the complex IT picture within the health service.

However the NHS says it is a “vital” part of plans for a ‘paperless NHS’ by 2018, announced by health secretary Jeremy Hunt two years ago.

The service went live in June as a direct successor to the ‘Choose and Book’ system launched in 2005, part of the (otherwise generally disastrous) National Programme for IT.

It crashed after just two days and was introduced with 33 ‘known issues’ including slow loading, glitches with functionality and problems displaying forms, NHS IT agency the Health and Social Care Information Centre admitted.

The system has since been taken fully offline several times, with more than two new software releases implemented aimed at fixing the functionality issues.

This is despite the fact launch was delayed for seven months in October 2014, a mere month before the system was supposed to go live, after it failed on 11 out of 26 criteria during a Government Digital Service assessment in July 2014.

In theory this was to give the team time to “carry out significant additional work”. During that period they did a “huge amount of testing”, according to HSCIC.

The lead supplier on the programme, BJSS, has been working on building the system since it won the contract in February 2012, but has refused – or perhaps been unable due to contract terms - to comment on the glitches. [You might also like: What is microservices?]

Why do problems with the system matter?

In short, the NHS needs the e-Referral Service to work in order to become ‘fully digitised’, as Hunt promised back in 2013.

Choose and Book was used by about 40,000 patients every day to book hospital appointments online, although another 40,000 still chose to rely on paper-based referrals, NHS England’s technology director Beverly Bryant said in July 2013.

The NHS hopes e-Referrals will encourage patients to book appointments online and better integrate with other parts of the health service, including GP and hospital systems.

The HSCIC says paper referrals are expensive, outdated and labour intensive.

They add to existing problems with long NHS waiting lists and there is plenty of evidence they put patients’ lives at risk far more than electronic referrals–NHS Wales’ Informatics Service estimates as many as 13,000 paper referrals go missing every year.

It is not mandatory to use the e-Referrals service, but the NHS hopes it will be so much more user-friendly than its predecessor that patients will opt to use it instead of paper to book appointments, allowing the entire referrals process to take place online.

That is why the problems with the service are so worrying: their knock-on effect on wider plans to digitise the NHS, which evidence suggests will cut costs, help to improve care and save lives.

A history of glitches 

Choose and Book – now the e-Referral Service - has a chequered past. Although the NHS likes to quote the statistic that it has been used by 40 million patients, implementation from 2005 was repeatedly delayed and there were technical glitches throughout.

The problems were partly within the system itself, built by Atos, and partly as it depended on other components of the National Programme for IT.

The national programme aimed to move the NHS onto a single, central electronic care record but was cancelled in 2010 after costing £12 billion but delivering little functionality, according to the Public Accounts Committee.

It was the biggest government IT failure in UK history and did huge damage to the reputation of technology in the NHS. Senior NHS IT staff say the shadow it cast has made it harder to recruit IT staff even to this day.

Although Choose and Book did eventually launch and was used for about a decade until e-Referrals launched year, it has only ever been used by half of the potential population, according to the PAC.

Senior NHS IT bods promised they would take Choose and Book’s failures into account when building the new system, but in April 2014 the PAC said it was sceptical e-Referrals would be used any more fully.

It called for NHS England to develop clear plans for how it will build confidence in the new system and improve its use.

Unheeded warnings

Unfortunately it seems some of the concerns about the service went unheeded before it launched this year.

The vision for the e-Referral Service was sound: build it using open source software, thus allowing it to integrate with other clinical services more easily than its proprietary forerunner, and use Agile development techniques to make it more user-focused, with the understanding that would encourage adoption.

However some have questioned have far this happen in practice.

“E-Referrals has all the hallmarks of a system that has gone live too soon before known glitches have been resolved and proper beta testing,” said Tola Sargeant, director at analyst house TechMarketView.

“Given the history of Choose & Book and the issues with uptake (which had more to do with politics and process change than the system) it will be a huge shame if users’ early experiences of e-RS are negative,” she added.

Speaking to ComputerworldUK shortly after launch, NHS patients and information director Tim Kelsey dismissed the problems with e-Referrals as “relatively minor and being resolved”.

However he admitted the e- service is a vital component of the various systems that make up what he dubbed the NHS's "digital national infrastructure". 

Fast forward to today and problems with the system still have not gone away. Three new issues have been reported to the HSCIC since a new version of software was released last weekend on 7-8 August.

The centre has apologised ‘for any inconvenience that these issues will inevitably have caused’.

However, as Sargeant suggested, a major concern is the effect early negative experiences will have had on patients and GPs: they can hardly have helped to increase adoption, which is the ultimate goal.

As IT journalist Tony Collins put it, “GPs do not exist to be guinea pigs for testing and providing feedback on new national systems such as the e-Referral Service.”

NHS-watchers will keep a close eye on the system and will surely be hoping the fixes being implemented now will finally iron out the new system’s teething problems for once and for all.

The last thing the NHS needs - in terms of reputation, cost and most importantly patient safety - is yet another failing IT project. Unfortunately, as it stands, that is what they have got.

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