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