If it is working, investigate?

For many months we have been trying to find out what percentage of referrals are currently made via the Government’s huge white elephant of failed IT called Choose and Book but haven’t found anything. Other figures like the percentage of referrals made by doctors vs secretaries have also eluded us until yesterday when we found this.

We have posted many times before on this huge and useless pile of NHS retarded computing which serves one and only one purpose to gather referral data for the Party. It has, and never has been, about “choice” unless it is to allow NHS managers to restrict true patient choice it is merely a bean counter for NHS managers and part of the (failed) commissioning process.

We respectfully submit to any investigation the following reasons as to why there is a fall in Choose and Book bookings in a simple format used by its architect (hint TB):

1) It is crap
2) It is crap
3) It is crap.

So if ever an investigation is never required it is into Choose and Book. If you have never ever been involved with it, used it or being on the receiving end of Choose and Book it seems a good idea - in theory. In Practice it is a nightmare.

All any investigation needs to do to find out why people are not using it is to try using it in the real world. Such an idea might be dangerous for it might involving those who support C&B interacting with real patients, dealing with real NHS IT and all its huge failings so will never happen.

Praise be to the Party for once again deciding to hold an investigation into something not working rather than fixing the actual problem. If something is good and works people use it. Any NHS manager able to work out the corollary to this argument?

No wonder you need an investigation.

A small victory for common sense?

One of the team saw this news item in Pulse magazine this weekend. For reasons best known to the Party it is scrapping its target that 90% of referrals should be made via the hugely expensive and failed Choose and Book (C&B) system.

Now this does not sound like an earth shattering story but look at when this target was supposed to have been met. Look to the article to see what the latest figures for percentage of referrals being made by C&B. 53% in June of this year (2010) and in June 2009 the figure was the same and that was down from a “high” of 56% the previous October.

res ipsa loquitur?

GPs know C&B is crap, anyone who uses it, predominantly medical secretaries in GP practices, know it is crap which gets crapper with every upgrade made to it. It is nothing more than a Party sponsored bean counter and a means to control access to secondary care. It is the prime denier of choice within the NHS as we know it and is still Party sponsored.

We said it was a small victory and that it is all it is. We know of some Soviets that are still forcing GPs to use C&B using the well known Soviet principle of Hobson’s choice.

More worrying is the bit in the article which says:

“The DH has indicated that GP consortia should maintain and invest in the system as they take over from PCTs and this week backed the system despite dropping the 90% target.”

Given the choice of investing in real healthcare for an ill patient, or investing in a very expensive failed piece of Party enforced IT, we wonder what our patients would want any GP commissioners to spend their tax pounds on?

What will the free from top down interference new Party allow? Will a certain percentage use of C&B now be a NICE new “outcome” to reflect “quality” practice and thereby tick another box instead of a top down “target”?

Praise be the Party for appearing to realize the error of their ways but in practice it is business as usual.

Choose and Book – get some more!

Earlier in the year we posted a piece of about one of the teams family’s experience of using Choose and Book.

We thought we would update you as to how well Choose and Book is serving its users. When we left we were still waiting to get an appointment with one speciality but had booked another appointment via Choose and Book at a date and a time of our Choice only to have the hospital rearrange (C&B) it for us.

A few days after the post we went on line and instead of the usual message we had seen for the past 4 and a bit weeks:

There are currently no appointments available please try again later. Please call the C&B Appointment Line on 0845 6066 8888 for further information.

This was the sight of an oasis in the desert of appointments for this speciality - 4 whole appointments. This was early in the morning before work and so the person who needed the appointment was roused from their bed, before reveille, and with much protestation and was asked “which one do you want?” for we know that when these appointments appear they disappear like snow in the Sahara at midday.

A rapid consultation of 2 peoples’ work schedules followed and 2 of these appointments were at the right hospital and at a convenient time and so one was booked and the details printed off.

At last we had been given a Choice and were able to Book it. Job done but now the real wait began.

Remember what the Party propaganda says:

“Choose and Book is a service that lets you choose your hospital or clinic and book your first appointment.”

But not your consultant . . .

