Access and Waiting List Policy - Aintree University Hospital

Access and Waiting List Policy, 2nd Edition – May 2016 Page 1 of 39
Uncontrolled copy when printed - Current version held on intranet
Issue number: 2nd Edition
Author with contact details
Tel: 0151 529 0463
Issue Date: May 2016 Review Date: May 2019
Level Trust wide and inclusive of services within the community for which the Trust has a contractual obligation to deliver.
Location of Staff applicable to
All Trust Staff Staff groups applicable to
All clinical staff
Please refer to references (Page 33)
Information Classification Label
NHS Confidential NHS Protect Unclassified
Access to Information To access this document in another language or format please contact the policy author.
Document Change History (changes from previous issues of policy (if appropriate) :
Issue Number Page Changes made with rationale and impact on practice
Date
RTT guidance updated (Pause removed &patient initiated delays updated)
Patient cancellation of elective admission
May 2016
NB: This version of the Trust Access and Waiting List Policy is pending Clinical Commissioning Group approval.
ACCESS AND WAITING LIST POLICY
CONTENTS
1.
Summary Page Guiding Principles Scope of the Policy Purpose of the Policy
3 3 4 4
4
Content 4.1. Waiting Time Standards 4.1.1. Referral to Treatment (RTT) Access Standards 4.1.2. Cancer Access Standards 4.1.3. Diagnostic Access Standards (DM01) 4.1.4. Access to Health Services for Military Veterans 4.1.5. Exceptions 4.2. Time Standards to be Adhered to by All Staff 4.2.1. Clock Starts 4.2.2. Clock Stops 4.2.3. Adjustments and Delays 4.3. Waiting List Management 4.4. Training
7 7 7 8 8 9 9
10 10 13 20 23 30
5 Monitoring of Compliance 31
6 Equality, Diversity and Human Rights Statement
32
1 Glossary of Terms 34
2 RTT pathway Guidance 38
1.0 SUMMARY PAGE
Aintree University Hospitals NHS Foundation Trust (hereafter referred to as ‘the Trust’) is committed to providing an exemplary standard of care to patients and an important component part of this is patient access to services. The Trust is committed to provide a service that is fair and accessible to all, providing patient choice and delivering a positive patient experience.
This policy outlines the scope and standards which must be followed explicitly for:
• Pathway management of all patients referred into the Trust • Current national standards and data definitions
All clinical and non-clinical staff involved in patient pathway management must ensure that their processes and procedures are consistent with this policy or have Trust approved Standard Operating Procedures in place which adhere to the guiding principles of this policy. 1.1 Guiding Principles
The NHS Constitution establishes the principles and values of the NHS in England and sets out the rights to which
patients, public and staff are entitled. The constitution incorporates seven key principles which set out the following
rights;
The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual
orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status.
Access to NHS services is based on clinical need, not an individual’s ability to pay. NHS services are free
of charge, except in limited circumstances sanctioned by Parliament.
The NHS aspires to the highest standards of excellence and professionalism – in the provision of high
quality care that is safe, effective and focused on patient experience.
The NHS aspires to put patients at the heart of everything it does. It should support individuals to
promote and manage their own health. NHS services must reflect, and should be coordinated around and
tailored to, the needs and preferences of patients, their families and their carers. Patients, with their families
and carers, where appropriate, will be involved in and consulted on all decisions about their care and
treatment.
The NHS works across organisational boundaries and in partnership with other organisations in the
interest of patients, local communities and the wider population. The NHS is committed to working jointly
with other local authority services, other public sector organisations and a wide range of private and voluntary
sector organisations to provide and deliver improvements in health and wellbeing.
The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and
sustainable use of finite resources.
The NHS is accountable to the public, communities and patients that it serves.
With effect from 1 st
April 2010 patients have the right to access services within maximum wait times, or for the NHS
to take all reasonable steps to offer a range of alternative providers including those within the private healthcare
sector (section 3a NHS Constitution).
The following NHS Constitution process flow must be followed when dealing with a patient request for further
information relating to exercising their rights under the NHS constitution.
1.2 Scope of the Policy This policy applies to all patients referred electively into the Trust for investigation and treatment, and for all members of staff employed by the Trust. In particular it applies to those staff involved in delivering or supporting direct clinical care. In instances where Trust services are unable to comply with this Access and Waiting List Policy the responsible Clinical Business Manager/Service Lead and Clinical Lead must, within a local standard operating procedure, clearly document revised processes to be followed and standards to be attained and seek appropriate Divisional and Trust approval for such variations. 1.3 Purpose of the Policy The Purpose of this policy is to guarantee that the best interests of our patients are served by ensuring that the Trust’s services are managed in line with national waiting time standards and the NHS Constitution (April 2010). This document outlines the Trust and Commissioner Requirements and supporting Standard Operating Procedures (SOP) for managing timely patient access to secondary care services from referral to treatment, as well as discharge to primary care.
