Personal View: Choose and book—whose choice is it anyway?
Authors: Nigel de Kare-Silver
Journal: BMJ (2005)

Last summer I took part in many of the workshops held across London for the NHS's national programme for information technology. Organised with little notice and undergoing continual cancellation, rescheduling, and relocation, many of the sessions somehow resulted in vibrant discussions with clear conclusions. The people who went were keen, if not passionate, to do what they could to make sure the outcome would be the best possible. We were unanimous in wanting to make sure that the NHS offered programs that used the best possible features of existing software and clinical practice and that offered clinicians and patients a signed pathway to the best possible care. We were clearly told by the session leaders from British Telecom and IDX, the companies involved, that their contract was to design and supply clinical software to be used universally across the NHS.

What did we get when we were presented with the draft version? We were shown screens of a third rate computer program lifted from the existing system of US hospital administrators. Its screens of nursing notes were cumbersome and displayed none of the features we had asked for. Promised that this early version was only for demonstration purposes, we departed disappointed.


The system appears to be no advance on existing services


Invited to a regional interim meeting at the BT tower, we were enthused by the somewhat glitzy opportunity to ascend to the conference facilities at the top, but our enthusiasm was defused by the lame presentations by various strategic health authority IT leaders. Afterwards a senior team member privately disclosed considerable embarrassment at the software demonstration, which had moved backwards from the versions shown months earlier.

Then there is “choose and book”—an IT module we will all be expected to use. This has a national implementation date, requiring universal application, of the end of December 2005. The idea is that all patients will, at the point of their referral, be given options of time, place, and date and that either the referral can be booked there and then or the patient is given a reference number and telephone numbers to confirm an appointment later. The module's blurb says that it will take GPs 20-30 seconds to progress through the screens. Who says? And on what evidence?

We sat through about half an hour of frustration while three trainers struggled with their computers to demonstrate the module. The application screens are slow, and the computers often fail to pick up the programs. There is no integration with existing clinical systems or with Microsoft Outlook. No alert box shows to let you know that tasks await completion or that a specialist has bounced the referral back to the referrer to suggest an interim clinical intervention or even to reject the referral. Tasks need separate screens that take several minutes to refresh and change. Promises abounded that the final application would be speedy and that our comments would be taken back to the people developing the software, but we were all too long in the tooth to do anything other than grin bleakly.

On PowerPoint presentations we were shown smiling GPs and specialists, happy with the trial software they had been using, but our requests for names and addresses so we could speak to them were met with silence. We were flashed anecdotes about clinicians who are pleased with the facility, but when we asked for figures on improved patient pathways or clinical outcomes we were answered with rueful smiles. When we got really frustrated we were told that this was a period of change that would have to be managed across the health service. We politely pointed out that the phrase “change management” applied to progressive developments, not a reversal to Neanderthal processes. The conversation was moved on.

Finally we were shown the really frightening module. “Choose and book” is intended to be the preferred pathway for GPs to seek advice, without referral, from colleagues in secondary care. Here there is a big problem. The advice cannot be filed, by either the consultant or the GP. Once the replies have been sent, the advice is deleted from the choose and book screens, and no mechanism exists to integrate it with clinical results. There is no file note for the GP or the consultant. This is a major clinical governance issue.

The ambition of the NHS agenda for IT change should be applauded. It is unfortunate that the system appears to be no advance on existing services. It is frightening that the political drive to implement the system is failing to take account of professionals' anxieties. It is alarming that despite the vast sums being invested the system appears to be primitive.

Before allowing its delivery, clinicians from all backgrounds must demand a service that is rigorous in terms of clinical governance, friendly in its user interface, fast, and relevant to the needs of clinicians and patients.