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Choose and Book use on downward slope

27 March 2012   Fiona Barr

Usage of Choose and Book has fallen from a high of 57% to 50%, with some areas almost halving their use of the Department of Health’s e-booking system.

Figures for NHS Hertfordshire show use of Choose and Book has dropped from a high of 60% of referrals to 35%.

In Bedfordshire, usage has fallen from 53% to 27%, and in Eastern and Coastal Kent it has fallen from 58% to 32% in January this year.

Some areas have maintained or increased usage. In Bournemouth and Poole, Choose and Book is used for 100% of referrals. However, the overall national trend is downwards.

The DH told EHI Primary Care that it could confirm the utilisation for January 2012 was 50%. February figures will not available until the end of this month.

When Choose and Book was launched in 2005, the then-Labour government set a target for it to be used for 90% of first outpatient appointments by 2007.

However, the largest percentage of referrals sent through the system has been 57% in January and February 2010.

A DH spokesperson said: “We are actively liaising with strategic health authorities, primary care trusts and those clinical commissioning groups that are formed in order to analyse the causes.”

She added: “We remain committed to working with the NHS (including GPs) to embed Choose and Book into daily clinical practice, so patients can reap the rewards of greater choice and more efficient healthcare.”

The fall in use of Choose and Book in areas like Hertfordshire has been linked to the end of GP funding for use of the system.

This was first provided through a national directed enhanced service and then followed up with local incentive schemes in many PCTs.

Dr Peter Graves, chief executive of Bedfordshire and Hertfordshire Local Medical Committees, told EHI PC that “historically, there were a host of difficulties with the system both nationally and locally.”

“[There were issues] such as difficulties in sending patients to the right consultant, clinics disappearing in front of GPs’ eyes, and patients turning up at the wrong hospital because it was unclear where their appointment was,” he said.

“All this meant that when there was an opportunity to drop it, some GPs did so.”

However, Dr Graves said that he knew of at least one clinical commissioning group that is considering reinstating payments.

He added: “I think it will reach a plateau, because some people do find it really useful. But I think that before it does that usage will decline further.”

A spokesperson for NHS Hertfordshire confirmed use of Choose and Book has fallen and is now around 35%.

She added: “Herts Valleys Clinical Commissioning Group is developing plans to address the fall in the number of referrals being made through Choose and Book.”

A boycott of Choose and Book has also been mentioned as a possible target for inclusion in the BMA’s forthcoming ballot on industrial action over pensions.

The DH spokesperson said that despite the fall in the percentage of referrals being made through Choose and Book, the number of patients handled by the service continues to rise.

An average of about 500,000 patient referrals are being made from GP practices to first outpatient services via the service each month.

In addition, more than 150,000 referrals are made to other services such as Allied Health Professionals, GPs with special interests and assessment services each month.

“These activity levels demonstrate that Choose and Book works well for many thousands of people every day and can provide significant benefits to patients and the NHS,” the spokesperson said.


EHI Groups

Related Discussions:

3 EHI Primary Care: Choose and Book | 901 days ag

Related Articles:

News: Barking and Dagenham hits C+B high | 23 December 2011
10 Insight: Choose and stuck | 17 March 2009
News: DH pushes GP choice and AQP to patients | 7 December 2011
5 News: Swindon GPs Optimise pathways | 29 February 2012
Last updated: 28 March 2012 17:19

© 2012 EHealth Media.


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When is a referral not a referral?

DaveJ 126 weeks ago

From my experience as a patient, I don't leave my GP consultation with an appointment, I leave with a message to come back in a few days when details of my referral will be ready and I can book my own appt. I cannot speak for all surgeries but I imagine many work in this manner. I don't really want to choose where I go, I just want to go to my local hospital and not have to wait ages.

I personally feel that C&B is a splendid idea. The issue is that, as Dr Cundy points out, it is cumbersome and time consuming.

