1 The Department of Health has a Public Service\ud Agreement target to ensure that by the end of 2005 every\ud hospital appointment in the National Health Service in\ud England (the NHS) will be booked for the convenience of\ud the patient, making it easier for patients and their General\ud Practitioners (GPs) to choose the hospital and consultant\ud that best meets their need. The Department aims to\ud provide patients with the opportunity to choose between\ud four to five healthcare providers for elective hospital\ud treatment by December 2005. In consultation with their\ud GP, patients should be able to choose, from a menu of\ud NHS and independent sector healthcare providers, their\ud preferred location for treatment. Patients should also be\ud able to book the time and date of their initial outpatient\ud appointment within 24 hours of the decision to refer the\ud patient for treatment. This target will apply to around\ud 9.4 million patients referred for hospital treatment by their\ud GP each year, around four per cent of the total estimated\ud 241 million GP consultations.\ud \ud \ud 2 Choice at referral can contribute to a more patientfocused health service, bringing benefits to both patients\ud and the NHS. But providing such a choice will not happen\ud by accident. There are a number of dependencies and\ud interactions with other policies that need to be managed.\ud Information Technology (IT) systems need to be developed\ud and modified and significant cultural, organisational and\ud behavioural changes will need to be made by patients,\ud NHS organisations and staff.\ud \ud \ud 3 This report examines whether the Department is on\ud track to deliver choice at the point of referral successfully\ud by the target date of December 2005. Our work has\ud found that:\ud \ud a Progress has been made towards delivering choice\ud at referral through establishing the required\ud organisational infrastructure, commissioning new\ud IT systems and modifications to existing ones, and\ud providing support for the NHS organisations that will\ud deliver it.\ud \ud b The engagement of GPs is currently low and is a key\ud risk which the Department must address to deliver\ud choice successfully. The Department plans to\ud address this risk through a campaign to inform and\ud engage GPs during 2005 and it will need to monitor\ud carefully the progress of this campaign.\ud \ud c Choice at referral will be delivered most efficiently\ud and effectively through electronic booking (e-booking,\ud also known as Choose and Book), in which the\ud Electronic Booking Service, commissioned by the\ud Department’s National Programme for IT (NPfIT),\ud is linked to upgraded or new computer systems in\ud hospitals and GPs’ surgeries. However, e-booking\ud will not be universally available by December 2005.\ud Until e-booking is fully adopted choice will have to be\ud provided in other, less efficient, ways.\ud \ud d Parts of the NHS still have much to do if they\ud are to deliver choice. A significant minority of\ud Primary Care Trusts do not yet have adequate plans\ud in place to manage the introduction of choice and\ud some may struggle to manage the required new\ud commissioning arrangements.\ud \ud 4 Our more detailed findings are as follows.\ud \ud Progress has been made towards\ud delivering choice at referral\ud \ud 5 The Department believes that choice is affordable.\ud Additional annual infrastructure and transaction costs\ud are estimated to be £122 million – or 1.4 per cent of the\ud current total expenditure on elective care. The main aim\ud of introducing choice is to improve services for patients,\ud but it should lead to increased efficiencies in primary and\ud secondary care services worth an estimated £71 million,\ud off-setting some of these costs.\ud \ud 6 It is essential that choice is supported by other\ud elements of system reform including e-booking, payment\ud by results, commissioning and appropriate capacity.\ud Modelling exercises have shown that the system reforms\ud should work in harmony with one another. Payment by\ud results should enable the transfer of funding to follow the\ud patient and there should be sufficient capacity across the\ud system to enable choice to be effective.\ud \ud 7 Much of the organisational infrastructure that\ud is required for choice is in place and there is clear\ud accountability for the delivery of the programme. To\ud strengthen detailed national programme management\ud arrangements the Department created, on 22 December\ud 2004, a new post of National Implementation Director\ud for Choose and Book, with effect from 10 January 2005.\ud The new Director will be responsible for overseeing the\ud implementation of choice within the NHS whilst the\ud National Programme for IT Group Programme Director for\ud Choose and Book will continue to be responsible for Choose\ud and Book technology development and deployment, patient\ud access and Choose and Book contract management.\ud \ud 8 The Department has provided different types of\ud support to the NHS – for example, ten pilot schemes\ud have been run to test the policy in practice. It has set up a\ud system for periodically measuring progress and used this to\ud establish the position at the end of October 2004, creating\ud a baseline against which to monitor future progress.\ud \ud 9 Research has identified what information patients\ud will want to base their choices on, and the Department\ud is seeking to provide this. While it is unlikely that full\ud information will be available for December 2005, the\ud majority of those aspects identified by patients as being\ud the most important, such as waiting times and basic\ud access information, will be in place. The Department\ud plans to increase the information available over time.