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Choose and Book chaos as trusts cancel appointments

Exclusive: Overzealous hospital managers are routinely delaying or blocking Choose and Book referrals for administrative reasons, leaving GPs to deal with angry patients whose appointments have been cancelled, a Pulse investigation reveals.

Some practices are reporting up to 15 cancellations a day as hospital trusts increasingly insist that all referrals made through the controversial system are confirmed within three days.

And LMCs have also claimed that Choose and Book is listing ‘phantom’ slots when consultants are away or on holiday, and that GPs are not being told when appointments are cancelled.

Department of Health guidelines suggest Choose and Book appointments should be followed up with a GP referral letter within three days to ensure the appointment is ‘clinically appropriate’.

But Dr Philip Fielding, chair of Gloucestershire LMC, said ‘significant’ numbers of appointments were being cancelled without practices being informed, and ‘irate’ patients were chasing up their appointments.

He said: ‘A system designed to give greater choice and speedier referrals is being limited by bureaucracy and has disadvantaged patients.

‘The whole idea of Choose and Book is to plan ahead. For elderly patients, it has caused more delay and angst.’

He added that GPs were also booking patients into ‘phantom’ appointments that were later cancelled as the system could not tell when a consultant was due to be away.

Dr Andrew Mimnagh, chair of Sefton LMC, told Pulse local practices were experiencing ‘14 to 15’ cancellations a day, and booking of appointments when consultants were away was a particular problem.

Dr Manoj Pai, former chair of Coventry LMC, said practices in his area had also been hit: ‘We have referred and it has gone through and patients have been told to ring again because the appointment is not possible.’

Eric Gatling, director of service delivery at Gloucestershire Hospitals NHS Foundation Trust, said: ‘From September this year we have been taking a more robust approach to ensuring that patient appointments are confirmed by the GP within the three day period, in agreement with the PCT.’

Richard McCarthy, deputy director of performance at Southport and Ormskirk Hospital NHS Trust, said the trust ‘recognises there are shortcomings in the operation of the service on both sides’.

A spokesperson from University Hospitals Coventry and Warwickshire NHS Trust said: ‘The trust’s procedures ensure that all referrals to the trust are placed onto the patient administration system as soon as the trust receives them. The system is monitored by the patient access team to ensure all patients receive the care they need in a timely manner.’

The controversy comes at a crucial time for Choose and Book. GP usage has fallen to about 50% of referrals, but DH plans outlined in May revealed GPs may soon be forced to use Choose and Book or adopt ‘labour-intensive’ alternatives.

GPC negotiator Dr Chaand Nagpaul said: ‘It is unacceptable for patients to be penalised this way. There is no legal requirement for a letter to be received within three days.’

A DH spokesperson said national figures on cancellations were not collected: ‘We would expect local hospitals to take action so that appointments are not cancelled unnecessarily if there are any delays in receiving referral letters.’



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Readers' comments (24)

  • Could we have some numbers to back this up. How many cancellations are due to failures to supply referral letters and how many for other reasons.

    As someone with some knowledge of both good and bad hospital booking processes here is my view of what is going on. Tthe main "problem" is that local hospitals have started applying the rules to prevent appointments being cancelled much later because the referral letter has not been submitted. Other reasons are probably very real but minor compared to the issue of delays in sending referral letter. They look as though they are being used as a smoke screen .

    This is just my prejudiced take on the story as it currently stands. That is why I have suggested some more numbers would be useful.

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  • Two things - firstly this is irresponsible tabloid journalism - labelling the hospital manager 'over zealous' is the journalist acting as judge and jury - not professional and certainly not balanced. Whatever happened to the pursuit of truth?

    Secondly, a careful analysis of the story reveals that this is an example of the GP not following the correct CaB referral process, and then blaming the hospital for rejecting it. This is then followed by the usual over-egging of the GPs complaint by throwing in all sorts of other appointment issues.

    I agree with the previous poster - stick to the facts, and provide the evidence.

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  • This article is mis-guided. As an ex-Choose and Book Project Manager, I know first hand that happens on both primary and secondary care and sadly how the patients are caught up in the cross fire. When C&B was first launched a lot of areas worked with both primary and secondary care to ensure robust governance and operational framework was put in place to ensure best practice and improved patient quality. As with most NHS Projects, the next 'big thing' would come along and most areas disbanded the C&B teams and the enthusiasm and best practice was lost. As a result most hospitals appointments and referral letters from both stakeholders (GP's and hospitals) are misguided and mis managed, resulting in stories like this. If CCG's want to improve the situation, invest in people with significant experience to work with GP's, patients and the hospitals to improve C&B and make it work for the purpose it was designed and further more, make a case for continued investment and improvement. It can and could do so much more than it currently does.

