Every PCT to miss Choose and Book target

The Department of Health (DH) has admitted that not a single primary care trust in England is likely to be in a position to meet its next Choose and Book target and is relying on paper solutions to deliver its flagship policy on choice at referral.

Just over 6,000 bookings have been made through Choose and Book since the scheme was launched 14 months ago compared with the estimated annual number of new outpatient appointments of 9.4million.

An email seen by E-Health Insider Primary Care reveals that the department this month considered changing its incentive scheme as it became clear none of the 303 PCTs in England would meet its targets but decided the loss of credibility in such a move would be unsustainable.

In the email to strategic health authorities (SHAs) Margaret Edwards, DH director of access,  writes: “I have decided that we should leave the second Choose and Book incentive payment unchanged. Whilst this means it is unlikely to be achieved by any PCT changing it would I think be more damaging.”

She adds: “We would have to significantly reduce the threshold as well as extending the time period thus reducing any credibility for any future incentive payments/target.”

The incentive scheme offers a payment of £100,000 to PCTs who can show that 50% of referrals in October for first outpatient appointments have been made through Choose and Book. In rough terms that would mean around 400,000 referrals going through Choose and Book in just one month compared to the total achieved for the last 14 months of 6,103.

Edwards says in her email that the capital funding that would have been paid to PCTs that met the target will be used to address the low take-up. She writes: “Until we have done some more work to understand what the real underlying problems are it is difficult to accurately estimate a realistic new threshold and timescale. Hence we could change it [the incentive scheme] and still find we don’t deliver.”

A week earlier, on 14 September, Edwards wrote to all strategic health authority chief executives to outline the government’s contingency plans.

In the letter she says: “There will be patients that will need to be offered a choice of provider and booked through a ‘manual’ system. This letter sets out the action PCTs need to take for those practices which will not have fully implemented Choose and Book and will therefore need to deliver this PSA target ‘manually’.”

The letter includes a template which it suggests GPs can use to see the choices commissioned by their PCT and discuss them with patients. It says PCTs should supply GPs with outpatient waiting time information for each commissioned specialty at least once a month.

Dr Mike Dixon, chair of the NHS Alliance and a GP in Cullumpton, Devon, said he was not surprised that PCTs had been unable to meet the targets.

He told EHI Primary Care: “The hearts and minds of GPs haven’t been won when it comes to Choose and Book. Even if the actual mechanisms are sorted out its still hard to see where we are going to find the time to do it.”

Dr Dixon said he thought the government would move away from its emphasis on the importance of patients having a wide choice of provider.

He added: “We need some contestability in the system but choice has to be more subtle than having a menu of eight to ten providers. I think Choose and Book will be overtaken by practice based commissioning. If practices like mine who have a strong patient participation group can commission the services that people want there really is no need to choose and book.”

A range of difficulties has held back the widespread uptake of Choose and Book so far including lack of clinical engagement, delays in IT upgrades and technical problems.

Colin Bexley, director of IT for West Midlands SHA, writes in his report to the SHA board this month that local health communities in the West Midlands are being advised to work with only limited numbers of pilot GP practices until performance problems are resolved in order not to further jeopardise clinical engagement.

His report adds: “Nationally the level of bookings through the national Chose and Book solution remains low and intermittent performance and reliability problems continue.”

Last week EHI Primary Care asked all 28 SHAs in England to predict how many of their PCTs would be in a position to claim the incentive money at the end of next month.

Only one, Dorset and Somerset, said it expected its PCTs to be able to earn the incentive although GP representatives in Somerset questioned this claim.

Dr Harry Yoxall, secretary of Somerset LMC, said figures from a couple of weeks ago showed 13 referrals had so far been made in Somerset.

He added: “It’s the LMC’s view that we can’t recommend practices adopt Choose and Book until its fit for purpose and at the moment we don’t believe it is. Its up to individual practices to make their own decisions but referral is a critical part of the clinical process and most practices will not want to interfere with that until they are satisfied the alternative is better for patient care.”

Dr Yoxall said the LMC wanted to see a proper pilot in place before any further roll-out takes place.

Dr Peter Christian, a GP in Muswell Hill, London, who was the second GP in the country to make a booking using Choose and Book, said he thought the health department had very little chance of meetings its targets.

He told EHI Primary Care that he and his five partners had so far done about 100 referrals using Choose and Book, out of the 6100 completed nationally since last July. He estimates it takes ‘a few minutes’ out of each ten-minute consultation to complete a booking.

He added: “I remain positive about the principle of doing electronic booking and the feedback from patients who have been booked by Choose and Book has been very positive. However my concern is that it is not fast enough and that the people who have designed it and are keen for GPs to use it are not fully aware of the pragmatic realities of a GP’s working day.”

Dr Christian’s practice is in the process of having the integrated system for Choose and Book installed which means booking can be made direct from his GP system. Until now he been using the web based system for Choose and Book which means GPs must copy the patient’s NHS number by hand from their record, go on to the internet and manually insert the number before making the booking.

The added time involved in using the web based system has added to the difficulties PCTs have had in persuading GPs to use the system.

Sean Riddell, deputy managing director of GP computer system EMIS told EHI Primary Care that EMIS has so far installed the integrated version of Choose and Book in 350 sites out of its total of approximately 5200 practices in England. He said the company has also only so far received orders from PCTs across the country for 2,333 which means that PCTs have yet to even order the integrated Choose and Book system for more than half the EMIS practices in England.

A spokesman for iSOFT conformed that the company has now passed Connecting for Health conformance testing for its Choose and Book software.

He added: “Passing conformance testing is a significant milestone which will accelerate the deployment process. The majority of our engineering and training resources are involved in deployment and are working to complete deployment as quickly as possible.”

Delays in making hospital patient administration systems compliant for Choose and Book have also added to the problems.

The health department also faces further problems next year if Choose and Book is still not widely adopted as while a manual solution may be able to provide information for choice at referral for four or five providers it would be much more difficult to do so when the policy is extended to support the government’s policy of much wider choice from April 2006.

Links

Margaret Edward’s letter to SHAs