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
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
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
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
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
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
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
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
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 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.
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
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