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Choose and Book in the spotlight as IT leader is grilled by GPs

You have responded to Pulse's campaign on IT by telling us about your frustrations in using Choose and Book in your own surgeries. Here, we put your concerns to Dr Mark Davies, clinical lead for Choose and Book at Connecting for Health and a GP in West Yorkshire

To what problem is Choose and Book the solution?
Dr Nick Davies, Halifax, West Yorkshire

Traditional paper-based referral remains largely unchanged since 1948. It involves 9.5 million letters flying around the NHS from organisation to organisation, and offers the patient little control or reassurance.

The NHS today is more complex than it used to be. As GPs, we need Choose and Book as a way of navigating the health service. With the system's Directory of Services, we have a searchable database of secondary care in England, with keyword functionality, for the first time.I would like to get back to the NHS when I started out in general practice, when GPs could refer patients wherever they wanted. Choose and Book is an important tool and will help us get there.

Why is Choose and Book so ridiculously expensive and cumbersome?
Dr Daniel Moore, Faversham, Kent

The NHS is one of the largest health care systems in the world and moving it from a paper-based to an electronic referral system was always going to be a big job.

It has involved integrating more than 30 different systems, requiring considerable financial investment. The cost of Choose and Book, by the end of January 2007, was £34.6m for central system development under a core contract with Atos Origin worth £64.5m over five years. A further £39.7m has been spent on additional services and functionality to be required as the system is rolled out. These costs are expected to total some £79.5m over the same period and are in budget.

There is a view that there are more important things for the NHS to spend money on. But although I sympathise, the NHS has historically under-invested in IT, spending 2% of its turnover, compared with 10 to15% at most large companies.

In cases where GPs are finding the system to be slow, the main reason is often due to local IT configuration. When configuration is correct, the speed of the system is not a barrier to its use.

Can you confirm appropriate consultations were made with patient groups, GPs and consultants before introducing the flawed system?
Dr Mark McCartney, Pensilva, Cornwall

Extensive clinician consultation took place on the Electronic Booking Service that would go on to become Choose and Book.

A total of 43 electronic booking pilots, involving a considerable number of trusts, were established in three waves during the early 2000s. The Yorkshire Institute for Clinical and Health Informatics undertook evaluation of these pilots and the benefits identified included:
• reduced administrative time at the practice and at the trust
• reduction in practice and trust staff time to follow up appointment queries
• reduction in postage and stationery costs
• fewer GP appointments by patients awaiting news of outpatient appointments
• reduction in inappropriate outpatient appointments
• reduction in DNAs
• reduced stress and frust-ration for patients and staff.

In spring 2002, electronic booking was piloted in Dorset, Greater Manchester, West Yorkshire and two areas of London. These pilots developed with the close co-operation of GPs and consultants – many of whom have remained actively involved in Choose and Book.Between early 2003 and the end of 2004, the NHS Modernisation Agency and the National Programme for IT held more than 600 meetings with NHS staff on electronic booking.

A key outcome of these consultations, which also involved close co-operation with the BMA, royal colleges and dozens of other stakeholders, was agreement that electronic booking would be crucial to allowing patients to book outpatient appointments.

Our patients don't want Choose and Book – they just want to go to a local hospital. How can you justify spending millions of pounds on a system that does not serve the interests of patients?
Dr John Leigh, Sunderland

Many patients do just want to go to their local hospital and that's a valid choice. Choose and Book supports them by securely and instantly transferring clinical referral details to hospital, and providing a range of channels to book or change appointments.

But if the local hospital doesn't fulfil the needs of patients, I want them to be able look at other options. And there are many other reasons for moving to electronic referral than just giving patients more hospital options.

We used to be able to choose any provider in the land. How is a choice of five hospitals a useful and cost-effective enhancement?
Dr Andrew Hammersley, Paignton, Devon

You're right. When I first qualified in the 1980s GPs used to be able to refer anywhere, albeit sometimes through some administrative hoops. We're moving to an NHS where not only can GPs refer to any provider in the country but patients are involved in those choices.

Patients already have a choice of a lot more than five providers and this will increase, taking us back to where we were but without the accompanying problems.

Why are some areas making use of Choose and Book compulsory and returning letters to specific consultants unanswered?
Dr Trefor Roscoe, Sheffield


t's not appropriate to start mandating Choose and Book be used for all referrals because there will always be some patients who may wish not to be referred electronically. A provider may only refuse to accept a referral on clinical grounds, or in accordance with the agreement of their commissioner – but I acknowledge running dual systems does cause problems for some hospitals.

In some locations, the system has been blamed for a number of things, including restricted choice either by not listing services by consultant or by removing services challenged by waiting time targets. We don't support these restrictive approaches but in a complex system such as the NHS it's inevitable the tools available may be used inappropriately – that doesn't mean the tool is wrong.

Why has Choose and Book been designed in a way that can prevent GPs from referring to the most appropriate consultant for a patient's problem? Am I paranoid to think this is deliberate?
Dr Melanie Wynne-Jones, Marple, Cheshire

You're not paranoid. There are good reasons why it is easier for trusts to manage pooled referrals rather than referrals to individual consultants – for example, in hitting waiting targets. This was a debate that pre-dated Choose and Book.

However, we recognise referral to a named clinician is needed in a number of circumstances for clinical or non-clinical reasons. The functionality to enable hospitals to make available slots for named clinicians has been available in Choose and Book since Release 2.0 in spring 2005, and the ability to support referrals to named clinicians was included in the original specification.

Whether the service is directly or indirectly bookable, the ability to make named clinician slots available is a decision for individual trusts. We recommend commissioners talk to all stakeholders to assess how the named clinician functionality should be used. Choose and Book should not be used to constrain the ability of a GP to refer some patients to a named clinician.

Why under Choose and Book are patients not allowed to wait longer to see someone locally? Why must they be forced to travel just to meet Government waiting time targets?
Dr Adam Pringle, Telford, Shropshire

We're not forcing patients to travel to meet targets. Patients can choose to wait longer if they are unable to commit to an appointment within current maximum waits or if they want to go to a local trust with no immediate appointments available.

Trusts will not be penalised if a patient decides to wait longer provided they have made two reasonable offers of appointment within the maximum waiting time period. Choice is about giving patients more options, not fewer.

Why did Connecting for Health not inform GPs patient information would be tapped off the Choose and Book messaging system and transferred to the Secondary Uses database where it can be accessed in identifiable form by people who are not involved in that person's clinical care?
Dr Paul Thornton, Kingsbury, Warwickshire

Information in the Secondary Uses Service is pseudonymised and not routinely accessible in a patient identifiable form. To this regard, patient consent is not required.

Access to the SUS is restricted to staff who have been registered and authorised.In cases where patient identifiable information must be made available – for example, in specific medical research studies – approval from the Patient Information Advisory Group must be sought. This approach has been agreed with the Information Commissioner.

Do you seriously believe 100% of referrals will ever be made through Choose and Book when large numbers of GPs and consultants refuse to use it?
Dr Neil Bhatia, Yateley, Hampshire

No. We never expected 100% of referrals to go through Choose and Book as there will always be exceptions, such as patients who don't feel comfortable with electronic referral.

But your view of the world isn't necessarily reflected in the facts. Some people will always be resistant to change but those numbers will get smaller.Use of Choose and Book is currently 40% but that figure hides 152 different PCT stories. There are several where utilisation is at 70, 80, even 90%, where Choose and Book is the usual method of referral. This illustrates that it works and adds real value to the referral processes.

Pulse sought questions for Dr Davies via Doctors.net.uk

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