The NHS Plan1 states that by the end of 2005 'waiting lists for hospital appointments and admission will be abolished and replaced with booking systems giving all patients a choice of a convenient time'. It also says that by that time it will be possible to book appointments electronically.
The current system for making appointments is far from ideal. The main problems are:
- A delay of at least 2-4 weeks from the GP seeing the patient and deciding a referral is required, to the patient being allocated an outpatient appointment
- Little choice for the patient of date and time of the appointment
- Often little choice over the location of the appointment
- Cancellation by either the patient or hospital can lead to a significant lengthening of the outpatient wait
- Because patients are not involved in selecting their appointment time, significant numbers do not attend.
Imagine booking a holiday under this system:
Client: I'd like to book a holiday. What have you got to offer?
Travel Agent: What about Italy? I'll write to the company to book you a holiday and then let you know the dates.
Six weeks later the client has not yet received a letter.
Client: I haven't heard anything yet, I need to book the time off work and my boss needs 6 weeks' notice to get cover. Did you ever write to book the holiday?
Travel Agent: Yes of course I did, but the company is very busy. There's not much I can do – you'll have to be patient. There are lots of other people in the same position as you.
Six weeks later (some might say this is much sooner than an outpatient appointment) the tickets arrive. The flight is the following day at 7am. (This is better than the NHS as some patients seem to get their appointment time after the date of the appointment. Then, to add insult to injury, they receive a letter from the hospital to say they will not be seen without a further letter from their GP as they did not attend.)
The following day the client checks in for his flight, only to be told that there is no seat available on the plane but not to worry as it will be re-booked in the near future.
This chain of events would be unacceptable to the most tolerant person, but that is exactly what goes on in the NHS every day.
Electronic booking: the current situation
Since 2001 many local health communities have been involved in pilot schemes for electronic booking and many readers will have participated in these. Current pilots are exploring direct booking of outpatient and day-case appointments by GPs, and bookings from outpatients for day cases and inpatients.
The electronic booking of appointments from GP surgeries to hospital outpatient departments uses NHSnet. There have been some problems with the reliability of NHSnet and the provision of a secure connection, but both these problems should be resolved in the near future. It should be noted that there are also pilots using faxed referral forms and a call centre for patients to telephone to book their appointments.
The majority of pilots have been driven by health authorities and hospital trusts and have looked at solutions which meet their own needs and the perceived needs of the patients. This mindset needs to be changed so that the needs of the GP and the practice are looked at closely along with the actual needs of patients who are likely to have quite varied requirements.
How electronic booking might work in practice
A range of alternative booking methods are currently being explored. These will provide a variety of access points into the system so that appointments may be made in the manner the patient or GP prefers. Possible options include:
- The GP books everything during the consultation; he or she uses the practice computer system and NHSnet to identify a local hospital with the appropriate specialty, and gives the patient a choice of hospital and appointment time
- The patient leaves the consulting room and another member of staff, using the practice computer system and NHSnet, goes through the options with the patient and books an appointment
- The patient goes home, consults his or her family and telephones the practice some time later to book an appointment; again the staff use NHSnet to make the booking
- The patient telephones a third party, who acts as a call management service and books the appointment for the patient
- The patient books the appointment using the internet or new technology being developed for television.
There are several potential benefits for GPs, depending on the system used.They include:
- Less time will be spent in chasing the hospital for appointments, rearranging cancelled appointments and in dealing with patients who feel they have been forgotten by 'the system'
- GPs can be confident that patients will be seen within an appropriate time period
- Underpinning new care processes that aim to move patients seamlessly through a pathway of care
- The GP will no longer be the first point of contact to resolve problems with secondary care providers if a booking service brokers directly between patients and providers
- The booking process may be delegated to practice staff in many circumstances
- The development of macros and protocols on practice clinical computer systems will streamline the process
- Local sites employing best practice can roll out shortcuts to other practices with similar IT set-ups
- IT systems will allow referrals to be generated as a by-product of the consultation and referrals will not need follow-up letters unless the clinical need changes
- Closer relationships with secondary care will develop from collaboration to produce clearer local systems
- Information feedback to primary care will improve with 'any-to-any' booking, for example GP to consultant, consultant to GP or in-patient to outpatient.
Disadvantages include the additional expense that would be incurred if a dedicated member of the practice staff with access to a private room and facilities to book appointments online was needed. It also seems improbable that the majority of GPs would have the time during a routine consultation to discuss all the choices with a patient and book an appointment.
However, time released by not undertaking unproductive activities such as rearranging appointments or dealing with cancellations could usefully be spent treating sick patients.
There is potential for an enhanced service to develop from an electronic booking system, with features such as:
- Electronic completion of admission information by the patient
- Electronic booking of transport
- Supply of clinical information via a website or email
- Email reminders of appointments booked over the internet
- Electronic booking of primary care appointments
The booking system could also be linked to the referral process.
It would be possible in a fully computerised 'paperless' practice, to decide on a referral, choose a hospital and time with the patient online, then electronically generate a referral letter from the patient's electronic health record and send it via NHSnet to the appropriate hospital clinician.
Pilot schemes have shown some significant gains for specific conditions. For example, the Royal Bournemouth Hospital has a protocol for post-menopausal bleed. The GP accesses the hospital's online booking system and selects the protocol. After adding very little information the patient has a booked appointment and no referral letter is required. This can all be done in less time than it takes to dictate a referral letter.
There is no doubt that the current system for booking hospital appointments and managing waiting lists is inefficient and contributes to prolonged and uncertain waits for patients. It is therefore long overdue for radical change.
Electronic booking has the potential to make great improvements, to the advantage of patients, GPs, hospitals and staff. The fact that it is now working successfully in some parts of the country shows that it should be evaluated to see how best to deliver these benefits more widely.
The significant amounts of money being invested in information technology will need to be used to maximum effect. If the Government wants to modernise public services to perate at the levels expected in the private sector services, then the NHS needs the same levels of investment and commitment. There is evidence that the Government wants this to happen – now is the time to back the rhetoric with resources.
- The NHS Plan – A Plan for Investment, A Plan for Reform. Department of Health, 2000.