My next project with the clinical commissioning group is to tame Choose and Book.
This is a potentially useful application that has, unfortunately, acquired a dreadful reputation among GPs because of the way it was initially designed, implemented and maintained.
Very importantly, few primary care trusts historically seem to have got to grips with the local problems on behalf of their GPs and patients. I want to change all that.
C&B is so complex and spreads across so many, different areas of the NHS that those new to it often find it difficult to know where to begin. So here’s an easy guide.
Three major problems affect GPs. These occur when referrers can’t locate clinics on the picking lists; when appointment slots can’t be booked once a referral has been raised; and the slipshod use of statistics about practice uptake of C&B.
So, my first action will be to arrange for the services of a local ‘fixer’. He/she will have three jobs, starting with collating all notifications of local C&B problems.
The fixer will also liaise with local hospitals over their Directory of Services when clinics or conditions aren’t being displayed properly, and arrange meetings with senior hospital management if it becomes clear that deeper issues have been uncovered.
Finding clinics more easily
Symptoms: doctors and their staff can’t find clinics in local hospitals, even though they should be there.
Causes: either the hospital has forgotten to put a particular clinic on its DoS, or it hasn’t included a complete enough set of SNOMED clinical descriptions. For example, none of our local ENT clinics appears on the picking list if the clinician types in ‘sleep apnoea’.
Cure: the fixer simply needs to contact his/her equivalent at the relevant hospital to tell them of the situation. Omissions like this are nearly always genuine mistakes, of which the hospitals are totally unaware.
It is in everyone’s interests to correct these errors: I expect hospitals will thank us for drawing them to their attention. I also expect changes to be made swiftly. Should the fixer discover that a hospital is reluctant to put a clinic on C&B then we will inform the Health and Social Care Information Centre.
Making appointment slots more available
This one’s a different ballgame altogether – which may be why it has a special acronym, ASI, which stands for ‘appointment slot issues’.
Symptoms: GPs and patients look for an appointment, only to be told that there isn’t one available and that the patient will be put on a list. Alternatively, appointments are repeatedly cancelled, or the hospital won’t accept the C&B appointment and contacts the GP to ask him/her to fax a copy of the referral.
Underlying problem: in most cases, hospitals simply don’t have enough appointment slots available; typically because they have only opened up a few weeks’ supply.
Their reasoning is that they don’t want to risk breaching the 18-week referral to treatment time target; but in trying to establish a simplistic cure they are making things much worse for themselves because the administrative overload is truly horrendous.
In some cases, ASIs can also occur when hospitals deliberately try to game their targets. They only create a short time range for new bookings and imagine that, by putting the people who can’t be booked onto a reserve waiting list, they are keeping the problem of missed targets away from the authorities’ eyes. They aren’t! What they are doing is all too visible.
Finally, there are those hospitals which demand a faxed copy of the letter before deciding whether to make an appointment. This is a breach of information governance because the hospital is being given confidential information before it has established a legitimate relationship with that patient.
One of the easily-acquired statistics about C&B, openly available on the web, is analysis of appointment slot issues. The target is 0% but values below 4% are considered acceptable.
Many hospitals have much higher values (often completely unintentionally): one in our local area is currently running at 14%.
So what are we going to do? We’ll need to consider arranging high level meetings between the CCG and each local hospital, possibly also involving staff from the HSCIC.
What should be said at these meetings? Whatever the cause, ASI problems hugely inconvenience the patient by making them unable to book, or mess them around when hospitals cancel bookings inappropriately.
Putting patients on another worklist isn’t an answer; this merely increases (hugely) the amount of administrative overload as hospital staff chase round trying to fit patients into slots. How much easier it would be if the slots had been made available in the first place!
C&B data enables us to drill down to find which clinics at which hospitals are suffering from slot problems. At each meeting we will present the hospital with this information.
In most cases, the cure is remarkably simple: the hospital needs to increase the time span of slots to be made available to approximately a week more than their current slot occupation.
Suddenly, the pressure on slots will disappear, patients will be able to book first time, there won’t be the phone calls, hidden lists, difficulties with contacting the patient at a later date and so on — and everything will settle down.
It’s a complete win-win situation: the patients don’t get inconvenienced, and the hospital saves money and staff time.
More difficult conversations
In some cases, opening up the slots in this way reveals an inherent mismatch between the provision of outpatient slots and the demand. That’s when the hospital needs to take decisions about the number of clinics it operates and their staffing levels.
The whole discussion needs to be owned by the senior hospital management: it is no good going to junior level managers to tell them the problem, only to find that their recommendations go up to a more senior level within the hospital —and then get turned down. And that, in a nutshell, is how to get C&B moving freely — as indeed it ought to be.
Dr John Lockley
Dr John Lockley is clinical lead for informatics at Bedfordshire Clinical Commissioning Group and a part-time GP.