From the consulting room: a few issues with Choose and Book

In his latest column, Dr Neil Paul lets off steam about Choose and Book, and comes up with a few ideas to make referrals work better in the era of choice.

Hooray! I only have to put up with Choose and Book (C&B) for another six weeks!

How so? Well, the government has decided to make unilateral changes to the GP contract and transferred the incentive money we get for using C&B to access.

It’s a way of claiming they are funding increased opening hours, and I assume they think people are so used to using C&B they will carry on anyway. But I’m not so sure.

Some may stop as a protest against the imposed changes and some - like me - will stop because we hate C&B and have only been using it for the money.

I have long been a critic of C&B; not its ideals but its implementation. And I think it is worth thinking about why some of us hate it so much, if anyone in the NHS IT Programme wants it to continue after 1 April.

Too slow

“A menu-based system is archaic. C&B reminds me of when the Internet was new!”The first problem with C&B is that it’s too slow. At best, it takes 45 seconds to launch and while I don’t refer every patient I see this is just too long. Once I finally get to the first screen, finding the right clinic and slot takes just as long.

Compare this to picking up my Dictaphone and saying ‘referral to Mr such and such at hospital x’ and letting my secretary sort it – C&B just doesn’t compare. I see patients in ten minutes; some minor ailments are dealt with in five. Using C&B reduces the number of patients I can see.

My father-in-law owns a company that delivers online room booking for hotels. He takes prides in how fast his software is and how he has managed to reduce the amount of information being sent to the bare minimum. Surely the size of the NHS could do something similar?

Too buggy

My computer still crashes with regular monotony. Turning off C&B functionality makes it more stable, if not perfect.

And why can’t I run the latest version of Internet Explorer with C&B? Surely the fact that C&B can’t cope with a standard browser, unlike almost every other website out there, means that its badly written and doesn’t adhere to standards.

Rubbish user interface

A menu-based system is archaic; especially when it is combined with such poor search functionality. C&B reminds me of when the Internet was new!

The Directory of Service is a disaster and I get massive, incomprehensible emails every month telling me about changes to it; I have given up reading them.

I recently asked a meeting how to find a consultant in chest medicine. Only one member of the audience knew to look in thoracic medicine. Nobody calls chest medicine that, at least around here, so why the listing?

Even when I have found the speciality I want, I have to select from a clinic sub-menu. This takes yet more time to load and doesn’t explain the terms it is using.

Have the people who built C&B never used Google or Amazon? Why can’t I get the service from C&B I get from them? Launch the window, have it load in under a second, find the clinic I want by typing its name into a search-box and go straight to it – while the system stores my “favourite” clinics for me.

Wrong concept

“[C&B] fundamentally misunderstands the relationship between a GP and a consultant. GPs ask a consultant for an opinion; we don’t demand an operation.”Although these are some of my suggested improvements, I think a more fundamental rethink of C&B is needed. I agree with choice, but it comes in two parts.

The first is choice of provider. I have always offered this, even before C&B. I will usually say who I would recommend – but I’ll always see if my patient has any preferences, including the quickest service.

A website giving me up to minute information on waiting times by clinic type or speciality would help me to work with my patients. The indicative waits in C&B make no sense.

It would also be great if there were biographies of the consultants that included their special interests and complication rates – and these should be available to patients. The site could also have links to the Map of Medicine and include pathways and guidelines.

Then, if I chose information on one service, the site could cleverly list alternatives with shorter waits or better complication rates - just like the best sales websites do. Even more cleverly, it could tell me what tests were needed before referral, in case I had missed any, and let me print off any outstanding forms.

The second part of choice is of appointment time and date, but this is something I don’t need to be involved in. It is an admin job that can be done while I am getting on with other things.

Pushing this task onto GPs also fundamentally misunderstands the relationship between a GP and a consultant. GPs ask a consultant for an opinion; we don’t demand an operation.

I have no problem with sending a referral electronically, but this functionality could be built into the GP computer system, as path links are. The consultant could then vet the referral and accept or reject it, before the hospital booking centre contacted the patient within a defined time.

If the referral contained the patient’s mobile number or email address, forward-thinking trusts could even contact them electronically.

Direct access

Direct access investigations may deserve their own system; similar to a streamlined version of the existing system. GPs could use their computer systems to select an investigation from an intelligent one-page screen.

On screen prompts could ensure all the relevant boxes were filled, the request would go off to a booking centre and patients could sort out an appointment with them.

Any outstanding tests could be organised by an administrator trained to offer choice, book transport, give out instructions on what to wear, eat and so on. The booking service could track DNAs and chase them up.

All of my ideas would offer choice, put patients first, match other NHS strategies and improve functionality and I would like to think they would be embraced by GPs, not rejected by them. I may be wrong – but not often.

About the author: Dr Neil Paul is a full time GP working at the Ashfields primary care centre in Sandbach. He has just been appointed to his primary care trust’s professional executive committee and has a lead role for IM&T and Payment by Results.