Two years on from the launch of the national booked admissions programme,£65m has been invested; but how has the first wave of 24 pilots performed?
A wide-ranging second interim report by Birmingham University's health services management centre paints a mixed picture of the innovation, which is supposed to make booking an NHS appointment as easy as booking an airline flight.
Launched as part of the NHS modernisation strategy, it is all about making sure the patient agrees a hospital appointment or admission date at, or close to, the time a decision is made that this is what is needed. To date there have been three waves of pilots.
There is an NHS plan commitment to introduce booked admissions into every acute hospital trust in the country by spring 2001. For daycase bookings, the report reveals 'real progress', made easier 'by the existence of dedicated resources and waiting times shorter than six months'.
As for the thorny area of inpatient booking - that has proved 'much more difficult to implement' and nothing more than 'a start' has been made.
Daycase booking has 'increased appreciably in all specialties'. The proportion waiting for admission with a booked or 'to come in' (TCI) date increased from 50.4 per cent to 71 per cent for the first three months of 2000 compared to the same period the previous year. There was also a cut in 'did not attends' (DNAs) from 5.6 to 3.2 per cent, and patient-initiated cancellations fell from 12.8 to 11.9 per cent.
The number of patients waiting for admission dropped by 5.2 per cent - not much different to the experience of non-pilots. The decrease in waiting times was 'slight'.
For day cases, two key monitoring measures - the percentage of patients waiting with a date and the percentage of DNAs - have shown most improvement in gynaecology and oral surgery compared to other specialties.
The Department of Health will have to concentrate most of its energy on inpatient bookings if it is serious about delivering on the NHS plan promise to roll out booked admissions to all treatments and outpatients by 2005.
Booking inpatient treatment is harder, says the report, 'because of the absence of ringfenced facilities for elective services, the lack of spare capacity, and the risk of emergency cases making use of facilities needed to honour the booked date'.
Overall, for the 14 pilots offering inpatient booking for some inpatient activity, the proportion of patients with a booked or TCI date increased from 37 per cent to 48 per cent. Only four pilots were able to increase the proportion of patients waiting with a date by more than 10 per cent.
Worryingly, in terms of the£10m invested by the government in the first wave, urology and orthopaedics have seen increases in the number of inpatients waiting - mirroring the trend in the non-pilots. Also, although overall there was a reduction in the number of people waiting, waiting times deteriorated slightly.
According to health minister John Denham, the report says 'booked admissions do work', and 'it is possible to increase access and convenience for patients and make better use of NHS resources'. But are the improvements so far anything more than marginal, given the millions spent on the pilots?
On a brighter note, the government will be delighted to learn that patients like booked admissions, with the 'vast majority' satisfied with their experience. 'The reported benefits of booking include being able to arrange child care, absences from work and transport to and from hospital.'
Fourteen pilots have introduced booking from general practice to secondary care using a range of methods, including fax, e-mail and electronic schedulers. But progress has been 'slower than in either day-case or inpatient booking'.
One of the key difficulties is that 'many GPs already run a highly pressurised appointment system', so the rolling out of electronic booking needs to reconcile 'the time available to see patients and the demands involved in booking'.
Also, when the pilots began, not all GPs were connected to NHSnet. The technical issues have 'largely been addressed', the report says, 'but the difficulties. . .
have affected the commitment of GPs and others'. The answer may be a period of consolidation using 'less sophisticated connections' such as fax or e-mail.
Consultants are 'increasingly enthusiastic' about the benefits to patients and themselves, but a few say that far from cutting inappropriate demand 'there will be more referrals as GPs refer patients to what is seen as a more convenient service', despite the use of protocols.
The leadership and training provided by the National Patients Access Team has been 'key' to the progress made so far, the report concludes. NPAT spokesman Richard Green says that the evaluation so far has shown that 'we can do booked admissions and the patients like them'.
He adds: 'In terms of what we hope to achieve, booked admissions have given us a glimpse for the future in terms of how we may be able to provide patients with certainty and choice for their care.
'The first wave has shown us much and those pilots have put in an awful lot of learning. Daycase booking has been particularly successful. We are learning a lot more from the second and third waves.'
NHS Confederation policy director Nigel Edwards says the pilots' performance has been 'really quite impressive' and 'showed the power of local bottom-up development'.
He says there has to be a certain amount of ring-fencing of elective capacity if bookings are to be honoured. Mr Edwards adds:
'Small changes in the system have huge consequences, but you have to change the whole system. It would not be realistic to think booking by itself is going to reduce waiting lists. It's part of a whole-systems redesign. One has to constantly remind people responsible for policy-making that you need sets of interventions, and those have to be dovetailed.'
It is the NHS plan, with its promises of more beds, staff and equipment, that holds the key to the success of booked admissions.
'This will allow effort to be concentrated on the outstanding cultural challenges involved in delivering the targets set out in the plan.'
So far, there is no sign of booked admissions delivering noticeably shorter waiting times, despite the rationale behind the programme that waiting lists appear 'increasingly incongruous in an era when patients expect to be active consumers of healthcare'.
As one consultant involved in the pilots said: 'Healthcare is the only thing we have to queue for and this has to be removed.'
The pilots' patients are still queuing, albeit clutching a letter with an appointment date. But they seem content and that may be enough in itself to keep the politicians happy.
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