Some brave practices jumped in feet first when the Choose and Book service was first introduced in the summer of 2004 and, despite the technical glitches, are enthusiastic about the benefits of the airline-style online appointment booking service.
But others complain that they have neither the time nor the resources to make it work. A recent survey of 200 GPs by Nuffield Hospitals found that only 51% of GPs intend to use the system and one-third (34%) planned to bypass it altogether and continue referring patients in the usual way.
The Department of Health (DH) says its research shows that patients want to be more involved in making decisions and choosing their healthcare. It also claims that feedback from pilot practices, or "early adopters", has been mainly positive.
The £64.5m scheme has been slow to get off the ground and has been plagued with delays. The government's original target was for the system to be fully operational across England by the end of December 2005, but in February this was revised to 90% of GPs making referrals through Choose and Book by March 2007.
A lot of work will need to be done to achieve this deadline. According to Connecting for Health, the Department of Health agency delivering the National Programme for IT, in mid-March the number of referrals made through Choose and Book totalled only 200,000. The service is currently receiving around 3,500 bookings a day. More than 40% of practices have gone live and made at least one booking, and 97% of NHS trusts can now accept bookings through the system.
Much of the work in establishing Choose and Book in GP surgeries falls on the shoulders of the practice managers. They play a central role in setting up the system, and it is their responsibility to coordinate change management within their practices.
The experiences of early adopters are that, though there will be frustrations along the way, there is not too much to fear. The Dukes Avenue Practice in Haringey, North London, was one of the first in the country to go live with Choose and Book.
One of the GPs, Dr Peter Christian, an IT enthusiast, was keen to get a headstart. His practice manager, Lesley Mayo, says they received a huge amount of help from the Haringey Teaching PCT Choose and Book team, which helped them to get all the practice's PCs set up with the appropriate software. Some machines needed memory upgrades, and a new server had to be installed. The IT team trained all the practice staff to use the system.
There were a number of initial problems. Until the beginning of this year the practice did not have Choose and Book software integrated with their EMIS system, and that made life more complicated. There were also ongoing difficulties in persuading the system to work properly.
But as the system has bedded in, it is now beginning to run more smoothly. With the new integrated system, EMIS automatically pulls all the patient demographic information across to the Choose and Book software.
If they wish, GPs can book the patient's appointment online during a consultation. When they type in the patient's postcode they can see the hospitals and clinics that are available to them in their area. At the moment bookings can be made only among local hospitals.
However, as GPs do not have time to discuss the finer details of the referral they print off a form, which the patient takes away. The patient can then make the appointment themselves either by phoning the Choose and Book Appointments Line or booking it online through the Health Space section of the NHS website. They can also ask a member of staff to help them book the appointment in the practice.
To date, the practice has made more than 200 referrals through Choose and Book and only 20 patients have asked for help from practice staff.
A major irritation for Mrs Mayo has been the small minority of patients who have not bothered to book their appointments. This makes extra work for her secretary, who must then chase up these patients.
The benefits of the system are that referral letters are sent electronically with the booking, saving admin staff the work of printing and posting them. Patients gain control over their appointments and are less likely to miss appointments.
Another perk is a facility that enables GPs to request advice from the consultant by email if they are unsure of the best course of action. This can sometimes save unnecessary referrals.
As an early adopter, Mrs Mayo says there have been many irritating hiccups to deal with, particularly when the
national spine has crashed. She believes the system still needs improvements.
"Like all new things, I do have some reservations about the software, and the screens can be bewildering – to be honest, it could be a bit more user-friendly. But they have already made a number of changes after comments from the early adopters, and the process has become more straightforward, although I wouldn't say it was perfect yet."
She says overall, however, the practice is positive about the system. In response to the critics who complain that using Choose and Book will unnecessarily extend the patient consultation, Mrs Mayo says they have found that it is the choice element that is time-consuming for the GP and not the actual use of the software. She points out that "choice" now has to be offered to patients even if a GP is not yet signed up to use the Choose and Book software.
"Practice managers should not be frightened of Choose and Book. We have no regrets about introducing it, and we've quite enjoyed the challenge. When the system works it's wonderful."
The Penistone Group Practice in Barnsley, a large practice with 11 GP principals, also decided to be one of the Choose and Book pioneers. Again it was one of the GPs, Dr Pat Brown, an IT enthusiast, who had a vision of how the application could improve patient care and persuaded the practice to dip their toes into the water.
