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A pain-free guide to choose and book

Dr Richard Vautrey puts Choose and Book in context and weighs up the pros and cons

Choose and Book (C&B) has had a troubled history. Although many practices are now using it routinely to make referrals, many more have found it frustrating to use, and others have made a positive decision not to use it. But the Government, from the Prime Minister down, remain committed to it.

To understand why there is such pressure behind the take-up of C&B we must understand the wider political context. The desire to see increased competition by having a number of different providers fighting it out is central to Government policy.

They believe, perhaps naively, that through greater competition, quality will improve and the price of provision will fall. What they see as professional monopolies will also be broken as a by-product.

In order for this new market to work, the consumer (what we quaintly used to call 'patients') must be able to have a choice. C&B was therefore designed to provide enough information for the consumer to be able to make a choice of hospital when a referral is made.

Politicians were also seduced by the ease with which a holiday could be booked in a travel agent. If it could be done there, then why would it not be possible to book a hospital appointment from a GP surgery?

That strong political agenda pushed for the introduction of C&B before the whole system could cope properly. This was exemplified by the setting of completely unrealistic targets, which only succeeded in undermining the credibility of C&B itself as well as the wider Connecting for Health programme.

The uptake of C&B remains quite patchy, with some areas achieving high utilisation while others show little sign of use. This makes the national average of 27 per cent of referrals going via C&B in September (compared with 3 per cent in December 2005) hard to interpret. What cannot be doubted is that the introduction of the C&B DES this year has encouraged many practices to give C&B a go, with the result that more and more bookings are now being made through C&B – now approaching 1.5 million.

The old way is not necessarily the best...

Many of us think of the traditional paper-based referral system as the gold standard. But it has many problems. With 30 or 40 steps involved, there is a lot of scope for error. It is also unsatisfactory for many patients who wait for months for notification from the hospital of an appointment date, following which there is invariably a call to the GP to see if their appointment could be expedited or changed.

The C&B system is generally quite easy to use. The referrer can do as little as inputting the specialty area required and then printing off the hospital options, together with the unique booking reference number and password for the patient to use later. The options from this point include the patient ringing a call centre to finalise the booking themselves or using other staff in the practice to complete the process.

Alternatively the GP, with the patient, could work through to the point of booking a clinic appointment while the patient is in the surgery. Undoubtedly patients are very appreciative if they leave the surgery with a clinic appointment date in their hand.

The referral letter is produced in the normal way except it is attached to the booking electronically at a later stage. It is a lot harder to lose track of letters using C&B compared with the paper system, and it is also possible to track the stage of individual referrals.

...but Choose and Book has its problems too

The disadvantages of C&B are only too familiar. There is clearly an increased workload – although this will vary depending on how much of the booking process is done in the practice. The integration with existing clinical systems is often poor (and in some cases hasn't yet been resolved) and this can slow the process down considerably.

The web-based system can be easier to use if a practice is having real problems. If the information on the system is poor, patients can be booked into the wrong clinic.

Many of the problems identified with C&B are more to do with changes in referral management being made by PCTs and hospital trusts. The introduction of referral management centres, demand management initiatives, generic referrals, lack of hospital capacity or funds to pay for increased capacity, waiting list targets and the widespread use of indirect booking are all working against GPs being able to refer their patients in a way we would want to see.

It means that even though the software might work, clinics are not available to book into, and so GPs and patients lose faith in the system.

These and other problems explain why the incentives in the C&B DES are not seen as enough by many practices to compensate them for the extra work and hassle involved.

But others have made serious attempts to make it work for them and are trying to achieve components of the DES. These practices will need to ensure they have procedures in place to monitor when it is not possible to use C&B for reasons beyond their control. They also need a clear statement from their PCT clarifying which referrals count towards the targets, and how the denominator will be calculated.

Richard Vautrey is a GP in Leeds and lead negotiator for GPC on Choose and Book

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