Britain's National Health Service jettisons Choose and Book System

When senior cardiologist Duncan Dymond complained in 2010 that patients were arriving at his hospital at incorrect times and, far worse, in need of a different specialist, it was neither the beginning nor the end of problems with the Choose and Book system. Installed in 2004 as part of a £200 million IT modernization of Great Britain's National Health Service (NHS), the patient booking system was supposed to enable patients to select a hospital for an outpatient appointment from a range of options, primarily with the help and direction of their general practitioner (GP). A letter with a referral number and a secure code was then generated so that the patient could either go online or call a central booking service to confirm the appointment. Initial contact could also occur directly through the national appointments line or at the HealthSpace website. The goals were threefold: to speed up the referral process, eliminate costly paperwork, and encourage patient participation to stem losses of up to £225 million annually from 1.6 million patient no-shows. Implementation was sluggish and plagued with glitches. One early problem was that many hospital Patient Administration Systems (PAS) and GP clinical computer systems were not compatible. Choose and Book served as the liaison between the two systems; thus, both had to be compliant. The objective to book 90 percent of all referrals by December 2006 was never met. Four years later, even though Choose and Book had been installed in 94 percent of all GP surgeries, it was used to book just 54 percent of appointments. Even a three-year £100 million incentive program to encourage physician adoption failed to sway doctors who had witnessed patients unnecessarily travelling to distant hospitals and referral letters rebuffed when patients sought confirmation. Designers also focused on building provider choice into the service. This turned out to be a solution in search of a problem. According to the NHS Alliance, a coalition of health care providers, managers, and patients dedicated to improving care and providing a voice to patients, the ability to choose physicians and facilities from a wide range of options was never a chief concern. Instead, patients were looking for swift referrals to their local hospital. In rural areas, choice was considerably limited anyway, and older patients, in particular, simply found the array of choices confusing, difficult to navigate, and time-consuming to select. Although many doctors were fans, system misfires created a significant population of disgruntled caregivers who refused to use Choose and Book. Glitches included appointment letters gone astray, last-minute cancellations, costs incurred for phone calls to the booking line in some locations, and treatment delays due to lack of visit categorization-either urgent or routine-not incorporated because cases requiring immediate treatment bypassed the queuing system. By 2014, Choose and Book's cost had ballooned to £356 million. It did provide reliable referrals for more than half of first-time outpatients and was used-at least to some degree- by more than 90 percent of providers. However, when a study by the Public Accounts Committee (PAC) reported that use by both doctors and patients had dropped and that waiting times for elective care had shown no improvement, Choose and Book's days were numbered. The system had never been able to function optimally because not all available outpatient appointments were listed. Members of Parliament (MPs) were fatigued by nearly a decade of patchwork fixes and frustrated that projected annual savings of up to £51 million had never materialized. The discrete replacement of Choose and Book by a new system of unstipulated-and perhaps greater-cost underscores both the mission and the challenges of NHS. Launched in 1948, the comprehensive health system is funded by tax dollars and administered by the Department of Health (DH). All British citizens are afforded care from their first newborn exam to their end-oflife care, with many services free of charge. NHS England covers 53 million citizens. Another 10.2 million people are covered by NHS divisions in Northern Ireland, Wales, and Scotland. The most pressing and urgent challenge NHS faces is the often lengthy waiting time to receive care, which can sometimes yield dire consequences. Health care for all, regardless of wealth, is a core value of British society. A 2013 Commonwealth Fund study of national health care systems ranked NHS first for quality of care, safety, coordination of care, patient-centered care, and cost. On timeliness of care, the UK ranked third. With timeliness of care the overriding goal, NHS planned to launch in England a new e-Referral Service in spring 2015. Director of Strategic Systems and Technology, Beverley Bryant, expects significantly reduced paperwork and fewer data errors, along with an accelerated referral process because patients monitor and manage their own hospital appointments. Several ideas to encourage adoption are being explored, including making physician participation mandatory and developing an incentive program that incorporates penalties as well as rewards. The goal is to improve upon or eliminate the flaws of Choose and Book-for example, moving away from the hybrid electronic/paper environment that has proved burdensome for hospitals. The switch to all digital will occur by 2019. The new system uses an open platform and a set of APIs, both of which provide more flexibility to integrate with other systems than the restrictive proprietary system Choose and Book employed. What's more, these changes should reduce operating costs. After a decade of technological advances, updates would have been necessary even if Choose and Book had been a resounding success. The new e-Referrals system must trump Choose and Book's record of booking 40,000 referrals every day, ensure that all appointment slots are available, and shuttle citizens to their appointments at a quicker pace, all while ensuring that existing health care inequalities are not exacerbated.

Case Study Question

1. Clarify and describe the problems of the NHS Choose and Book System. What people, organization, and technology factors were responsible for those problems?

2. To what extent was Choose and Book a failure? Explain your answer.

3. What was the economic and social impact of Choose and Book?

4. Describe the steps that should have been taken to make Choose and Book more successful.