£52,000 per booking- the new NHS booking system

Health Secretary John Reid defended a £200 million electronic appointment system set up to deliver patient choice, which had resulted in just 63 e-bookings.
The Government was warned in a report that urgent action was needed to deliver on its pledge to give patients more choice of where and when they get hospital consultations.
But commenting on the National Audit Office report, which also found widespread resistance on the ground, Dr Reid said the problem had been "exaggerated".
The NAO looked at Department of Health progress towards its target of offering every patient referred by GPs for non-emergency treatment the choice of four or five hospitals by December 2005.
It found a tiny fraction of referrals had so far been made through the new e-booking service, many GPs were against the principle, and nearly a third of Primary Care Trusts had no plans to implement it.
GPs' reluctance, and non-compliance of IT systems in surgeries and hospitals with the £196 million central e-booking system, along with an intermittent technical fault, were blamed for hampering progress.
Out of 9.4 million non-emergency referrals, up to December last year, just 63 were booked through the NHS's new Choose And Book computerised system, rather than the hoped-for 205,000.
And the system will only be operational across between 60% and 70% of the NHS by December, NAO warned.
While acknowledging some progress had been made, the report exposed a gulf between the Department's target on patient choice and plans for implementation on the ground.
Nearly a third of Primary Care Trusts have no plans to introduce any patient choice while more than a quarter predict they will not achieve the December target, NAO found.
Reproduced by the Express om 21st January 2005 at:
http://www.express.co.uk/story.html?story=3&r=110614404418913396

Abysmal progress' over NHS patient choice

Progress towards giving NHS patients a choice of hospitals for their treatment is "abysmal" and will not meet Government targets, it is claimed today.

Only 63 patient appointments had been made by the end of last month through electronic booking when 205,000 had been planned.
By the end of this year the Government is committed to all patients having the choice of four or five hospitals. At the heart of this drive is a plan for 60 to 70 per cent of the appointments to be made electronically through a system called "choose and book".
This is central to the Government's thinking on modernising the NHS, giving patients more power and expanding the use of private providers.
But, according to a National Audit Office (NAO) report today, GPs, who are crucial to the plan, are mostly negative about it; electronic booking is seriously behind schedule and interim measures will not be cost-effective.
The report says choice cannot be delivered without GPs' support and their low engagement with the idea is a real risk to its success.
Edward Leigh, the chairman of the Commons public accounts committee, said: "Plans to reform the NHS have been dealt a blow.
"There has been abysmal progress towards delivering electronic booking of hospital appointments from GPs' surgeries by the target date of December 2005. By the end of last month, only 63 live electronic bookings had been made, against a forecast of 205,000, at an average cost so far of £52,000 a booking. This is against a background of some nine million referrals each year."
Mr Leigh said there was "a very real danger" that patient choice would be undermined if full electronic booking was not available.
"GPs around the country are already very sceptical about patient choice: 60 per cent are negative towards patient choice including even those who know most about it," he added. "Nothing short of an easy-to-use, fully functioning electronic system for appointments will persuade them that choice has a future."
Electronic booking for GP referrals has a set-up cost of £196 million over five years with annual costs of £122 million, offset against administrative savings of £71 million, according to the NAO.

A survey for the NAO among 1,500 GPs found that only 45 per cent knew "a little" about delivering choice and 49 per cent knew "very little". Nearly two thirds (61 per cent) said they were "very" or "a little negative" about it.
The NAO report called on the Department of Health to take steps urgently to improve GP support and to look at ways of accelerating the e-booking scheme.
Sir John Bourn, the head of the NAO said: "Enabling patients who are referred by their GPs for hospital treatment to choose where they want to be treated promised to bring benefits to the patients themselves and to the wider NHS. Providing such choice will not be simple, however."
John Hutton, the health minister, said he welcomed the report because it confirmed that greater choice would deliver benefits to patients.
"Offering four or five providers for hospital referrals by December 2005 is a big challenge. As we set out in the document 'choose and book', this will be offered mainly through IT but also other means, such as phone booking," he said.

