Choose & Book  GP Registrars  Barking, Dagenham & Havering  Wednesday 9 th 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 1 st 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 InternetBMS PAS system Available appt. slots Booked appt. slots Directory of services Provider info PCT Commissioning rules Appt. reminders DNA queries Referral letter Advice & 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 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 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 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 ???