Annex 5 - Specification for a directed enhanced service in England: choice and booking

Introduction
1. It is the Government’s priority for England to:
  • Provide patients with an offer of choice when it has been decided they need a first consultant outpatient appointment; and
  • Offer patients booked appointments in secondary care by delivering booking arrangements through the national Choose and Book system.
2. This one year directed enhanced service (DES) for 2006/07 supports the drive to deliver this priority to patients. It is designed to provide an incentive to general practice to offer choices to patients who are referred for a first consultant outpatient appointment by a GP and also utilise the Choose and Book system available to practices. This DES will be reviewed for 2007/08.

3. The total investment available for this DES in 2006/07 is £50million.

PCT Duty
4. Primary Care Trusts (PCTs) will have a duty in 2006/07 to make payments to practices at the end of the year in respect of this DES, providing that the results of a new patient experience questionnaire and/or the booking validation are sufficient to trigger an award. Payment for delivering booking arrangements will be triggered by the system at supra PCT level. Aspiration payments will be made as set out in paragraph 12 - go to this section.

5. For practices that close down, split, merge or start up in year, it will be for the PCT to decide with that practice what awards will be made to them in respect of this DES.

Patient Experience Survey
6. The Department of Health is developing a new, national, patient experience survey to help understand how well Government priorities in the NHS are being implemented across England. Initially, this practice level survey will focus on access to primary care and offer of choice of secondary care provider. The focus on access is set out in a separate DES for 2006/07. The plan is to develop questions that require yes/no answers. The British Medical Association’s GP Committee will be working with the Department of Health and NHS Employers on those questions.

7. Detailed information about the survey will be provided to practices and PCTs later. However, the plan is that existing systems will be deployed to facilitate administration (including identification of the cohort of patients) and thus will be managed remotely from the practice. For those practices without access to the appropriate software or Information Technology separate arrangements will be made. The cohort will include a statistically viable sample of all patients that are referred for an outpatient consultant-led appointment to assess and trigger payment for the offer of choice.

The award
8. The award will comprise two components for payment to practices. Component one for delivering choice and component 2 for implementing and utilising the Choose and Book system. An award of component 1 is not dependent upon an award of component two and vice versa.

Component one
9. Component one is an award for offering choice to patients through an initial discussion between GP and patient about the range of clinically appropriate choice of providers available and some clinical information to help patients make an informed decision. The scheme is underpinned by providing patients with information confirming the offer of choice eg providing patient booklet and through patient choice advisers employed by PCTs.

10. Practice responsibility to support choice. Practices will be required to provide the following support for patients to make an informed choice of hospital/provider and utilise the Choose and Book system.
  • The patient’s referrer, normally their GP, should generate a shortlist of clinically appropriate provider choices.
  • The patient’s referrer, normally their GP, should initiate the choice offer and discuss the relevant clinical aspects of choice with the patient.
  • Practices should work with PCTs to support patients in discussing other aspects of choice.
  • Patients should have access to meaningful information in the practice to support their choice decision, including;
  • The patient information booklet tailored to PCT commissioned choices.
  • The At A Glance poster of commissioned choices for the top 15 referrer specialties (this is for GPs rather than patients)
  • Where patients can access further information and local support, including advice from patient care advisers, and an explanation of process.
  • Outpatient waiting time information for each commissioned specialty (PCTs have been instructed to provide practices with monthly outpatient waiting time information).
  • Practices should work with PCTs to quality assure the choice process from the patient perspective.
Component two
11. Component two of this DES is an award made in response to the practice’s utilisation of the Choose and Book system for first consultant out-patient appointments. This will include bookings ie, converted unique booking reference numbers (UBRN) made in the GP surgery, by the appointments line, the internet, local booking services or via Indirectly Bookable Services (IBS). In the event of system(s) failure the commitment to award practices will still hold on a pro-rata basis.

12. Practice responsibility to support utilisation of the Choose and Book system.
  • The patient should leave the practice with a Choose and Book generated appointment request (UBRN) and a patient password.
  • The patient should leave the practice with an appointment with their chosen provider or written information about what they do next to complete their choice and make a booking.
  • The practice should generate and attach a referral letter to an appointment request or auto generate a referral letter via a GP integrated system eg, EMIS, within agreed time limits. For cancer referrals (maximum 2 week wait) or urgent referrals this must be within 1 working day and for routine referrals normally 3 working days unless there are exceptional circumstances, which may include delays for inclusion of any test/diagnostic results, or when information cannot be forwarded subsequently.
Validation and Payment
13. Of the total investment available for this DES, 50% will be allocated to each of components 1 and 2. Within each component, half of the funds will be available as an aspirational payment and half will be triggered through validated data.

14. Component one 50% of the value of this DES will be paid to the practice if at least 60% of the patients, via the patient experience questionnaire, agree they were offered a choice of provider. Note that the requirement is for the patient to recall a choice conversation.

15. Component two. Data to indicate GP use of the Choose and Book system will be obtained from the system itself at supra practice level by Connecting for Health reports throughout the year for PCTs. Practices’ utilisation will trigger payment on a sliding scale based on percentage of first consultant out-patient referrals made using the Choose and Book system by the practice in the period 1 September 06 to 28 February 07 ie UBRNs converted. This will be paid regardless of how the actual booking is made eg, via the internet etc.

% referrals (Converted UBRN) as % of total Proportions Payment of Component 2
% %
50 60
60 70
70 80
80 90
90 100

Aspirational Payments
16. For both components of this DES there will be a 50% aspirational payment available with the remainder to be paid on confirmation of successful achievement of the standard. At the end of the DES period. If practices fail to achieve the minimum level, PCO’s should initiate arrangements for the managed repayment of the aspirational funding or, for a balancing mechanism which offsets this repayment against other income due to practice.

17. For Choose and Book utilisation the aspirational payment will be provided on the basis that practices agree to implement and utilise the Choose and Book system for at least 25% of referrals to consultant out-patient appointments in June 2006

System Fall Down
18. PCTs will make prompt payments to practices upon completion of each component and the expectation is that that by the end of this DES, practices will have received relevant funding for both components. If, by the end of 2006/07, a practice has not been able to implement a particular programme due to circumstances beyond its control (eg due to national or regional difficulties), the commitment to award payment to practices will still hold and the practice should receive a pro-rata payment for the work that they have completed. This payment to be decided by the PCT.

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