Published: 17/03/2005, Volume II5, No. 5947 Page 4 5

North London's Whittington Hospital is a building site. Behind its busy accident and emergency department stands a huge and controversial private finance initiative project. Work has come to a halt, as a result of the problems of its main contractor, Jarvis.

Less apparent to onlookers, a few departments are working to deploy the complex and nearly as controversial choose and book IT system. Work has certainly not come to a halt, but progress cannot be described as rapid.

Since choose and book went live across the Haringey health community last summer, just 24 bookings have been made to the Whittington and its near-neighbour North Middlesex University Hospital.

One reason is that few GPs are actually using the system. Although 11 practices are due to go live this spring, just two are using the system at the moment. Another reason is that they have few specialties to refer to.

Dr Peter Christian, a partner at the Dukes Avenue practice in Muswell Hill, counts just eight specialties across both hospitals with services that he can book into when he logs on to demonstrate the system. However, just as those at the Whittington say building work on its PFI project is about to resume, those involved with choose and book in Haringey say its roll-out is about to pick up momentum.

The Whittington's experience of ebooking predates the introduction of choose and book. Medical director and lead consultant for general surgery Celia Ingham Clark says a system for colorectal and gastroenterology was developed as far back as 1997.

She says the idea was to give GPs more control over the referral process and to build in guidance for them at the point of referral so that patients were more likely to get 'to the right place, to see the right person' first time.

Early learning An audit of the system confirmed referrals had indeed become more timely and appropriate. It also showed that electronic booking cut did-notattends from about 22 to 5 per cent.

With this experience behind it, the Whittington was asked to become one of four early adopters for choose and book, working with Haringey teaching primary care trust and North Middlesex.

Rumours soon surfaced in the press that there were problems with the choose and book system and concerns about security. Also, that it was proving difficult to integrate with existing systems and that it wasn't working with the national 'data spine'.

The national programme for IT says all four early adopters received the first version of the system from provider Atos Origin, and that it had the functionality demanded by the original specification, which has now been updated. Release two is due later this year.

Dr Christian says there were glitches, but the problems have been sorted out and that he is disappointed with the reaction of the media. 'I feel a mixture of fed up and totally dismayed by what the GP comics write about choose and book, ' he says. 'I didn't expect an all-singing, all-dancing system from the off. I've enjoyed being involved in sorting it out, and I remain very enthusiastic about it.' Nor does security seem to have been a major concern in Haringey. Everyone involved can show off a photo-ID smart card that has to be inserted into a reader before they can log into the system, using a password. Different users get access to different levels of information.

But integration has been an issue.

And roughly 50 per cent of Haringey's practices have systems supplied by Emis, which has yet to agree an implementation plan for choose and book. The national programme says it is in 'conversation' with Emis and other suppliers about this.

This doesn't mean GPs with Emis systems can't use choose and book, but it does mean the two can't be fully integrated.

Spine trouble

Choose and book uses elements of the national data spine, including the messaging service, the patient demographic service, security features and the database of organisations and clinicians.

But choose and book is not integrated with the spine when it comes to one critical element: the exchange of clinical information.

Although in fairness the national programme says it was never intended to be at this stage.

Once Dr Christian has identified his patient, he gets a unique booking reference number. Then he has to select a specialty, and after that a clinic.

Once he has done this, a letter is generated for his patient containing instructions on how to make an appointment by phone or online. A referral letter is also generated which can be sent to the hospital as an attachment to the booking.

The data spine, in other words, is not used for transferring clinical data. Dr Christian admits this may be one reason that confidentiality has yet to arise as an issue. 'The idea of an electronic letter to the local hospital is not worrying, ' he says.

Nevertheless, he wants the system to do as much as possible. He wants his patients to be able to book hospital appointments as easily as he can book flights.

He wants bookings to generate blood tests and other tests automatically.

He'd like to be able to include more information from his existing systems in referral letters, and to be able to exchange e-mails with consultants.

But Dr Christian admits 'it is all a bit frustrating because of the limited number of specialties to refer to. I have been begging them to get something like dermatology online, so we can get lots of people going through. That is when we'll find out if it really works.'

Four specialties are now covered by choose and book at the Whittington:colorectal; general haematology; lumps and bumps and general surgery; and vascular. The trust is working hard to add gynaecology. North Middlesex can already manage gynaecology, along with colorectal, vascular and reproductive medicine.

Whittington Hospital choose and book administrator Ash Miles says there is no lack of clinical support for it: 'Everyone who sees it likes it. We have clinicians approaching us to be involved, mainly because of [the possibility of reducing] inappropriate referrals.' However, there are some basic problems to overcome, such as the difficulty of pinning down exactly who does what and when so that the information can be used on the system.

For example, Ms Miles says it was relatively simple to add in general haematology, because the Whittington has only one clinic, run by one consultant. It has been much harder to add gynaecology, which covers a wide range of services, delivered at different clinics by up to a dozen consultants.

Ms Ingham Clark is also confident that the system will be used, once the difficult transition from having mainly paper-based referrals to electronic referrals has been negotiated. 'It is a bit jam tomorrow, at the moment, like the new hospital, ' she admits. 'But it will be wonderful eventually.'