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The new Choose and Book system risks becoming another white elephant in NHS IT

If the next version of Choose and Book is going to be a success then major changes will need to be made not only to the software, but also how it is used, argues Dr Grant Ingrams

Choose and Book is ripe for re-development but it must be redesigned to take into account the needs of mainstream general practice. For the new Choose and Book system to be universally adopted, it must make the referral process for GPs, hospitals and patients more effective than a paper-based version (which the current version is not).  

Prior to the introduction of Choose and Book, the usual process was to dictate a letter for the secretary to type and, after checking and signing, it was sent into the black hole of the local hospital.  A significant amount of reception and doctor time was taken up with chasing these referrals and countering the hospital mantra that any delay must be the fault of the referring GP. The wish for an electronic referral system that could overcome these problems initially came from GPs who could see the many advantages to a well-designed system.  Quite late in the day the referral system was hijacked to include the political imperative of ‘choice’.  This fact alone, turned many clinicians off from using it.

Choose and Book was formally procured by the National Programme for IT (NPfIT) in 2003 and rolled out from 2005 with the initial cost quoted as being £200 million. It was dogged by problems from the early days, many of which have not been fully resolved. GPs who had poor initial experiences of it have been resistant to trying it again.

One of the first problems GPs reported was the speed of using it.  Although blamed on the Choose and Book software, this was commonly due to problems with the local IT infrastructure.  For my practice the problem was due to insufficient specification of my desktop, a problem with a hub, and a problem with the N3 connection.  Once resolved the software became fast enough to use during consultations.  But why was the system rolled out without a basic review of the technical requirements?

Choose and Book was developed to be used as an integrated part of GP clinical systems, with a back up ‘naked’ online booker but in reality, the integrated booker often does not work at all, or exhibits other glitches like not automatically attaching referral letters. Consultants also had complained that they often had patients turning up on the wrong date or to the wrong clinic.

Despite a shaky start, by 2010 57% of referrals were being made via Choose and Book.  However, this was probably as a direct result of a Directed Enhanced Service funding general practices to use the service as, following the withdrawal of the DES, usage dipped to 49%

The potential for success

That said, when it works it works well.  With use of intelligent proformas referrals can often be made during a consultation and for several years my patients left the consulting room with an actual outpatient appointment in their hands.

Many of the problems with Choose and Book are not related to the software at all.  Appointments are often not available to book, resulting in patients getting frustrated.  Hospitals continue to repeatedly cancel and rebook appointments, making a mockery of the whole concept of patients booking an appointment convenient for them.  Many hospitals still write back to a different GP than the one who referred. There are an increasing number of services which require GPs to allocate pseudo-appointments further undermining Choose and Book.

Some areas have implemented referral management centres as part of the thinly-disguised saving scheme, QIPP.  These centres seriously undermine the concept of Choose and Book, with the choice of options offered being given by someone who has no understanding of the patient.

IT for NHS needs

If the next version of Choose and Book is going to be a success major changes will need to be made not only to the software, but how it is used. The replacement must be based upon what is needed by patients, GPs and providers.  

The first improvement is that Choose and Book must become robustly and fully integrated into all GP clinical systems, allowing seamless referral without opening any additional programme.  Connection speeds, drop-out rates and down-times need to be minimised with guaranteed quality of performance.  It must be possible to complete a straightforward referral in less than a minute.

The second improvement is that hospital departments must be required to provide appointments available to book in all but very exceptional occasions.  The use of pseudo-appointments should be banned within Choose and Book.  If, for some legitimate reason, a service cannot provide directly bookable appointments, an alternative solution must be found.

Well-designed electronic referral software which is quicker and easier to use than a paper-based system will be readily taken up by general practice.  Improvements in efficiency may be achieved but it will not save any money.  Proper engagement and consultation with mainstream general practice is imperative.

If this the new system doesn’t focus on the needs of patients, GPs and providers, it will prove to be yet another IT white elephant.

Dr Grant Ingrams is a GP in Coventry and the former IT lead on Coventry and Rugby CCG

Readers' comments (7)

  • I couldn't agree more! I gave up using C&B in the consultation a long time ago. My staff are currently spending a disproportionate amount of time chasing referrals and for those of my patients who do battle with the system an unacceptable number are being referred back to me because the booking centre cannot offer them an appointment even after being asked to ring back several times over several weeks. It has deteriorated into gamesmanship at the expense of patients in order to stop the hospitals breaching their timescales and is creating no end of additional work. As for cancellations, well dont get me going on that subject.........

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  • Hadrian Moss

    Totally agree. We never took on C&B in the consulting room, choosing to delegate this to our secretary in my practice. Though we do use it 100% of the time for services that are available through C&B.

