Published: 17/03/2005, Volume II5, No. 5947 Page 4 6

Despite opposition from GPs, the roll-out of choose and book will continue unabated.

Alexis Nolan talks to the system's beleagured champions, and opposite Lyn Whitfield meets some early adopters

If a week is a long time in politics, what's a month? If you're involved in the choose and book programme the word nightmare probably springs to mind.

Within a matter of weeks of interviewing choose and book programme director Claire Mitchell and clinical director Dr Michael Thick, the ground quickly shifted under the programme. January's National Audit Office report highlighted low levels of support from GPs and an electronic booking system some way off its ultimate target. And more recently HSJ reported that the government is insiting GPs wanting to take up practice-based commissioning will have to implement choose and book (news, page 6, 3 March).

While it is fair to say the programme has never been without its detractors, Ms Mitchell and Dr Thick are robust defenders of what has been achieved so far, and what can be achieved before the end-ofyear deadline. 'Mass roll-out is what we are looking for, ' says Ms Mitchell.

'It will not be 100 per cent but it will be as close to that as we can get.' If she is unwilling to be more specific, the NAO is not. It says the national programme for IT expects that by the end of this year 60-70 per cent of hospital patient administration systems and GP systems will be linked to the electronic booking service.

Five early adopter trials in London, Derbyshire and Yorkshire started in July last year, and electronic referrals are now being made in six health economies. The choose and book programme decided to focus the pilots on a small number of areas and only a handful of GPs and acute trusts for a limited range of specialties.

'A huge amount of work was done with the secondary and primary care providers to get us a really good basis so that we can go in and start being aggressive this year, ' explains Ms Mitchell.

The programme worked hard on making sure existing hospital and general practice systems could be compatible with the core software, which links to the NHS national data spine. But there have been problems along the way. The programme has had to overcome an intermittent fault with authentication, which prevented access to e-booking. Another is that although four types of GP systems can be linked to e-booking, the largest, Emis, has not yet agreed an implementation plan.

The electronic booking system has been designed to handle 15 million referrals a year, but by the end of last year just 63 live bookings had been made. Earlier estimates had been for 205,000 bookings by this date. The figure does the programme no public relations favours and, combined with complaints from GP bodies about security, confidentiality and practicality, has put the programme on the back foot.

GP resistance

The GP issue is something that clearly needles those involved in the programme. 'The system and service as It is currently configured will do everything that people do now and a whole lot more. And obviously its primary intention is to make the whole process of getting patients through their clinical encounters much more efficient, ' says Dr Thick.

'The professional organisations took the cautious view first. They focused on trying to show that there was a problem; first, that we hadn't done any communication or engagement with the clinical fraternity and second, far from keeping the patient/doctor confidentiality sacrosanct, it compromised it.' Dr Thick disputes the first charge by pointing out that the reform of patient booking has been under way since 1998. 'All the processes that were designed and covered from then until now have been built into the new service. That means that, given that there were 46 pilots for booking at the end of 2002, we have touched probably 3-4 per cent of the NHS as a whole. If you think of the number of people we have had to talk to to be able to do that it is enormous. The gathering of clinical views is very considerable.' That has been followed up, he says, with monthly meetings over the last two years of the National Clinical Reference Panel - 'an accumulation of the great and the good, the interested and the knowledgeable' - to scrutinise what was going into the service and the way it was done.

'All the people working with us have been out into the service to talk to those communities that are interested in starting. We have got pages and pages of events that have touched a massive number of people in the NHS, ' says Dr Thick.

'So we get a bit cross when people say we haven't consulted because the opposite is true. We have done a massive amount of consultation.' This is not just at national level but locally; every month the programme meets with the booking and choice leads of strategic health authorities. 'We have taken great trouble to explain to everyone who cares to listen that the service does not threaten the way they behave, it only improves it, ' adds Dr Thick.

He blames much of the reticence on the coincidence of change and modernisation in the health service and the movement of consumer focus from the wider public sector into health.

'It is part of the culture of the way the place used to work. So It is perhaps not surprising that people tend to be reactionary to it despite the fact that It is a very good idea.

People think because the government said e-booking was good, it has to be resisted - It is as nonsensical as that.' But It is clear that GPs feel neither engaged nor comfortable with the system and the whole concept. A survey of 1,500 GPs as part of the NAO report found that 94 per cent knew little or very little about choose and book and 92 per cent felt they had not had the opportunity to feed into consultation on the programme.

The fact that 46 per cent were not aware of the end-of-year requirement to offer four or five choices for elective surgery is alarming.

However, more than 40 per cent of GPs said choose and book offered greater convenience to patients and greater patient involvement in treatment decisions, and 30 per cent thought it could reduce did-notattends.

A Medix survey of 900 doctors for Computer Weekly last month showed that 70 per cent of GPs thought the new system would be less secure than current methods.

At an NHS Alliance event last month, journalists were allowed to stay on to see a demonstration of choose and book to some of its executive members, including a staunch opponent. Many of the GPs appeared to know little about the system, but by the end of the session they were generally positive - especially about the fact that GPs themselves do not have to make the booking for patients.

They can give them the options and the patient can then explore them and confirm a booking either through another member of practice staff (usually a receptionist), or by themselves through the internet or a call centre.

Time sensitive

Nonetheless, the amount of time spent with patients running through the software remains one of the programme's main stumbling blocks.

Royal College of GPs health informatics standing group chair Alan Hassey says: 'We have major reservations about the current model, which seems to have up to 17 steps to take before the choose and book process can be completed. We do not think this is workable.

However we are optimistic that the system can be modified to meet the needs of patients and GPs.' Although this may not be what the programme wants to hear, at least the college is in some senses working from within. Two of its members, ex-chair Professor Mike Pringle and Dr Gillian Braunold, are choose and book clinical leads and are discussing with stakeholders away from the limelight how improvements could be made. They are due to report their findings later this month.

In the meantime, use of choose and book is increasing. While 14 general practices and eight acute trusts were live in February, the programme is expecting this to rise to 40 and 14 respectively by the end of this month. A marketing drive this spring will be followed by a major roll-out in the summer.

However, progress has not been fast enough to avoid the introduction of interim solutions to try to ensure that the choice target is met. If a GP's system is not compliant, they will be able to access choose and book over the internet, but may still have to send paper referral letters.

If a hospital's system is not compliant, its appointment dates and times will not be available on choose and book. If a patient chooses such a hospital, the hospital will have to contact the patient to agree a date for a consultation.

Ironically, while this may help the government meet its choice target, the NAO warns that the introduction of interim measures could detract from the efforts needed to introduce full e-booking, confuse communication strategies and set back clinical engagement.

The arguments will continue, but the system will continue to be rolled out. For Dr Thick it will not be soon enough. He supports the need to change from the 'inconvenience' and time-consuming nature of the current process. 'Last month, someone in my family needed a consultant appointment. It took five phone calls. When they turned up, the consultant wasn't there. Then three days after the appointment we got a letter saying please ring to take up the appointment two days before, ' he says.

'I work on this stuff [choose and book] and I think how can this happen, It is just so awful. This is going to be a godsend, an absolute godsend.'

Find out more

Patient Choice at the Point of Referral , National Audit Office

www. nao. org. uk

Choose and book

www. chooseandbook. nhs. uk

Key points

The National Audit Office predicts that 60-70 per cent of hospitals and GP practices will be linked to the electronic booking service by the end of the year.

By the end of last year the system had seen just 63 referrals, despite an earlier target of 250,000.

Various surveys continue to show strong suspicion and lack of knowledge among GPs.