Choose and stuck

Choose and Book usage has been stuck at around 50% for months. Fiona Barr wonders if there are fundamental problems with the electronic booking system and the model of choice that it delivers.

Choose and Book is suffering from a 40% deficit. That is the difference between the current 50% take-up of the e-booking system and the 90% target that has been in place since 2005.

The difference means that more than four years after its launch, Choose and Book is still far from being the normal method of referral that the government had hoped it would be.

Henry Potts, a lecturer at the Centre for Health Informatics and Multiprofessional Education (CHIME) at University College, London, argues that a fundamental problem may lie at the heart of stagnating uptake. He wonders whether the concept of choice that it delivers is really what patients want.

“The choice they may be offered might be 10am or 10.30am on a Tuesday, when what they might really want – whether or not it is possible or desirable – is Saturday morning ultrasound and Saturday morning consultant clinics,” he says.

Fundamental problems?

Potts, who has led research into Choose and Book, also wonders if Choose and Book was ever really fit for purpose.

“Choice as realised by Choose and Book is the product of a particular government’s ideology,” he argues. “It was stuck on to what was being developed at a late stage and has failed to do what it was trying to do.”

Potts points to the Department of Health’s own choice survey figures as evidence. The latest figures show that 46% of patients recall being offered a choice of hospital for their first outpatient appointment in September 2008. A 40% to 50% recall has been a fairly consistent figure since the November 2006 survey.

Not that much choice

A study published by CHIME last summer, and based on research in 2006, found that 66% of those referred via Choose and Book were not given a choice of date for their outpatient appointment, 66% said they were not given a choice of appointment time and 86% reported being given a choice of fewer than four hospitals.

When the research was published, NHS Connecting for Health argued that the figures were based on research that was two years out of date. But Potts claims figures from the choice surveys have changed little since then, making CfH’s rebuttal unconvincing.

One problem is that the national choice survey figures do not distinguish between patients referred via Choose and Book and by traditional paper-based methods; but in either case it is clear that the majority of patients are still not experiencing a choice of hospital.

Further questions about the effectiveness of Choose and Book were generated in January, when a study by doctors from Lewisham Hospital found ‘did not attend’ rates were actually higher for those referred via Choose and Book than than for patients referred using traditional methods.

David Bowdler, ENT consultant at University Hospital Lewisham, argues that what the vast majority of patients really want is good local services, not the ability to be seen two weeks faster at a hospital 40 miles away.

He and his team plan to do more research into the reasons behind the DNA rate, but one suggestion is that patients may have ended up with a quicker appointment via Choose and Book whether they wanted one or not.

Mr Bowdler adds: “Patients can be referred here from Croydon simply because of the shorter waiting time when actually they don’t want to travel from Croydon to Lewisham for their appointment.”

Varying experiences

Meanwhile, there have been persistent complaints from some GPs that Choose and Book is difficult for professionals to use.

Dr Paul Cundy, a GP in Wimbledon and former chair of the Joint IT Committee of the BMA and Royal College of GPs, argues that the system could get up to 70% usage if it was made “slicker, faster and more user friendly.”

He does not currently use the system – although some of his partners do – because of frustrations about the time taken to make appointments and the difficulties patients have in getting through on the appointments line.

He adds: “I’m very keen on using IT, but at the moment it’s not helpful to me and I think lots of GPs feel the same. The fact that usage is still around 50% does suggest that more works needs to be done to improve the system.”

However Dr Amir Hannan, a GP in Chorley, Greater Manchester, believes Choose and Book is simply a reflection of the way the world works in 2009, with choice over every aspect of life from holidays to healthcare.

“If its not working as well as it should be then we just need to sort that out. There is no way we can go back to the old days of ‘I’m going to refer you but you won’t know where or when.’”

He says while many of his patients will choose the local hospital in other instances the system comes into its own. He adds: “I used it this morning for a patient who had shoulder pain and was very distressed after being seen by at least two doctors with no result. I was able to refer her to someone in a different part of Manchester who had told me he was doing some good things with shoulder surgery. I found her an appointment within 10 days and the way it worked was just stunning.”

Not changing working practices

Criticism of Choose and Book was raised in a recent report by the BMA which found that, in some practices, the reality of Choose and Book was very different to the system as envisaged by the government.

For instance, at the practice end choices of appointment bookings were sometimes delegated to reception staff rather than being made with clinical input. And at the hospital end, most letters sent electronically were then printed out for the consultants to review with only a “tiny minority” of consultants reviewing letters electronically.

The BMA report said: “Potential benefits – including letters not going missing, a clear audit trail, confidential exchange of information directly between clinicians and a reduction in administration – are largely lost when the letters are printed out and sent back and forward between the booking office and consultant.”

The BMA concluded that while the system was working welil for some, GPs and consultants were still struggling to make the system work as intended.

For its part, the national Choose and Book team has been working hard to tackle issues like slot availability, which led to one in five patients being unable to book an appointment through Choose and Book last year, and to make the system itself more user friendly for both hospitals and GPs.

Whether such fixes will get to the root of improving awareness of choice and take up with Choose and Book remains to be seen.