A big rise in GP referrals being deferred because no appointment slots are available, in the wake of the covid pandemic, has sparked concerns that patients are going undiagnosed and missing out on the correct treatment.

Outpatient referrals are typically classed as having an “appointment slot issue” (ASI) when no booking slot is available within a timeframe specified by the provider, under the NHS e-referral system.

The latest NHS Digital figures, show the number of ASIs was 52 per cent higher in March 2022 than February 2020 — up from 245,582 to 374,209. This is the latest publicly available data. They appear to have continued to rise further since January (see chart below for the trend over the past two years).

The statistics suggest ASIs accounted for 77 per cent of all bookings in March 2022, 26 per cent of all referrals and 19 per cent of bookings and referrals combined. In February 2020, this was 32 per cent, 17 per cent and 11 per cent respectively.

The Royal College of GPs said there was a risk of patients “simply disappearing” off lists if the issue was not properly managed, while charity Patient Safety Learning said the issue was a “growing problem” which NHS England must “urgently investigate”.

The most common reason for a clinic appointment not being available on the e-RS is that organisations have not made enough appointment slots available, according to NHS Digital.

When an ASI occurs, it appears on an NHS provider’s ASI worklist, until it can contact the patient to arrange the appointment. However, referrals are automatically removed from worklists after 180 days if no action is taken by the trust. This feature – unless the risk is properly mitigated – can lead to patients being ejected from the system with neither the GP nor the provider aware of their treatment status.


Patient Safety Learning chief executive Helen Hughes said: “NHS England needs to urgently investigate, quantify the scale of the problem and take action if we are to prevent these capacity problems resulting in avoidable harm for patients.

“Patients who cannot access outpatient services may deteriorate further while they wait for care, and it is not clear that in these cases there is the appropriate support available for them. There is also the potential for patients to be misdiagnosed and receive inappropriate treatment without specialist involvement, and the potential of a postcode lottery of care emerging for some conditions.”

RCGP vice chair Gary Howsam said any system that automatically removed people from a list must have “fail safe measures” to flag when patients are going to be removed “so they don’t simply disappear off the list without the GP and patient knowing, as this creates anxiety and clinical risk”.

He added: “Where patients are on an extended list, as we are increasingly seeing as a result of the backlogs caused by the pandemic, those patient lists need to be actively managed to make sure patients are informed of their likely wait time and that any further delays are communicated.”

NHS England, however, played down the issue. It said in a statement that ASIs represented a “tiny” proportion of the overall number of referrals.

It added: “After two years of unprecedented pressure on all services, it is testament to our hardworking staff that the number of these issues remains tiny in the context of the millions of outpatient referrals booked each month, and all teams continue to work hard to ensure more appointments are available for those who need them as part of our elective recovery plan.”

Significant local variation
Around six trusts recorded at least 10 times as many ASIs as first outpatient bookings in the most recent period.

There is no rule around what represents a safe level, and the trust with the highest ASI proportion of first outpatient bookings — Sheffield Children’s Foundation Trust — said it had mitigations in place.

The trust said patients on the ASI list were “all added to our patient administration system (Careflow) and so we do not lose sight of referrals if they were to go over 180 days”.

Chief operating officer Craig Radford said the trust reduced the booking range in the e-RS in most specialties which meant referrals would result in an ASI; they were then booked by the trust outside e-RS.

He added in a statement: “We intentionally introduced this practice because during Covid restrictions, and after grading, many appointments were changed to virtual which created inconvenience for patients to cancel and reschedule appointments.

“Our services with new wait times of six weeks or less have now reverted to the normal bookable e-RS process, and we are working through transitioning all services back to this process.”

While there is no rule of what represents a safe ratio, the higher the ratio, the greater risk that is needed to be managed; and in 2017 NHS England set an objective for providers to reduce ASIs to a rate of just 4 per cent or less of their total outpatient activity.

There is significant variation at integrated care system level. One ICS said more patients are being held as ASIs until an appointment can be allocated because outpatient capacity is currently reduced due to issues including infection prevention control measures and staffing levels. Appointments are also being prioritised for patients who have been waiting for longer.

Several systems cited the impact of covid-19 on acute capacity, which they said led directly to ASIs increasing.

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