Dr Mark Davies, medical director, Choose and Book
In the latest article from the clinician’s leading Connecting for Health, Dr Mark Davies the medical director for Choose and Book, sets out the progress being made on Choose and Book.
I met up with an old medical school friend of mine recently who plays drums in a band. He’d invited me along to one of his gigs but before we set off I began chatting to his wife, who is also a GP, over coffee. The fact that I was working with NHS Connecting for Health came up and inevitably Choose and Book was raised.
She didn’t hold back; she had better things to do than book appointments in consultation, her patients didn’t want choice and just wished to go to their local hospital and she was shocked by headlines about the cost of the system.
Frustratingly other colleagues in my profession share these views, which are largely based on a misunderstanding about what Choose and Book is and a raft of inaccuracies.
152 different PCT stories
The reality of Choose and Book is that the utilisation and GP experience is enormously varied for a number of reasons. Utilisation of Choose and Book is currently 40% but that figure hides 152 different PCT stories. Each area differs and there are several where utilisation is at 70, 80 and even 90%, where Choose and Book is now the usual method of referral. Here the patient experience is a positive one and frankly Choose and Book is just the way things are done. Although, equally there are areas where utilisation is significantly lower.
The fact that for several PCTs it is now the usual method of referral proves that it works and adds real value to our referral processes. I think that will be encouraging to PCTs that are struggling at the moment to continue and work through any challenges they may have.
Only minority of Choose and Book appointments made during consultation
A key challenge has been shaking off my colleagues’ misconception that Choose and Book will mean they will spend valuable consultation time booking appointments. In reality just 9% of appointments booked through Choose and Book at the moment are booked by GPs during the consultation.
Choose and Book was designed to be a flexible tool and that is exactly how it is being used. Where it makes sense for a GP to book an appointment within a consultation, for example an elderly patient who might struggle to follow the booking procedure or it’s a cancer two-week wait referral and you didn’t want them to leave the practice without an appointment – then GPs are booking appointments in consultation and I have booked appointments myself under similar situations. But in the vast majority of cases, that isn’t the best use of a clinician’s time and the patient can and would prefer to book from home or with a non-clinical member of staff. In fact the majority of appointments are being booked outside the surgery completely by the Telephone Appointments Line.
For a GP the NHS is becoming more complex; there are more providers and more care pathways out there to which GPs can refer their patient. As GPs we need Choose and Book as a way of navigating these services. With the system’s directory of services, for the first time we have a searchable database of secondary care services in England with keyword functionality. We would like GPs to be using keyword searching more as when it is set up correctly by the hospital it will be a more reliable way of getting the patients into the right services first time. Next year when we introduce SNOMED coding for keywords this should be even easier.
Choose and Book simply an electronic referral tool
Another common misconception of the Choose and Book system is that it is synonymous with the choice agenda, when in fact they are very different things. Choose and Book is a flexible electronic referral tool that sets out to support a number of things for patients, one of which is full booking; one of which is electronic referral and one of which is choice. Like my friend’s wife, some colleagues say that they are not going to use Choose and Book as their patients don’t want choice but choice isn’t the only reason for using the system.
Certainly when I refer my patients the majority want to go to the local hospital and that’s a valid choice, however if for whatever reason the local hospital didn’t meet my patients needs then I want the opportunity for them to look at other options – that was the system I worked in when I started General Practice 15 years ago and thankfully that’s what we are getting back to.
In some areas I am aware that the system has been blamed for restricted choice either by not listing services by consultant names or by removing services that are struggling to deliver waiting time targets. We at CfH have been clear that we don’t support these restrictive approaches but in a complex system like the NHS it is inevitable that the tools we provide can be used badly – but this doesn’t mean that the tool is wrong!
Delivering Choose and Book is not just about putting in place a new, more modern IT system, it is also about a new way of doing things and so it is natural that take up varies while people learn how to use it.
Benchmarking GPs experiences of Choose and Book speed
However, confidence in the system is required if we are to get people to continue using it, so we are working hard to ensure that experience of the technology is positive. We know that some GPs and consultants are finding that the Choose and Book system can be slow. If they are sitting at their PC faced with slow response times that is all that they have to judge the system on. That is why we are going to considerable efforts to try to communicate to people what kind of experience they should be expecting. We are publishing these benchmark timings on NHSnet Once armed with this benchmark information they or a non-clinical colleague can go back to their PCT and say ‘this is what I’m supposed to be getting, why is it slow for me?”. These benchmarks are a basic starting point, but we want them to be faster. You will see these timings progressively come down as we challenge ourselves and GP system suppliers to reduce the benchmarks.
Giving patients confidence, certainty and choice
For colleagues who are still uncertain about Choose and Book, my challenge is a simple one – if you were going to be referred to hospital yourself and you had an outpatient appointment, what would you prefer? Would you prefer to arrange your own appointment at a time and place that suits you and have the security of a referral being passed electronically? Or would you just like to be dropped into a waiting list, not knowing what’s going to be happening to you and hope that the piece of paper the GP puts in the post arrives at the right place? I know which option I would prefer.
Patients most eloquent advocates
Over three million people have now been referred through the system and some of its most eloquent proponents are these patients who have been through it.
From my own experience, I find it most striking when during a consultation I tell a patient that they can choose where they are seen and when they are seen before they leave the surgery. The most common reaction is one of surprise that the NHS is being so flexible and responsive.
Implementing Choose and Book has proved to be very challenging and much more so than anyone expected but the NHS has made and continues to make good progress and the vision is beginning to take shape. I have spent the majority of my career as a GP referring patients to hospital using a paper-based referral system which has seen little change since the NHS was set up in 1948! It offers patients little control or reassurance about when or where they are seen and doesn’t allow me as a GP to search for what services are available to my patients – it’s time for a change.
Links
Benchmarking Choose and Book speeds
Email: chooseandbook@nhs.net