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Independents' Day

We must open up circumcision debate

Last week Professor Michael Thick talked up the merits of Choose and Book ­ here,

Dr Francesca Lasman, who resigned as IT lead last month, explains why she did so and why she feels there are problems at the heart of the Government's flagship IT scheme

I have resigned as IT clinical lead for my PCT. This was a post I had taken on in January 2003 to represent hard-working GPs who wanted IT to make their life simpler.

I resigned because I didn't think the IT was making their lives simpler in any way at all. And the final straw was the NHS's £95 million bribe to get GPs involved in a programme that I believe is cumbersome, overambitious and could stifle local innovation.

Long before Choose and Book, my semi-rural practice had been developing a system to allow the exchange of referral and discharge letters using secure mail in a standard format. This was so that data could be automatically imported into the hospital or GP computer system.

We agreed to be early adopters of the e-booking project, the first incarnation of Choose and Book, because we hoped our experience would be used to inform its development.

Unfortunately it appears that Choose and Book is a scheme being driven entirely from above. It takes into account the views of grassroots GPs only when they happen to coincide with the national political brief.

For a brief description of Choose and Book, see right.

My decision to resign was finally triggered by the announcement of the £95 million incentive scheme to introduce a system that no one locally has yet seen, using guidance that has not yet been written, and incorporating the untested element of choice.

The few bookings that have been made so far have not involved any choice, just booking to a familiar local hospital.

Although both the concept of choice and that of e-booking have been the subject of successful pilot schemes, the live system is the pilot for combining the two.

This creates all sorts of problems and the result, so far at least, is a top-heavy, cumbersome, administrative system, with limited benefits to patients and significant drawbacks for clinicians.

The problems are set out on the right.

If something is to be salvaged from the current mess there needs to be a sea-change in the attitude of the national Choose and Book team. My proposal is presented in the flowchart (below right).

This system would require far fewer changes than the current proposals and would allow both primary and secondary care to operate much as now, but with streamlined, faster processes. As long as the booking process did not take too long, I believe the patients would be just as happy with this system as with being able to book in the GP consultation.

Choice would be offered sensibly, with the most important information for the patient being offered by the GP. It would also allow local modernisation initiatives to be implemented without any hassle caused by Choose and Book.

If such a system is rejected then I have a message for John Reid. Please, for the sake of good patient care, slow the whole juggernaut down to allow sensible testing and piloting of systems. Also consider allowing clinical assessment services to be applied across the board.

If we plough ahead on the current course GPs will, I believe, insist on sticking with their safe, tried-and-tested referral systems and the millions of pounds already spent will be wasted.

Francesca Lasman is a GP in Huntingdon, Cambridgeshire, and formerly IT clinical lead for Huntingdonshire PCT ­ she pioneered an electronic referral system in her practice and PCT

Choose and Book

in a nutshell

Choose and Book is intended to allow the referring primary care clinician, their administrative staff, or the booking management service (NHS Direct), to give patients a choice of five hospital providers for every elective referral, and to book an appointment electronically

The 10 biggest problems with Choose and Book

1. The referring clinician has to decide exactly which clinic the patient should attend, and whether the problem is urgent, instead of leaving the specialist service to sort this out.

This is fine for an experienced clinician referring to a familiar hospital. But it is potentially difficult when choosing somewhere unfamiliar. To get round this there is an optional decision tree being developed for each sub-specialty.

This is called service selection booking guidance (SSBG). To accommodate choice, this SSBG will have to be applied nationally. Potential problems here are how to write this guidance safely while not taking up too much time.

GPs may be tempted to direct patients to their familiar hospital where they do not need to use SSBG, thus scuppering choice. National SSBG could also stifle local modernisation initiatives.

2. The national 'one-size-fits-all' IT solution results in both primary and secondary care trying to fit their administration systems to the IT, rather than the IT accommodating local ways of working.

3. Trying to change too many things at once (introducing choice, e-booking, and all the other aspects of NPfIT) is bound to cause problems, particularly as there is too much riding on systems that are not yet in place.

4. Booking into predetermined clinic slots removes the opportunity for secondary care triage. It also discourages new ways of working ­ such as referrals direct to continence advisers or physios for urogynaecology.

5. Secondary care clinicians are not saved any time as they have to look at all referral letters to ensure they are appropriate for their clinics. They can also, at the press of a button, reject the referral, creating a potential source of conflict with primary care.

6. Timescales throughout the project have so far been unrealistic. Eight months after our first go-live date (June 2004) Huntingdonshire PCT is still not ready to go live and has no definite date for the first early-adopter practice.

7. Poor communication, too many different providers with different agendas, and no live test system for early adopters to play with before installation in their practices have all hampered implementation. So have problems with hardware, especially upgrades and card readers.

8. It has been difficult to plan training as there are still too many unknowns. Screen shots of how the system will look are not enough!

9. The current software seems time-consuming to use. No one has yet tried to use it with choice, and this is bound to be more time-consuming for the clinician. The GP has to get at least as far as selecting the clinic type and urgency in order to get the unique booking reference number (UBRN) which is needed for anyone else to complete the booking.

10. The waiting times for clinics in different

hospitals are not accessible until the GP has got access to the UBRN. This should surely be available at the start!

How Dr Lasman thinks Choose and Book should work

Step one

GPs offer choice by accessing a spreadsheet from a dropdown menu of specialties. The spreadsheet would give the PCT-commissioned five providers for that speciality, with sub-speciality clinics and waiting times for day cases, inpatients and outpatients. Any other information, such as car parking, would be obtained by the patient via the booking management service.

Step two

The GP clicks on the selected clinic and is taken to a link providing any additional information such as printable patient information or clinic pro formas.

Step three

The GP dictates a referral letter or completes a pro forma in the normal way. At this point their involvement ends.

Step four

The referral letter is sent to the specialty at the chosen hospital either directly or via the booking management service if the selection had not been made in the consultation.

Step five

The hospital triages the letter, directs it to the correct clinic, and contacts the patient to arrange a convenient appointment time. Since this process can be completed using e-mail, it should be possible to make it much faster. Existing (though not yet released) software in Choose and Book, called clinical assessment services, could be used to implement this.

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