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Choose and Book – good and bad

I am a GP who works in a practice in the New Forest with 12,500 patients and four hospitals within a 20 mile radius. I am also the chief executive of Wessex Local Medical Committee which represents 3,000 GPs working in the 420 practices in Dorset, Hampshire, the Isle of Wight and Wiltshire. Over the past two years I have used Choose and Book extensively as a GP. Also, as an LMC, we have tried to work collaboratively with primary care trusts and the strategic health authorities to maximise the benefits of Choose and Book and solve some of the problems.

The concept of offering patients’ choice and sending electronic referrals is not new. When I first became a GP in 1987, I had the option of referring a patient to any hospital or named consultant within the country. In Dorset, a system of electronic referrals was widely used prior to the introduction of C&B.

The time from seeing the GP to an appointment being sent from the hospital has always been a variable feast - subject to delays at the practice or more significantly at the hospital end. Appointments were often cancelled and rebooked a couple of times.

So a system which allow patients choice of hospital and appointment time with an electronic referral pathway should resolve most of the problems for patients, hospitals and GPs. So what are the real problems and how can they be solved?

The problems:

The directory of service (DOS) is too complicated and patients end up in the wrong clinic

Clinics are removed because of possible breaches in waiting times

Very few named consultant clinics

Too many appointments are being cancelled by the hospital and rebooked

Integrated C&B crashes the system

C&B is slow or unavailable

The directory of service

When I use C&B, it is not always easy to find the appropriate clinic in a hospital. Each hospital seems to define their own structure. For example, with a patient I referred recently with haematuria (blood in the urine), I selected urology then looked at four different hospitals. One had a haematuria clinic, one appeared to see these patients in a general urology clinic and another treated this problem as a two week cancer wait. Message to hospitals: please simplify and make your DOS more uniform.

Clinics removed because of potential breaches of waiting times

This happens all too often when a hospital cannot offer an appointment before 13 weeks. The hospital has no hope of reaching 18 weeks from referral to treatment, with an expected maximum wait of 5 – 8 weeks for OPD if this is not sorted out. Patients will make a choice based on location and waiting times. What is happening is that their choice of location is all too often being removed because of waiting time targets imposed by the NHS. Real choice is saying to the patient, hospital A-which is your preference-can see you in 15 weeks but hospital B-which is further away-can see you in 8 weeks. That is real choice. One could be forgiven for believing the system is set up to allow performance management to be a simple exercise. Some hospitals reject the C&B referral and then demand the practice fax the referral letter or send it by ‘snail mail’ so they can bypass the system. This just causes more delay and more time for the practice. Message to PCTs and hospital: offer patients real choice and stop manipulating the system.

Very few named consultant clinics

Once upon a time, a GP knew all the consultants at the local hospital and was on first name terms - they were general surgeons or general physicians. Now that we have much larger hospitals with greater consultant numbers-no generalist and all specialists- many GPs do not know their surnames, let alone their first names. It is therefore appropriate that more referrals are generic. This does have limitations because if the GP is not sure about which consultants or which clinic to refer the patient to, when a patient phones to make the appointment, the person dealing with the problem may also not be sure. Too often patients are being booked into the wrong clinic and this is a waste of the patient’s time as well as the clinics.

There are times when GPs do have personal knowledge of consultants and will agree with a patient they should see Dr X or Mr Y for specific reasons. This facility is generally not available because it is too difficult for the hospital to manage waiting times. I will tell patients when they phone to make an appointment and insist on being booked in to Dr X’s clinic. In over 50% of cases the patients are told that this is not possible. Message to PCTs and hospitals: choice does not always mean choice of clinician but there does need to be the facility to allow this to happen.

Too many appointments are being cancelled by the hospital and rebooked

My personal record is five for a patient. If you have a system which allows the patient the choice of appointment times, to cancel this and then send them a rebooked appointment seems to negate the ethos of C&B. I have enquired of hospitals why this has been done and have been told it is because of consultants not being available. When I discussed it with some consultants, I was told the new patients were cancelled because if they were seen and listed for an operation this would breach the in-patient waiting times, so it was better to delay the patient from being seen in OPD.

Message to hospitals: cancellation of booked appointments should be an exception rather than a rule. The “games” that are played to enable targets to be reached need to stop.

Integrated C&B ‘crashes’ the system

Some practices have stopped using the system which is integrated with the clinical system as each time it is used the clinical system ‘crashes’ and so the practice uses the non integrated web based system. C&B will only survive if it becomes faster, more reliable and is seen as a benefit to the clinician rather than something that takes longer and is unreliable.

Message to C&B teams: please make the system faster, more reliable, work within the clinical systems and save GPs and medical secretaries’ time

In conclusion, it has to be right to offer patients informed choice and provide them with the ability influence the time of their appointment. We must make the system easier for both patients and practices. It must evolve to make the referral process faster and more reliable. Sorry, hospitals but you really do need to sort your end out. I know it is difficult but without this the whole system will die!

Dr Nigel Watson is a member of the BMA’s GP committee

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