From a professional perspective, my trust recently tried to introduce C&B for Cardio-respiratory and it simply didnt work. Inappropriate booking were made and patients found it very frustrating and upsetting not to mention the inconvenience of having to start again through C&B to re-schedule. As a result, I worked closely with a Cardiology consultant and some local GP's and we have set up a mechanism to utilise the same system used by GP's for electronic ordering of Pathology and Radiology and applied it to other diagnostic "services" such a Cardio-respiratory (included in this has been Rapid Access Chest Pain clinics - so sort of a consultant referral). Once the order is placed, patient details and the answers to pre-determined questions drop onto an outstanding order queue which is administered by the Cardio admin team. They pass the info to the technicians who vet the request and then an appropriate appointment is made and sent to the patient. The process for the GP takes about 2 minutes, and another 2 minutes for the Cardiology people. As the patient details passed from the GP clinical system include patient telephone number, I guess we could even SMS appt details which may even result in the patient having the appt date and time before they left the consultation!.

I see no reason why this couldn't be extended to other specialties

This isn't drum beating or saying aren't we great but just demonstrating that other alternatives are there and do work. The success is proven in the fact our referral for Cardiology services have risen dramatically. When I asked a local GP about it, she responded with "well it 's quick, easy and it works"


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On the other hand

Paul Cundy 126 weeks ago

Dear All,

An alternative view is that the problem with C&B is that all the GP "sees" is what the providers will allow them to see. We've had local hospitals load up slots that didn't exist to get the custom and then suprise suprise they ring the patient needing to "re-schedule" the appointments.

There is however no doubt some GPs love it. Personally I don't have enough time in my consultations to deal with their problems as well as wait for the diary to be consulkted when choosing an appointment. that task should be done elsewhere.

If usage is falling then that might help us pursuade the centre that what they need are some modifications; 1) allow a simple e-referral mechanism and 2) allow a set of "favourites". Starters for (No) 10.

Regards

PauL C


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The Centre?

CanUseeTheLight 126 weeks ago

To paraphrase Douglas Adams, those who seek power should on no account be allowed to have it. The Centre got us into this mess what makes you think they can actually listen to the likes of clinicians and what they might find useful?


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The Centre??

Dave Kelsall 126 weeks ago

What makes you think "the Centre" still exists?

Almost everyone employed by the Blair government to deliver CAB has either retired or moved onto something more lucrative than NHS.

Paul's suggestions echo the original concept of CAB - before the politicians and their private sector contractors got their hands on it and changed it from the eBooking concept borrowed from EasyJet into a tool for "extending and empowering Choice" when all most of us want is a convenient time slot at the nearest hospital.


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Look beyond the IT technology to NHS culture and structure as the real problem.

John Aird 126 weeks ago

Perhaps we should look beyond the issues associated with CaB and ask why is it there at all.

If the NHS operated as the single organisation the patient thinks it is, then there would not be the need to try and join up so many, logically associated but operationally different, elements such as appointment booking. But the NHS still seems an organisation with operational, financial and cultural divides.

One of the original good intentions of NPfIT was for a single system (even if only atr a high level) across Acute, Primary, etc. Once that was lost we were inevitably heading back to "boarder controls". Just think how much trouble and money has been spent (wasted?) trying to join the various cross boarder elements of the patient pathway together through IT.


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Building on a non existing system

CertaCitrus 126 weeks ago

If I understand correctly, GP's would have welcomed an electronic referral system but it was the add ons that didn't work.

The existing communication between health administrators and patients which followed the GP's referral was moved into the GPs workflow.


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Choose and Book? Don't make me laugh

Daniel Defoe 126 weeks ago

Let's be clear about this; Choose and Book "transmogrified" from something which was intended to be an online way of a GP making a referral. It started as "e-booking", and became something which somebody thought the majority of patients might want - a choice of some sort about where to go, and who to be seen by based on some information which might be available. And again, let's be clear, it wouldn't matter how much information was made available to some/most people; at the end of the day, they (and that's me included) want to have sufficient trust and faith in my GP to refer me to wherever is best, based not only on his clinical judgement, but also perhaps on what he might know about me "socially" - for instance whether it might be better for me to be treated where my family can visit me regularly rather than on the Isle of Skye where the outcomes are better.

