Brought to book

Dr Mark Davies
GP Clinical Lead, Choose & Book

This is the tale of a recent development in the NHS.

In the autumn of 2004 a new service was introduced in a small number of NHS communities in parts of London and the north-east of England that set out to improve the experience of patients referred by their GP to a consultant.

This service has evolved as a result of several stages of NHS testing and consultation, which took the form of 600 meetings, seminars and working sessions with GPs, consultants and others in 2003 and 2004 alone. Over this time over 2,000 ‘coal-face’ clinicians have been involved in the design of the product. It uses standards of technology and information governance that are far higher than anything implemented in the NHS before.

In the last few months, people who have actually been using this service – particularly the doctors – have become firm enthusiasts. There is a growing list of health communities keen to adopt it as soon as possible.

Judging by some views in the media, you wouldn’t think I was talking about Choose and Book would you?

But this is the reality. And for every GP and other commentator who has written Choose and Book off in the press (most of whom, to my knowledge, have not actually used the system), I can show you plenty who know it and like it. There are many clinicians who don’t fully understand what it’s all about and there are many myths building up about it. This is the inevitable consequence of something that has become highly politicised and yet many have yet to actually see it.

The National Programme recognises that the NAO report into Choice at the Point of Referral published in January highlighted concerns about clinical engagement and that this was widely reported at the time, but that aside, we are getting positive feedback from those clinicians using the system.

So why all the effort and expense?

Flawed current system

"It’s about using the power of technology to improve how we do things" — Dr Mark Davies, clinical lead for Choose and Book, NPfIT

I hope I don’t need to persuade readers of the flaws of the current paper-based referral and booking process. Can anyone really claim it is anything other than archaic, inefficient and risky, not to mention a real pain for patients? It may have been appropriate for 1948 but it’s well overdue for a rethink.

I have yet to see a rational argument for why my patients have to wait up to 15 weeks for confirmation of a hospital appointment where they have had no say in when or where it is. It is like telling your travel agent you want a holiday, then having to wait an unspecified period of time before being told where the system has decided to send you – and when.

This wouldn’t be acceptable for a holiday so why do we accept it for our patients who may well be in pain or anxious? I fail to understand some of my colleagues’ eagerness to defend this state of affairs.

Under Choose and Book, patients can choose where and when they are seen by a specialist. They can either work this out there and then (either with the GP or one of the practice staff such as the receptionist), or, as is happening most often, they can call the Choose and Book Appointments Helpline after leaving the surgery (either immediately or after consultation with family, carers or colleagues).

It’s not about ‘doing what we do now’ electronically, but rather using the power of technology to improve how we do things.

System benefits

"Patients love it and this is a clear message coming out of the earlier adopters" — Dr Mark Davies

The benefits of the system to both patients and the NHS are many and some of them are listed below. But what do those who are actually using the system highlight?

Firstly (and despite all sorts of claims to the contrary) it is clear that using the service takes far less time than has been feared In my experience of the Choose and Book software to generate an appointment won’t add significantly to a consultation. The software itself is very quick. GPs don’t need to do the booking in the consultation. GPs can choose whether to have the discussion about which hospital to refer to or to allow the patient to consult with practice colleagues or the Appointments Helpline. The choice conversation can happen with someone else other than the GP.

Secondly, experience to date indicate huge drops in Did Not Attend rates (DNAs) – hardly surprising given that patients have actually had a say in when to go along. The service also improves clinical safety by ensuring a referral never gets lost. The National Electronic Booking Pilots in 2002-2003 showed that in South East London, offering patients a choice of date and time for their first out patient appointment led to a 47% reduction in DNAs. I believe Choose and Book will have a similar impact on a national basis.

Thirdly, Choose and Book includes tools to ensure the right patients get to see the right consultants, and it also allows GPs to discuss cases electronically with consultants in hospitals, often helping to ensure that patients do actually need a referral and if so are booked into the correct clinic.

Fourthly – and perhaps most importantly – patients love it and this is a clear message coming out of the earlier adopters. Even at this stage we can see the experience of patients referred to secondary care changing radically, and I have no doubt that we will soon wonder why we didn’t do this years ago.

Challenge

In the longer term, surgeries will see the benefits of not having to deal with patients making follow up appointments or phone calls to find out what has happened to their referral, and staff will have to spend far less time chasing up appointments as they will be able to track referrals through the referral pathways and generate a work list to avoid lost letters.

We have always known, and said, that the national roll-out of Choose and Book will be a challenge; but as we stand right now we have a system that works and that is delivering real benefits in early adopter sites. The benefits of a successful roll-out will far outweigh the relative inconvenience that change inevitably causes to working practices in the short term.

I would ask those working in the NHS to look at it for themselves and make a judgement about whether this makes sense for our patients. I will leave you with a recent quote from one of the few commentators on the service who actually knows about it.  A Barnsley GP who is an early adopter, said: "My message to GPs and practices is to try the system. It will take investment and time to get it right but the benefits will be worth it in the long term."

Dr Mark Davies
GP Clinical Lead, Choose & Book
National Programme for IT

Related links

National Programme for IT