2.0 INTRODUCTION
This policy gives guidance to staff within the Trust on providing access to services for patients. This will be achieved by ensuring that all staff understand their role in managing patient access and the delivery of waiting time standards. Patients’ experience of the NHS can be improved by ensuring they receive high quality care, in the right place, and
minimising the time they wait for treatment and care. The underlying principle in relation to consultant-led waiting
times is that patients should receive high quality care without unnecessary delay.
In the majority of cases, it will be clear how the rules should apply. However, where there is doubt, or where
decisions on their application are finely balanced, then local decisions should be made within the framework of
national rules and in line with what is in the best clinical interests of the patient, and considering how the patient
would perceive their waiting time.
In summary, national waiting time rules provide a framework within which the NHS has the autonomy to make
sensible, clinically sound decisions about how to apply them, in a way that is consistent with how patients
experience or perceive their wait. They also ensure that waiting times are recorded and reported consistently across
the NHS in England.
This document sets out the policy to be followed by all staff when dealing with or managing waiting lists and patient
waiting times within the Trust, including referral to treatment (RTT), cancer patients, diagnostics and Ex-Military
Service Personnel and must be provided to the following staff groups for reference.
Medical staff
Medical secretaries
Operational Management Teams
Cancer Trackers/MDT Coordinators
It is the responsibility of Clinical Business Units (CBU) to ensure all relevant staff are aware of the correct waiting list
administration processes and that those staff possess the necessary knowledge and skills to ensure compliance.
The local application of this policy should be considered by the Clinical Business Units when undertaking
departmental/CBU training needs analysis to ensure that the central RTT team are appraised of future training
needs and therefore able to plan programmes of education appropriately. It is the responsibility of all staff to adhere
to the notes in this policy.
This policy document must be readily available in every CBU that deals with waiting lists/access and must be
available in each clinic room for reference purposes. A signed copy of this policy should be held by the Clinical
Business Manager.
Chief Executive: The Chief Executive has overall responsibility and accountability for delivering access targets
as defined in the NHS Plan, NHS Constitution and Operating Framework.
Chief Operating Officer: The Chief Operating Officer is responsible for ensuring that there are robust systems
in place for the audit, management and delivery of access standards.
Divisional Chief Operating Officers: Responsible for the monitoring of performance in the delivery of all
access standards and ensuring that Clinical Business Units deliver the activity required to meet those standards.
Divisional Director of Operations for Support Services: Responsible for final sign off of performance in
relation to the delivery of the 6 week diagnostic wait standard and all cancer access standards.
Divisional Director of Operations for Surgery and Anaesthesia: Responsible for final sign off of performance
in relation to the delivery of all RTT access standards.
Clinical Business Managers: Responsible for the monitoring of performance in the delivery of all relevant
access standards and for ensuring the specialities deliver the activity required to meet the waiting list targets.
Hospital Consultants: Consultants have a shared responsibility with their Clinical Business Managers for
managing their patients waiting times in accordance with the maximum guaranteed waiting time to deliver all
relevant access standards.
Clinical Nurse Specialists: Clinical Nurse Specialists have a shared responsibility with their Consultants and
Clinical Business Managers for managing their patient’s waiting times in accordance with the maximum
guaranteed waiting time.
Patient Appointment Centre: The Patient Appointment Centre (PAC) is responsible for arranging
appointments and for carrying out the operating procedures for the administration of the patient’s referral and for
entering all information onto the PAS system accurately. In Clinical Business Units where this function is
devolved responsibility passes to the Clinical Business Manager.
Head of Business Intelligence, Information Services and Clinical Coding: Responsible for administering
data required for managing and reporting RTT waiting times, activity and outcomes.
Waiting List Clerks/Medical Secretaries: Responsible for ensuring waiting lists are managed in line with their
job descriptions and locally derived standard operating procedures which underpin this policy. All 2ww patient
referrals, diagnostics, treatment episodes and waiting lists must be managed on the Trust’s PAS and Somerset
system. All information relating to patient activity must be recorded accurately and in a timely manner.
MDT Co-ordinators and Data Clerks: Responsible for monitoring cancer and RTT pathway for patients,
ensuring they are managed in line with this policy and assisting in the pro-active management of patient
pathways on PAS in line with their job descriptions.
