Primary careThe Choose and Book Service at 18 months oldFollowing extensive trials and resulting adjustments, nationwide rollout of the Choose and Book Service is now under way throughout England. Dr Richard Gibbs and Dr Sebastian Alexander from the Choose and Book National Team report on what it offers at present, how it works and what needs to be done next at local levels to speed its rollout. ABSTRACT Choose and Book is a new service for patients being rolled out throughout the NHS in England. For the first time, it combines electronic booking with a patients choice of hospital, date and time for his/her first appointment with a consultant. Current features of the service are described together with an overview of its mechanics and achievements to date. Experience from the first implementations of the new service, which requires a radical departure from traditional appointment-booking practice, has been collated to form guidance for new users. Br J Healthcare Comput Info Manage 2006; 23(1): 18–20. Choose and Book is a new service being rolled out for patients throughout the NHS in England. For the first time, it combines electronic booking with a patients choice of hospital, date and time for his/her first outpatient appointment. Following extensive site testing and consultation with the NHS, the Choose and Book ICT system was successfully delivered by NHS Connecting for Health (CfH) on 2 July 2004 as part of the National Programme for IT. As expected with the introduction of a new service of this size and complexity, a range of organisational, cultural and technical barriers have to be tackled and overcome. Rollout of the service, which is part of the Government initiative to improve NHS responsiveness to its users, is being welcomed by patients. Service featuresPatients may choose their appointments in their GPs surgery (with the GP or the practice staff entering the chosen appointment), or on their own by phone or via the Internet after they have left the surgery, if they prefer. If the hospital chosen by the patient does not yet have an ICT system that is compatible with the Choose and Book system, the patient calls it directly to make an appointment. It is anticipated that the majority of hospital systems will be compliant by the end of 2006. GPs and staff responsible for the booking of outpatient appointments can track appointments on the system. Decision supportThe Choose and Book ICT system provides a link to www.nhs.uk, where information about hospitals and other providers of outpatient services may be found. Service selection and booking guidance is also available electronically to assist GPs/practice staff on referral options. It provides details about individual hospitals, such as procedures performed and investigations that are required before a referral is made, and information about patient pathways. To help patients make their decisions, there are information booklets also published on the nhs.uk website designed to reflect each of the services commissioned by each PCT (available at the surgery). In addition, there is a Choose and Book helpline. Patient confidentiality and system securityA key concern for clinicians has been just how would a nationwide service with an ICT system as its heart ensure patients confidentiality? Its a factor that has been taken very seriously from the outset of the development of the Choose and Book service. There are several layers of security for protecting patients information, including encryption for sending and receiving information and access controls. To gain access at either end of a transaction (at the GP surgery or the hospital), an ICT-system user must have a PIN and a smartcard. Each card contains a unique digital certificate, which is checked against an NHS staff directory and which, if found to be valid, authenticates the user. The booking transaction is then encrypted within the local application and only then will it leave the organisation to be stored at the central data facility. When data leaves this centre it is re-encrypted for onward transmission to the receiving organisation, where it is then decoded and used. Both the GP application and patients web application have been extensively tested by leading security consultants and government-accredited auditors. The Choose and Book application meets international and British security standards and complies with the requirements of the 1998 Data Protection Act. UpgradesThe Choose and Book ICT system continues to be developed to give additional functionality to the NHS and to incorporate feedback from end users. Software release 3.0 will be available in spring 2006. An example of the additional functionality that will be available in this release is the ability to flag patients with special needs, for example, language-translation services, so that their chosen hospital can ensure the need can be met. Version 3.0 will also extend the choice options available to patients. Rollout to dateUptake of the Choose and Book service is now increasing nearly exponentially. By mid-January over 80,000 appointments had been made; the present rate is almost 2,000 bookings a day. Over 90% of acute-care trusts and 28% of GP practices use the system. In the two or so years of the services development and piloting, a number of understandable myths and misconceptions have arisen. The rollout-programme team have, therefore, produced an extensive myth buster see box 1. Box 1. Myth bustingAs is typical with a programme of this size and complexity, a number of myths have arisen about Choose and Book. Mythbusting fact sheets are available for primary and secondary care at www.chooseandbook.nhs.uk/staff/mythsandcases Some commons myths about Choose and Book have included: 'GPs must book the date, time and place of appointment within the primary care consultation'GPs do not need to book the time and date of appointments if they do not wish to. The minimum the GP needs to do during the consultation is to initiate and print an appointment request for the location or choice of locations using Choose and Book. This does not include the date and time of the appointment. The GP will need to ensure that the choice options that are generated are clinically appropriate to the patient. 