Reproduced from:
http://portal.telegraph.co.uk/health/main.jhtml?xml=/health/2005/01/24/nhs19.xml&sSheet=/health/2005/01/28/ixhmain.html

PATIENT CHOICE AT THE POINT OF GP REFERRAL

PATIENT CHOICE AT THE POINT OF GP REFERRAL
Parliamnent's own watchdog the National Audit Office today reports:

1. The Department of Health has a Public Service Agreement target to ensure that by the end of 2005 every hospital appointment in the National Health Service in England (the NHS) will be booked for the convenience of the patient, making it easier for patients and their General
Practitioners (GPs) to choose the hospital and consultant that best meets their need.
The Department aims to provide patients with the opportunity to choose between four to five healthcare providers for elective hospital treatment by December 2005.
In consultation with their GP, patients should be able to choose, from a menu of NHS and independent sector healthcare providers, their preferred location for treatment. Patients should also be able to book the time and date of their initial outpatient appointment within 24 hours of the decision to refer the patient for treatment.
This target will apply to around 9.4 million patients referred for hospital treatment by their GPs each year, around four per cent of the total estimated 241 million GP consultations.

2 Choice at referral can contribute to a more patient focused health service, bringing benefits to both patients and the NHS. But providing such a choice will not happen by accident. There are a number of dependencies and interactions with other policies that need to be managed. Information Technology (IT) systems need to be developed and modified and significant cultural, organisational and behavioural changes will need to be made by patients, NHS organisations and staff.

3 This report examines whether the Department is on track to deliver choice at the point of referral successfully by the target date of December 2005. Our work has found that:
a Progress has been made towards delivering choice at referral through establishing the required
organisational infrastructure, commissioning new IT systems and modifications to existing ones, and providing support for the NHS organisations that will deliver it.
b The engagement of GPs is currently low and is a key risk which the Department must address to deliver choice successfully. The Department plans to address this risk through a campaign to inform and engage GPs during 2005 and it will need to monitor carefully the progress of this campaign.
c Choice at referral will be delivered most efficiently and effectively through electronic booking (e-booking, also known as Choose and Book), in which the Electronic Booking Service, commissioned by the Department’s National Programme for IT (NPfIT), is linked to upgraded or new computer systems in hospitals and GPs’ surgeries. However, e-booking will not be universally available by December 2005.
Until e-booking is fully adopted choice will have to be provided in other, less efficient, ways.
d Parts of the NHS still have much to do if they are to deliver choice. A significant minority of
Primary Care Trusts do not yet have adequate plans in place to manage the introduction of choice and some may struggle to manage the required new commissioning arrangements.

4 Our more detailed findings are as follows.
Progress has been made towards delivering choice at referral

5 The Department believes that choice is affordable.
Additional annual infrastructure and transaction costs are estimated to be £122 million – or 1.4 per cent of the current total expenditure on elective care. The main aim of introducing choice is to improve services for patients, but it should lead to increased efficiencies in primary and secondary care services worth an estimated £71 million, off-setting some of these costs.

6 It is essential that choice is supported by other elements of system reform including e-booking, payment by results, commissioning and appropriate capacity. Modelling exercises have shown that the system reforms should work in harmony with one another. Payment by results should enable the transfer of funding to follow the patient and there should be sufficient capacity across the system to enable choice to be effective.

SUMMARY
PATIENT CHOICE AT THE POINT OF GP REFERRAL 2
7 Much of the organisational infrastructure that is required for choice is in place and there is clear
accountability for the delivery of the programme. To strengthen detailed national programme management arrangements the Department created, on 22 December 2004, a new post of National Implementation Director for Choose and Book, with effect from 10 January 2005.
The new Director will be responsible for overseeing the implementation of choice within the NHS whilst the National Programme for IT Group Programme Director for Choose and Book will continue to be responsible for Choose and Book technology development and deployment, patient
access and Choose and Book contract management.

8 The Department has provided different types of support to the NHS – for example, ten pilot schemes have been run to test the policy in practice. It has set up a system for periodically measuring progress and used this to establish the position at the end of October 2004, creating
a baseline against which to monitor future progress.