“ . . . fit your treatment in with your other commitments and work . . . choose your appointment that fit your carer’s schedule . . .”

but only after several weeks wait and from a choice of only 4 slots only 2 of which were at the right hospital so clearly the promise of being able to book in the doctor’s surgery with the doctor then and there was honoured.

Now if you are dealing with children, the elderly or dependant patients the ability to choose a time is important. We usually reckon that if you have a hospital out patient appointment it means losing half a days work which as a GP would mean cancelling a full surgery, possibly not doing visits and possibly another clinic or minor operating session.

We here at ND Central try to get appointments on half days off or do an extra surgery to make up for an appointment but we can be flexible. A lot of employed people do not have such flexibility or understanding from their employers. If you are an employee with a child or an elderly relative this can mean that hospital appointments, especially if recurring, be a real nightmare.

So having a fixed appointment means you can plan ahead which we did.

A week later we received a letter saying we needed to ring the hospital in order to book an appointment which we thought we had already done and being technocrats we had done it the sleek modern way online. How smug are we!

So we rang the number on the letter and this is the conversation that followed:

“Comrade patient I am Comrade Senior Appointment Clerk Commissar Olga Bollocovic how can I help you?”

“We have had a letter saying we need to ring to make an appointment but we already have one we booked online.”

“That is because comrade patient you cancelled it the computer says you did so 3.473 days after you made it.”

“No we did not!”

“Oh we meant the consultant read your comrade doctor’s referral letter and decided that you had booked the wrong clinic so you now have to make a new appointment . . .”

So after over a month of waiting, booking an appointment online, with only a choice of times and places not clinic types, we are told we had cancelled the appointment and now had to make another one which we did.

If this situation happens where a patient books a clinic but when the consultant finally sees the referral letter decides it is the wrong clinic we are told it should be the hospital’s job to rebook the appointment.

This happens all the time as many patients do not know what clinic they need so if for example they have a cataract they will book an "eye surgeon" appointment which may mean they land up in a squint clinic for children such is the sophistication of the C&B software and the fact that the consultants no longer allocate the appointments after reading a referral letter.

The new improved computer interface allows the patient, who may not know what is wrong with them, or what clinic they need to book the appointment before the referral letter has even been done. Choose and Book software is all knowing and all powerful and can sort all of this out.

We then had to reschedule surgeries school runs as a result.

We counted up how much effort we had put in to get 2 hospital appointments. We have a total of 9 pages of A4 paper sent out from hospitals to make/cancel/rearrange 2 appointments. We have had to make several phone calls to confirm/ rearrange appointments as well as confirm our intended attendance. We have had to go online every day for over a month to try and get an appointment – you could, if you wish, ring up every day to be told there are none.

Not bad eh? Clearly an improvement over the send one letter get one appointment back usually for the right clinic.

Praise to the Party for whom Progress means taking one step into the electronic age and in doing so going 15 steps further back into the Stone Age. The worst bit about it is that those who trained us and mandated Choose and Book use said it would be a paperless, one stop exercise.

Did we miss something? And remember this is being repeated all over the country many, many times each day. Efficiency saving, sorry, gain anyone?

Choose and Book some more. A patient’s experience.

At the end of last year we had a little rant about the how to use C&B properly book.

Well one of us here at ND Central has had to use C&B first hand for a family member and to say that it is a crock of brown stinking useless sh*te would to be give it more credit than it could ever merit based on how well it works.

Have a look at the scans above and we shall dissect one of the most expensive pieces of useless government software ever devised and its complete and utter failure to do anything.

Remember dear reader that this software was designed to be used by doctors, some of the most intelligent people in any society and very few (if any) of them use it because it is complete and absolute crap.

If someone suggested Brillo pads as an alternative to toilet paper would you use it? Ask any UK medical secretary Brillo versus Andrex? Choose and Book versus the old paper system that worked and was so much less labour intensive and quicker?

By way of background we wanted two appointments for the family member concerned one of which we were able to book in the surgery the other we could not.

So let us look at the letter. Easy to read as we copied the text to a grammar checker and it gave a Flesch grade level of 7.4 equivalent to a college graduate or very difficult to read.

