Cash constraints may 'grey out' C+B options, warns LMC

Tags: booking Choice Choose and Book Community GP GPs PCT PCTs

08 Aug 2006

Patient choice may be restricted or “greyed out” under Choose and Book as cash strapped hospitals struggle to meet financial and waiting list targets, a local medical committee has warned.

Avon LMC, operating in an area with one of the worst financial deficits in the country, claims patients may only be offered second or more remote choices because local hospitals will limit appointments on the Choose and Book system.

In its latest briefing paper for GPs on Choose and Book the LMC says: “Local capacity planning appears increasingly at odds with C&B philosophy. There have been several discussions locally where it has been acknowledged there will be insufficient capacity in some areas to allow patient preference. In such cases the choice will be refused or ‘greyed out’ under C&B.”

Steve Mercer, chief executive of Avon LMC, said the fear was that choice would be limited because hospitals would be unable to afford to build spare capacity in to their systems.

He told EHI Primary Care: “I’m not saying this is happening yet but the issue has popped up in three different trusts. If a hospital has met its capacity and the patient is then offered an appointment 25 miles away patient choice won’t be choice.”

John Penrose, MP for Weston-super-Mare, Somerset, said he feared Weston General Hospital could be a likely candidate for “greying out” because both the hospital and the PCT were under financial pressure.

He told EHI Primary Care that the PCT has been historically underfunded to the tune of £12-13m and Weston Hospital was also too small to cope with the health needs of the expanded population of the district and therefore faced severe financial difficulties. He added: “I’ve heard concerns about “greying out” and although I don’t think its happening yet in Weston it would be likely to be one of the first hospitals to face capacity constraints so I would think it’s only a matter of time before it does happen.”

Restrictions on choice have already been raised by Devon LMC where cardiology appointments at North Devon’s district hospital in Barnstaple were unavailable for booking and patients were sent instead to Sidmouth community hospital.

Dr Charlie Daniels, chairman of the LMC and a GP in Torquay, said: “Cardiology was removed from Choose and Book because they didn’t want their waiting time target to be breached. When people started complaining about it they put it back.”

Avon LMC says it is also concerned about where responsibility will lie for managing referrals if hospitals start to refuse to accept referrals because of waiting list targets.

Practices in Avon have had one of the lowest uptake rates for Choose and Book in the country although Mercer says more practices are now starting to get involved.

However the LMC’s latest advice to practices is that it urges “great caution” in adopting Choose and Book, although it says it is up to individual practices to decide for themselves.

The LMC claims the directed enhanced service (DES) for choice and booking does not compensate practices fully for the work involved and estimates that a practice engaged in full Choose and Book would be undertaking unreimbursed additional work, possibly to the cost of about £4,000 per GP per year.

Mercer says that the LMC has sought accurate information on the workload involve d in Choose and Book for more than a year but without success.

He added: “I think it’s a national disgrace that no-one has been able to set down the total workload per GP.”

Mercer said the LMC was keen to see PCTs in its area introduce the “medical secretary” method for Choose and Book which allows practices to send Choose and Book information through the post and has led to widespread take-up of the e-booking system in Somerset.

Links

PCT achieves 87% C+B referrals with flexible system

Reader's Comments

Here we go again. . .

08 Aug 06 21:08

Has Choose and Book reduced capacity in Outpatients all of a sudden? Has it closed clinics? Of course it hasn't. It's just blown aside the mask of paper, snail-mail and byzantine bureaucracy that hide the true state of Acute capacity.

There are so many outdated 1950s processes in the NHS hidden by obscure information cul-de-sacs (culs-de-sac?). Choose and Book makes it more difficult to hide sloppy capacity management, and gets blamed for what it highlights. With all its quirks and idiosynchrasies, CaB is infinitely better than the old paper based referral processes. The average for manual systems was 17 days from referral to notification of appointment when I last audited it. Think about that. My GP is worried enough about my health to send me for a Consultant's opinion, and I wait weeks just to find out when my appointment will be?!

I work with dozens of GPs and Practice Staff who use CaB routinely and wouldn't go back to the old ways, and we still see LMCs queuing up to score points against PCTs and the NHS at the expense of their patients. I've spent years defending GPs' status as independent contractors, but feel disillusioned when I hear such blatant nonsense from the minority who set Professional self interest above better, safer patient care.

Thank the Lord my family and I don't live in Avon!

Transparency is the 1st step to choice

rowan.johnson@royalfree.nhs.uk

09 Aug 06 09:08

I don't think the issue here is any criticism of C&B; infact the opposite; as choose & book is highlighting the lack of choice inherent in a cash-strapped, and deadline-led NHS, making it clear to patients & GPs @ the point of referral. The issue as it always has been, is that choice is an anathema; you cannot have choice without spare capacity, and you will not ever have spare capacity in the NHS. It seems to be more an issue of different priorities coming to loggerheads; to be seen to be offering choice & transparent democracy for all, which, certainly C&B is a very healthy step towards, in terms of transparency, and the clinical needs of patients in a commisioning led world... Never the twain shall meet, it seems!

C&B

09 Aug 06 09:08

From the article there would not appear to be any 'putting self interest' above patient care, but more a concern that there are some issues that need addressing to ensure that care is not compromised. I suppose it is a logical arguement that unless there is extra capacity, then some people will not have their 'choice'. Probably more of an issue when there are regional centre involved, where people from outside the area want to use the service and therefore there is no space for locals, I believe Bristol could face this issue, and it is right that this is discussed. Similarly the advice seems to be not to reject C&B, but to particpate with caution, which also seems reasonable. It may be by their approach those in the Avon area will collectively end up with a very workable system by working through such issues. In my experience of an LMC there is no 'point scoring' against PCTs and Trusts, but we all speak as we find.

Who chooses? Who books?

lherbert@doctors.net.uk

09 Aug 06 22:08

There are 2 strands to the C&B work - the technical side where we all wish to implement a rapid, transparent process, and it is in (almost) everyone's interest to get appointments arranged quickly - and the political side where it has always been the case that if the hospital waiting list was too long they would be removed from the list of choices available - "greyed out". The conflation of the 2 parts means that the poor old techies will get it in the neck for the political part. "Choose and Book" is a great phrase - note it hs no noun. It has never said "who" it is who chooses where you book. It will become more and more clear that the system is designed to move patients around to available capacity. Discussions with C&B co-ordinators (not where I work I hasten to add as this is not an anonymous post) revealed that they were told that if patients wished to choose an unavailable choice, they should be advised to call back at the beginning of the next month. A waiting list for the waiting list! Anyone remember that wonderful moment before the last election when someone explained to Mr Blair that the 48 hour rule for GP appointments meant you coldn't get to see your GP? Watch and wait!

What HAS changed with CaB

10 Aug 06 20:08

There have always been capacity constraints in Outpatients. Nobody can argue that. GPs traditionally refer to their local District General Hospital, and hope it has the capacity to see the patient promptly, but they have no clue whether it can or not. And nor does the patient until a couple of weeks later when they get an appointment in the dim and distant future; and quite probably coinciding with their planned holiday or daughter's birthday. CaB allows the GP and/or patient to find out if the local DGH has a long wait and 'Choose' (See? The clue is in the name) an alternative provider that *can* offer a timely appointment. Who knows, with PbR, that may be the trigger your local Trust needs to sort out its capacity management! Yes it's running late. Yes it's still clunky. Yes we're still waiting for half of our Trusts to become Directly Bookable.

But can we stop using it as a whipping boy for the problems the NHS has been facing for 58 years, and get on with it?