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.

Simple?

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).

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.

Burke and Hare do Choose and Book 001.

As the festive season approaches you may be struggling to find a present for someone. If you are looking for something that will cost you your marriage or lose you a life long friend and that special someone happens to be a user of the Choose and Book (C&B) system may we suggest you look no further than here.

This little festive gem will bring seasonal joy to any user, or non-user, of C&B as we hope we shall show with some extracts from its 24 pages of joyous reading. It was found using a link from the weekly BMA unsolicited email shot to its member using the intriguing title of “How to use Choose and Book correctly” or to give its official title “Responsibilities and operational requirements for the correct use of Choose and Book”.

Now it is cold and damp outside in Northernshire today so, dear reader, pull your chair closer to the fire, pour yourself a glass of mulled wine and something for your blood pressure and we shall examine some of the pearls of festive joy we have discovered.

Look first at who the “Target Audience” is, well it is the Christmas panto season, on the second page (PCT CEs, NHS Trusts CEs, SHAs CEs, Communications Leads, SHA Directors of Performance, SHA Chief Information Officers, SHA Choose and Book Leads) and then look at the extensive circulation list. Clearly this document is intended for those who use C&B are a daily basis.

Read the Foreward obviously written by retired doctors who have not worked with patients for years as the following sentence clearly illustrates:

“As set out in the Operating Framework for 2009/10, the long term transformation of the NHS requires a move away from top-down methods to an enabling role for the centre, with more power and responsibility residing with patients and clinicians.”

The next and finally paragraph illustrates so well this monumental sea change in Party Central policy change comrades as more than mere words:

“This guidance has therefore been prepared to help organisations understand the importance of using Choose and Book correctly. Standards and requirements described here should be recognised and implemented in all organisations using Choose and Book and providing services to NHS patients so that all patients wherever they are in England experience the same high quality access to NHS care.”

Fired up with winter warmth from these inspiring seasonal words lets us continue onto the first Chapter “Clinicians using the system themselves”.

“Whilst aiming to be flexible and support many different models of referral, Choose and Book was designed, and is still intended, to be used by clinical staff to initiate and accept a referral, with non-clinicians fulfilling some of the purely administrative functions associated with the process.

The ‘Gold Standard’ for the correct use of Choose and Book is, therefore, for a referrer to have a choice discussion with the patient and subsequently to initiate the referral, with the patient still in the consultation.”

The last paragraph reads:

“Within a provider organisation, the ‘Gold Standard’ is for a clinician to review their own referrals online, accepting, re-directing and rejecting referrals themselves using Choose and Book, and for provider administration staff to do any re-booking, letter-issuing or other administrative tasks, as required.”

We wonder how many real working GPs in the UK will recognize this as the antithesis of how C&B is being used? No Brownie points for any of us here at ND Central or we suspect in most UK practices. Another glass of mulled wine to ease the next chapter in?

Chapter 2 “Free Choice”.

Well that glass went down very quickly and rapidly into the fire but please do not do this, dear reader, as glass in the ashes is a Health and Safety issue for our maids.

Chapter 3 “Promoting (not mandating) the use of Choose and Book”.

1st paragraph reads:

“PCTs should encourage referrers and provider organisations to use Choose and Book wherever possible, by actively demonstrating its benefits rather than by mandating its use.”

Clearly no local Politburo commissars know this as C&B has been MANDATORY for all referrals (apart from the several pages of exclusions of course) forever as local PCT commissars crawl up politicians’ gastrointestinal tract in search of the Order of Gordon 1st Class for being good little comrade Soviet top down enforcers.

“Choose and Book is by far the safest and most reliable way to make patient referrals. In a choice environment, where patients have the option of going to a wide range of provider organisations, it is simply not practical to rely on the old, paper-referral method. PCTs should therefore work with local referrers to help them understand all the benefits of Choose and Book (for both themselves and their patients), helping them to overcome real or perceived barriers that are in the way of effective implementation and proactively encourage usage of the system.”

We like that paragraph lots of weaselly management speak like “it is simply not practical to rely on the old, paper-referral method.” Why it was less work, less paper, quicker, cheaper easier to use for all involved and meant the patient saw the right doctor?

“helping them to overcome real or perceived barriers” The real barriers are the biggest obstacle for any real doctor or secretary using it as crap is crap and the stench of uselessness is real to all who struggle to use it. But then:

“Use of Choose and Book should not, however, be made mandatory.”

Praise be to the Party for this little gem which we shall return to. Please feel free to read it for yourselves and compare it to your own experience of C&B.

We would however recommend a good case of wine and a catering pack of your favoured antihypertensive agent be on hand as you do so.