Why did GPs turn their back on Choose and Book?

NHS England has scrapped its £356m outpatient booking system, Choose and Book, which was largely ignored by doctors

NHS England has decided to scrap its £356m outpatient appointment booking system, Choose and Book, despite it being regarded as one of the few successes of the failed £12.7bn National Programme for IT (NPfIT).

The system was introduced in 2004 to enable patients who needed an outpatient appointment to select, with their GP, a hospital appointment at a convenient date and time.

The aim was to speed up the process and cut out the paperwork, but it wasn’t widely used by doctors and hospitals because of difficulties integrating the system.

Choose and Book is now due to be replaced by the new e-Referral Service later this year.

Another NPfIT failure

The Choose and Book system had been criticised for a number of years. Back in 2006/7, the Department of Health set a target of 90% of hospital referrals to be made through the electronic Choose and Book system but, two years later, the NHS was still falling well below, with an uptake of around 40%.

Earlier this week, a public accounts committee (PAC) report said the use of Choose and Book by GPs across the UK had been variable. It stated Northampton General Hospital used the system to book “most, but not all” of its appointments, while Homerton University Hospital said a significant number of referrals were made on paper.

NHS England told the PAC that many GPs like Choose and Book, and that half of all referrals are received this way. The National Audit Office estimated that additional savings of up to £51m every year could be made if Choose and Book was used to book all appointments.

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Why did Choose and Book fail?

John Black, president of the Royal College of Surgeons, warned in 2009 that the system was “forcing patients and doctors apart”.

But why did some GPs refuse to use the Choose and Book system?

Dr. Richard Vautrey, deputy chair of the BMA’s GP Community and a GP in Leeds, told Computer Weekly that GPs felt the Choose and Book system wasn’t fully integrated with existing systems in practices. “It never worked very quickly or instantly,” he said. “And, in a ten-minute consultation, it wasn’t possible.”

He said when GPs got onto the system and searched for the availability of hospital appointments, the hospitals hadn’t made enough available. “And when you’re pressed for time in consultations, you can’t be spending time looking for hospital appointments that don’t exist.”

This left patients frustrated with the lack of availability. “There isn’t enough capacity in the system to deliver what people were expecting,” said Vautrey.

He said the practices which wanted to use the system often had to leave it with secretarial staff to follow up with patients after consultations.

Too prescriptive

A previous head of information governance at a hospital in England told Computer Weekly Choose and Book wasn’t used widely by NHS GPs and hospitals because it was “too prescriptive”.

He said the system was tied to local clinical commissioning contracts, so if a patient wanted a procedure from the best surgeon, but the surgeon worked at a hospital that wasn’t in the clinical commissioning group, Choose and Book wouldn’t offer an appointment with them.

GPs, by their nature, want the best for their patients, and so many chose not to use the prescriptive system.

Beverly Bryant, director of strategic systems at NHS England admitted this week that the NHS was aware Choose and Book had been hit and miss for some practitioners.

“But we know that Choose and Book has worked for some and not for others, and a combination of electronic and paper referrals is still being used in some areas,” she said. 

“With the new NHS e-Referrals Service we want to build on the successes of Choose and Book and use the lessons learnt. This isn’t about re-inventing the wheel, it is about taking the next step.”

She said NHS England must understand what referring clinicians and organisations want from the new system.

“Managing a mixed economy of paper and electronic referrals is onerous for hospitals and the lack of total slot availability makes it difficult for referring GPs to move away from paper,” she said.

E-Referral IT procurement

Atos Healthcare currently runs the Choose and Book contract, which is due to run until December 2014. The NHS told Computer Weekly that a number of contracts have already been let for the replacement e-Referral Service, including the initial development software which was procured over the G-Cloud framework and won by BJSS in July 2013.

Another contract to replace the NHS Appointment Line service was signed to Conduit in March 2014 and tendered over the Department of Health Managed Contact Centre Services Framework, and InTechnology has also been contracted for the e-Referral service Infrastructure-as-a-Service contract, which was also procured over G-Cloud and signed in March 2014.

The NHS said: "Further tenders for future development and support will be issued in 2014 and beyond."

A new NHS e-Referral Service

The NHS announced this week that it plans to replace Choose and Book with an e-Referral Service by the end of the year, using the latest agile and open technologies to drive up utilisation.

“The new NHS e-Referral Service will harness some of the new technologies used by the most successful IT companies in the world and, using the latest agile development techniques, will deliver a service designed and assured by the users, that patients want and the NHS needs to deliver modern and efficient healthcare,” said Bryant at NHS England.

But Vautrey said that the new e-Referrals system will have to be as easy to use as e-Prescription to succeed.

“All GPs will use electronic methods rather than handwriting because it is easier and simpler,” he said. “No GP will handwrite a prescription because it is easier on computer.”

During the PAC hearing, the idea of imposing an incentive and penalty scheme for doctors and hospitals was raised.

Vaultrey said that a penalty system would be completely the wrong idea. “If an IT system works, is not clunky, doesn’t get in the way and is timely - GPs will always use it,” he said.

The Computer Weekly source agreed and said that the penalty scheme would be a “bullying tactic” to get GPs to use a system which he said may turn out to be “Choose and Book by a different name”.

He said the only way to make the new system successful would be to widen the net and make commissioning healthcare easier and to provide more choice when booking appointments. 

Empowering patients

Vautrey also said the e-Referral system needs to be easier for patients to use and be “no more difficult than booking a train journey”.

The PAC meeting agreed and suggested the new service should be available via a mobile application so patients could change appointments more easily.

“When you do that, there’s no need for the GP to be involved in process,” he said. “If patient does it all, the GP only has to upload a referral letter.”

“We need to be empowering and encouraging patients to take better care of their healthcare,” said Vautrey.

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