THE NATIONAL PROGRAMME FOR IT (NPFIT) IN ENGLAND

How Can Clinicians be Encouraged to Use the Choose and Book Service?

Reza Rabiei

1,2

, Allen Hutchinson

Department of Information Studies, University of Sheffield, Regent Court, 211 Portobello Street, Sheffield, U.K.

Shahid Beheshti University of Medical Sciences,Velenjak Street,Tehran, Iran

School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, U.K.

Peter A. Bath

Department of Information Studies, University of Sheffield, Regent Court, 211 Portobello Street, Sheffield, U.K.

Keywords: Choose and Book service, National Programme for IT (NPfIT), User encouragement.

Abstract: In recent years, there has been increasing attention towards developing person-based electronic information

systems in different countries. In England, the Choose and Book Service, a key component of the National

Programme for IT (NPfIT) in England aims to offer patients the facility to choose and book their hospital

appointments at a time, date and place convenient for them. However, anecdotal evidence suggests limited

uptake and use of this service by clinicians. However, there has been limited evaluation of the service. The

aim of this research was to explore clinicians’ perceptions of the Choose and Book service. A qualitative

approach, using in-depth, semi-structured interviews was used to collect data from clinicians. Framework

Analysis was used to analyse the data. A main sub-theme emerging from the analysis was encouragement

for the clinicians. Although both GPs and consultants were positive about the benefits of Choose and Book

for patients, they saw no or limited advantages for themselves. Clinicians noted a number of factors that

would help to encourage them to use the Choose and Book service. Deployment of information systems

does not mean that users will necessarily use it in their practice. Depicting a broader picture of benefits for

different user groups, improving the usefulness and the reliability of information systems and rewarding

users are among the approaches that could help to encourage users.

1 INTRODUCTION

In recent years, different information strategies and

programmes have been developed in England with

the ultimate aim of improving care delivery through

improving the accessibility of information at the

point of need (Burns, 1998; NHS NPfIT, 2004).

A key element of these programmes, has been the

development of an electronic booking system (Fleet

and Blandford, 2005), now called the ‘Choose and

Book service’ (Department of Health, 2002). This

service enables patients to choose and book their

first outpatient appointments from a choice of

hospitals or other alternative providers (Department

of Health, 2004). Implementing the Choose and

Book service is regarded as a reform in delivery of

healthcare services, because this service can

empower patients by helping them to make their

informed decisions (Miller and May, 2005).

The deployment of the Choose and Book service can

bring benefits for patients and primary care settings

as well as secondary care providers. For example,

this service can improve patient certainty and

improve the speed of the referral process (Walford,

2006). In addition, ‘Choose and Book’ can facilitate

chasing referrals in both the primary and secondary

care settings (Department of Health, 2004).

However, similar to other information systems, the

deployment of services like ‘Choose and Book’

cannot guarantee the usage of these systems

(Department of Health, 2004). As Sittig et al. (1999)

noted, unless key user groups, such as physicians

and other clinicians use these systems, many of the

intended benefits, such as improving patient care

may not be achieved.

211

Rabiei R., Hutchinson A. and A. Bath P. (2009).

THE NATIONAL PROGRAMME FOR IT (NPFIT) IN ENGLAND - How Can Clinicians be Encouraged to Use the Choose and Book Service? .

In Proceedings of the International Conference on Health Informatics, pages 211-215

DOI: 10.5220/0001539602110215

 SciTePress

With regard to the Choose and Book service, there

has been anecdotal evidence of limited uptake and

use of this service. Clinicians who did not use the

service noted that Choose and Book was both

difficult to use and time-consuming because

navigating the system for choosing appropriate

clinics was not always straightforward (Rhys, 2006).

However, there has been limited empirical research

evaluating ‘Choose and Book’ and further research

is necessary to investigate clinicians’ views and

experiences of the Choose and Book service, and to

understand factors that influence use of the service.

The aim of the study described here was to evaluate

clinicians’ views on the Choose and Book service.

2 METHODS

This qualitative study was conducted through using

in-depth, semi-structured interviews in August-

December 2007. The settings for this study were

General Practices and one NHS hospital in the

north of England. The participants of the research

were clinicians (General Practitioners and hospital

consultants) and non-clinicians (administrative staff

both in practices and hospital and departmental

managers in the hospital) who were either users of

the service or had views about it.

Before data collection a favourable ethics

opinion was obtained from one of the Local

Research Ethics Committees (LREC) in the UK

National Health Service (NHS). Before undertaking

interviews, a participant information sheet was sent

to a random sample of staff and they were asked to

sign a consent form to indicate that they agreed to

be interviewed. Interviews were digitally recorded

and then transcribed verbatim. To analyse the

interview data, the method of Framework Analysis,

developed in the context of applied policy research,

was used (Ritchie and Spencer, 1994). In this study,

data were analysed by one of the researchers (RR),

and coding of data was facilitated by using QSR

NVivo 7 software.

