Wednesday, 27 January 2010

Burke and Hare do Choose and Book 004.

Welcome back dear reader. Recovered from the excitement of the last episode in this exciting winter tale of woe? There is not much further to go, just 2 chapters so charge your glass, it is now a little warmer here in Northernshire and the snow is gone but still draw up to the fire and we will begin.

Chapter 9: “Availability of Appointment Slots on Choose and Book”.

This chapter starts with 3 paragraphs of the finest Party speak out as to what those at the top think should be happening (and is?) in the real world:

“Where services are provided under a standard NHS contract, appointments for these services must be made available on Choose and Book. It is a contractual responsibility for provider organisations to ensure that they have sufficient appointment slots available to meet patient demand and PCTs should ensurethat these contractual obligations are met.

Patients must expect to be able to book an appointment at their chosen provider organisation using Choose and Book. Lack of available appointment slots prevents patients, referrers and The Appointments Line (TAL) from booking appointments. This creates additional work for provider and referrer organisations, and a very poor patient experience. It also undermines one of the key objectives of Choose and Book, which is to provide patients with greater certainty about their appointment, at a very uncertain time in their lives.

Shortages in available appointment slots usually occur because provider organizations are unable to meet demand and/or have actively reduced their appointment slot polling, perhaps in an attempt to meet 18 Weeks Referral To Treatment targets, but have done so without increasing capacity.”

Any real world GPs reading this sentence:

“It is a contractual responsibility for provider organisations to ensure that they have sufficient appointment slots available to meet patient demand”.

must be tearing their hair out as when, if ever, has the NHS been in the Utopia described here?

When, if ever, have PCTs met their contractual obligations?

Anyone sued a PCT and won for breach of contract? We think not as they get away with doing nothing all the time.

“Lack of available appointment slots prevents patients . . . creates . . . a very poor patient experience”.

Nothing new there, comrades, C&B is just the start of any patient’s “very poor experience” of the NHS. The last paragraph must be one of the greatest examples of someone telling Grandmother how to suck eggs.

How many people in your average Poltiburo reading that will think:

“Oh no we shouldn’t have done that, we should have employed more doctors and nurses to increase (clinic) capacity, built more operating theatres and increased their funding and staffing to increase capacity.”

Rather than employed a clerk to “actively reduce their appointment slot polling”.

One method is cheap, involves little work, thought or expense and does nothing for patients. The other does not.

Which, dear reader, do you think happens in the real world outside of Choose and Book La La land? Is there now a department in the Department of Health called the Neverland Choose and Book Ranch?

The last paragraph clearly was written there:

“PCTs must take ownership of local appointment slot and capacity management issues in their area and proactively monitor and manage their local provider organisations in line with their existing contracts.”

Does that mean an end to patients being sent back to their GPs to book another C&B appointment slot when there are no slots for a particular clinic after a “request” is put in by a surgery for an appointment? Mental image of revolving door comes to mind going round and round and going nowhere other than in circles of denial of patient care while NHS managers twiddle their thumbs.

We are sure that PCTs and their commissars having read chapter 9 will be increasing capacity in the NHS in the biggest “surge” of clinic expansion in the history of the NHS. (Not).

On to chapter 10: “Directory of Services (DoS)”.

To quote from the second paragraph:

“The DoS is often described as the ’heart‘ of the Choose and Book application, because it holds information that describes the services that organisations offer and enables referring clinicians to search for appropriate services for their patients.”

Well if this is the “heart” of Choose and Book then it has been in asystole ever since its inception.

It must have been designed by a dyslexic illiterate simpleton on speed whose first language is reverse Polish logic who has never worked in General Practice or done anything remotely medical like work as a secretary, receptionist or GP in the real world, oro as an appointment clerk, medical secretary or consultant in a real world hospital in the NHS.

There used to be a computer operating system called DOS (Disk Operating System), that at one time, before Windows, operated computers and was useful.

The NHS does not do useful but it does do crap hence the initials DoS.

Notice the subtle play on words to remind you of something that was once useful and associate that within your mind in the hope you think it is something good and useful rather than what it actually is namely crass DROS (Dickweed Redirection of Service).

For those of us of a sad ilk the term DoS also stands for Denial of Service (attack) for attacks on computer installations but in this case the DoS has come from within the system itself and a DoS is all that DoS delivers.

It has put more doctors, secretaries and receptionists off using C&B than any other part of its, sorry for the grunt word, p*** poor design.

We will quote an example of a colleague’s experience who thought C&B was good until this happened to them. They had wanted to refer a patient with suspected gallstones to see a surgeon in case the patient would benefit from having their gallbladder removed.

So our colleague thought, as a doctor, and went into DoS (DROS), thinking that this will be under gallstones which is normally the preserve of the general surgeon ergo to refer look for a C&B appointment as follows:

General Surgery > Gallstones.


