Hi, I’m Tom Hallam, a user researcher working on the NHS e-Referral Service and NHS.uk based in Leeds at the Health and Social Care Information Centre (HSCIC). I would like to share our story of working on a new prototype that allows patients to book hospital outpatient appointments on their mobile devices.

It’s the next step in improving the NHS e-Referrals Service, which launched in June 2015 replacing Choose and Book. We’d like to make the NHS e-Referral Service as easy to use as possible, which means improving both usability and accessibility across different types of device but also changing behaviour around how clinicians manage referrals and patients interact with clinicians and the wider NHS.

Our discovery research

During discovery we explored the challenges preventing uptake of patients using the NHS e-Referrals Service patient web interface.

Currently the NHS e-Referrals Service can be used in three ways:

  1. Clinicians can refer and book appointments directly during or after a consultation.
  2. Patients can book by themselves by telephone, after their consultation and the clinician has created a referral.
  3. Patients can book online, after their consultation and the clinician has created a referral.

Seventy-nine million appointments have been made since Choose and Book launched in 2004, but only around 10% were booked by patients through the web interface.

The diagram below shows how the age groups being referred for the most appointments are least likely to use the online booking and more likely to rely on ‘enforced proxy’ (which means a clinician making the appointment for them). For younger age groups, a much higher proportion are already booking by the digital channel compared to telephone services.

This is a lead indicator that digital take up will be higher in future, as these younger age groups become older; however there is a need to accelerate this to reduce the costs to complete the millions of patient referrals and bookings to help tackle macro-level NHS issues.

Chart for blog post

Source: HSCIC systems data (first outpatient appointment on Choose and Book)

During the last four years the digital landscape has changed remarkably, and there has been a big growth in uptake of internet access and smartphones among those aged 55+.

Ofcom data reports that in 2015, 85% of people have internet access, 50% of those aged 55-64 have their own smartphone, and nationally, and 54% of all households have a tablet computer.

Convenience is key

Through research, patients tell us they need flexibility so that they can go to an appointment at a convenient time; they may alternatively want the first available appointment if they need to be seen urgently. These and other user needs have fed into our design considerations.

For those who do need to book a referral quickly, our research tells us we should simplify the journey to meet the needs of those people who want the first available appointment slot.

When comparing online booking to telephone booking services we have identified an information gap; when people call to arrange an appointment they are given more contextual information to help make their clinic choices.

Distance from home is displayed in the current online booking system, but information about parking and facilities such as cafes are not. Every patient will have specific personal criteria that determine how they make an ‘informed choice’.

Much of the information (and many of the indicators) that patients use to make decisions about where to have their appointment are already available online, but located across several different websites, making it harder for the user to navigate.

One hypothesis we are testing is that patients are not familiar with variability in NHS service ‘quality’, or the indicators on which hospitals are measured. While NHS Choices and transparency tools such as MyNHS provide lots of great information such as user ratings, CQC Ratings, and ‘referral to treatment times’, there is a big risk that including all this information in the booking interface would overwhelm patients with data. We are currently researching the top information priorities for the booking process and this will guide our next design iterations.

We identified that more relevant information could be introduced to users over time to reduce the burden of having to search for hospital data, making their comparison experience and choice simpler. We are collaborating with the NHS England Patient Choice Team and NHS Choices to map data flows between systems and solve integration challenges to enable this to happen.

Our Alpha prototype

At the start of our Alpha work we looked at booking services on GOV.UK and worked with a supplier of GDS-compliant booking services to develop a first prototype for testing our research to date. Based on the output of the testing, and following some new additions to our team at HSCIC (Tony, Ben, Zubeir and Tom), we created a new mobile-first prototype, built using the NHS.UK prototyping kit.

We have continued to collect insight from many sources, such as patient surveys and workshops, usability testing, pop-up testing, user experience mapping, and engagement with health and IT professionals through NHS e-Referrals and HSCIC events.

The insight has helped us to continually identify user needs and iterate the prototype. For example in early testing, users complained that the calendar views didn’t show enough available appointment slots, and desktop screens often contained information not suitable for mobile devices.

To resolve this we created a booking ‘happy path’, which is shown in the image below and includes the steps a user needs to go through – this includes confirming contact details with the Patient Demographic Service (PDS), which is part of the national SPINE infrastructure:

Image 2  

We also compared other commercial and health websites that quickly identify and present available ‘slots’ or appointments, including Give Blood:


These findings were helpful in evolving our thinking about displaying information to users. Instead of calendars with empty slots, our prototype should allow patients to see all appointments, with the earliest available displayed first.

The whole team paper-prototyped possible solutions. This meant we could try out lots of ideas quickly before any digital designs or code were created.

Through discussion and consolidating our designs we came up with a stripped-back style that allows users to filter and sort clinics so they can introduce as much or as little complexity as they need. We felt that “forcing choice” on all patients by asking them to use a wizard would be a burden for those wanting the first available appointment.

These are some of the screens showing our proposed clinic selection solution:

Image 4

We are using analytics on the existing service to iterate the prototype too. We understand our cost per transaction but our current position on completion rate identifies a gap we need to address while we iterate any new service that is deployed.

We are continually involving clinicians in our work, with a recent comment from a Chief Information Officer at a large acute trust commenting at the HSCIC Open Day in February:

One product stood out as an absolute gem in the way it used new technology to bring a well thought interface to the ever-increasing in numbers of user of small screen devices like smartphones and handheld devices.

What’s next?

Having completed significant research and design iterations we are optimistic that the interface design changes will improve the experience for users. We’ve planned further testing with users at several hospitals, to help us finalise our Alpha.

Further progress to beta and live service iteration is dependent on additional funding but we think there is a really good case to give patients a better experience, make them more aware of the choices they have and reduce costs, which both support reducing pressures across the wider NHS. Analytics would then continue to play a major role in monitoring the new interface to ensure drop off rates are low and information displayed to patients is continually optimised based on actual usage data.

There are other areas for us to explore that we have on our backlog, including: text and email reminders, follow-up appointments, and connecting new identity solutions to work alongside the NHS e-Referral Service.

Please try our latest prototype available at this link:


Of course please feedback below too – all comments are very much appreciated!

Thank you for reading.



  1. Comment from Dr Paul Thornton

    Dear Tom,

    If C&B is such a good idea, shouldn’t the priority be to make the existing service much faster so that many more referrals can be initiated by the GP with the patient in the consulting room as it was originally intended. Instead it is so slow and clunky that GP’s have given up using it.

    Where C&B is used it has become a back office function that is commonly additional to, or duplicating, the existing excellent GP software systems for rapidly generating and despatching referral letters to the service that the patient has already agreed, with GP advice, in the consultation.

    The graph you show above that shows “number of referrals by age” is only showing the referrals that are already arranged via choose and book.

    By comparison with the data here:

    which is linked off:

    It would appear that only about a third of new referrals are going through C&B. Is that correct?

    Could I also ask if you know what arrangements are being made for the sensitive patient information that has been sent via choose and book, to be deleted from the choose and book servers once the information has been successfully delivered to the destination provider unit that actually needs to hold that data? Why does the choose and book service need to retain that data?


    Dr Paul Thornton


Leave a comment