\ud The key risk to the delivery of choice\ud is the engagement of GPs\ud \ud 10 Choice cannot be delivered without support from\ud GPs but our survey of GPs found that around half of\ud GPs know very little about it and 61 per cent feel either\ud very negative or a little negative. GPs’ concerns include\ud practice capacity, workload, consultation length and fears\ud that existing health inequalities will be exacerbated. The\ud Department has deliberately held back its main effort to\ud inform and engage GPs about choice until it has had a\ud working e-booking system to show GPs, but it intends to\ud mount a campaign to inform and engage GPs during 2005.\ud Until e-booking is fully adopted\ud choice will be supported by\ud other mechanisms\ud \ud 11 The Department has commissioned Atos Origin to\ud develop a national system for e-booking, which will be\ud linked to upgraded or new Patient Administration Systems\ud in hospitals and IT systems in GPs’ surgeries to provide\ud an overall service known as e-booking. The National\ud Programme for IT has planned the roll out of e-booking on\ud an incremental basis to minimise risk, and to link it by the\ud end of 2005 to some 60 to 70 per cent of hospital systems\ud and GP practices.\ud \ud 12 E-booking is the most effective and efficient way\ud of delivering the Department’s plans for choice, and\ud alternative booking mechanisms offer poorer value for\ud money. Atos Origin has delivered a functioning system\ud and the first booking using e-booking was made in\ud July 2004. However the roll-out of e-booking has been\ud slower than planned and at the end of December 2004\ud only 63 bookings had been made. Problems have\ud included the reluctance of users to work with an\ud unreliable end-to-end system, limited progress in linking\ud to GP and hospital systems, and the limited number of\ud GPs willing to use the system.\ud \ud 13 The Department believes that new releases of\ud software have addressed the reliability of the whole\ud end-to-end system and that having a fully operational\ud system will encourage GPs to engage with e-booking. The\ud roll-out of changes to hospital systems to allow them to\ud link to e-booking is gathering pace and four types of GP\ud systems can now link to e-booking, although the largest\ud supplier has not yet agreed an implementation plan. A\ud combined team of Departmental and NHS personnel\ud are working with the three main existing GP system\ud suppliers to agree a national deployment schedule. This\ud work should be completed by February 2005, along with\ud a nationally negotiated commercial arrangement. The\ud Department is also developing and trialling contingency\ud plans against further delays, as well as alternatives to the\ud fully integrated Choose and Book solution.\ud Parts of the NHS still have much to do\ud \ud 14 Programme management arrangements in the NHS\ud are incomplete. While most Primary Care Trusts expect to\ud be able to deliver the choice target, there is variability in\ud their overall performance. As many as a quarter of Primary\ud Care Trusts currently forecast that they will not deliver the\ud choice targets. In addition, some Primary Care Trusts may\ud struggle to manage the new commissioning arrangements\ud and two-thirds have yet to commission the required number\ud of providers. The department is developing a framework of\ud support to assist trusts to overcome these obstacles.\ud \ud 15 The Department needs urgently to address the low\ud level of GP support for their plans for implementing\ud choice at referral, and should:\ud \ud I Press on urgently with its plans for informing GPs\ud about the implementation of choice at referral and\ud its impact on GPs and patients.\ud \ud II Monitor the views of GPs, for example by a regular\ud survey, repeating key questions from our own survey,\ud to assess the rate of progress being achieved towards\ud the level of support needed to meet its target of full\ud implementation by December 2005.\ud \ud III Consider whether further action is needed to secure\ud the required level of GP support, once GPs are fully\ud informed on what choice at referral involves.\ud \ud 16 The Department should also:\ud \ud IV Complete its planned benefits realisation plan for\ud choice at referral by the summer of 2005, along with\ud a monitoring mechanism and quantified targets.\ud \ud V Keep under regular and close review the progress\ud of its planned implementation of choice through\ud implementing e-booking and consider the scope\ud for accelerating the roll-out of e-booking to make it\ud available everywhere by December 2005.\ud \ud VI If it becomes clear that it is not possible to deliver\ud e-booking everywhere by December 2005, the\ud Department should:\ud \ud a monitor closely the development of the interim\ud solutions to ensure that they meet their delivery\ud dates; and\ud \ud b ensure that the implementation of interim\ud solutions does not detract from the priority of\ud bringing in fully integrated e-booking systems\ud as soon as possible.\ud \ud VII Establish an evaluation framework for Primary\ud Care Trust commissioning to assist Strategic Health\ud Authorities in assessing the capacity and skills\ud of Primary Care Trusts in this area and securing\ud improvements in capacity and skills where necessary.\u
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