"Choose and Book", the barrister and the cowpat

We have a good ENT department locally. I send nearly all my ENT referrals to David, who is one of the older consultants. I have grown up with him, I suppose. He took out my daughter’s tonsils. I am very choosy about who operates on my children. I trust him. "Doctor, would you let this surgeon operate on your children?" you should ask. Make sure your doctor answers without hesitation.

A few weeks ago, I suggested to Mary that I should refer her to David to sort out her problems with obstructive nasal polyps. I’ve known Mary for twenty years. When I first met her she was in remission from a childhood leukaemia. She has been in remission ever since and so she is deemed to be cured. It still concentrates the mind, and she comes to see me from time to time about this that and the other. She is a successful criminal barrister. I expect she will take silk in a few years time, if silk is still there to be taken. It may not be because the government thinks that silks are elitist and expensive. They are right. Silks are an elite group of highly intelligent successful lawyers who can command high fees. Not a CPS quacktitioner amonst them. Like most busy people, Mary is well organised and so always manages to book an appointment to see me. We usually chat about working for the government. She has a bitch about the Crown Prosecution Service, and I have a bitch about health care professionals taking over the world and then we both have a bitch about government bureaucracy.

I suggested a “named consultant only” referral to David, but she was keen to try “Choose and Book”. She did not want to get an appointment when she was scheduled to be in court. And that’s what it’s all about, isn’t it? Choice. Choice and convenience. In the old days, I would have written a short letter to David. His secretary would have sent her an appointment and she would have been seen but not, it has to be said, on a day of her choosing. We can do better than that now. And the government is so keen to get Choose and Book working that it is now paying the practice £5 for every patient we refer under the Choose and Book system. Ker..ching. So I wrote my usual “Dear Comrade” letter to the Choose and Book Commissar knowing at least that Mary was a highly intelligent professional and would know how to navigate “the system”.

I received the following letter from her today:

click to enlarge

I begin to understand the hidden agenda of Choose and Book. Our monthly audit of referrals under the system shows that on average 25% of patients do not make an appointment. We have to follow them all up as they might have something serious. A few have changed their mind but most of them, particularly the elderly patients, have been defeated by the system. Think of the money that saves. And what, in context, is a Customer Service Agent? A full time job with a pension for sure. But what exactly does the agent do all day?

The government is not resting on its laurels. So impressed are they by Choose and Book that they have introduced an even more refined hospital system called "Clinically Prioritise and Treat". In the old days, when I referred a patient to David, I would classify the referral as "routine", "soon" or "urgent". David always read the referral letters himself and would assign an appointment priority of "routine", "soon" or "urgent" on the basis of the information I had sent him. He rarely changed the priority I had given but, if he did, it was most usually upgrading a "soon" to an "urgent".  He did  this prioritisation each week. It only took a few minutes, and then his secretary sent out the appointments. He did not have a protocol. He did not have a "toolkit". The government thought this was terribly inefficient. They sacked his secretary, with whom he had been working for years, and instead there is a departmental typist/telephonist. Most of David's corresspondance is now typed in New Delhi. It's cheaper. Meanwhile, the NHS Institute for Innovation and Improvement (no, really) has introduced the "Clinically Prioritise and Treat" protocols and toolkits.This "system" has an acronym, CPAT and is thus known as COWPAT. Who thinks up these acronyms? Did Mrs Whitehouse really propose to call her first organisation the "Clean up national TV" campaign?

Cowpat

CPaT is a very simple approach, supported by a toolkit that does three things:

1. Provides detailed information that enables trusts to understand how their waiting lists are managed
   
2. Offers techniques to promote shared understanding by clinicians, managers and administrative staff
   
3. Identifies ways of improving the management of waiting lists by introducing fairer, more systematic processes for the selection of patients, helping to reduce overall waiting times

This means that patients can be seen in accordance with their clinical priority and also provides a sound basis for the introduction of consistent booking systems.

