Technical problems, delays in delivering upgrades and failure to engage GPs means the roll-out of Choose and Book, the national electronic appointment booking system, is behind schedule and, at best, will only offer 60-70% availability by the end of  2005. 

As a result the Government target to deliver patient choice by the end of the year is likely to be missed, according to a report [891K, PDF] published today by the National Audit Office.

The report focuses on progress against the government’s commitment to offer every patient a choice of where they are treated when they are referred by a GP for elective treatment. The Choose and Book electronic booking service is key part of the scheme which aims to offer most patients a choice of four or five care providers, including at least one from the independent sector.

Despite Choose and Book milestones having twice been revised twice since May 2004, only one has so far been achieved – this being for a single booking to occur in London.  Of the 205,000 electronic bookings that were due to have been completed by December 2004 just 63 had actually occurred, the report found.   Eventually Choose and Book is meant to enable choice to be offered to patients in up to 9.4 million elective referrals a year.

The findings, set out in today’s report entitled ‘Patient Choice at the Point of Referral’, provides grim reading for the Department of Health (DH) and National Programme for IT (NPfIT)as it sets out a series of problems and delays related to both Choose and Book and the wider IT modernisation programme. 

The NAO report, reviewed and signed off by the DH, says that Atos Origin, the supplier of the national component of the Choose and Book system, delivered a functioning system by July 2004, but the subsequent roll-out programme has been slower than planned.  The total cost of introducing Choose and Book is put at £196m by the NAO.

“Problems have included the reluctance of users to work with an unreliable end-to-end system, limited progress in linking to GP and hospital systems, and the limited number of GPs willing to use the system," says the NAO. 

Technical problems with the system have included an intermittent fault with authentication through the NHS Spine that “has prevented access to e-booking and other IT systems.”

Key reasons for delays in the roll-out programme, which mean Choose and Book will now only be partially available by the end of 2005, are identified as the slippages in the twin programmes of GP and hospital system upgrades – both necessary to make e-booking work and essential foundations for the wider national programme. 

The NAO says there have been serious delays to NPfIT’s delivery schedule, including the replacement of hospital Patient Administration Systems (PAS) to enable hospitals to connect to Choose and Book.  “The Department had planned on upgrading 22 Patient Administration Systems by December 2004, but only seven were actually completed by this point,” says the report.

On current DH plans only 60-70% of hospital PAS systems will be compliant with Choose and Book by October 2005.  But the NAO says “even against the agreed implementation timetable there has been some slippage”.

Similarly, the schedule for upgrading GP systems to make them compliant with Choose and Book has also been subject to delay, with a maximum of 90% expected to be compliant by the end of 2005.

The report says: “The Department does not expect the suppliers to upgrade all minor systems but will wait for users voluntarily to adopt the Local Service Provider solution.  For this reason, GP system compliance is not expected to rise above 90%.”

Hitting this target for compliant GP systems is also in doubt, unless all major suppliers are signed up, and there are problems with this.  “The lack of an agreed roll-out schedule with EMIS – the main supplier of GP systems – puts the implementation of e-booking through primary care systems at risk.”   

Without a fully available Choose and Book service the NAO says that the Patient Choice policy will be difficult to deliver.  “E-booking is the most effective and efficient way of delivering the Department’s plans for choice, and alternative booking mechanisms offer poorer value for money."    

To overcome these delays the NAO says NPfIT is planning two interim booking solutions by the end of May, as alternatives to the fully integrated Choose and Book solution (a development first reported by EHI last week).  In addition Atos Origin has been paid £1.6m by NPfIT to build an additional stand-alone demonstrator of the Choose and Book system.

The delayed delivery of the e-booking system is also said to be having wider consequences, making it much harder to engage with sceptical GPs. “The Department has deliberately held back its main effort to inform and engage GPs until it has an integrated end-to-end electronic booking system (‘Choose and Book’) to show them," says the NAO.

An NAO survey of 1,500 GPs found that around half of respondents knew very little about choice and some 60% felt negative to some degree, and the report declares: “Choice cannot be delivered without support from GPs."  

Sir John Bourne, head of the NAO said that enabling patients referred by their GPs for hospital treatment to choose where they wanted to be treated offered benefits to both patients and the wider NHS, but providing such choice would not be easy. “GPs’ support may be hard to secure and indeed choice will be hard to deliver successfully by the end of 2005 if the electronic booking system is not largely up and running by then."     


Patient Choice at the Point of Referral – report and summary in Document Library
National Audit Office