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GPs may face penalties for not using new-look Choose and Book for referrals

GPs may face penalties if they do not refer all their patients via the new e-referrals service due to be launched later this year, under plans being considered by NHS England.

Chief executive Sir David Nicholson admitted that managers had been ‘unable to persuade’ GPs to use Choose and Book for all referrals, but that he was considering whether to make the system mandatory after it is relaunched as a new ‘e-referrals’ site by the end of 2014.

NHS England has set its sights on getting 100% of practices using the new system by 2017 - based on flight-booking websites - and this is the first time that managers have raised the prospect of forcing GPs to use it to make referrals.

NHS England had previously said that they would prefer not to mandate the use of e-referrals and  want GPs ‘to be persuaded to use it, want to use it because they see the value of it.’

But speaking to MPs on the Public Accounts Committee this week, Sir David said they were looking at an ‘incentive stroke penalty system’ to maximise uptake.

Managers told MPs the new system will allow ‘anyone to anyone’ referrals, with GPs – and in some cases patients - able to refer to any NHS service and diagnostics.

It will be available on mobiles and will automatically update the GP record. Patients will be able to book follow-up appointments, which will be linked to ensure that they happen in a pre-determined order.

Sir David told MPs: ‘GPs, of all our clinicians across the NHS, are probably the most technically advanced. They’ve got more digital systems than almost anybody. So it’s not that they’re frightened, they just don’t like the way the system works and it affects their patients they think they don’t want different ways, and we’ve been unable to persuade them of that.’

‘But I think we’re getting to the point here, where we’ve heard from e-referrals implementation, is that we want to get a system where we can make it a mandatory system as we go forward.’

He added: ‘The question we’ve got to ask is, in a sense - to get as wide a support for it as we can – and then: What is the incentive stroke penalty system we want to put in place to ensure that it actually works?’

Dr Una O’Brien, permanent secretary at the Department of Health, said the key objectives of the new service were to reduce DNAs and allow clinics ‘to run really smoothly’.

She said: ‘So it’s trying to take the best of Choose and Book and apply it in a more modern context given what we’ve learnt about how people interact with the system.’

The e-referrals system will come into operation at the end of 2014, and is central to health secretary Jeremy Hunt’s plans to create a ‘paperless NHS’ by 2018.

The current system ‘Choose and Book’ accounts for around half of GP referrals currently being made, but this proportion has been falling of late.

Dr John Canning, a GP in Middlesbrough and a member of the GPC, said Choose and Book was useful, but GPs should not be penalised for not using it.

He said: ‘There are times you can’t find things, there are times it tells you can’t do this that or the other. So the incentive is making it work in an intuitive way, and if it works properly, works well we are then in a position to actually save because we can redeploy staff and use our resources differently and better.

‘I don’t think penalties work. It’s going back to the standard thing that we’ve done throughout the system. It is a culture of fear, and a culture of penalty, whereas good organisations work on a culture of encouragement.’

A spokesperson for NHS England told Pulse: ‘We hope that by building a new system that is easier for GPs and providers to use then uptake will increase and we have a programme of support in place, through our partners HSCIC, to help health economies to adopt Choose and Book and its successor NHS E-Referrals.’ 

‘Imposing penalties into a  system like NHS E-Referrals will require cooperation across health economies for it to work.  An e-referral system will also require  clinic slots to be made available to encourage GPs to use it.’

‘Once the new system is live we will work hard to achieve our 100% target by 2017.  We will listen to why health economies stay wedded to paper; we will support GPs and providers to move off paper; and if we reach a tipping point where we feel there is no explainable reason why the minority aren’t moving to it, then we will mandate it.’

This article was ammended on 17 February to include a comment from NHS England.

Readers' comments (23)

  • Vinci Ho

    Told you
    It is Ministry of Love(1984)
    Interesting-
    The centre figure of Mid Staffordshire crisis talked about 'penalty'

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  • If it worked properly we would use it more.It a bit of a joke.Usual big brother menacing approach from NHSE,have they been on the compassionate managment course yet!

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  • Wrong approach: with the old C&B good uptake from GPs *if - and only if* the Trusts involved populated their directories accurately.
    You only need threats - or incentives - when the system makes life more rather than less difficult.
    How many sanctions were needed to get radiologists - and other acute sector HCPs - to use PACS?
    I rest my case

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  • If it worked, if it was easy to use, if it saved time in the referral process then it would be taken up. No incentives or penalties needed. C&B was dire. Any hope for e-Referrals? Not holding my breath.

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  • I don't think the penny has dropped that with ten minute appointments, we do not refer patients there and then. Most of us save up our referrals, dictate our letters and give them to our secretaries to process.

    I think they envisage us booking the appointment,like a flight, while we debate with patients where they would like to go and on what day and time. It isn't going to happen, due to time constraints.

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  • We have been promised named consultants for ever, when this happens it may be viable to use for every referral.

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  • I did use C&B for all my referrals but due to the last initiative to reduce referrals, all our referrals are now going through a referral meeting. The secretary now does the referral - probably C&B but offering no real patient choice. Which does he want - referral management or C&B properly - he cannot have both!!