So your average demented, elderly or illiterate patient will have no problems based on the words but the concepts contained within the easy to read text might be more difficult.

Go to section 2 and see where you can make your appointment.

A call centre? Well our experience of call center’s staff whose sick notes we sign is that they are usually drug addicts or alcoholics so you know at once you are in capable hands to navigate though the complexities of “choosing” your healthcare with these experts. This is an enhanced service where if your referral has been screened by a clerk in a referral management center you will have to argue the case in order to get your, or did we mean their, choice for your appointment?

This is just our experience from the local commercial call centers. We know from our experience of swine flu that those employed by NHS call centers are a completely different caliber of operative. Far better than anyone with a medical degree as they can diagnose and prescribe in 3 hours of training something that no UK GP could.

You can even read the Party approved call center script here. Go on have a laugh we did.

Now section 2 also hides a very publicly hidden “cost” to the NHS “free” at the point of need agenda so beloved by the Party.

For a pensioner on a budget a mobile is good way of saving money until you start to use Choose and Book and try to use a government sponsored call center “please wait while I put you on hold as the computer is not working”. Something is usually not working in call centers and it is called the staff. Trust us some of our better staff dished the dirt when they joined us looking for better jobs.

Look at the last paragraph regarding mobile phones. How many real GPs, not politicians, have had patients ask them to make their appointment as when they try to do it on a mobile they are put on hold and charged a fortune to the point of no credit and more importantly no appointment. They are repeatedly told to ring back as no appointment slots are available.

When you can neither Choose, or Book who you going to call? Your free at the point of delivery GP and their staff of course.

No wonder pensioners are called bigots for how can they not afford to use mobile phones as they have all been to the same public schools and universities that politicians have been to and they get massive pensions and expenses as well?

Section 3 says “Your choices”. In the letter it says you can book ONE of your choices. Curious that we had asked for 4 choices of hospital (can’t “choose” your consultant though comrade) but then we are only good communist serfs so therefore 4 now equals 1 in NHS “Choice” la la land. Go to the nhshealthspacewebsite and you choose all four to see what appointments are available.

Clearly good one size fits all here comrades and remember we have the benefit of a University education and one CSE in Maths between us at ND Central so we should find this all a walk in the park.

We have access to the Internet as do just 66% of the population which means Choose and Book is true egalitarian medicine and "choice" along the lines of if you can afford to pay you can have more "choice". If you have Internet your choice is greater than those with just phones (90% of population for landlines 79% mobile phones source).

On to the second page and there is your password. This is the thing that we as GPs have seen most of with Choose and Book a whole generation of people of all ages saying “I rang up and was asked for a password but I couldn’t find it”.

In the good old days, when most people could read, the only password you needed for a referral was “Good morning/afternoon doctor”.

Now we come on to the most interesting bit. Being techies here we have been using the internet for the last 4 weeks to access an appointment. And what do we get?

“Please choose one or more of the clinics below and click “Continue to Step 2” to view all available appointments.”

Select all 4 we did as clearly as internet babes we are given more “Choice” than those using telephones and this is what we got:

Hospital 1 Approximate wait time 80 days
Hospital 2 Approximate wait unknown
Hospital 3 Approximate wait unknown.
Hospital 4 Approximate wait time 39 days

And the most important bit after all of this was the message in red:

There are currently no appointments available please try again later. Please call the C&B Appointment Line on 0845 6066 8888 for further information.

This cycle for many people is repeated time and time again and mobile phone bills increase as calls to Choose and Book are charged at a higher rate than from landlines.

The old system consisted of patient using the password and this simple system:

“Good morning doctor. I think I have a hernia can I see a surgeon?”

“Certainly. I will examine you, confirm you have one and who would you like to see?”

“Who would you recommend as I would not like a call centre smack head to decide? I would rather to talk to a professional. I would like to see Mr X who did my friends and he thought highly of him, can I see him?”

“Of course, Mr X is very good, I will dictate a letter which our secretaries will type and send off to the hospital and you will receive an appointment through the post. Let us know if you hear nothing in 4 weeks”. (Text in quotes 117 words vs 300 for C&B Call Guidelines core from the C&B text above).