In practice, C&B - even for those who have the ability and resources to make a choice - isn't available to the customer; it's been something, so far, for GPs to make a bob or two on by demonstrating compliance.

Let's drop it now, and save whatever it's currently costing, and let's replace it with "e-booking" since PBR should, I guess, be encouraging that...


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The Voice Of Reason

CanUseeTheLight 126 weeks ago

Lets be careful now Mr Defoe you sound dangerously like a pragmatist rationalist, a man after my own heart.

The ability for a GP to electronically refer a patient for a service should not be complicated and it should not cost the earth. It simply takes the will to see whats really required and the focus to deliver it and for interested parties to play nice.


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Not just a bad start....

Infoman 126 weeks ago

CanUseetheLight nearly hits the mark when he states: "The only choice a patient wants to make ..... is how soon can I see the best doctor." But of course even this simple problem breaks down into a far more complex information issue.

First, it actually two questions: who's the best doctor. Secondly how soon can I seen them. Even this pre surposes that my main criteria is "soonest" followed by "best". Not aways true of course.

The evidance further highlights that patients when surveyed highlight concerns about many other aspects (distance, access, parking) or they are simply not worried at all and rely on the advice of their GP.

This all highlights the fact without the supporting information by which patients can make complex multi-factual judgements about: "best Dr, fastest access, closest to home, best outcome, lowest infection rate etc. they are disempowered from exercising choice and must rely on their GP's judgement - which in the absence of meaningful information I do.

So without any consumer driven motivation to change practice is it any wonder that GPs and hospitals stick with the status quo of referral letters. My local practice has never mentioned choice nor choose and book. On prompting by me they simply state that its not operating in our area.


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Patient choice? do they really want it?

personal opinion 126 weeks ago

I have been around long enough to remember when patients were first given a 'choice' of where they wanted to be treated. At that time it was called GP Fundholding. Irrespective of your political views as to whether this was right or wrong, the truth is that patients by-and-latge voted with their feet and went to the local hospital and saw that same consultants.

I have evidence to back this up as 'patient choice' ws a major theme in my MBA dissertation - so I think I know what I am talking about.


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Not just a bad start

CanUseeTheLight 126 weeks ago

I applaud Geepsi%u219s resilience but reading this comment highlights several thoughts I have had about C&B over the years. A one size fits all solution was never going to work across the NHS %u213 acute v mental health referral / outpatient process are not the same. The only choice a patient wants to make (this is certainly what goes through my mind when in that position) is how soon can I see the best doctor? C&B does not provide for that, its not like booking a restaurant or a flight. I would like to know what percentage of booked appointments are the result of a %u21Cwhat do you think Doctor?%u21D moment. Given C&B has been running since 2005 I would like to know how much each 1st (and it is only the 1st) has actually cost the tax payer as compared to the cost before, maths should be quite simple ((total cost of supply since 2005 GP time since 2005) / (number of booked appointments) %u213 (cost of all the failed appointments). I went though such a back of a fag packet exercise in 2006/7 when we began to hear how great it was from CfH, each first appointment was costing well over 30,000! Obviously as time goes on the cost comes down but if after 7 years C&B is still not achieving its intended aims and GP%u219s still find it a difficult system to use why are we still trying to fit the square peg in the round hole? Having spent a significant amount of time working through the C&B specification / MIM I am not at all surprised that we are where we are, I also know of Trust%u219s which stopped providing %u218outpatient%u219 services specifically to avoid it and its associated costs. Obviously they simply relabelled their service as something other than outpatients. How many other Trust%u219s have done the same? The is nothing wrong with C&B in the broadest terms i.e. a GP want to get a patient seen by a secondary service some time soon. There are however much simpler and cost effective ways of doing this using IT.


