Burke and Hare do Choose and Book 002.

Welcome back dear reader to our humble but warm fireside on these cold, icy Northernshire nights which are good for neither man nor beast especially real world GPs. Are you sitting comfortably? Another glass of mulled wine perhaps before we continue on our perusal of the Choose and Book Christmas special?

We are now onto Chapter 4: “Acting on behalf of Referring Clinicians” from the wonderful winter's evening read found here:

“Clinicians (e.g. GPs) should be aware of their responsibilities when referring patients, especially when delegating these responsibilities to non-clinicians (e.g. PCT-based referral management centres) to act ontheir behalf.”

Lots of words later implying that this is a tightly regulated process such as “strongly enforced by the Registration Authority (RA)” –whatever that is and

“parts of the referral process may sometimes be delegated (with caution) to named and adequately trained administrative staff.”

Well this is called General Practice and responsibility and delegating to our staff is nothing new to real world GPs but to the authors of this report it is a road to Damascus moment. The art of being a good officer is, after all, delegation.

More sinister is the next paragraph:

“When deciding that an onward referral is indicated, a clinician accepts the clinicalresponsibility for that referral, and for the actions of any staff acting on their behalf.”

Seems OK thus far as that has always been the case even with paper referrals but read the next paragraph:

“Although not always ideal, parts of the referral process may sometimes be delegated (with caution) to named and adequately trained administrative staff working within the same referring organisation, usually where direct contractual and supervisory arrangements are in place. If referrers delegate the short-listing of services in this way then, in keeping with General Medical Council recommendations on delegating responsibilities, they are responsible for ensuring that staff to whom they delegate are adequately trained and have sufficient clinical knowledge of the patient and their condition to make the referral and/or short list appropriate services”.

Digest and pour yourself, if you are a GP or any genuinely responsible person with concerns for your healthcare, another glass of mulled wine (preferably a pint) and pull your chair closer to the fire as things are going to get colder.

Now we wonder how many GPs got up one morning and thought let us invent a referral management centre? According to this chapter we are now responsible for the actions of those Poliburo commissars who MANDATED the referral management centre onto GPs probably without any consultation – they just appeared. However the PCTs are NOT responsible (for their actions) according to this less than learned tome it appears that GPs are for the whole referral process.

A possibly interesting legal point here?

If a PCT, which establishes and runs a referral management centre, diverts a referral letter from a GP, for example a letter specifically addressed by the GP to a chosen and named orthopaedic surgeon (more on this later), to see a physiotherapist then the GP is legally responsible for the PCT’s actions?

We know this is correct as we all know NHS mangers are responsible for nothing so Choose and Book enables those in the bottom third of our education system to kill and injury patients without ever going to medical school and walk away Scot (or is it Gordon free?) and blame it on the doctors? Nice one comrades.

Choose and Book empowering incompetence through unaccountability and inability. Why have a Lockheed SR-71 designed on a slide rule by people with ability 40+ years ago when you can have Choose and Book designed by committees manned by those with inability and no experience of real world General Practice?

One did the job and holds numerous records. The other is British.

This is bad enough, dear reader, but pour yourself another pint this time of Southern Comfort with an old Peculiar chaser, it is after all winter and read on into Chapter 4.

“Referrers (e.g. GPs) may wish to consider using a Clinical Assessment Service (CAS), if one exists, if referral pathways are complex and if this will provide additional clinical benefit for patients. CAS functionality is supported by Choose and Book, but should not be used as a disguise for purely administrative referral management centres.”

May wish to consider? Once again we had zero NHS “choice” and they provide no additional clinical (medical) benefit.

For those readers not familiar with a CAS concept (or is it spelt Kaz?) it is whereby a local Poliburo (PCT) decides it will try to save money and intercepts GP referral letters to real medical consultants using the “Choose” and Book computer system = more Soviet style control.

The Politburo then allows a delta grade (sometimes) a “medical” pratitioner decide whether your patient, who you referred to see a consultant, needs to see that consultant or, if the delta grade thinks otherwise, you can see someone cheaper.

If the deltas are lucky you get better and they save money. If they are not it is back to the GP to be re referred back to the original consultant and hope that the delta grade reads the sentence “has already seen or had treatment X and it did not work” before you are finally get to see the original consultant.

This KAS concept exists for one reason only to save PCTs money. It was never ever designed to improve patient care and it fails miserably at this.

It is not a “Clinical” service as clerks and alternative practitioners are not medical, it is not “Assessment” as they can’t even read to whom the letters are addressed and serious cases slip through with alarming regularity and it is not a “Service” it is a disservice to any patient unfortunate enough to have their referral diverted to care on the cheap.

It is in fact CRRAP (Clinical Referral Redirection Approval Process) not CAS and designed and run by morons.

Once again Referrers may wish to “consider” using a CAS even though in practice we have no choice despite the “not mandatory” clause we discussed earlier but we have only the NHS “choice” as GPs and patients.

Let us paraphrase the last paragraph of Chapter 4:

“PCTs should take responsibility for these CAS services (no chance NHS management has no responsibility only incompetence), ensuring that they are set up with the support of (NO they were forced on us) local referrers and that administration staff do not assume clinical responsibilities (which they do call centre staff tell our patients they need to see a physio not a surgeon even when patients argue against them).”

Well a couple of pints of winter warmth added to by the smug satisfaction of knowing that all that should have happened with the implementation of Choose and Book in Northernshire has not from this wonderful piece of seasonal joy has left us a little tired.

The snow is falling, the mercury, sorry mercury substitute, in the thermometer is falling and so we must put our slippers, night gowns and night caps on and retire upstairs using the light of our candles to the 4 poster in our large manor house before braving the winter cold in the morning for the Saturday sea of wellness and DNAs (did not attends due to hangovers). It is Christmas after all.

Priase be to the Party and all its stooges. Will there soon be a bumper sticker saying we love Choose and Book?

Doubt it.