If you examine just the text of the Choose and Book Appointment request letter there are 216 words. That does not include the appointment or the instruction of how to make a choose and book appointment

Now someone once said that The Ten Commandments required a mere 300 words and the American Declaration of Independence 1,300 words. However, the EU regulations regarding the export of duck eggs require 26,900 words.

So what used to be a simple system has evolved into a monstrous system that fails to deliver. Our family member is still waiting after 4 weeks to be given an appointment. Does that mean that when they get one it will only take 14 weeks until treatment? Or has the waiting not yet begun because they have been denied an appointment by the Party and its all wise commissars?

Look on Choose and Book websites and this scenario of no appointments does not exist.

Remember we know the system where would you suggest we go next?

We did manage to book one appointment in the GPs office for the patient concerned and chose a date that would mean no time off work to take our family member to their appointment. Our choice was respected as a few days later a letter arrived from the hospital concerned with another appointment date and time. We now have to lose half a days work as the appointment has been changed to another day with no explanation as to why.

More massaging of the 18 week wait target by giving a dummy appointment which does not exist? 18 week wait target met box ticked when actual wait longer? Cancel the non existent appointment and send a real one. No gamesmanship here comrade patients just genuine “world class Choice”.

Praise be to the Party for giving us something we never needed “Choice” = none and the ability to “Book” not an appointment.

Choose and Book is a lasting legacy to the centralized, institutionalized incompetence and inability in UK healthcare. If anyone wants to save money shut it down and efficiency saving would be instant as staff time wasted using C&B could be more usefully deployed by doing something useful for patients.

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.

NHS Computing and the 12 rules of NHS management a case study

If you read the above and have an IQ greater than the Party then you will see a pattern here with health policies. Let us use Choose and Book (C&B) as an example.

Rule 1) If there is no problem make one

There has never problem with GPs referring to anywhere until Comrades Gordon and Tony (G&T) decided that there was a problem = no choice. Anyone who has worked in the NHS for all the years that comrades Blair and Brown have done would know that there has always been a choice but G&T based on their vast experience of healthcare decided they had to introduce choice to replace that which was there in the first place.

The only restrictor of choice was, and still is, NHS management and government not NHS doctors. So Choose and Book was a solution to a problem that was never ever there for either patients or doctors. It therefore fulfils the first rule par excellence.

Rule 2) If it is simple make it complicated

In the before G&T “Choice” days GPs used to send letters to their consultant colleagues with what was wrong with their patients and which consultant they as GPs felt their patients should see. The consultants read the letter decided if the referral was appropriate and then arranged for a letter to be sent out to the patient with an appointment or sent the letter to the correct consultant.

Now this simple process has been made complicated. Instead of a secretary typing a letter putting in an envelope and sending to a consultant for their consideration the following extra “enhanced service” has been produced.

Letter goes to a “referral management centre” RMC where, instead of referring up to a more specialized and qualified individual (a consultant), it is passed to a clerk or alternative therapist. The patient, instead of receiving a letter with an appointment, now gets a letter with an appointment to ring a call centre to be told what “choice” they have. This “choice” is determined by the local Politburo who use RMCs to restrict choice. Instead of one letter it is now one letter, a phone call and maybe many, many more of both (this is an abridged a summary of 3 pages of A4 as to what can happen for a simple Choose and Book referral).

For the elderly this is extremely confusing. C&B is now a choke for if there are no appointments on the C&B system (because of the 18 week rule) then patients are told to ring again to a call centre (several times) before being told to ask for another referral from their GP. If you don’t get an appointment you don’t appear on a waiting list and so the 18 week rule is achieved using Choose and Book.

Rule 3) If you can’t find a solution have another meeting

Choose and Book = meetings meetings meetings meetings meetings and over time the Gods of C&B cease to talk to those that identify the many problems. This leads to more meetings to find out why no one talks to those having meetings from which they are excluded.

And so the cycle repeats and achieves nothing but more meetings.

Rule 4) If other meetings don’t work employ more managers

More managers have to be employed to sort this simple problem out. Rule 4 is simple it is the way of the health service and a growth industry with zero return.