3 RESULTS

3.1 Participants’ Characteristics

Twenty clinicians including 14 General

Practitioners (GPs) and six hospital consultants

(specialists) were interviewed. The interviews

lasted between 27 and 75 minutes (mean = 42

minutes). Twelve of the interviewees were male

and the rest of them were female. The age range

was 36 to 57 years old and above. In order to

maintain the confidentiality of the participants’

information during data analysis and in reporting

the findings, the identities of participants were

anonymised, and here they are described as being a

GP or a consultant.

3.2 Interview Results

In all of the practices, a combination of electronic

Choose and Book and paper-based referral was

used. Even in practices in which ‘Choose and

Book’ was the preferred method of referral, the

traditional paper-based process was still used, for

example, to refer a patient to a named clinician or

when the preferred care provider or service was not

available on the system. In the hospital, there was a

specific office for Choose and Book referrals, in

which a group of administrative staff were in

charge of managing the electronic referrals.

A sub-theme emerging from the analyses was

the encouragement that clinicians might receive for

using the Choose and Book system.

3.2.1 Approaches for Clinicians’

Encouragement

When the interviewees discussed approaches that

could help to improve the usage of Choose and

Book, they suggested methods, such as considering

financial incentives, demonstrating benefits of the

system, and improving system from technical point

of view.

With regard to financial incentive, the current

approach was that practices that do a certain

number of referral through Choose and Book would

receive financial support, and the GPs were paid for

the amount of time that they were spending on

working with the system. In relation to this, a GP

noted:

‘There is a recognition of that time, in that we

get a payment for using Choose and Book and I

don’t think you can make that kind of change, in

general practice, without producing some payment’

[GP14].

However, some interviewees noted that using

the system during consultation would increase the

consultation time. In support of this, a GP said:

‘…, I would then go to the appropriate Choose

and Book system that I wanted, and either it

wouldn’t let me book anything or frequently the

clinic I wanted wasn’t available on Choose and

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Book. It took such a long time, often to get

absolutely nowhere,…’ [GP11].

Some GPs noted that the incentive they

received for working with the system did not meet

their expectations. For example, a GP said:

‘…, if you added up all that extra doctor time, I

am not really sure if, the money that we get gets

anywhere near the actual time we put in’ [GP5].

Another important point mentioned by the

interviewees was that although the approach of

being paid for using the system might help to

develop practices, it is not really an appropriate

method for encouraging clinicians. When they were

asked to explain further, a GP who had decided to

stop using the system said:

‘…, there are times when incentives are of

limited use because of there isn’t the capacity to

absorb it. It doesn’t matter what incentive is given

it can’t be done’ [GP13].

Another approach suggested for encouraging

clinicians was convincing them that there are

benefits for both clinicians and patients. Both

consultants and GPs noted that the system should

bring some benefits for its users. One of the

consultants said:

‘The only way you can persuade people to use

information systems is to prove it is useful’

[Consultant1].

In support of this, another consultant added:

‘Consultants have to be convinced of the

benefits of an electronic booking system, they have

to see that it’s at least as good as what we currently

have or better’ [Consultant3].

Obviously, an example of an information

system being useful could be the ability of the

system to make the clinicians’ job easier by saving

their time. One of the consultants mentioned:

‘The only way is that you show it takes less time

to do Choose and Book in a way of accepting,

because all clinicians have to get letters and we

have to grade them and make decisions about them’

[Consultant3].

Concerning the benefits, it should be said that

clinicians seemed reluctant to use IT in their job if

there was no direct benefit or clinical use for it.

Although some GPs and consultants noted that

using this system would, for example, help GPs to

make sure that appointments for their patients were

available when they were leaving GP surgeries,

others saw little or no value in using the system by

clinicians. For instance, a GP said:

‘From our point of view, I don’t really see any

from the doctors’ point of view, I don’t see any

great advantages’ [GP5].

Some GPs noted that the process of

electronically choosing clinics and booking

appointments is not regarded as a clinical task, but

it is an administrative task. A GP mentioned:

‘I don’t think there is any way you will

encourage doctors to do administrative work, now

using IT for clinical issues is different altogether…

but if there is no clinical relevance to a doctor you

will not get them to do it’ [ GP7].

With regard to showing benefits, some

consultants noted that the benefits of an

information system should not be limited to

benefits for clinicians, and they might be happy to

use the system if there were benefits to the patients

and in the healthcare settings. A consultant

suggested that:

‘The benefit does not have to be to them, it may

be a benefit to a patient, and it may be a benefit to

the hospital. You have to demonstrate a benefit’

[Consultant1].

Similarly, a GP said:

‘when you go on Choose and Book I get

appointments for people in like 2 weeks or 1 week,

very quickly so that’s a good incentive’ [GP12].

Apart from the factors mentioned above, a

consideration of the technical issues was of great

importance to encourage clinicians to use the

system. For example, reliability was a main

technical feature that could be both encouraging

and discouraging. A consultant mentioned:

‘You implement it and then you show that it

works. So, the first problem you get, people will say

“oh, it won’t work”, or “we can’t use it”, or “it

takes too long”’ [Consultant6].