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  • C & B FO

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  • We have used C&B from day one and found the system to work for us extremely well... Being able to book an appointment with consultant and hospital of choice during consultation ...priceless

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  • Peter Swinyard

    Let's be real. Away from the metropolitan areas there is no real choice. People want to go to the DGH and sometimes to the ISTCs (where we have to steer some people as budgets topsliced to pay for them).
    We use electronic notes all day. Why? Because they are better/more versatile/easier to search than the Lloyd George record envelopes. Build a better mousetrap and we will all buy into it.
    The original C&B and its later iterations are so clunky that I gave up some time ago and very rarely use it - the "choice discussion" in my CCG is done by the referral management centre with the patient on our behalf.
    Heavy handedly trying to force GPs to take up technology will result in the Awkward Squad finding all sorts of ways to mess up the system royally! Don't tempt us!!!

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  • Took Early Retirement

    Never used it and will not use it as leaving NHS in 108 days.

    £20Bn thrown away on unnecessary IT changes with very little to show for it and no one held to account.

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  • When will they realise this system is not seem less
    and costs time . This means already pressured consultations can be affected. Delegating to other
    Staff .... Who picks up the Tab.. Failure to adequately
    cover the costs of it is just an example of taking general
    Practice for granted.
    If it's a requirement. Fund it!

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  • Not all Doctors - especially the experts you may need to see can be accessed by Choose & Book. Part of a Drs skill is to know the best ones not directed not to be told where to send. The NHS needs to stop delays caused by their system as one could be being sent from pillar to post 18 weeks each time , causing your condition to become irreversible as GPs insist on using the online system [maladministrated by those on remits] This is positively libellous/dangerous in my case.
    Could this be the privatisation[ discrimination] by the back door we are told is imminent..1?If you took a Code of Ethics it would not allow them to do this??!!Who is in charge them or you?Or could there be a conflict of interest?

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  • Oh just what I need. This sort of story coming along to wreck e-RS before it even starts!

    Sigh... it can all work great, as along as we avoid the mistakes Choose and Book made.
    Don't pay people do do it
    Don't threaten people into doing it.
    Support people and have actual hands on nerds doing it, not managers.
    Ensure engagement between Primary and Secondary Care.
    Don't break existing pathways where the system just won't work.

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  • I think that they should run a user-friendly site that works before they talk about penalty charges. Proove that it works for a year, get feedback and then go-ahead and charge if its not used.

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  • That's all well and dandy unless the major issue with C+B is sorted out - the capacity of the providers at the other end who, if they haven't got that capacity shouldn't be offering appointments.
    I am sick and tired of admin idiots the other end telling patients 'we have no appointments available so go back to your GP to be re-referred.'
    NO! NO! NO! NO! NO! I WILL NOT.
    I used Language Line for a Russian immigrant without a jot of English and out of curiosity decided to book the appointment for him - the admin person said 'but if we have no appointments we will advise your patient to contact you to be re-referred'.
    WHY WHY WHY WHY WHY I shouted - this is the one and only referral, so if they don't have appointments then don't offer them on C+B!
    'Its just what we have advised to say'
    Up yours with brass knobs on.
    I hate this nonsensical bureaucrap which gets in the way of me doing my job.
    SORT IT OUT.

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  • PS
    @john glasspool
    Only 3650 days to go :(

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  • I don't know what all the fuss is about! I know at times it can be frustrating but I refer and hand an appointment to my patient before they leave my 10 minute appointment! I save me referral letters to later in the day and do them myself as our medical secretary has more important things to do!

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  • David Nicholson's comments to the Select Committee nicely illustrate why the NHS continues to suffer from so many problems. Will it improve when he leaves? Sadly I doubt it.

    Until "management" learns about simple human psychology we will continue to see more examples of money being thrown at problems instead of a thoughtful examination of the underlying cause followed by a rational plan based on its outcome being implemented in a sensibly staged action Programme with defined evaluation points allowing for modification as inevitable problems are identified. Some hope!

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  • appalling bullying management style again.....there is usually no need for choice as none often practically exists,also it is a damaging waste of valuable consulting time...theses idiots think it is sensible for gps to waste consulting time on an admin job..nhse are the problem and damaging the ability of nhs to cope...again...

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  • This comment has been moderated

  • As a patient I don't want to use C&B, and I do want want my GP to do that that.
    Some GP's use private companies that they own, but never ask the patient to consent to their information being sent to this third party.

    For this reason, patients should decide how they want their appointment made and dealing direct with the hospital is the right way.

    The tools may be there to do this quicker, but sadly they do not work unless everyone is the system falls down.

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  • The same old excuses from GPs. What I do agree with is that forcing a discussion around choices in a 10 minute consultation even with a well motivated GP is not fair on patients. Most patients are not prepared or confident when they see the GP but certainly the following day they will have had time to think about their circumstances. If the new e-referral system does give the patient the chance away from the pressured 10 minute consultation to look at choices then surely as GPs you can not deny your patient that right to choose. Even if they choose their local DGH and wait 8 weeks plus before 1st appt and then another 10 weeks for their op. Most self employed manual workers would surely prefer to be seen in 2 to 4 weeks and operated on within another 6 but most are never given that option. By their GP. So much for the Hippocratic oath.

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  • The ten minute consultation is definitely not fair on GPs, never mind the patient. Speak to your MP. We need more GPs.

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