Sir,

Choose and Book (C&B) is a national electronic booking service introduced in England since 2004.1 An audit of C&B was performed at the West of England Eye Unit (WEEU) in Exeter over concerns of inappropriate referrals with this system. The total number of referrals received between 19th February 2007 and 15th May 2007 was 609. The total number of rejections during the same period was 148. We calculated an average number of 10.32 referrals and 2.49 rejections per working day. The most common reasons for rejections were: redirection of referral to another clinic (61%, mostly to cyst or minor operations clinics), necessity to book additional assessments for same visit (15%, including orthoptic and optometric assessments and glaucoma screening tests), and upgrading the priority of a referral from routine to urgent (14%).

We noted a poor understanding across the spectrum of hospital staff in our department of what C&B was and how it worked. We also noted that some general practitioners (GPs) delegated the bookings to administrative staff. Some patients were not receiving cancellations following rejection of a C&B request. The system should allow GPs to identify a rejected C&B request, rebook it and inform the patient of this change. Following the identification of this problem in our audit, the C&B team introduced an automated cancellation letter. Presently, we are assessing ways of redirecting appointments within WEEU rather than sending rejections back to the GP. We also wish to be able to include ancillary tests (such as visual fields and orthoptic and optometric assessment) as part of C&B system. At present, WEEU runs a C&B system in parallel with a paper-based referral letter system but this audit highlighted the present difficulties with C&B at WEEU and ways to address these issues. We are arranging a meeting with local GPs to update them on our services (especially with respect to the management of age-related macular degeneration) and how to use them better. However, we will have to continue with the paper-based partial booking system until the electronic system is easier to use and more flexible.