Archway Surgery.       Archway Development & Consulting Ltd
Prison Services
Dacorum PCT
NHS Organisations impacting Primary Care
Freedom of Information Act
NPfIT site
Primary Care Computing Specialist Group
TheRegister on IT
Foundations of Iraq


NatPact Web Site
GP contracts
Choose and Book


Practice Based Commissioning Problems

PBC Briefing Notes (Dacorum and Watford)

PBC Background

The Answer Lies in Outpatients?

Choose and Book: No choices allowed


Archway Development &   Consulting Ltd
54 High Street
Herts HP3 0HJ
Tel 01442 817217
Fax 01442 879647
email here
Registred in England
Company No 3326461
Registered Office
C21 Herbal Gardens
9 Herbal Hill
London EC1R 5XB




   NHS Guidance pdf     Commissioning Web Site     Payment By Results Delay  Primary Care Contracting

Primary Care Based Commissioning Chapter 6
                         EXTREME CATS
Other links relating to this:
               Extreme CAS and CATS and Referral Management
Currently G.P.s see patients and refer some on to their consultant colleagues when it is thought that hospital facilities will be required, or when the patients and the G.P. need advice on how best to manage the patients' problems.  Under the new EXTREME CATS  being proposed, direct communication between G.P.s and NHS Consultant specialists will be forbidden, except for 999 and via casualty, or for the two week cancer wait patients.  All other urgent and non-urgent referrals will have to be made via a new intermediary service, for approval and vetting, or for the patients to be given treatment without any consultant input.  Patients will have no choice offered to them at the G.P. surgery.  Patients and their referrals will have to go through this service, a new Primary Care Super Surgery.

The local PCT (there may be others with similar ideas) would like to create an amalgamation of Referral Management Services, a Clinical Assessment Service, a Primary Care Treatment Service and Choose and Book Management Service.  This is said to smooth the pathway of patient care and to reduce the use of hospitals.

Local GPs make all their referrals to a new PCT run amalgamated service, which becomes the local Superior Super Surgery. All Practices in the area served by this new service are demoted from G.P. practices to Feeder Stations for the new service.

The Feeder Station Practices transfer the responsibility and clinical judgments to the new PCT Super Surgery.

The Feeder Stations (FS) make all referrals and send copies of all incoming correspondence about patient care (outcomes) to the PCT run Super Surgery (SS).   The SS then logs and counts the referrals and does a paper exercise on the validity of the referral.  It also logs the outcomes of the referral.  This would require Fundholding type software run centrally, data input staff, and assessment staff and doctor time.

The referral could be sent back to the Feeder Station, but is likely to be passed onto the new Clinical Assessment and Treatment Centre Services, where some patients are seen, by the triage team of nurses, physios and the new breed of Senior, Superior, or Proper G.P.s. If patients are deemed worthy enough, the Choose and Book team then books the patient to see a Consultant via the Chose and Book system.  If a patient saw a consultant as part of the earlier triage process, that is, in primary care, then any operation is unlikely to be carried out by that surgeon.

The Super Surgery is the one that makes the traditional referral on to Consultants at Hospital, or may even pass on the original referral letter from the original feeder practice. It is at that stage patients are offered choice of provider (hospital) by this centralised Choose and Book team.

When the patient has been seen, the consultant’s letter goes back to the Feeder Station practices, and also back to the Super Surgery to log onto its system.

If any procedure is required, the hospital Consultant then refers back to the Choose and Book team at the referral management centre, super surgery,  to give the patient choice of hospital provider for any procedure.

To make sure the system cannot be by-passed, the Feeder Practices’ G.P.s will not have access to the NHS Choose and Book system, or rather they would have access; it is just that there would be only be one choice item on the C&B menu for GP referrals… the local Super Surgery. Nothing else is allowed or seen on the computer.

The Feeder Stations will not be able to make direct referrals to any hospital, say St Marks, where the patient was seen before, without sending the referral to the Super Surgery first. Once taken through the assessment process the referral may be passed onto St Marks. 

A flaw in this control system will be for the G.P.s close to county borders. They will be able to escape this system and refer directly to their nearest hospital. If they can do that directly they will then have to offer choice, so they will see the full choose and book menu.

How could such a vision be possible?
1.    We all make some rubbish referrals from time to time.   These do take up consultant time; the actual cost to the Hospital Trust of these duff referrals (say to orthopaedic surgeons, when no operations follow) is quite low.  Indeed the Payment By Results tariff assumes a proportion of duff referrals. Saving PCT cash to reduce hospital revenue does reduce hospital income disproportionally.  It is cherry picking in reverse.  
2.    All other schemes, such as protocols, forms, teaching G.P.s seemed to have failed to reduce referral rates (I seem to remember we did have systems to control referral rates within our surgeries in Fundholding days, but we must NOT mention that F word).
3.    Some practices have vowed not to use Choose and Book. At the moment the software is ghastly so that approach is not unreasonable.  These G.P.s are willing to subcontract all their C&B work to the new Super Surgery system.  By doing that they will transfer their choices and responsibility of referrals to hospitals for the new Super Surgery, which will do the Choose and Book work on their behalf.

The Super Surgery Treatment Centre would soon follow up patients and develop a list of patients, just like some consultant do now. The Super Surgery is likely to have to be set up as a PCT PMS.  The PCTs are under orders by the Government to give up their provider functions, and that would include this Super Surgery system. Once established it would have to go out to tender as an APMS.  This would be an extremely rich picking for Archway Development and Consulting Ltd (dream on) or more likely for the likes of Care UK, Clinicenta, Atos Origin, Netcare, Mercury Health, Serco, United Health, and even Harmoni.  The service would have control of all referrals in the area, and could develop into the single monopoly polyclinic, with patients registering directly. A single practice moving into the building would do it for them.  

G.P.s should develop for ourselves our own polyclinics or the PCT will create one, and then sell it off.

G.P.s will not be able promise a patient that he or she will be seen at a consultant led hospital clinic, or for that matter  G.P.s  will not be able to make any statement in the consulting room to patients as to where or when or by whom they will be seen, 

G.P.s will find it too easy to pass on the decisions of whether to refer or not, and thus pass on the clinical and insurance risk to the new Super Surgery Service.  G.P.s will de-skill themselves as demoted to feeder stations for the new super surgery.

Further blogs on CATS and CAS are on

Gerry Bulger

July 2006

Contact here