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  • Vinci Ho

    There are clearly two factions here : pro C&B and anti C&B . While it is not quite professional to report news with a judgemental angle , it is also very important not to 'ignore' these cancellations . They are indeed happening everyday . GP referral letters is only one issue . It cannot be THE issue.
    Perhaps C&B is just a mean of transparency to show how difficult it has been for at least some hospitals to cope with their workloads . This is not new but is going to get worse with austerity measures. God bless......

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  • I am still a conscientous objector to choose and book and refer my patients by letter in the traditional way. This has caused my practice no problems whatsoever and saved me and my staff a lot of unnecessary and unresourced work and my patients a lot of hassle and anxiety.

    Come and join the non users.

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  • I'm moving away from C&B as the time goes - the connections are slower (?more users), doesn't always give me the right choice, some choices are unreasonably difficult to understand (breast, other 2ww is not a cancer referral but 2ww, breast is cancer referral).

    Worst of all, I'm forbidden to give choice by my CCG (or PCT as they were) - I'm told I shouldn't use the local private hospital even though they have contract with NHS and appear on C&B, I shouldn't refer to other trust as it costs more, I can't pick consultants by name as it make waiting too long in some areas etc etc. So what's the point - other than making GP work as free admin for secondary care of course.......

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  • Neil Bhatia

    I'm so glad I gave up using C&B many years ago. Won't use it again.

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  • My experience is that choose and book has always been chaotic. The only choice is for patients who don't care where they go, ie they don't want choice . Any that are specific about their requirements find their choice blocked.

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  • All of the comments above are not new and not surprising given the lack of ownership and direction of what has the potential of being a good system. I have seen if in the majority of cases work well, likewise I have seen poor experiences. Lets not forget, it's not so much the software that supports C&B that is the issue but the organisations which own and drive it. It is a health economy wide system and not one individual or organisation is to blame. Perhaps if all those so anti actually got involved with the solution then maybe it could be in a better state to be continually improved to move with the times, the patients and the GP's expectations and actually deliver something worth while. Lets be clear - I am not for nor am I against Choose and Book. I do however, think people forget that Project Managers are merely there to implement any given project; not be politically aligned to any view point.

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  • Vinci Ho

    Interesting comments
    More are welcome

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  • @Vinci Ho - Its a shame that C&B never got to fruitition in most areas and as such the batton gets dropped and people move onto the next "must do" project. Shame. People expect quick wins, don't invest in the long term or the bigger picture.
    What do you do? (if you don't mind me asking?) Thanks.

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  • In my area it is the GPs Secretaries who use the Choose & Book not divulging the passwords & numbers . I can't even get follow up appt s with a cardiologist who asked for next available appt & referral to the Rapid CHest Pain Clinic. . It is so bad am having to think of moving out of area as it appears to be the LA holding the purse strings directing through contract . Yes the ones who can't run parking ethically.

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  • There's been another reason for increased rejection rate for C&B appointments in my hospital recently: increased scrutiny of consultant to consultant referral rates (with attached penalties) has made us realise that many come from the wrong initial referral to C&B so we've been told to reject any that look as though they've been misdirected.

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  • C&B was set up initially without any reference to secondary care doctors; the problems they identified (and I was involved just before implementation) have never really been sorted. From the hospital perspective the software system depersonalises referrals, stops clinical prioritisation and wastes consultant time; when I discovered that it took ten times as long to diarise appointments I gave up looking at C&B (not least because in addition it was impossible to re-prioritise referrals that I judged urgent, but had come through as routine). Any administrative fiddling should be set against the background of the system, which allows choice largely on waiting time reduction when initial patient surveys confirmed that wait time was a low priority compared to seeing the right person at the right hospital. When there are hospitals close together patients end up seeing different specialists on different sites; the speed of appointment is far outweighed by the huge disadvantage of fragmentation of case notes. A quick appointment may end up in the wrong sub-specialty clinic (it's no good sending a hip patient to a hand surgeon). Lastly it was not uncommon for referrals to come with results added straight off GP systems; on one occasion there were 30 pages of them!

    There will always be gaming in systems. Rules will be obeyed to the letter, however stupid they may appear to clinicians, but I have seen no advantages to C&B whateverand the sooner it goes - given that it's as bad now as at its imposition - the better!

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  • As a GP who has used C&B since it started, I have seen it improve significantly. Only this week I had a patient with a non-urgent problem who told me he was prepared to travel to have his problem dealt with quickly. I logged into C&B, typed in his condition and found a routine appointment for him in only 10 days time. My local hospital is dreadful when it comes to having services on C&B, but luckily both my patients and I get to choose from lots of other really good hospitals (NHS and private) that really care about putting patients first. Cancelling appointments because a letter hasn't been added within a few days is not good patient care - working with GPs and commissioners to ensure that the process works for everyone - is good care. Come on everyone - lets put the past behind and make this really excellent system work for us all and especially for our patients.