The consultants generally used the paper-based

system of accepting, rejecting or directing the

referrals, and at the time of the interview they had

no access to the system. However, some of them

were interested to try the system to see whether

there would be any benefit for them or check the

system to make sure about the reliability of it.

Some consultants noted that a factor influencing the

decision whether or not to use Choose and Book

could be certainty about the reliability of this

system. In relation to this, a consultant said:

‘I think there is a certain amount of uncertainty

as to how robust the Choose and Book system is.

People are just not sure that it will work. I think

that would be one thing’ [Consultant3].

Similarly, to indicate the importance of

reliability in encouraging clinicians, a GP said:

‘I think if it worked more often, if the system

didn’t keep failing, then we would use it more often

THE NATIONAL PROGRAMME FOR IT (NPFIT) IN ENGLAND - How Can Clinicians be Encouraged to Use the

Choose and Book Service?

213

because if you try and use it and it fails then you

are not going to do it’[GP9].

Another important technical factor that had a

considerable impact on encouraging clinicians was

the speed of the system. Both GPs and consultants

noted that the speed of system was a factor that

could help to encourage clinicians to use it. It

seems that the speed of the system has improved

recently and GPs were more satisfied with this

technical aspect of the system. In reference to this,

one of the GPs mentioned:

‘We have got incentives to use the system as it

gets faster, and it’s an awful lot better than it was,

and we are using it’[GP4].

It seemed that, there would be better use of the

system if more attention was paid to encouraging

clinicians’ to use it and to developing the system by

involving users and addressing their concerns.

4 DISCUSSION

Successful implementation of information systems

when clinicians see no, or limited, clinical benefits

would be difficult, and this would be challenging

when information systems add extra time to clinical

practice (Øvretveit et al., 2007).

Our results showed that clinicians, especially

the GPs, were concerned about the impact of the

Choose and Book system on their workload and

noted that using system in consultation influenced

their productivity in terms of number of patients

that they could see in surgeries. Pothier et al.

(2006) noted that allocating extra time for using the

system within the consultation is challenging for

time-pressured GPs. In this case, clinicians were

encouraged to use the system by giving financial

incentives to practices that made a certain number

of referrals through Choose and Book. Although

some practices may meet this requirement and, as a

result, gain this financial support, achieving the

required number of referrals may be difficult, or

impossible, for some practices because of the

number and type of their referrals that can not

always take place through Choose and Book. In

such cases, these practices could be penalised,

rather than being encouraged, because of their

inability to meet the required criteria. For this

reason, much stronger motivators should be

applied, such as further development of the system

based on users’ needs and expectations to improve

their acceptance (Collins et al., 2005). Inadequate

attention to this important aspect, as Hendy et al.

(2005) suggested, may lead to clinicians’

resistance; in this study, we found GPs who

stopped using the Choose and Book because they

found it inappropriate for patient referrals.

Another important factor that can help to

encourage clinicians to use an information system

can be the potential benefits of the system. GPs and

consultants noted that there would be no, or limited,

clinical benefit for them from using the Choose and

Book system, and this was a reason for their

reluctance to use the system. However, the benefits

of the system are not limited to clinicians, and there

are several benefits for patients, which range from

improving patients’ certainty about their

appointments to improving the speed of the referral

process (Collins et al., 2005; Cummings and

Mitchell, 2005). Therefore, attention should be paid

to making clinicians aware of a broader picture of

the advantages that can be achieved through using

the system. Obviously, before convincing the

clinicians, there should be some technical and non-

technical improvements. For example, improving

the reliability of the system (Kirkley and Rewick,

2003) and minimising system downtime (Lium et

al., 2008) could be an important technical

improvements.

5 LIMITATIONS OF THE STUDY

A limitation of this study was that we only

interviewed consultants in one NHS hospital, and

the results may not be transferable to all NHS

hospitals. In addition, at the time of the interviews,

the system was still being developed and

implemented. Therefore, the views of the

consultant may now be different if they now have

access to the system. However, the study proved to

be useful in terms of addressing issues that General

Practices experienced, and the results could be

useful in suggesting approaches for improving the

electronic Choose and Book process.

6 CONCLUSIONS

Implementation of information systems in

healthcare cannot guarantee the use of, and

satisfaction with, these systems. Implementation

and development of information systems, especially

when users realise that these do not fit in with their

way of working and do not improve their

performance is challenging. Approaches that could

help to improve the use of information systems,

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such as Choose and Book include: paying adequate

attention to users’ expectations, improving users’

understanding of benefits and current developments

of the system and finally, improving technical

aspects in further developments.

ACKNOWLEDGEMENTS

We are grateful to all participants who took part in

this research. In particular, Dr. Derek Burke is

gratefully acknowledged for facilitating data

collection in the NHS Trust.

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