9 Research has identified what information patients will want to base their choices on, and the Department is seeking to provide this. While it is unlikely that full information will be available for December 2005, the majority of those aspects identified by patients as being the most important, such as waiting times and basic access information, will be in place. The Department plans to increase the information available over time. The key risk to the delivery of choice is the engagement of GPs

10 Choice cannot be delivered without support from GPs but our survey of GPs found that around half of GPs know very little about it and 61 per cent feel either very negative or a little negative. GPs’ concerns include practice capacity, workload, consultation length and fears that existing health inequalities will be exacerbated. The Department has deliberately held back its main effort to inform and engage GPs about choice until it has had a working e-booking system to show GPs, but it intends to mount a campaign to inform and engage GPs during 2005.
Until e-booking is fully adopted choice will be supported by other mechanisms

11 The Department has commissioned Atos Origin to develop a national system for e-booking, which will be linked to upgraded or new Patient Administration Systems in hospitals and IT systems in GPs’ surgeries to provide an overall service known as e-booking. The National
Programme for IT has planned the roll out of e-booking on an incremental basis to minimise risk, and to link it by the end of 2005 to some 60 to 70 per cent of hospital systems and GP practices.

12 E-booking is the most effective and efficient way of delivering the Department’s plans for choice, and alternative booking mechanisms offer poorer value for money. Atos Origin has delivered a functioning system and the first booking using e-booking was made in July 2004. However the roll-out of e-booking has been slower than planned and at the end of December 2004
only 63 bookings had been made. Problems have included the reluctance of users to work with an
unreliable end-to-end system, limited progress in linking to GP and hospital systems, and the limited number of GPs willing to use the system.

13 The Department believes that new releases of software have addressed the reliability of the whole end-to-end system and that having a fully operational system will encourage GPs to engage with e-booking. The roll-out of changes to hospital systems to allow them to link to e-booking is gathering pace and four types of GP systems can now link to e-booking, although the largest
supplier has not yet agreed an implementation plan. A combined team of Departmental and NHS personnel are working with the three main existing GP system suppliers to agree a national deployment schedule. This work should be completed by February 2005, along with a nationally negotiated commercial arrangement. The Department is also developing and trialling contingency
plans against further delays, as well as alternatives to the fully integrated Choose and Book solution.
Parts of the NHS still have much to do

14 Programme management arrangements in the NHS are incomplete. While most Primary Care Trusts expect to be able to deliver the choice target, there is variability in their overall performance. As many as a quarter of Primary Care Trusts currently forecast that they will not deliver the choice targets. In addition, some Primary Care Trusts may struggle to manage the new commissioning arrangements and two-thirds have yet to commission the required number of providers. The department is developing a framework of support to assist trusts to overcome these obstacles.
summary.

RECOMMENDATIONS

15 The Department needs urgently to address the low level of GP support for their plans for implementing choice at referral, and should:
I Press on urgently with its plans for informing GPs about the implementation of choice at referral and its impact on GPs and patients.
II Monitor the views of GPs, for example by a regular survey, repeating key questions from our own survey, to assess the rate of progress being achieved towards the level of support needed to meet its target of full implementation by December 2005.
III Consider whether further action is needed to secure the required level of GP support, once GPs are fully informed on what choice at referral involves.

16 The Department should also:
IV Complete its planned benefits realisation plan for choice at referral by the summer of 2005, along with a monitoring mechanism and quantified targets.
V Keep under regular and close review the progress of its planned implementation of choice through implementing e-booking and consider the scope for accelerating the roll-out of e-booking to make it available everywhere by December 2005.
VI If it becomes clear that it is not possible to deliver e-booking everywhere by December 2005, the Department should:
a monitor closely the development of the interim solutions to ensure that they meet their delivery
dates; and
b ensure that the implementation of interim solutions does not detract from the priority of
bringing in fully integrated e-booking systems as soon as possible.
VII Establish an evaluation framework for Primary Care Trust commissioning to assist Strategic Health Authorities in assessing the capacity and skills of Primary Care Trusts in this area and securing improvements in capacity and skills where necessary.

Reproduced from:
http://www.nao.org.uk/publications/nao_reports/04-05/0405180es.pdf