The practice started using Choose and Book in the autumn of 2004 and has since then made more than 1,000 referrals through the system. They too have adopted the process of the GP giving the patient a preprinted form to take away and book the appointment after they have concluded the consultation. Receptionists help patients make their bookings and go through the process with them in a private area where they cannot be overheard.
Practice manager Mary McEnhill says that they have also endured some intensely frustrating times when the system has been unusable, but there have been no significant problems for several months now.
Ideally, the practice should be able to offer patients a choice of four hospitals, but that is not happening yet. At the moment they are only able to book appointments at their local hospital in Barnsley and at some of the nearby Sheffield hospitals.
As more choice comes onstream, practices will be able to use the Directory of Services to guide patients through an increasingly wide range of providers. The directory is the core of the Choose and Book application. It holds information on the services that organisations offer and enables referring clinicians to search for the appropriate services to refer patients to. It will be crucial in improving care pathways and ensuring patients are referred directly to the right clinician.
The Penistone Group practice is paperless and works extensively with templates, which draw on automatic Read-coded data from their clinical systems as well as allowing doctors to enter selective data on specific conditions and symptoms. This means that the GPs are able to give the hospital clinician better information at referral, enabling them to be far more prepared when they see a patient for the first time.
The practice has had a policy of not pushing Choose and Book at GPs. "From my past experience of introducing IT innovations in general practice, if something looks as though it is going to be time-consuming then the best way is to introduce it bit by bit. Those GPs who are interested will become more enthusiastic of their own volition," says Miss McEnhill.
Removing appointment uncertainty
She believes most practice managers will cope with introducing Choose and Book as they are used to dealing with technical failure. Her advice to fellow managers is to ensure that they have at least one GP in the practice who is prepared to provide support and become actively involved.
From an early stage she involved administrative staff because they were key people who could ensure that Choose and Book runs smoothly in the practice. They were trained for their appropriate roles and, once the practice had adopted a workflow, provided by the PCT, they were able to get a clearer picture of how things were going to happen and who was going to manage each task.
The reception manager was designated to be the Choose and Book coordinator. He reports to Miss McEnhill on progress and has authority to contact the PCT directly if there is a problem.
"We have had no regrets as a practice about using Choose and Book," says Miss McEnhill. "The GPs are happily using the system, and the patients are very positive about it. I believe it is the way forward, despite all the technical hitches.
"The patients are not yet being given any real choice of referral, but they say they are very happy to be going out of the surgery with a date for their appointment. Taking away that uncertainty about the date of their hospital appointment is a real improvement, and that is personally how I am measuring the success of Choose and Book."
As for the doubters ...
Dr Prit Buttar, of the Abingdon Surgery in Oxfordshire, says he does not believe his patients will want to be referred to hospitals outside the area.
"It is a nonstarter for me. I am just not interested in it. I wouldn't have a clue about different surgeons around the country. Like most GPs, I have a fairly clear idea about local specialists, but even then I struggle to keep up with personnel changes at the local hospital.
"As the government has driven down waiting times there is now very little incentive for patients to shop around.
"The mechanics are ludicrous. If you start adding up the sums and the amount of time it would take, it is crazy. My practice makes more than 1,800 referrals a year – if each takes an extra three to four minutes it would add many more hours to the week. I don't think patients want me to act as a glorified travel agent or booking clerk. They would rather I spent the time doing a better clinical job."
Dr Buttar says he also fears that when every practice is using the system it will have to cope with at least one million referrals a month and the technology will not be able to cope.
"The bottom line is: it's not in my contract and I don't have to do it. I don't think any of my patients are interested in it."
Dr David Lewis, a GP principal at the Tudor Surgery in Watford, is also not sold on the idea of Choose and Book.
He has calculated that, with approximately 50 elective referrals to hospital each week, his practice would need to spend nearly £4,500 this year for additional staff time to implement the Choose and Book services for their patient population of 6,400.
Assuming they received the directed enhanced service of £0.95 per patient as payment for implementing the Connecting for Health IT package, of which Choose and Book is a part, the practice will achieve a net profit before tax of nearly £1,500. This, he says, is meagre compensation for the three partners' additional time and effort.
"I have talked to several early adopters locally. While the government says it takes 85 seconds from going into the site, making the appointment and coming out, the adopters say that is rubbish. Our PCT is still not completely connected into the system. When it is, we will do the minimum 10% of referrals – that's five patients and no more."