Published: 16/09/2004, Volume II4, No. 5923 Page 12 13

Choice at the point of referral is taking the NHS into largely uncharted territory.

By December 2005, patients requiring planned hospital care will be able to book appointments from a choice of four or five hospitals (or other alternative providers) at the point of referral.

It is called 'choose and book'.

In late August this year, the Department of Health issued policy guidance for choose and book, while the national IT programme issued a detailed delivery framework covering the electronic services needed to deliver choice at referral. The NHS is now busily digesting these documents as it begins to develop the services.

Meanwhile, many health economies are pursuing pilot projects.

The DoH and national IT programme guidance as well as the local experience of delivering choice at the point of referral are raising important issues and controversies.

What does choice mean?

A patient sees their GP and needs a referral to hospital.Under existing arrangements, the GP would write a referral letter to a named consultant which usually results in an appointment at an outpatient clinic some time later.

Under choose and book, patients are offered their choice of four or five hospitals and the opportunity to book a convenient appointment with the appropriate consultant within the next 13 weeks via a computerised system.

DoH guidance says that patients must have the necessary support to make their choice in terms of information and the chance to discuss the clinical implications of any decision.

The four or five choices offered to patients will be drawn from 'choice menus' developed by PCTs. Patients will not normally be allowed to select care from trusts not listed on these menus.

Two models are being explored.

The first involves GPs referring a patient directly via their desktop system. This requires the national IT programme and primary care trusts to get the technology on to GPs' desks in time for the December 2005 deadline.

The second model would see a GP referring patients to a 'clinical assessment service' (CAS) for a clinical decision about their future treatment. Once a clinical assessment has been made, it would be the CAS that offers choice and books appointments (see diagram, opposite), or organises further investigations.

This is the option favoured by many PCTs, not least as it acts as a triage, double-checking whether GPs are referring appropriately.

Many PCTs are turning their referral management centres (call centres used to manage patient referrals under choice at six months) into clinical assessment services by bringing in additional clinical expertise. Some are setting up their CAS within NHS Direct. The DoH says using a CAS must not introduce delay into the referral process.

What does choice mean for PCTs and SHAs?

Choice at the point of referral has huge challenges for PCTs and SHAs, with an SHA choice lead from the South West declaring that: 'Choice is going to force us to rethink the remit of PCTs.'

These challenges include setting up 'directories of service'. These are the bibles of choice - detailing what services are on a PCT's choice menu, along with vital information such as waiting times, quality and location. PCT managers say this will be a demanding and potentially onerous task.

The directories will only be one element of providing information for GPs and the public to support choice-making. PCTs are working with public health colleagues and voluntary groups to look at patient information needs.

A PCT choice director said: 'You cannot assume that everyone has access to the internet or can even read. Some patients will need more support than others and some GPs are going to need support to deal with patients who tell them: 'You decide, doctor. You know best.'' Choice also requires PCTs to add a new, and very significant, element to the ongoing drive to encourage clinical engagement with the reform process.

An SHA choice lead warned: 'If electronic booking is delayed, the danger is that GPs will look at the system once and decide that it doesn't do what they need and reject it.'

An acute trust manager explained that consultants stand to lose a high degree of control over which patient they see and when. This could, he suggested, cause concerns that their professional role was being undermined and that choice would turn them into 'technicians', simply carrying out the work to be determined by others, with little influence over the scheduling of individual patients or the flexibility to see patients urgently or transfer them to a colleague.

Choice will also have a huge impact on the commissioning of services. Many PCTs are working together to develop joint commissioning approaches. This is partly to increase their buying power - particularly with the independent sector without which most PCTs will not be able to offer four or five choices within a reasonable geographic area.

The instability that choice will introduce into the NHS - with patients flowing across boundaries in a way that could prove difficult to predict - will also require the development of sophisticated commissioning and monitoring arrangements.

SHAs are trying to strike the right balance between making sure central expertise is available and pushing commissioning to the front line - even as far as GP practice level, another highly significant new policy being introduced in parallel to choice.

Finally there is the training challenge. Choice will involve a wide range of people. One SHA estimated it would eventually have 50,000 staff involved in choice at the point of referral, all of whom would need training. l What are the target dates?

From January 2005, patients requiring cataract surgery will be offered a choice of hospital at the time they are referred for treatment.They will be followed in April by patients who need a heart operation.By December 2005, choice will be extended to almost all patients, through there are some exceptions.By then patients should be able to take advantage of the national IT programme's computerised choose and book system at the time of their referral.

A number of 'early implementers'will be starting choice at the point of referral from this month.

The limits of choice The choose and book policy framework sets out a series of exemptions to choice at the point of referral.

These include:

Patients attending a rapid access chest pain clinic under the two-week maximum waiting time;

Patients attending cancer services under the two-week maximum waiting time;

Maternity services;

Mental health services;

Some paediatric services;

Secondary and tertiary services.

Where there are what the DoH guidance calls 'real capacity constraints', SHAs can allow PCTs to limit choices. There is little clarity about what constitutes 'real' constraints on capacity, as opposed to - one assumes - those claimed by trusts which simply do not want to receive choice patients for financial or other self-serving reasons. Equally, it is not clear how the SHAs would exercise their judgement in practice.

Patients will be offered choice for an entire elective care episode, from outpatient appointment through to treatment.

What does choice mean for acute trusts?

Choice will pitch acute trusts into competition for patients with each other and with the independent sector.However, it is generally accepted that a successful choice programme will depend on close collaboration between trusts and PCTs - for example, in commissioning services so as to ensure the viability of specialties or in developing patient pathways and protocols for referral.

However, even such hand-in-hand approaches to the challenge of choice leave acute trusts grappling with some thorny issues.These include:

How do trusts make sure they can deliver on 13-week appointments when staff give only six weeks' notice of leave?

What happens when all appointments have been taken? Can trusts still receive patients who choose to be treated at the trust?

What happens if large numbers of routine patients choose to move to an independent provider or another NHS unit? Some trusts fear that this trend could leave them with a high proportion of complex cases.

This would have a knock-on effect on outcomes which in turn could affect its reputation and star-rating, and therefore the attractiveness of the trust to patients exercising choice in the future?

Trusts with multiple sites will count as one provider against the requirement of four or five choices - but must offer patients a further choice of which site they attend for their appointment or treatment.This is a change from earlier drafts of the guidance and is proving 'challenging'.

How a cataract patient might exercise choice, based on the pilot scheme currently running in west Yorkshire. In the past, the optometrist would refer the patient to the GP who would write a letter to the hospital who would write to the patient with an appointment time for outpatients.