Barnsley - an early adopter

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					Barnsley – an early adopter
“As Choose and Book rolls out, it will be vital
to engage GPs in the process. As an early
adopter site, my message to other GPs and
practices is to try the system. It will take
investment and time to get it right but the
benefits will be worth it in the long term.”
Dr Pat Brown, GP

Learning from local experience

   Target and accountability to be clear
   Operational management responsibility of a local executive
   Championing of a clinician with local influence and credibility
   Engagement through SHA

Operational delivery
  Support for primary care teams
  Multi system diagnostics
  Responsive problem solving
  Coaching and assurance

Implementation case study      Barnsley – an early adopter February 2005   1
       Barnsley – an early adopter continued

Process overview
In March 2004 the Barnsley Health and Social Care                 Before The patient would be referred by the GP to a
Community was selected to become an early adopter for             consultant of the GP’s choice and the patient would wait
the implementation of the Choose and Book programme.              four or five weeks for confirmation of the appointment.
This selection was based on the culture of collaborative          If the patient was referred to the wrong consultant, their
working and the available IT infrastructure.                      wait would be repeated to see the right consultant.
In April 2004 a dedicated project team was set up, which
                                                                     GP decides                 If referred to the       Patient attends
consisted of primary and secondary care clinicians, trainers,        to refer and               wrong clinic the         clinic
IT staff, local managers, Connecting for Health Choose and           chooses hospital           process starts again

Book specialists and a full time project manager. The project
team worked from April to July 2004 preparing for the go-
                                                                     GP writes                                           Hospital books
live of Choose and Book with the PAS vendor, and later               referral letter                                     appointment and
integrating the GP EMIS system. The first bookings were                                                                  writes to patient

made in July and the Web Based Referral (WBR) approach
was rolled out in four GP practices and three specialities at        Hospital adds              Patient receives         Consultant reviews
Barnsley Hospital NHS Foundation Trust by December 2004.             patient to                 notification             the referral
                                                                     waiting list               and waits
As at February 2005, 103 bookings had been made via
Choose and Book.                                                                                   2-15 weeks
                                                                                No patient choice of provider or appointment time
 “The Choose and Book process is fairly straightforward.
 If the GPs are not doing the full booking during the
 consultation, they ask the patient to come to reception          Now The patient is referred to the right consultant clinic
 with a slip of paper detailing the relevant outpatient           at Barnsley Hospital NHS Foundation Trust, by the GP
 department or clinic. We then take the patient to a              using service selection booking guidance in the Directory
 private room and book them in there and then. One                of Services.
 patient commented that although Choose and Book
 appeared to mean more work for the practice – it was             Shortly The patient will be referred to the most appropriate
 much better for her to firm up a suitable hospital               service, whether it is in the community or secondary care,
 appointment while in the surgery instead of being left           by the GP using service selection booking guidance in the
 dangling until the letter arrived from the hospital.             Directory of Services. The patient will be able to choose the
     “There is also an option for patients to go home and         appointment time and date.
 call us later when they have had a chance to think about
 what date suits them best. We then simply do the                    GP, with patient,           Appointment is          Consultant reviews
                                                                     refers to the most          booked through          referral to confirm it
 booking over the phone.                                             appropriate service         web based referrer      is appropriate
     “Like anything else new, you need time to get used to           using service
                                                                     selection booking
 it. But I can already feel myself getting quicker with the          guidance in the
 system and it’s definitely getting easier with every                Directory of Service
                                                                     choosing from a
 booking I make.”                                                    menu of 4-5 options
 Eileen Mellor, Practice receptionist, Penistone Group Practice

                                                                                             One day / single GP visit
                                                                           Patient has choice of both provider and appointment time

       Implementation case study                   Barnsley – an early adopter February 2005                                                      2
       Barnsley – an early adopter continued

