The NHS e-Referral Service (e-RS) is a flagship NHS system. It is used by over 1,100 NHS organisations and their patients to choose, book, and change over 75,000 referral appointment requests every working day, with over 50,000 services available to book.

The Challenge

When BJSS and NHS Digital originally built e-RS in 2015, to replace the previous Choose and Book system, the service was operated by dedicated computer, networking, and storage equipment. This meant that, in addition to the equipment used to provide the service, enhanced resilience was needed too. Spare equipment to automatically take over if something failed, in addition to dedicated data communication and environmental control equipment, was also required. While this dedicated structure made e-RS reliable and secure, it made it expensive to maintain and complex to manage.

However, with time, improvements to public cloud offerings became available. Cloud enables organisations to host their data remotely, rather than maintaining their own computing equipment. NHS Digital was keen to explore the viability of transferring e-RS to the cloud. It hoped that this would save taxpayer money and also support the NHS’ Internet First policy of providing access to digital systems by other providers such as dentists, optometrists, and pharmacies. BJSS, drawing upon its extensive experience in executing technology projects for the NHS, was entrusted with the task of assisting NHS Digital in their ambitions. This comprehensive migration, spanning across 18 environments, encompassed the transfer of a remarkable 235 million documents stored in a database, amounting to an impressive total data size of approximately 13 terabytes.

This led to the most significant and ambitious cloud migration undertaken by the NHS to date.

The Solution

BJSS' extensive cloud experience played a crucial role in selecting AWS as the cloud provider for e-RS and determining the most suitable services. An initial cross-functional team from BJSS and NHS Digital thoroughly assessed the feasibility of migrating e-RS to the cloud. These recommendations were independently reviewed by NHS Digital's Technical Review Group, who granted project approval.

This resulted in a joint BJSS and NHS Digital Delivery Team of 28 covering platform engineering, architecture, application development, functional and non-functional test, delivery management, business analysis, database administration, service management and operations.

They delivered:

  • The opportunity to realise significant cost savings from moving to a more flexible and resilient storage and management system
  • Improved ability to manage changes in demand and to understand system performance, providing more responsive support for users.

Throughout the migration process, BJSS employed FinOps principles to gain visibility into the NHS's cloud spending. The team implemented effective cost controls and took responsibility for monitoring costs at a granular level. This approach enabled them to assess the cost versus risk of migrating different workloads, facilitating prioritisation, and contributing to the overall success of the cloud migration.

The migration of e-RS to the cloud stands as a significant milestone in the NHS' digital transformation journey. While optimising costs, the service's performance has also seen substantial improvements. Leveraging 21 best-of-breed AWS cloud tools and services, e-RS was developed with scalability, availability, and durability at its core.

Given the sensitivity of medical data and personally identifiable information, robust security measures were meticulously implemented during the migration process. The service now benefits from enhanced security, including sophisticated and regularly updated protection and firewalling measures.

The Outcomes

Moving to the cloud has resulted in e-RS achieving significant performance, security, and cost-saving improvements.

Handling outpatient hospital appointments, e-RS provides real-time information about available services and clinicians. After the migration e-RS served 85,000 active users with 400 dynamic weight web pages a second. At peak load, 20,000 patient units can now be accommodated. The service has largely replaced paper-based referrals, slashing the time to process a referral by 75 percent and reducing missed appointments by half.

The National Audit Office (NAO) estimates that these improvements are saving secondary care providers over £50.5m every year. These long-term cost savings will enable the NHS team to continue to enhance the e-RS service, instead of managing spiralling costs. In turn, it improved the resilience and quality of the service. The migration also enabled the integration of NHS apps and improved management of referrals while reducing its carbon footprint.

Through BJSS’ support, NHS Digital has delivered its first major cloud migration and has created a system that will make the health service more connected and efficient than ever before. Above all, the successful migration to the cloud has produced real benefits that have improved the lives of NHS patients.

“There is a wealth of benefits that come from moving large systems like e-RS to the cloud. Costs are lowered, reducing pressure on the public purse, there is better security and reliability, as well as greater flexibility, performance, scalability, and availability, to name a few.”

Neil Bennett, Director of Services, NHS Digital