    There is a national program for N3 upgrading and in my area the connection speed is significantly faster.

    However, the level of apathy from our local I.T. Department whenever we mention our slow desktop PCs is an embarrassment.

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  • It kind of tickles me when everyone talks about Choose and Book as if it was a new concept we were using a significantly quicker system called "Booked Admissions" in London as far back as the year 2000. The reason it proved to be such a good system was because it was designed by software developers working with Lewisham Hospital I.T people with the Hospital Consultants and local GP's, my Practice at the time being in Catford was a front runner.. But politics then reared its ugly head with an election and the incoming Governrment scrapped it, only to spend the next 10 years inventing Choose and Book. If that wasn't a case of reinventing the wheel then I am not sure what is. What a waste of money. But thats politics and the NHS for you.

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  • I whole heartedly agree with the author of the article that how the system is used has to be changed for it to be a success, as to changes to the software well there are definitely areas for expansion and some elements could be tweaked/improved, but process and usage change is the thing that will make the biggest difference. Particularly how Primary care and Secondary care are supported at a local level in its use, if you don't have someone who understands the system and related processes fully acting as a mediator between all areas of the health economy that uses it then it is destined for continued chaos. Things like using the system back office data to take difficult or non-compliant providers to task over the number of cancelleations and appointments booked outside of C&B, likewise the same person collecting feedback from providers when difficulties occur around speed of referral letters being attached or what information is required in an electronic referral template etc these are all areas that should be dealt with and followed up by support staff removing these extra pressures form consultants/GPs. After all these are the sort of things your CSU commissioning teams, locality/relationship managers should have a strong working knowledge of - if they don't know how the systems in BAU use work in healthcare how can they provide proper support.
    As for referral management centres and thinly veiled saving schemes for QIPP, I couldn't agree more, especially as in the majority of cases long term cash black holes - think directing everything to community reduced tariff services via C&B only for say 40% of those patients to be deemed to require secondary care anyway, leading to a further full tariff OP referral on top (not including the cost of the RMS). Cost saving QIPP referral management can be acheived using C&B + MoM etc effectively at Practice level.
    For an example of good practice, engagement, support and success with C&B etc over the past 5 years look to NHS Barking and Dagenham

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  • I whole heartedly agree with the author of the article that how the system is used has to be changed for it to be a success, as to changes to the software well there are definitely areas for expansion and some elements could be tweaked/improved, but process and usage change is the thing that will make the biggest difference. Particularly how Primary care and Secondary care are supported at a local level in its use, if you don't have someone who understands the system and related processes fully acting as a mediator between all areas of the health economy that uses it then it is destined for continued chaos. Things like using the system back office data to take difficult or non-compliant providers to task over the number of cancelleations and appointments booked outside of C&B, likewise the same person collecting feedback from providers when difficulties occur around speed of referral letters being attached or what information is required in an electronic referral template etc these are all areas that should be dealt with and followed up by support staff removing these extra pressures form consultants/GPs. After all these are the sort of things your CSU commissioning teams, locality/relationship managers should have a strong working knowledge of - if they don't know how the systems in BAU use work in healthcare how can they provide proper support.
    As for referral management centres and thinly veiled saving schemes for QIPP, I couldn't agree more, especially as in the majority of cases long term cash black holes - think directing everything to community reduced tariff services via C&B only for say 40% of those patients to be deemed to require secondary care anyway, leading to a further full tariff OP referral on top (not including the cost of the RMS). Cost saving QIPP referral management can be acheived using C&B + MoM etc effectively at Practice level.
    For an example of good practice, engagement, support and success with C&B etc over the past 5 years look to NHS Barking and Dagenham

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  • I practice between two hospital catchment areas.

    I have always used C&B to give my patients choice.

    My practice has the highest elective surgery costs in my commissioning group as the other practices are nearer the hospital we have less expensive contracts with.

    We have been told to bring our costs down in this area by restricting patient choice.

    What to do?

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  • choose and book has wasted possibly hundreds of millions maybe billions trying to solve an imaginary and very minor irrelevant problem.there never was nor is any need for it.99 per cent of my patients are interested in going to the closest hospital.in many areas there is no 'choice' as there is only one hospital.it has ramped up expectations in a desperately stretched service to no useful end.it wastes vast amounts of desperately precious consultingtime ..so as well as the scandalous waste of money it damages patient care.
    overall it is a profound failure instituted by delusional people with no understanding of primary care.
    i doubt someone whois denied a life saving drug or investigation feels money was better spent on a childish scheme like this for people who like to play computer games.
    losses shouldbe cut and the culpable who have caused this sad waste should be held to account...........

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