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Political Solution

NHSCIO 126 weeks ago

C&B was a politial solution to try and enforce Choice at point of referral. It replaced local ebooking solutions which were perhaps more functionally rich. At the Trust end, its even worse as referral management means multiple systems (so it doesn't really happen as well as it could) and C&B can't even pass on the GP's attached letter to the receiving system. Its probably more expensive to handle a C&B referral than a paper one which is pretty poor.


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But do patients really want to choose?

personal opinion 126 weeks ago

See my other comment within this thread..

The real truth is that patients don't want a choice, they trust their GP to be able to make that descision for them. Not only that, but the main criteria patients use when deciding is "can I go to my local hospital?"


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Political Solution *and* poor processes

Nick Tordoff 126 weeks ago

The problems NHSCIO highlights all contributed to the C+B fiasco along with a very poor user experience with the whole NHS smartcard model which is not fit for purpose.

However one inportant issue which has been skirted around is the abject failure of a number of trust to re-engineer their booking processes to deal with the new system. This was compounded by existing so called work arounds that Trusts had already bolted onto their existing antiquated paper booking systems to cope with 18 weeks.

The vision of Choose and Book, even given the political overlay, was and remains a powerful one, yet implementation of that vision seems to have failed at almost every stage and every level. It would be very easy just to blame one bit or another. I think we have to take a very hard look at why, structurally, culturally and politically we are unable to make big system change like this happen.


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Agreed

CanUseeTheLight 126 weeks ago

I can find nothing to disagree with any of the above.

The business case was described at the highest level with the incorrect , in my opinion, assumption that the case would apply at the lowest level ie a GP requesting an appointment on behalf of a patient.

I suspect that when looked at from a top down and bottom up perspective the task was deemed to be too complex and the top down imposition approach selected.


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Tainted by a bad start

Geepsi 127 weeks ago

I use C&B for 98% of all my referrals but count myself lucky that I was in an area where the local hospital, PCT and GPs worked together to work around the inherent problems with the system.

C&B was hobbled by a clunky, difficult to use, interface which, in itself was enough to put people off. (e.g.Even now there is no clear end-point to the booking process, you just have to assume that the booking has worked as the only way to be certain is to leave the booking, check the worklist then start again if it has failed. A simple splash screen saying 'booking made' would make all the difference)

But much worse than this was the total failure to take into account the way referrals work. By this I do not meen the admin systems but the decision making at both ends of the referral. This led to problems getting patients to the right consultant in the right clinic and it is still the case that I get rejected referrals from distant hospitals because I do not know the minutiae of their clinic system. I simply cannot know the rules for the 120 providers within 50 miles of my practice and the information given by these providers is often inadequate.

The system still makes assumptions that the referral process is entirely linear. An example of this is there is no facility for specialists to view my letter before an appointment is booked. This means we have to use work-arounds, such as dummy appointments, to allow use of referral management--a basic tool in the new NHS.

As a result, it is not surprising that GPs are falling back on systems that have stood the test of time rather than use C&B. Without the hard work locally I would do the same.

Ultimately GPs are practical people. They use the system that makes things easiest to get what they need. The very fact that C&B needed any payment is not a marker of GP greed, it is a sign that the system was not sufficiently developed to make it easier than the paper alternative. This applied and, to a certain extent, still applies for GPs and providers and, for many, the payment compensated for the extra time ( and hence cost) of the system.

I do not think that C&B is fatally wounded, but a long hard look, plenty of user input and a degree of re-design could make it sufficiently attractive to users that they *want* to use it.


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Starting Properly is of Prime Importance

nicksamuel 126 weeks ago

As a professional who (amongst other things) has designed IT systems from the ground up, it is a repeated frustration that these expensive national systems seem to omit the proper analysis of the current systems from the development process. In my book, compiling the knowledge and usage of any current systems is a fundamental part of a robust design process that will address the requirements of the target users. I have seen from experience that omitting this leads to poor usage, longer lead times to the finished product and repeated redevelopments that would be unnecessary if the job had been started properly. More interestingly, I believe that this has been known for decades.


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