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The Department of Health has made progress towards its target that, by December 2005, each NHS patient referred by a GP for non-emergency hospital treatment will be offered a choice of four or five healthcare providers. However, according to the National Audit Office, there remain significant risks for the Department to manage, especially that of securing the engagement of GPs, which is currently low, if the target is to be achieved.

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Under the new system, patients will be able to choose their preferred location for treatment, in consultation with their GPs, from a menu of NHS and independent sector healthcare providers. Giving patients this choice can contribute to a more patient-focused health service, and give patients the opportunity to influence the way they are treated, the ability to discuss different treatment options and greater convenience and certainty in arranging further treatment.

According to today’s report to Parliament by head of the NAO Sir John Bourn, progress has been made towards delivering choice at referral through establishing the required organisational infrastructure, commissioning new IT systems and modifications to existing ones, and providing support for the NHS organisations that will deliver it.

Choice cannot be delivered without support from GPs; they will be responsible for ensuring that patients whom they refer for elective care are given the required choice of providers. The engagement of GPs is currently low, however, and is a key risk which the Department must address to deliver choice successfully. An NAO survey of GPs has shown that around half of respondents knew very little about choice and some 60 per cent felt negative to some degree.

GPs’ concerns included whether their practices had the capacity to deliver choice, the workload, the amount of time for consultation and fears that existing health inequalities will be exacerbated. The Department has deliberately held back its main effort to inform and engage GPs until it has an integrated end-to-end electronic booking system (‘Choose and Book’) to show them, but it intends to mount a campaign during 2005 to inform and engage GPs. The Department will need to monitor carefully the progress of this campaign.

Choice at referral will be delivered most efficiently and effectively through the Choose and Book Service. However Choose and Book will not be universally available by December 2005. On present plans only 60 to 70 per cent of the NHS will have Choose and Book available by December 2005. Until Choose and Book is fully adopted choice will have to be provided in other, less efficient, ways.

The Department has recently appointed a new National Implementation Director for Choose and Book to work alongside the existing National Programme for IT Group Programme Director and has asked the NHS to plan how to deliver choice even where Choose and Book is not yet deployed. This would use interim IT systems which are planned to be available by end May 2005.

Parts of the NHS still have much to do if they are to deliver choice. A significant minority of primary care trusts do not yet have adequate plans in place to manage the introduction of choice and some may struggle to manage the required new commissioning arrangements. Just over a quarter of Primary Care Trusts currently forecast that they will not achieve the choice targets. And two thirds have yet to commission the required number of providers. The Department is developing a framework of support to help trusts overcome these obstacles.

Among the NAO’s recommendations to the Department of Health are that the Department addresses urgently the low level of GP support, including informing GPs about the implementation of choice and its impact on GPs and patients. The Department should also consider the scope for accelerating the roll-out of Choose and Book. If it becomes clear that this will not available everywhere by December 2005, the Department should monitor closely the development of the interim IT systems to ensure that they meet their delivery dates and ensure that the implementation of interim systems does not detract from the priority of bringing in Choose and Book as soon as possible.

"Enabling patients who are referred by their GPs for hospital treatment to choose where they want to be treated promises to bring benefits to the patients themselves and to the wider NHS. Providing such choice will not be simple, however. The Department of Health must take urgent and effective action to inform and engage with GPs about the new arrangements. GPs’ support may be hard to secure and indeed choice will be hard to deliver successfully by the end of 2005 if the electronic booking system is not largely up and running by then."

Sir John Bourn, head of the NAO

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