A pioneering computer system hopes to take some of the paper and pain out of the referral process.

The government has said booking hospital appointments should become as easy as booking hotel reservations. King's College Hospital has implemented a programme to achieve this goal. Part of the project is to promote electronic referrals from GPs to outpatient clinics.

We started a pilot scheme in October 2000. The aim was to beat the shortcomings of the traditional system, which can take up to three weeks by the time the GP has written or dictated a letter to the consultant, the letter has passed through the post room, and the consultant has forwarded it to the appointments clerk.

Under the pilot, the GP completes the electronic referral protocol, and the patient goes to the practice reception where they will be offered a choice of appointment times and dates. An appointment is booked online and the patient is given a printed confirmation.

The sheet has instructions about which department to go to and a named appointments officer with a direct telephone number at the hospital.

At the hospital, the consultant opens the referral screen and confirms that it has been read.

Appointments can be brought forward if necessary.

The system means that patients suffer less delay and have more choice and time to plan their attendance. For GPs, the system means no lost referrals and better communication between primary and secondary care.

CCS Revive was the chosen communication software. It is highly rated and already in use at Lewisham Hospital, which copes with a large number of GP referrals. The system works through NHSnet and the practice must have a full local area network (LAN) connection.

Every GP needs a desktop NHS connection, as does the practice nurse and the appointment maker.An extra printer in the practice reception is needed for appointment confirmation.

We held a launch meeting to introduce primary care staff to the project.We invited GPs to take part.

Two who were particularly enthusiastic became part of the project implementation team, which comprised:

na project manager, responsible for overall management of the programme and the introduction of the scheme to all interested parties;

nan information management and technology co-ordinator, responsible for liaison with software supplier CCS, the development of the project initiation document and the detailed inventory of requirements;

na project nurse to develop the referral protocols with consultants and GPs;

nan IT trainer for GPs, hospital consultants, practice staff, receptionists, hospital secretaries and anyone else involved in the process.

Six practices volunteered for the pilot.

They were some of King's biggest referrers.

Eight protocols were ready for the pilot, with a plan to develop a protocol for every condition/specialty/disease by summer 2002.

Protocols are now available for respiratory medicine, dermatology, cardiology, breast, thyroid, hernia, vascular surgery, pain, colposcopy, urogynae/urodynamics, general gynaecology, menopause, menorrhagia, colorectal, urology, paediatric dermatology, gastro/upper GI (dyspepsia), diabetes, care of the elderly, paediatric respiratory wheeze and paediatric general surgery.

Protocols are in development for rheumatology, medicine/general surgery, maxillo-facial, orthopaedic, endocrine and ophthalmology.

Once a GP practice agreed to use the system, training was arranged within a week of the date set to go live. All members of a practice team would be trained at the surgery.

Training a GP takes about 40 minutes and reception staff about 20 minutes.

Each practice was asked to identify an 'expert user' who would know the whole system and could train new users and act as a troubleshooter. King's has a helpdesk for any difficulties, but even if the practice system crashes, a GP can still refer.

In the event of the King's IRC patient administration system crashing, the GP can still complete the referral details, and the patient will be asked to call for an appointment later.

Once the pilot started, a monthly user-group meeting was convened, involving the practice expert or practice manager, two hospital consultants and two GPs from the implementation team. Users' suggestions for software changes were sent back to CCS. Response times from CCS to any queries or issues were extremely quick.

The consultants did not attend many meetings as they did not experience problems. They have a simple system: the referrals are logged on their homepage, which they have to check daily.

They ensure that someone else checks them in their absence. They have to confirm when they have read the referral and respond to any requests from GPs for advice and guidance. The helpdesk logged calls and recorded problems and solutions that were then discussed at the user group.

Results Twenty-four of 160 referring practices are now online and over 1,878 referrals have been received;

we have also recived 146 GP requests for advice and guidance. Though it is too early to have a clear view of the system's impact, it appears to have reduced non-attendance at outpatient clinics. Nonattendance for appointments booked electronically is about 8 per cent, compared with 20 per cent for those booked in the traditional way.

