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For more information, go to www.arthritisresearchuk.org

The good and bad of the Choose and Book system

Published on 01 July 2008
Source: Arthritis Today

Since April this year the NHS has expanded its Choose and Book system to give patients more choice about their care – and when and where they receive it. But how well does it work in practice? Arthritis Today’s resident rheumatologist, Dr Philip Helliwell, offers a personal opinion.

Dr Philip HelliwellAs my colleagues will tell you I am the Victor Meldrew of the medical world. I seem to grump about everything, especially if it is new. I have recently started doing a new rheumatology outpatient clinic in a hospital near to Leeds. As it was a newly established clinic there was no waiting list for new patients. Until the waiting time built up I was seeing people from many miles away, sometimes almost 40 miles away. These people had been attracted by the short waiting time and they had known about it through the government’s new system for booking new out-patient appointments – the Choose and Book system.

Several patients saw this as a good opportunity to get an early opinion from a specialist about their arthritis. They also saw it as a chance to get a ‘short cut’ into their local rheumatology service, which it doesn’t; they would have to continue making an 80-mile round trip to see me at the clinic.

So, here is my first gripe about Choose and Book. It may work if the GP and patient only want a one-off opinion (or in the case of a surgeon – a simple operation) but if the person is referred with a potentially complex and long-term illness such as arthritis it is less satisfactory. People are happy to travel to see a specialist occasionally but not to have all their care at some distant hospital. It doesn’t make sense. One GP colleague pointed out that this system may work well for London where several hospitals are available in a relatively small area but it just doesn’t work out in the provinces.

So how does Choose and Book work? For those of you with internet access you can visit the Choose and Book webpage, where there is information for the public and a frequently answered questions section. The problem with the website is that it only gives you the positive side to the system.

Here is the reality. You go to your GP with a painful knee. After examining you they decide that it is appropriate to refer you to hospital. At this point they have to offer you a choice of four places to go – three NHS and one private. You choose and are given a web address and/or phone number to ring later to make your appointment. You are also given a password which you use when booking the appointment, which you can do the same day if you like. Your doctor has to put your details into the system and include a referral letter and any appropriate blood tests. Of course if they are busy this may not be done immediately or done perfunctorily so that when you book your appointment a full referral letter is not available.

In reality GPs suggest one hospital (which they have always done) and you put that one down as your preferred location – without any element of choice occurring. And if this is the local hospital, the next nearest being 20 miles away, this makes sense. In cities such as London there may be several hospitals within a 10-mile radius so the element of choice may be more appropriate.

a medical professional with a patientHowever, let’s assume you have chosen a hospital, after careful discussion with your doctor, so what next? You leave the consultation and usually the practice administrative staff will give you the hospital details and a password. If you are computer literate you can book your appointment online. If not, you can use a Freephone number. The process of having to arrange your own appointment is particularly challenging for older people and for those whose first language is not English. The website says that when you get through you can ask to converse with someone in your own language but if you can’t speak English how can you get this far? I have heard of practice reception staff doing all the booking and arranging for patients – something they did under the old system!

Talking of the old system, your doctor can still refer you by the previous route – by writing a letter which is posted to the specialist of choice who then puts the patient into an appropriate clinic. This probably still goes on in 20 per cent of cases. However, there are other problems.

A brilliant system with a fatal flaw?

There now exists in primary care a group of specialist GPs who can give a ‘specialist opinion’ about arthritis or a musculoskeletal condition within the primary care sector (sometimes known as GPwSIs). They may work from their own practices or they may work from clinics with other specialist GPs. Some primary care trusts (PCTs – the organisations which manage primary care doctors) even insist that all referrals are made via these clinics, so that only those people who cannot be treated in primary care are referred to the hospital. While GP specialists often provide an excellent service for people with musculoskeletal conditions, the reality is that it can mean that patients have an extra ‘hurdle to jump’ before they can see a hospital specialist. And it doesn’t fit in with the choice agenda introduced by the government, unless of course the GP and patient chose the GP specialist.

man and a physiotherapistI have had patients come in and say what a brilliant system it is but from a practising clinicians point of view the system has a fatal flaw. The choice only extends to the hospital of choice rather than the consultant of choice. In the world where many consultants have very focused skills it has meant that patients have ended up booking totally inappropriate appointments both wasting their own time and that of the hospital. In the old days a good GP would have chosen the right specialist for the right problem.

From my point of view the following points are the most important:

  • Almost 80 per cent of referrals are now made by the Choose and Book system. The quality of the referring letter has fallen – it is now often brief and misses much of the relevant history because the GP is under pressure to get the information into the system.
  • Some people are put into inappropriate clinics – for example someone with potential rheumatoid arthritis is put into a clinic specialising in osteoporosis. Also, there is no continuity of care. Someone who had seen Dr X 2 years ago now appears in Dr Y’s clinic at the same hospital.
  • People come from afar expecting to access a short cut into their local rheumatology services and are dismayed when this doesn’t happen.
  • There is often no choice offered anyway. According to a recent survey only 40 per cent of people are offered a choice of hospitals by their GP.
  • The process of making an appointment is threatening and sometimes impossible.

So, if you can, do visit the website and do discuss this with your GP when next you need an appointment. Your GP is still the best person to give you advice on any hospital referral and can help you choose the most appropriate consultant to manage your condition. If you need support in navigating through Choose and Book the GP practice staff are there to help. I, meanwhile, will continue to grump away at the hospital end in true Victor Meldrew fashion.

Dr Philip Helliwell is a consultant rheumatologist at St Luke’s Hospital in Bradford, and a senior lecturer in rheumatology at the University of Leeds.

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