What do we need to prove the Choose and Book concept?
1) Live bookings                                                The team spent time explaining the application and
To achieve live bookings there needs to be the right IT         answering concerns to enable staff to support each other.
infrastructure in place, a Directory of Services (DoS) loaded   The team also logged issues in training sessions and
and users trained to use the application.                       produced a question and answer report for practices and
                                                                outpatient departments so that learning could be shared.
The right IT infrastructure in place
                                                                Training on the software took an average of 1 hour and 15
 “The pace is picking up as we progress.”                       minutes. As Barnsley started with IT literate practices,
 Malcolm Braim, IT Director, Barnsley PCT                       training maybe longer for practices that also require basic
                                                                IT skills training.
The overall message is that the software is getting better,
                                                                2) High volumes of bookings
but it has been a challenge. Many of the issues relate to
                                                                As of February 2005 there have been 106 referrals from
the early adopter status of Barnsley and testing the
                                                                practices to Barnsley Hospital NHS Foundation Trust, 67%
application in a clinical environment. The team looks
                                                                of referrals were from the Penistone Group Practice.
forward to working through the remaining issues in
partnership with Connecting for Health.
                                                                3) Many practices using Choose and Book
                                                                There are 44 practices in Barnsley PCT. The team aimed for
A Directory of Services
                                                                eight practices booking in the first stage of implementation,
 “The directory will be crucial in improving care pathways      starting with the most IT literate. As of February 2005,
 and ensuring we get patients to the right clinician first      there were four practices with the ability to book.
 time round. There’ll be a lot of work to do to develop
 this properly and consultants will need to specify their       4) Choice of providers
 exact areas of specialism – but it will be a valuable tool.”   As of February 2005, the only provider on the application
 Dr Pat Brown, GP, Penistone Group Practice                     was Barnsley Hospital NHS Foundation Trust. Choice
                                                                options will be introduced as they become available.
The DoS is vital to implementing choice and ensuring GPs
                                                                5) Ability to book to many specialities
refer patients to the right place first time. At present the
                                                                As of February 2005, it was possible to book to clinics in
DoS uses named consultant clinics, so there has not been a
                                                                the following three specialities; ENT; Gastroenterology; and
noticeable impact on secondary care.
                                                                the Rapid Access Chest Pain Clinic. More specialities are
Barnsley’s vision is that Choose and Book is not just a         due to come online during 2005, with Cardiology and
technical process but about primary and secondary care          Rheumatology from 28th February 2005.
service redesign. To ensure the patient gets to the right
place first time it is essential the DoS incorporates all       6) Ability to book to different types of clinic
scheduled care and is underpinned by service selection          At present booking is only possible to a named consultant
booking guidance. This will become especially relevant          clinic (‘Mr Smith’s ENT list’), which will develop to pooled
when other service options in primary care come on stream.      referrals for a speciality (‘ENT Outpatients’) and ultimately
                                                                will include all possible bookable services in both the
Support and training for GPs and practice staff
                                                                community and secondary care. All of which will be
The team linked Choose and Book to a wider programme
                                                                underpinned with service specific booking guidance to
of GP IT skill escalation in General Practitioners.
                                                                ensure the patient is booked to the right service first time.
The team analysed work processes in individual practices
and worked with practice and hospital managers in               7) Bookings to all types of appointment
identifying functional roles. It was then possible to tailor    As of February 2005 only routine appointments could be
training around the identified roles. This approach allowed     booked, however urgent and two week cancer waits are
migration to new more efficient and effective working           due to be rolled out in 2005.
practices over time and with confidence.

       Implementation case study              Barnsley – an early adopter February 2005                                         3
        Barnsley – an early adopter continued

