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Saturday 26th May 2018

Choose and Book

30th April 2007

With it becoming increasingly clear that the roll out of the Choose & Book programme will delayed even further with a major deadline in March being missed, we look at the obstacles it is facing and what the future holds for this key element of the government’s Choice, waiting time and IT strategy.


What is the Choose & Book programme?

Choose & Book is an on-line appointment booking system which allows patients to make an appointment at a hospital of their choice at a date and time which suits them. This can be done whilst they are still at their GP surgery having just found out that they need to be referred, or afterwards by the patient once they have had time to look at their options and decide where and when they want to be seen. Choose & Book was launched in mid 2004 and is a major part of the overall National Programme for IT being rolled out by Connecting for Health. It goes hand in hand with the pledge that patients will be able to choose where they are referred for specialist attention from a list of alternatives, including at least four different hospitals nominated by their PCT plus all Foundation Trusts and independent providers. At the beginning of this year, the Nuffield Hospital in Plymouth was the first independent provider to set up a Choose & Book interface allowing GPs and patients to choose to make appointments with them. Many other independent sector providers are planning the same capability to make sure they are considered when patients exercise their choice.

Where has roll out got to?

Technical interface problems during the launch process, and slow roll out to the wider NHS following success with early adopters, have meant that targets to achieve various levels of uptake of Choose & Book across the country have been missed by a long way. Choose & Book was meant to be fully rolled out by December 2005, and when this deadline was missed new interim targets were set to keep up the pace of change. But the Health Service Journal reported at the beginning of the year that no SHA was on track to meet the latest target - to have 90% of referrals made via Choose & Book by the end of March. Although there is a steady increase in uptake month on month, national uptake still currently lies just below 40%. Behind these figures, though, a handful of PCTs are hitting 90%, and others are achieving around 70%.

Speaking to Healthcare Today, Jane Cummings, National Implementation Director for Choice and Choose & Book, explained that the challenge is not just in getting GP practices and hospitals to go live, but also in moving from partial use of the system to full take up. One hundred percent of PCTs and NHS Trusts are now sending and receiving referrals via Choose & Book, and more than 2 million referrals have been made using the system to date, with a rate currently being achieved of approximately 12,500 per day. But not all GP practices within PCTs are using the system each week. And whilst some trusts are still only using indirect booking processes within the Choose and Book system, many of those trusts that are using its full direct booking capability are only doing so for some clinics. The main obstacles to roll out appear to be the following:

  • Hospitals not making sufficient appointment slots available. This means that a certain percentage of patients have more limited choice about where they can go, and are left having to use the old system to make their appointment. There are concerns that the practice of limiting appointment slots may be being used by trusts to force delivery of the 13 week maximum wait for an outpatient appointment, by simply not offering appointments later than this point in time. Such practice is explicitly forbidden by the new model NHS contract taking effect from April, but there are examples where efforts to increase uptake of Choose & Book are being seen as thinly veiled attempts to manage demand and hit the 13 week maximum wait. GPs in Bedfordshire have taken legal advice after their local trust announced that it would turn away any referrals not made via Choose & Book; the PCT in Milton Keynes has issued similar instructions to local GPs making Choose & Book effectively compulsory and referrals made any other way invalid. The Choose & Book team at the Department of Health have just finished a round of SHA level workshops demonstrating a capacity model they have developed which helps trusts to link clinic templates and slot availability with capacity plans to deliver contracted levels of activity and the 13 week maximum wait, right down to consultant level.
  • Local engagement. Surveys have regularly shown that NHS staff agree with the aims of Choose & Book and the wider NPfIT plan, and indeed some feedback indicates that staff wish the Choose & Book system could go further to be used for making other appointments such as mental health and physiotherapy. But problems on the ground, and the extent of the change to daily working practices, has made Choose & Book unpopular. Jane Cummings acknowledges that hitting the uptake targets has been difficult because “Choose & Book is tackling a complex clinical and administrative process, involving a huge cross-section of staff, and represents a major transformational change in the way services are delivered?. The Choose & Book team has worked hard to win hearts and minds, establishing positive working relationships with the BMA, setting up User Groups to receive feedback, producing case studies, DVDs, and quick reference guides, and sending in support teams where local health communities are really struggling with implementation. But uptake remains patchy, with some GPs not using the system at all, and others only using it for relatively straight forward referrals.
  • Technical integration. Despite high profile reports of the system crashing, Choose & Book has been available more than 99% of the time. What is proving to be a problem, however, is the interface with local trust and primary care IT systems. Most, though not all, hospital PAS and primary care systems are now Choose & Book compatible, but in some areas the interface is cumbersome and slow, with delays frustrating users to the point where they give up using it. Choose & Book has also effectively been the trail blazer for a number of other IT developments, such as the role out of smart cards to GPs and use of the N3 network, and has suffered the teething problems from these developments as well as its own.
Despite these problems, Choose & Book, and indeed the wider NPfIT programme, remain on budget.

What benefits is Choose & Book achieving where it is being used?

Although a more comprehensive review is planned to quantify the benefits being realised from Choose & Book, there are already case studies which point to its potential. Most importantly for the programme, there is growing evidence that where patients are exercising choice of provider, they are opting for hospitals where they can book their appointment directly via Choose & Book. Kettering Hospital Trust was achieving 68% take up of Choose & Book by November last year. It found that patients booked through the system had a lower DNA rate to those booked through the traditional referral route (5% compared to 8.5%), and that changing to Choose & Book has shaved nine days off the patient pathway just through faster administration – a real help towards hitting the 18 week waiting time target next year. But there are anecdotal reports that the system is not being used as intended even by those that have adopted it, and full benefits are not being reaped. For example in some places hard copies of referrals are still being printed off from the Choose & Book system to give to consultants for vetting, rather than being dealt with directly on-line, introducing an unnecessary step in the process and a delay. More needs to be done to see how Choose & Book can generate the significant cash releasing savings in administration costs relating to out patient referral processes that it should be able to.

What does the future hold for Choose & Book?

SHAs are being geared up to performance manage fast delivery of the 90% target, and negotiations are ongoing about whether the incentive scheme for GPs to get them to use Choose & Book should be rolled over into 2007/08. Despite serious delays with roll out, and still a mountain to climb to achieve critical mass, there seems to be no sign of the government wavering from its commitment to deliver Choose & Book because of its ability to lever patient choice of provider and the 18 week maximum wait from GP referral to treatment.

Latest news

  • Use of Choose & Book dipped in April 2007, having already failed to achieve a major target by the end of March. Rates of use are now recovered back to March levels, but this is a further blow to a programme that is meant to be achieving 90% uptake by now.
  • The BMA General Practitioners Committee considered recommending a boycott of Choose & Book by GPs in protest at their 0% pay award for 2007/08.
  • It is now unlikely that the Department of Health will recommend that incentive payments for using Choose & Book will continue in 2007/08. Some PCTs are, however, offering their own local financial incentives as part of the GMS contract.
  • Patricia Hewitt has launched ten choice library pilots, where librarians will be trained to help patients find and make sense of information about different providers, and make their electronic appointment booking. Dr Foster has also been commissioned to build NHS Choices - a ‘super website’ portal providing access to a range of data and information about provider performance which patients would be able to access. The Liberal Democrats have dismissed the developments as superficial and gimmicky.
  • The fourth national patient choice survey, published in March 2007, has found that more patients are being offered choice of provider and more patients are aware and making use of choice.

For more information on Choose & Book, go to:



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