CPaT is based on two principles:

• That the proportion of priority patients a clinician sees has a direct impact on the waiting time for all other patients. The higher the proportion of priority patients, the longer routine patients will have to wait for treatment
  
• Patients categorised as routine are not always seen in waiting time order. Some patients wait longer for treatment as a result of displacement by ‘queue jumping’. If routine patients are seen broadly in turn, the maximum waiting time for all patients will fall
  

You can use CPaT to measure whether patients are being seen in chronological order by looking at variation in waiting time between the original decision to admit (ODTA) and the date of admission for treatment. Where routine patients are not seen in waiting time order, the variation is greater. You can then use the CPaT toolkit to promote discussion pinpointing the cause of variation in waiting times at trust, site, speciality, sub-speciality and procedure level. Once you have identified these causes, CPaT suggests how to address them to reduce maximum waiting times. Whilst there will always be an element of variation within the system, you should aim to keep this to a minimum.

Masochists who wish to immerse themselves in COWPAT should visit the dedicated website.   Always remember, though, what this is all about:

A Focus on the Whole Patient Journey
The efficiency of the whole patient journey is more important than the individual team's efficiencies. An outline approach of how to look at the bigger picture.

Does it work in real life? Of course it does. In Bolton, up in Lancashire, they were having problems with tummy pain. In the old days, people with tummy pain were seen in the A & E department by a doctor, who examined them and then made a diagnosis. What a dreadful system but in those days doctors did not have the benefit of "Root Cause Analysis using fishbone technique". They have just introduced it in Bolton:

What was the problem?

Following the Trust Enterprise Value Stream Analysis Event in October 2006, the Abdominal Pain Value Stream was identified as a priority. At Bolton Hospital, management of abdominal pain wasn't standardised and there was a perception that the patient journey was delayed by a lack of access to diagnostics and clinical decision making at appropriate points in the pathway. It was also believed that some admissions could be avoided and that there was a lot of rework in following up patients who were brought back for diagnostics and review. The process for clinical coding may also have been impacting on income streams and clinical data tracking. This Value Stream Analysis was conducted in February 2007.

"Root Cause Analysis using fishbone technique"

What they did to identify the cause of the problem

A team of more than 25 staff from different departments and disciplines conducted the Value Stream Analysis. The scope included all adult patients with abdominal pain presenting as an emergency to Bolton Hospital Accident and Emergency Department or Assessment Units up to the point of discharge from hospital.

(Full analysis here.)

This is beyond credibility. It is beyond satire. I cannot cope much longer.

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A regular reader says, "For how the government now regards citizens (sorry, subjects), please see" :

The Unknown Citizen

(To JS/07/M/378 This Marble Monument Is Erected by the State)

He was found by the Bureau of Statistics to be
One against whom there was no official complaint,
And all the reports on his conduct agree
That, in the modern sense of an old-fashioned word, he was a saint,
For in everything he did he served the Greater Community.
Except for the War till the day he retired
He worked in a factory and never got fired,
But satisfied his employers, Fudge Motors Inc.
Yet he wasn't a scab or odd in his views,
For his Union reports that he paid his dues,
(Our report on his Union shows it was sound)
And our Social Psychology workers found
That he was popular with his mates and liked a drink.
The Press are convinced that he bought a paper every day
And that his reactions to advertisements were normal in every way.
Policies taken out in his name prove that he was fully insured,
And his Health-card shows he was once in hospital but left it cured.
Both Producers Research and High-Grade Living declare
He was fully sensible to the advantages of the Installment Plan
And had everything necessary to the Modern Man,
A phonograph, a radio, a car and a frigidaire.
Our researchers into Public Opinion are content
That he held the proper opinions for he time of year;
When there was peace, he was for peace; when there was war, he went.
He was married and added five children to the population,
Which our Eugenist says was the right number for a parent of his generation.
And our teachers report that he never interfered with their education.
Was he free? Was he happy? The question is absurd:
Had anything been wrong, we should certainly have heard.

W. H. Auden