Rule 5) Do not involve anyone with ability as they might come up with the solution and put you out of a job

Drs used to get asked for their opinions but do not now go to meetings unless they are brain dead or like to avoid patients. Even the people who the C&B system was designed for Drs, the secretaries in surgeries and clerks in out patients, have not been invited to meetings for months as they dared to criticise and interrupt the local C&B commissars pre written answers to their questions which they were not allowed to ask.

So the managers who never use C&B for they never see patients drive C&B forward. Ever onward and downward.

Rule 6) If you fail you will be promoted. If you are not, set up a consultancy (see 7)

Many idiots who have failed to deliver even basic working IT systems at a local level have been promoted due to their failures. Bit like a pilot who crashes their paper dart being allowed to fly the space shuttle. NHS IT is full of failed rocket scientists who the private sector would not touch with a barge pole. Makes sense and explains a lot does it not?

Rule 7) If 1-6 do not work employ management consultants (not consultants see rule 5).

Due to the fact that NHS managers are thick this has to happen. Who do they employ who knows anything about the NHS problem they have created? They employ their thick friends indirectly. The thick failures set up as management consultants and tout their “alleged” experience in the NHS to the private sector who use them to milk the political gravy train. Commercial and successful companies pull out. We get the dross.

Rule 8) All new policies must generate extra work for all involved to achieve the same goal or ideally less.

Anybody using Choose and Book seen their workload reduced? Just ask how many doctors use it because it saves them so much time? Ask their secretaries which was easiest to use the old paper based system or the new system?

Ask hospital consultants how it has doubled their workload in some departments because the wrong patients turn up at the wrong clinic and how much extra paper work has been generated at the hospital end for clerks?

If you can’t refer to a particular department you now send a letter (even ‘though all referrals must go electronically) with a covering letter saying why you are sending a letter because the electronic system did not work. If you don’t send the second letter the referral will bounce because it has not been sent electronically.

Rule 9) If a change is unpopular tell them you are re-applying for your job or change your job title and tell them it’s someone else’s department.

Can anyone complain about Choose and Book? If you do who do you complain to? No one answers or gets back to you or it is someone elses’ department and you never hear from them. You have to sort it out yourself or use something that works called paper.

Rule 10) If you cock up have a listening exercise. Hear and change nothing.

Choose and Book managers no longer talk to the users’ of Choose and Book as all they get is abuse it is so bad. If you do not talk to the end user there can never be a problem and you can report this back to Party Central and get a promotion (see rule 6).

Lots of listening but nothing has changed. It has just got worse and worse and worse. A previous simple and flexible system made worse on a political whim and flight of fancy.

Rule 11) You have power and are unaccountable.

Many Politburos’ Chief Commissars have imposed unilateral “every one must use Choose and Book” policies in order to be awarded their Order of Postman Pat 1st class unless of course it is one of the 575 exclusions where C&B does not work and you MUST use paper. Managers have imposed a failed system and by using rule 10 they are completely unaccountable. The Party and C&B move on like a glacier with all using it waiting and praying for global warming in order to stop its progress.

Rule 12) Reinventing the wheel is called innovation just make sure that the new wheel is a square one.

A system that worked has been replaced by a very expensive failure. Just ask a politician how many countries have bought Choose and Book? Compare that with other IT systems like Windows.

People pay to use commercial software e.g. Windows because it is useful. Choose and Book has to bribe people to use it because it is crap.

Rule 13) Managers can’t be expected to count.

The Bottom Line guys. What was meant to cost £ 6 billion is now forecast to cost up to £ 50 billion with the clock ticking constantly. Peanuts considering all the banking bale outs but remember the US moon race is reckoned to have cost $ 100 billion to put a man on the moon in a decade. You do the maths.

If any journos want a story on sleaze ask yourselves how many politicians from our last Prime Minister’s administration were/are directors or advisers to companies supplying the NHS IT disaster? This is one waiting to be reported.

Possibly the biggest IT white elephant of all time? Probably. A large bean counter by any other name certainly something of no use to any one involved in health care . . .

Other than Managers and the Party.

Praise be to them both.