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  • I would like a system where the GP writes a referal letter - hands it to the patient and the patient then takes over the process of finding a provider i.e. gets providers to bid for the work. Any bids below the national trarif the patients gets to share with the GP on a 50 /50 basis.

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  • I work in a primary care referral management centre where we use CAB for everything. In our part of the world we have made it easy for GPs to use the system because we handle the booking of appointments for them, offer choice to patients and deal with any rejections. CAB can work but you need to invest in this kind of system. In my experience the major cause of hospitals cancelling appointments is that they are furiously moving patients around to try and hit their 18 week RTT targets. Counter productive, not patient friendly at all and driven by central targets set by DH!

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  • I cant stand C&B. its very name is misleading. its slow, patients have a great difficulty to actually book an appt- repeatedly told to call back or simply cant get through, and most of the time we are not allowed to refer to a place where the pt chooses to go!. I have had pts in tears simply because they cant book the appt in the first place. I have had other patients who have been able to get an appt, but then recieve a letter that says the appt has been postponed, then recieve another letter to say the appt has now been cancelled and they need to be re-referred!! OUTRAGEOUS. i certainly would prefer paper referrals- but this is simply not allowed in a lot of cases, and you get letters back asking for a c&b referral.

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  • I am not sure where the problem lies. A recent problems with the local trust was that some clinics were only bookable when the trust felt that it had the capacity. I have been given the impression that the waiting times for a number of clinics are much longer. Urgent appointments tend not to be available on C&B.

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  • I agree with comments that it's hard to quantify the problem without accurate data!

    Choose and Book data feeds do contain this information - both cancellations and referral letter attachment come through as separate entries linked to the organisation performing the action. It should therefore be straightforward to identify which referrals are being cancelled by secondary care providers before the letter has been attached.

    Trusts may not know that their own Choose and Book data is available for them to download from the NHS Spine each month.

    We do this kind of thing regularly, let me know if I can help.

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  • My experience of Choose and Book was woeful at times. Try to book a 14yr old to any mental health related appointment and you will be lucky to see any available slots appear anywhere . Services that should be available are witheld from the system and the patient usually end up with hobsons choice or none at all. Fax referalls now are hit with ever more stringent qualifying criteria.
    There is no excuse for not supplying a referal letter at the time of creating a CaB request other than laziness.
    In any case CaB will only ever work if everyone uses it. When choose and book brought up unsuitable options direct appointments were made instead. Thus depleting the options available via CaB even more. This is a viscious circle and will ultimately bring down CaB as everyine tries to short circuit the process.

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  • Bornjovial

    As a GP using C&B and as a GP with special interest in I.T , I see both sides of the coin.
    There are 3 main problems.
    1) C&B process itself
    2)Primary care related
    3) Secondary care related
    C&B is one the few well planned ideas in recent NHS IT but could be much slicker. It takes a long time than available in an appointment to be able to do C&B full justice. In a 10 minute appt one may decide on referral at 1 ,5 or 9 th minute. At that point it takes between 3-7 minutes to do a C&B. I tend to ask mobile numbers as well as some local hospitals do send out a text reminder. Also I tend to dictate the referral in front of the patient usually which takes up a few minutes. Some referrals are complex and hence are done later eg looking at old paper notes etc.
    2) Due to above and also medical and Human factors many referrals are not done in the time frame (?too tight for GP land). Eg secretary being off in a small practice or part time GP will have to come back to check the referral or waiting information from another clinic who advise referral to Y speciality to patient but don`t send a letter!!!
    3) Hospitals very often seem to allow booking into non existent clinics or when the consultant is on annual leave then they postpone the appointment several times( ???gaming the 18 week data) and this causes ill will with the patient.
    Remember patient sees the GP for worsening situation for no extra cost but hospitals get paid per appointment - even DNA`s.

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  • When referrals are sen tot hospitals, they take time in responding, extending the waiting time. It is quite common for the hospital to change the appointment at the last minute, one of my own appointments was delayed because they didn't have a junior doctor to sit on on the session, but nobody asked me for my consent and this has happened more than once!

    Choose and book gives you a date and time, but no guarantee that your appointment will be honoured, but can guarantee there will be a last minute change, which then takes your appointment out of the 18 week time span.

    Somebody did a greta course on how to buck the system!

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  • I have one simple question, does anyone feel GP's do anything right?

    I am stunned at the amount of GP bashing that goes on and wonder how GP's find the time to deal with patients when they have to deal with the constant barrage of criticism directed at them.

    If they made GP's fee values, I am sure there would be more cooperation across the board!

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