Boy, were they wrong. The local idiots do not do gallstones in general surgery as you are taught in medical school although for some reason you can find them under Gastroenterology but they do not remove gallbladders which is what was wanted.

Still it is gallstones so a receptionist might book it unaware that gastroenterologists do not remove gallbladders, they are not surgeons, but it says gallstones so that is alright and they will book a patient an appointment so will meet targets. The patient will come back to GP land and say “they won’t remove my gallbladder can I see a surgeon ..” .

A wasted gastroenterology appointment followed by the finally correct general surgery appointment assuming that the gastroenterologist refers the patient to the surgeon but more likely they will write back and suggest that the GP does this and so the process repeats itself and in doing so delays patient care and increases the local hospitals income. And increase “productivity” graphs?

Instead after half an hour of ringing round, that is the equivalent of seeing 4 patients under the old average minutes per patient, but with NHS efficiency savings this is now 3 patients, with some idiots in the BMA wanting 20 minutes a patient appointments, presumably so more doctors can book C&B appointments themselves while ignoring illness, they finally found how to refer a patient with gallstones.

They found it under General Surgery > Lumps and Bumps > Gallstones along with haemorrhoids and virtually every other surgical problems that can be removed unless it is more than 1.5cm large in which case the NHS is incapable of removing a single 3cm large gallstone.

So much for all of our medical training as to what we should have been removing as junior doctors on “lumps and bumps” operating lists.

Instead of us doing simple operations like removing lipomas and sebaceous cysts, we should after all the super improved reforms of MTAs and Modernising Medical Careers (MMC), have been taking out gallbladders instead as they are the new “lumps and bumps” leaving consultants to do the sebaceous cysts and gallstones greater than 1.5cm or those “lumps and bumps” located in the neck. C&B’s DoS tell us so.

We won’t recount another colleague’s experience of trying to find Nerve Conduction Studies. If you have a day (or a month) to spare and wish to experiment with mind altering substances there is a small chance that you might just find it.

These examples took hours of our secretaries time to find, in a world class PCT with “world-class” IT provision, and DoS defies all logic human, Vulcan, Klingon or otherwise.

It is impossible to use even if you have ten minute appointments and do nothing else other than make a C&B appointment. You can’t do both namely see a patient and use C&B which is why so few, if any doctors who work in real time General Practice, use it.

Needless to say neither doctor citied above now uses C&B and both have “lost” their Smartcards. Check eBay for a laugh and remember how many “secure” Smart cards have gone missing.

Onto the second sentence in the paragraph more Party speak:

“For provider organisations, the DoS provides a ‘window’ through which they can display and ‘advertise’ their services.”

Ah ha the now dead NHS internal market being given new life by these fine market sounding words. Anyone thinking that the DoS “advertises” services must have been a keen reader of Pravda as the information is nigh on useless.

The final paragraph says it all:

“By following this guidance, referrers should know which patients are most appropriate for a service, provider organisations should receive appropriate referrals and patients should be given appropriate and helpful instructions prior to attending their appointment.”

We would wish to paraphrase this and say:

“That after doing GP training and knowing what is, or is not available locally and, if need be nationally, a GP will be able to refer a patient to the most appropriate service without the aid of an expensive useless pile of crap called Choose and Book. This is, after all, what good GPs should be doing, and were trained to do, anyway.”

They did this before Choose and Book and for a lot less money and more efficiently too. Patients actually had choice as well.

Praise be to the Party who, as ever, have shown us GPs how wrong we are, and in doing so have given us the wonder of Choose and Book. Shame the authors never did any GP or medical training or things could only have got better . . .

Jo Stalin would have been so proud and envious of his protégés (stooges).


Jobbing Doctor said...

A classy rant. Well done.

By the way, it is pretty much the same here in Dullshire.


Northern Doc said...

Thank you JD for your kind comment. The author of this is like yourself 1 in the USA with 500,000 and 500 being the figures. Regarding carpets we don't even sit down and on occaisions have wiped our feet as we leave a house!

Anonymous said...

I am in secondary care. Our hospital is not just world class, it is stellar class. To maintain our status in the galaxy we need to practise what we call gaming. Gaming is working the internal market to maximise income. One way of doing this is to ensure that if a patient needs a cholecystectomy they do not go to a surgeon directly. First they need to attend gastroenterology after which a big bill will be sent it. Then they go to see a surgeon. Then they have their surgery. And then an even bigger bill is sent in. Simple. But it is money down the drain. In the old system the hospital got a fixed amount of money so we had to be sure to minimise expense and eke it out to deliver the care our patients needed. Why did they ever move away from such an efficient system?

Hayley said...

I think most people who have to work with it hate Choose and Book, for a variety of reasons, not least because one does not actually get to choose...

A New Kind of GP said...

I'm so glad that I work in Wales where we don't have Choose and Book.
Vive la difference!