Though encouraging, this suggests that patients will still, on occasions, fail to attend, despite being given the opportunity to arrange convenient dates to come to hospital.

The system does involve a considerable culture change for GPs, many of whom are not happy with a keyboard, and fear an increase in workload. There is also a misconception that GPs must make the appointment, while, in fact, receptionists can do it.

It is possible that if more day-to-day support were available, more GPs would become involved.

Patient benefits Nationally, all patients with cancer or suspected cancer must be seen within two weeks, and so the CCS system supports achieving this target.

The CCS protocol-driven system is designed to alert GPs to alarm symptoms when referring patients, and will alert GPs and receptionists if a two-week target date is required. Each GP receives monthly updates on waiting times for first available outpatient appointments.With this information and the new referral process, the doctor can choose whether to refer to a specific consultant or not.

The CCS system is designed to be completed with the patient present, so they can book their appointment online.However, some GPs choose to do this at the end of the surgery session. In this case, the patient is asked to telephone the practice within one working day to book the appointment (some practices have suggested patients can telephone at a given time during the day to minimise disruption within the practice).

The national objective is to ensure that appointments are offered and agreed within 24 hours of the decision to refer.

One of the most common questions is: 'How long does it take to complete the referral protocol?'There is no definitive answer, as it depends on the length of the protocol and the complexity of the patient.

Cardiac referrals, for example, may take two or three minutes to complete, whereas the care of a patient who is elderly is more detailed and may take longer.

The practice receptionist makes the appointment and, at this point, demographic details will be checked to ensure the hospital has the patient registered at the correct address.

Should the patient have a long medical history, the doctor can type 'see GP notes' in the free text boxes and add relevant information into the GP notes box at a more convenient time.This enables the appointment to be negotiated with the patient, but gives GPs the freedom to complete information after the patient has left the surgery.

CCS has developed an interface with EMIS, a practice system supplier, which enables common clinical information about the patient to be transferred into the protocol automatically - for example, past medical history or current medication.

Junior GPs tend to be happier with protocols, preferring easy prompts to writing a 'good' referral letter.GPs accustomed to writing referral letters find it a bigger step to change the way they work.

Many GPs are not keyboard literate, so completing the referral electronically involves a steep learning curve.This can be slow and embarrassing in front of patients, which is why some GPs prefer initially to complete it after the patient has left.

On average, two or three referrals have been made per day per surgery, with a relatively small impact on doctors' time. Even so, one practice extended its morning surgery by half an hour with the same number of patients and found this gave it the extra time it needed.

One benefit for consultants has been that they no longer spend large amounts of time vetting letters to determine urgency.

The answers to the questions will dictate urgent, routine or cancer target.

GPs' input into the development of the protocols is very important, and once the GPs use them we get feedback and can easily amend something that has been forgotten or does not add value.

The future for the programme is that all specialties will have protocols and all GPs will be connected so that electronic booking is the normal way of referring.

Booking systems will need to be developed throughout the patient journey so that by 2005 patients will be able to book any aspect of their healthcare, wherever it is provided.

The next phase of the programme includes a booking system for diagnostic purposes, so appointment dates for diagnostic and investigative tests can be arranged at the outpatient appointment.

For the patient, a faster, more efficient, referral process means more choice, fewer hospital visits and shorter waiting times, which alleviate some of the anxiety related to coming into hospital.

Jill Solly is booked admissions project manager, King's College Hospital.

Key points

A pilot electronic booking project for outpatient appointments at King's College Hospital, London, has been well received by consultants.

But only a minority of practices are taking part - only 24 of the 160 local practices are participating.

A considerable culture change is needed to persuade practices to become involved.

GPs accustomed to traditional referral letters find electronic referrals a big step.

More day-to-day support might encourage GP involvement.