Positive contact with patients                                    Improved referral tracking
Practice staff have found that Choose and Book provides a
                                                                   “With a paper referral, there’s always a risk of losing
positive patient contact, and has replaced the negative
                                                                   track of a patient’s letter if, for instance, a doctor reads
contact of chasing referrals.
                                                                   it but then redirects it somewhere else. But with Choose
                                                                   and Book, the referral is always at your fingertips and
Improved clinical information
                                                                   it’s easier and quicker to help patients when they call us
 “We are a paperless practice and we work extensively              to ask a question about their appointment or clinic.”
 with templates which draw on automatic Read Coded                 Justine Britton, Outpatients Clerical Services Manager,
 data from our clinical systems, as well as enabling us to         Barnsley Hospital NHS Foundation Trust
 enter selective data on specific conditions and symptoms.
 This means we can give the hospital clinician better
                                                                  Choose and Book will provide an accurate referral tracking
 information at referral, enabling them to be far more
                                                                  system for both primary and secondary care.
 prepared when they see a patient for the first time.”
 Dr Pat Brown, GP, Penistone Group Practice
                                                                  Reduced Did Not Attend (DNA) rates
                                                                  At present, it is not possible to prove Choose and Book
Template referral letters will carry all the necessary clinical   reduces DNA rates. However, practice staff have noticed
information and enable better diagnosis and treatment             patients are becoming more involved with their care as
plans. Information will include: medical history; clinical        they realise they have flexibility. This is creating greater
notes on the previous six GP consultations; investigation         ownership and responsibility by the patient and they
results; medication; allergies; and lifestyle data. Improved      anticipate a reduction in DNA rates.
management of clinical information will also dramatically
reduce the time clinicians spend looking for missing              Saves time
information and reduce delays in care.                            Claims that the booking process takes ten minutes or more
                                                                  is clearly not born out in practice. At Penistone Practice it
Improved clinic planning                                          only takes two minutes to book a patient to a clinic,
                                                                  however this time is often longer as the general
 “There’s also potential for the system to speed up the
                                                                  practitioner discusses choice options with the patients. In
 grading process for referrals – with consultants able to
                                                                  addition, there is flexibility in who undertakes the booking.
 access the referral on-line, read it, accept it and send it
                                                                  GPs that want to book directly can, but equally practice
 back to the clerk – rather than sending pieces of paper
                                                                  staff can undertake the function.
 back and forward.”
 Justine Britton, Outpatients Clerical Services Manager,          In terms of time saved chasing referrals, one of the largest
 Barnsley Hospital NHS Foundation Trust                           practices estimates that ten hours a week of support staff
                                                                  time is spent chasing referral letters at present. When
                                                                  Choose and Book covers all specialities and providers, this
The number of bookings made so far has not made a
                                                                  time will be saved.
significant impact on secondary care, but as volumes
increase the team expects secondary care clinicians to be         A number of practices welcomed the template referral
able to plan further in advance for their clinics.                letter as it saves time writing individual letters and
                                                                  information such as previous medical history and
                                                                  medication automatically goes into the letter from the
                                                                  patient’s notes.

                                                                  Improved commissioning
                                                                  In the future, the PCT will be able monitor referral patterns
                                                                  and ensure services commissioned are responsive to patient
                                                                  needs and choices. This will also offer the opportunity to
                                                                  manage resources better and reduce potential financial risks.

       Implementation case study                  Barnsley – an early adopter February 2005                                       4
       Barnsley – an early adopter continued

Critical success factors
Visionary leadership                                               Build capability
                                                                   Construct Directory of Service
 “Choose and Book will be the glue that holds the
                                                                   The Directory of Services should help guide GPs and patients
 system together.”
                                                                   to the right clinics first time round. For some specialties such
 Ailsa Claire, Chief Executive, Barnsley PCT
                                                                   as rheumatology and dermatology, there are many different
                                                                   clinics and complex algorithms governing which clinic is right
Barnsley benefitted from executive level commitment and            for each patient. The Directory of Services needs to be
belief in the concept of Choose and Book. The health               sophisticated enough to accommodate these differences and
community sees Choose and Book as more than just a                 developed in a way which simplifies the referral process for
technical process, but an opportunity to reform delivery of        GPs rather than obscuring. An early start on drawing up a
services in primary and secondary care. The vision is of GPs       DoS with input from both primary and secondary care
utilising service selection booking guidance in the Directory of   clinicians will be invaluable.
Services to ensure the patient is referred to the most
appropriate service, whether it is in the community or             Run basic IT training for GPs and support staff
secondary care. In addition to the patient being able to           Choose and Book requires a basic understanding of IT prior
choose the appointment time and date to suit them.                 to implementation, for example file management and
                                                                   saving data.
Clinical and support staff engagement
The team sold Choose and Book based on what it meant               Upgrade IT infrastructure (PAS to 18.2 version / provide
locally; improved clinical information; increasing basic IT        Internet access).
skills in practices; improved referral data; and lever for         The speed of implementation is dependent on the level of
service redesign.                                                  technology available. The team recognised this early on
                                                                   and chose practices with a high level of capability in the
The team made a conscious effort to actively involve
                                                                   first phase of roll out.
clinicians and support staff in practices and secondary care.
Presenting Choose and Book to each of the five locality
                                                                   Dedicated time and a flexible approach
meetings, the Professional Executive Committee and Local
                                                                   Having two full time staff focusing on implementing
Medical Committee.
                                                                   Choose and Book was a real benefit. This also meant the
The team took an honest approach to clinical engagement            team had a flexible approach and worked with staff
so that clinicians recognised there would be problems but          timetables to carry out training.
would be prepared to work through them to establish a
                                                                   The team also gave GPs and practice staff the space and
safe and effective way of working. The team ran a number
                                                                   time to gain confidence in how to use the application and
of sessions where lead clinicians talked to their colleagues
                                                                   develop their current way of working, recognising that
about their experiences in an open and honest way.
                                                                   people adapt to new ways of working at different rates.
The team also took the approach that it was good to have
enthusiasts, but it was also good to have a healthy balance of
sceptics. Once sceptics became convinced, they became
powerful advocates amongst their colleagues.
There is more enthusiasm in primary care so far, but they
expect that as more patients become booked directly into
clinics secondary care colleagues will recognise the benefits
and they anticipate an upsurge in interest.

