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A faulty production line

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)

  • @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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