How end-to-end referral transformation takes shape in practice – launch of RIVIAM for Bath and North East Somerset, Swindon and Wiltshire (BSW)

Improving access is rarely just about putting a form online.

For trusts, ICBs and community providers, the greater challenge lies in establishing a referral pathway that functions effectively from initial contact through triage, coordination, and onward care.

That means joining up digital front door, referral management, Single Point of Access (SPoA), multi-agency approach and clinical systems in a way that makes sense for the people making referrals and the teams receiving them.

It also reflects the wider direction of travel set out in the Neighbourhood Health Framework, with its focus on more joined-up health and social care, stronger community services and access designed around people, place and population.

That is the context for our work with HCRG Care Group for BSW.

A practical example at scale

On 1 April, HCRG Care Group went live with a new digital front door for referrals across children’s and adult community services.

This is a significant programme. 

The launch covered eleven children’s community services across Bath and North East Somerset and Wiltshire, and twenty-one adult community services across Bath and North East Somerset, Swindon and Wiltshire (BSW).

It supports a wider transformation of care pathways across the entire area, serving a population of just under one million people.

For us, what matters is not simply the scale of the rollout, but what it shows in practice.

It demonstrates how a more joined-up referral model can be designed and delivered across multiple services, geographies and referrer types, while staying grounded in the reality of how services and teams work day to day.

You can also read HCRG Care Group’s press release on the milestone. 

“Our implementation for BSW shows what referral transformation looks like - a single, joined-up pathway from digital front door through to care co-ordination and delivery.

Delivered on time and at scale, through close co-design and partnership between RIVIAM and HCRG Care Group, it’s already making a real difference to how teams work and how nearly one million patients across BSW are supported.

We’re delighted to be helping lay the foundations for wider system change, including supporting Integrated Neighbourhood Teams and more effective team working and multi-agency care.”
 

~ Claire Hopkins, Delivery Director at RIVIAM Digital Care

More than digitising referrals

This is not just a forms project. 

The aim was to create a clearer route into services, improve the quality of information coming in, and support a more consistent referral process behind the scenes.

That included dynamic forms to guide people through the right pathway, Postbox functionality so additional information can be submitted after referral, and a single web entry point to support a more accessible, no-wrong-front-door experience.

But the real value sits behind the front end. 

It is in the way the pathway is structured on RIVIAM for the SPoA, how information moves, and how the referral model supports the operational process around it.

Provider teams manage referrals in RIVIAM as a live operational workflow. 

Referrals are automatically routed into pathways, steps and service lines on RIVIAM, teams can progress and reassign work as needed, open a single view of referral details and documents, record actions and outcomes into a timeline, work at a patient level across related referrals, and track flow using consistent statuses and reporting. 

What changed

Before this work, the referral landscape was fragmented, with different services using different routes and provider teams receiving information in inconsistent formats. That created avoidable follow up, delays at triage, and limited visibility of what was happening across services.

The new model creates a single, consistent digital front door across children’s and adult services, with structured routes for different needs, services and referrer types. 

For professionals, parents, carers and self-referrers, that means a clearer route into support and fewer points of confusion.

For provider teams, it means referrals arrive in a more usable, structured way, supporting more consistent handling and reducing the administrative burden of chasing missing information.

In the early stages, that shift shows up in practical ways: referrals arrive in a more consistent format, teams have a clearer queue to work from, and it becomes easier to see what is in progress and what needs action.

Spreadsheets and word documents are a thing of the past. 

How it integrates

Integration was an important part of the design for HCRG Care Group working with RIVIAM because referral transformation does not end when a form is submitted. It has to connect with the systems teams use every day to review, triage and act.

That will include direct integration with TPP SystmOne™ over the next few months so referral information can move into the operational workflow rather than sitting outside it. 

This will reduce duplication, support clearer visibility for teams, and helps the referral pathway function as one joined-up process rather than a series of disconnected steps.

How it stayed safe

For a programme like this, safety, information governance and operational fit have to be designed in from the outset. 

The reality is that trust and system leaders will not adopt a new route into services unless they can be confident it protects patients, supports good decision making, and stands up to scrutiny.

That meant agreeing the right governance upfront, shaping the model around live service requirements, and ensuring the right controls and auditability were in place for how information is captured, handled and accessed. The aim was to support safe triage and co-ordination, with the right information available at the right time, while maintaining appropriate oversight and accountability.

This includes building in auditability and clear role-based access, and aligning delivery with established clinical safety and information governance expectations for live services.

What it took – our Solution Model 

This was delivered through close collaboration and co-design with HCRG Care Group over a number of months, because pathways only work when they reflect how services operate day to day, and efficiencies and outcomes can be determined. 

We worked with operational and clinical stakeholders to define a Solution Model including referral journeys, and to design the routes and information requirements.

We also supported co-design with service users – building in feedback to ensure optimum usability and accessibility. 

Once we had implemented the solution in March 2026, we provided training and implementation support so teams could adopt the process with confidence and reduce disruption at go live.

From our perspective, this is the part that determines whether a programme succeeds. 

A referral pathway only creates value when people can use it well in practice and when it reduces work rather than shifting it elsewhere.

What you can expect if you are tackling this challenge

If you are dealing with fragmented routes, inconsistent referral quality and manual workarounds, an end-to-end approach typically focuses on three things: creating a single route in, improving the quality and structure of information at intake, and connecting that intake to the operational systems and teams responsible for triage and onward care.

There is a need to balance all the needs of different stakeholders – referrers, teams receiving and co-ordinating referrals and care delivery services acting on them. 

The practical outcome is not just a better experience for referrers. It is a pathway that is easier to run: fewer avoidable follow ups, more consistent handling, and clearer visibility of what is happening across services.

And the overall aim is to provide improved care for people, supporting prevention and better health outcomes. 

Improved system-wide working, including a multi-agency approach with VCSE 

This also creates a foundation for more optimum wider system working over time, because once referral intake is consistent and connected, it becomes much easier to evolve SPoA models, support neighbourhood-based care pathways, and strengthen co-ordination across organisational boundaries.

With RIVIAM’s multi-agency referral services, care co-ordination can be extended so HCRG Care Group can more easily work together with commissioned VCSE services across the area.

Why this matters

Many organisations are still trying to improve access while dealing with fragmented referral routes, disconnected systems and manual workarounds.

In that context, the challenge is rarely the form itself. It is whether the whole pathway works.

That is why end-to-end referral transformation matters. 

And it is why a digital front door only creates real value when it is connected to referral management, SPoA and the wider system behind it – including VCSE. 

What comes next

We are continuing to work with HCRG Care Group to deliver more of their wider transformation plan for BSW, building on this foundation to support the next stages of change.

So, this is not a one-off go live. 

It is part of an ongoing partnership, and we are excited to see what that will make possible next, and the outcomes that can be achieved.

Talk to us

If your organisation is rethinking digital front door, SPoA, referral management, multi-agency working and clinical system integration, we would be glad to talk.

You can book a demo by contacting us at [email protected].