'Significant time in consultation will be taken up agreeing a password with the patient'Automatic generation of patient passwords is part of the Choose and Book software. The password can be printed along with the appointment reference number, but on a separate piece of paper. Patients can then use the appointment reference number and their passwords to make their own appointments outside the consultation, or to change the appointments later if necessary. 'Choose and Book will not work with GP systems'Certificates of compatibility have been given to all the major primary care system providers including EMIS, Seetec and In Practice Systems. All these systems are currently live and being used as part of everyday working life. Primary care system providers are in the process of providing compatible upgraded systems to other GP surgeries. Where compatible systems are not yet available, GP surgeries can use Choose and Book Web Based Referrer. This is a version of Choose and Book that uses a Web browser to access the application as opposed to accessing Choose and Book through an integrated primary care system. BenefitsChoose and Book is enabling a more responsive service to patients. The service overcomes the time delays and administrative burdens of the paper-based referral system and minimises associated errors. Patients plans are no longer put on hold for weeks while waiting for appointments to be offered. Feedback from patients during the trials and from the early adopter sites has been consistently favourable see box 2 for examples. Box 2. What patients think of Choose and BookThe feedback from patients using the Choose and Book service has been positive. Clearly patients like the certainty of appointment that Choose and Book gives them: "Choose and Book is brilliant! It is definitely benefiting patients like myself. I think the service is up to the minute and a massive improvement on what we had before." A patient from Cambridgeshire. "The Choose and Book system I feel is better, because you know that youve got an appointment." A patient from Kent. "It is a fabulous system ... The adviser went through all the available dates. I received my letter within two days and I have seen the consultant. It is a fab system." A patient from West Yorkshire. During the process of choosing a hospital and booking an appointment, patients are drawn into more active involvement in their healthcare, and this has many other advantages, including a dramatic reduction in missed hospital appointments, which under the paper-based system typically run at about 10% to 20%. This then makes it easier for hospitals to manage their clinic workload and ensures valuable capacity does not go unused. Implementation issues and guidanceThe Choose and Book technology was delivered by CfH on time in the summer of 2004 and subsequent releases have also been delivered as planned. But a mix of organisational, cultural and localised technical problems has meant the rollout of the service throughout the NHS is taking longer than first anticipated. Because the Choose and Book service introduces several changes in traditional working practices, clinicians and their administrative staff, particularly in primary care, need to review and redesign their current processes and roles within their teams. It requires careful planning and strong leadership from the boards and senior managers of PCTs and hospital trusts, as well as time to bed down the new routines. The engagement of clinicians is a key element in ensuring the successful rollout of the new service. Project teams need to identify local clinical champions who they can work with to engage other clinicians in their area. The organisational, cultural and technical issues need to be managed in a co-ordinated way. All the stakeholders clinical, administrative and managerial need to be properly engaged. The change plans for the clinical teams need to be lined up with the delivery schedules of the IT suppliers. This is why a high-quality project manager, covering primary and secondary care, is essential for a successful local implementation. The toolkit The experience of many of the early adopters has been collated via lessons-learnt reports and seminars, and has fed directly into the creation of the Implementation Toolkit (www.chooseandbook.nhs.uk/implementation). Much of the guidance material is role-specific and is designed for board members, project managers, primary care clinicians, practice managers, IT directors, secondary care clinicians, medical secretaries and hospital booking administrators. Each checklist highlights key areas that need to be addressed for local implementation, and is available at www.chooseandbook.nhs.uk/staff/implementation/roles The Implementation Toolkit is regularly updated and hard copies may be ordered from the Choose and Book website. " Dr Richard Gibbs, Executive Lead, Choose and Book National Team. Dr Sebastian Alexander, National Clinical Lead, Choose and Book National Team.
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