       Implementation case study               Barnsley – an early adopter February 2005                                         5
       Barnsley – an early adopter continued

                                                                   Patient experience and
                                                                   patient information
Process analysis
                                                                   Having information about appointment dates and times
 “It’s important to recognise, however, that GPs are
                                                                   right at the point of referral reassures patients about the
 taking on a significant new role with Choose and Book
                                                                   time they may need to wait for their appointment. It also
 and we’ve spent time working with them to tailor the
                                                                   helps reduce their anxiety by giving the opportunity to fix
 booking software and systems more closely to the way
                                                                   that appointment there and then, and knowing that if
 they work.”
                                                                   they need to change that appointment later, then they
 Malcolm Braim, Director IT, Barnsley PCT
                                                                   can do so.
                                                                   The previous negative contact between practice staff,
Practices work quite differently to each other and GPs
                                                                   clinicians and patients of chasing referrals and repeating
within the same practice can work differently to one
                                                                   medical history will be replaced by a positive contact.
another. This variation applies to referral criteria, processes,
                                                                   Practice staff have also noticed patients becoming more
letter creation, use of the clinical system and computer
                                                                   involved in their care, which creates ownership and
literacy. The team analysed work processes in individual
                                                                   responsibility by the patient.
practices and worked with them to tailor training and
support to each practice. This approach allowed migration
to new, more efficient and effective working practices over
time and with confidence.
                                                                   Next phase of roll out
                                                                   The team is keen to maintain the momentum and extend
Learn lessons from others
                                                                   the number of practices using Choose and Book and the
Participating fully in the Strategic Health Authority-wide
                                                                   range of services and specialities available in the context of
Choose and Book programme means that experience and
                                                                   choice. The team has put forward a proposal to
expertise is shared. For example, the Directory of Services
                                                                   Connecting for Health to accelerate roll out in advance of
is being developed so that patient choice options are real
                                                                   already challenging targets.
and comparable.

                                                                   Being an early adopter
                                                                   As an early adopter, there were high national expectations
                                                                   and the team had many set backs and missed deadlines. It
                                                                   was the team’s strong belief in the concept of the ‘right
                                                                   place – right time’ that kept the momentum going.
                                                                   The team hopes to communicate successes and lessons
                                                                   locally and nationally.
                                                                   The team’s clinical lead, Dr Pat Brown, has been invited
                                                                   to join a national Clinical Reference Panel, which the
                                                                   team hopes will provide a forum for Barnsley to share
                                                                   their experience.
                                                                    As at 1 June 2005, Barnsley had 433 bookings through
                                                                    Choose and Book, with 8 live booking GPs booking into
                                                                    8 live specialities.

       Implementation case study               Barnsley – an early adopter February 2005                                         6