Choose & Book

GP Registrars Barking, Dagenham & Havering Wednesday 9th January 2008 Urswick Medical Centre

Dr Richard Burack

What is it?

Since summer of 2004 in England Answered the research showing patients

wanting to be more involved in choosing their healthcare, making decisions

What is it?

Works via a web-based programme Pt needs to have their data / details /

demography matched with the National Spine to work properly

First OP appts only, specialist care only

Is it working?

> 5 million referrals since inception First 2 years before 1st million < 1 yr to get the other 4 million

88% of GP practices in England > 15,000 referrals daily 45% of total NHS referral activities from GP to

specialist

Is it working?

Reduction in hospital DNA rates Doncaster NHS Trust found a 60% drop in DNA rate Kettering & Ashford NHS Trusts, 33% reduction in DNA rate

Decreased waiting times 18 week target / pathway for patients met easier

For patients

Patients can choose form at least four hospitals Patients can also choose the date and time of their

appointment Patients experience greater convenience and

certainty More secure, less chance that information is lost

For patients

Plan and manage around existing appointments Fit their treatment with other commitments, home

and work Choose appointments that fit with their carer’s

schedule Check status of their referral, can change or cancel

their appointments over the phone / internet easily

For GPs

Clinical Engagement Possible reduction in non-clinical appts Possible reduction in non-clinical time Full directory of clinical services available Immediate on-line booking, UBRN met

For GPs Extra IT resources

Funding for new spine compliant PC Secure logins / increased security

Extra remuneration (C&B DES / LES) Component 1, offer choice (24p) Component 2, 60% survey satisfaction (24p) Component 3, Use booking system (24p) Component 4, 90% UBRN conversion (24p)

Process of Clinical Engagement

Inside the clinician…

GP/patient

Primary care system

Consultant/patient

CAB

Internet BMS

PAS system

Available appt. slots

Booked appt. slots

Directory ofservices

Provider infoPCT

Commissioning rules

Appt. reminders

DNA queries

Referral letterAdvice &guidance

Choose and Book

NHS change equation

Frustration with

the current situation+Perceived barriers to

the change>

Advantages of where

we’re trying to get to

Frustration with current situation System based on the convenience of the service not the patient

Inefficient with multiple steps (30 – 40) possible errors ( eg missed referral letters) expensive

Limited choice

Difficult to track what is happening and if it goes wrong very difficult to see where ( lack of an audit trail)

Difficulty accessing information about available services

Difficult to support protocols / guidelines / templates

“As I hope you are aware, a significant number of GPs involved in ‘choose & book’ pilots have found it to be most unsatisfactory and time-consuming.

Furthermore, the so-called ‘choice’ is no more than the PCT following a political diktat, and was roundly condemned at our LMC meeting.”

Rational

Political

Emotional

Reactions to change

Resistance

Why should clinicians resist choose and book?

A feeling that is threatens something of value

A misunderstanding of CAB and its implications

A belief it doesn’t make sense clinically

A low tolerance for change - politics

Another ‘more for less’ initiative

Perceived barriers…

Consultation length

Information support

IT issues - training / performance

Staff capacity / resources

Development of booking guidance (protocols)

Primary care

Perceived barriers…

Patients will be booked into clinics before consultants prioritise referrals (Loss of control)

Risk of fragmented care

Consultants will gradually develop common ways of working

Impact of financial flows (PbR, practice based commissioning, choice)

Secondary care

Working with resistance Anticipate and plan for it

View it as a natural process and a sign that you are engaging

Support people in expressing resistance

Take your time

Don’t take it personally

Making the referral and booking the appointment with the patient

The GP does it all

Setting the scene Busy Monday morning 10 minute appointments Dr Abbott has 18 patients to see in 2.5 hours

Authentication

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James Abbott

I think you need to see a specialist. Using the new

Choose and Book service, we can book an appointment for

you.

Choose and Book icon/button/function key

GP System: Patient details page

The advantages for the GP

Simple referral process Full directory of all the secondary care services

available Decision support information for referral Advice and guidance facility Fewer queries from patients chasing referrals

C&B Advantages (Grp 1) Spend 10 minute discussing the ‘advantages’ of

having C&B as a service for Pts, offered by GP Advantages from the Pt perspective Advantages from the GP perspective Include good / positive possible outcomes from C&B

C&B Disadvantages (Grp 2)

Spend 10 minute discussing the ‘disadvantages’ of having C&B as a service for Pts, offered by GP’s

Disadvantages from the Pt perspective Disadvantages from the GP perspective Include problems possibly encountered in implementing C&B

nationally

C&B – the future (Grp 3)

Spend 10-15 minutes discussing the positive potential for C&B in the future NHS

Where could C&B take ‘us’ What uses could it afford to Primary Care / NHS service

provision for the Pts Impact on other areas within the modern NHS, 18 wk waits,

IMT DES etc

C&B Advantages Spend 10 minute discussing the ‘advantages’ of

having C&B as a service for Pts, offered by GP Advantages from the Pt perspective Advantages from the GP perspective Include good / positive possible outcomes from C&B

Advantages

Greater opportunity to influence the way they are treated by the NHS

Ability to discuss their treatment options so that they experience a more personalised health service

Greater convenience and certainty reducing the stress of referral Choice of a place, date and time that suits them, enabling them to

fit their treatment in with their life, not the other way around

Advantages

Reduced anxieties of waiting for their appt Patient focussed service provision Increased referral security Reduction in DNAs Reduction in non-clinical primary care consultations Reliable and comprehensive clinical information

Advantages

Reduced anxieties of waiting for their appt Patient focussed service provision Increased referral security Reduction in DNAs Reduction in non-clinical primary care consultations Reliable tracking of booking, reduction in admin time on

the paper chase etc.

C&B Disadvantages

Spend 10 minute discussing the ‘disadvantages’ of having C&B as a service for Pts, offered by GP’s

Disadvantages from the Pt perspective Disadvantages from the GP perspective Include problems possibly encountered in implementing C&B

nationally

Disadvantages

IT literacy from practice / secretary / GP Pt compliance to be on spine Time within consultation C&B can be slow, slow/lengthen the consultation How secure is the C&B / NHS spine Service disparity depending on ability of NHS Trusts to

engage / link PAS systems

Disadvantages

PCT govern the choice? Efficiency savings factor somewhere Linked to C&B DES, financial penalties for not

achieving targets UBRN conversions are at patient level, NOT practice

C&B – the future

Spend 10-15 minutes discussing the positive potential for C&B in the future NHS

Where could C&B take us? What uses could it afford to Primary Care / NHS service

provision for the pts? Impact on other areas within the modern NHS, 18 wk waits,

IMT DES etc

C&B – the future

Patient choice, pt involvement, pt lead NHS, PPG influencing commissioning decisions

Linking up with PBC, primary care commissioning services Service re-design based on 18 week target pathways Service re-design based on being less than PBR tariff Carrot & Stick, financial implications are always a PCT method

of paying GPs, likely to continue

C&B – the future

Meant to be a 2 way process, this could / should be developed Other ???