All Staff for whom this document applies: All staff will ensure that any data created, edited, used, or recorded
on Trust IT systems within their area of responsibility is accurate and recorded in accordance with this policy
and other Trust policies relating to collection, storage and use of data in order to maintain the highest standards
of data quality and maintain patient confidentiality.
4.0 CONTENT OF THE POLICY
4.1. WAITING TIME STANDARDS
This section describes the waiting time standards to be adhered to by all staff when dealing with or managing
waiting lists and patient waiting times within the Trust, including referral to treatment (RTT), cancer patients,
diagnostics and Ex-Military Service Personnel.
4.1.1. Referral to Treatment
The NHS Constitution provides patients with a right to access services within maximum waiting times, including
the right to start consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions.
If this is not possible, the NHS Constitution requires the NHS to take all reasonable steps to offer patients a
range of suitable alternative providers and it is the responsibility of the trust to ensure patients have the
information they need to exercise those options if need be. The Referral to Treatment operational standards
are1;
92% of patients on the active consultant led RTT caseload (Incomplete Pathways) are waiting no longer than 18 weeks (Contracted Standard).
90% of admitted patients to be treated within 18 weeks of referral – admitted patients are patients who have an admission as part of their consultant led pathway (Local Standard).
95% of non-admitted patients to be treated within 18 weeks of referral – non admitted patients are patients who do not have an admission on their consultant led pathway (Local Standard).
To support the delivery of RTT access standards all specialties will aim to offer patient care within the internal
operating standards and time periods illustrated in Figure 1.
Figure 1: Trust Internal Operating Standards and Times Periods
NB: A guide to RTT codes is included within appendix 2 of this policy 1 Local targets can be applied by Monitor
4.1.2. Cancer Waiting Times
In addition to the individual patient rights as set out in the NHS Constitution (and its supporting handbook) there
is a set of cancer waiting time performance measures for which the NHS is held to account for delivering by
NHS England. There are a number of government pledges on waiting times, including:
A maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive
treatment for all cancers;
A maximum 31-day wait for subsequent treatment where the treatment is surgery;
A maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy;
A maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen;
A maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive
treatment for all cancers;
A maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment
for cancer;
A maximum 62-day wait for the first definitive treatment following a consultant’s decision to upgrade the
priority of the patient (all cancers);
A maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms
A maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms,
even if cancer is not initially suspected.
The tolerances within these contracted and locally agreed standards are there to deal with valid exceptions such
as patient choice to be seen outside of agreed 18 week or cancer access standards, patients cooperation in
being seen within nationally agreed timescales (i.e. DNA’s and cancellations), and clinical exceptions, where
patients cannot be treated due to clinical reasons. The overall goal of the Trust and of this policy is to treat all
patients within nationally agreed timescales.
4.1.3. Diagnostic Waiting Times
Many patients require diagnostics to determine their diagnosis and therefore appropriate treatment. Diagnostics
must always be performed and reported within clinically appropriate timescales which do not exceed a maximum
waiting time of 6 weeks.
The Trust reports waiting times on the following 15 key diagnostic tests:
Imaging - Magnetic Resonance Imaging
Physiological Measurement - Cardiology - echocardiography
Physiological Measurement - Cardiology - electrophysiology
Physiological Measurement - Neurophysiology – peripheral neurophysiology
Physiological Measurement - Respiratory physiology - sleep studies
Physiological Measurement - Urodynamics - pressures & flows
Endoscopy - Colonoscopy
Endoscopy - Cystoscopy
Endoscopy – Gastroscopy
Diagnostics should take into account the patient’s stage on pathway and target date for treatment to ensure that the test is performed and report available within a timescale that does not delay treatment.
4.1.4. Access to Health Services for Military Veterans
As per DOH guidance War pensioners and Ex-Military Service personnel should receive priority treatment if their
condition is directly attributable to injuries sustained during service (unless there is an emergency case or
another case demands clinical priority) but note that priority should not be given for unrelated conditions.
General Practitioners should make it clear in referrals for treatment that the patient is a military veteran and
requires priority treatment for a condition that, in their clinical opinion, may be related to their military service.
4.1.5. Exceptions
The right to treatment is subject to various exceptions. In particular, the right to treatment within 18 weeks from
referral will cease to apply in circumstances where:
patients choose to wait longer;
delaying the start of a patients treatment is in their best clinical interests, for example where smoking
cessation or weight management is likely to improve the outcome of the treatment
it is clinically appropriate for a patient’s condition to be actively monitored in secondary care without clinical
intervention or diagnostic procedures at that stage
patients fail to attend appointments which you had chosen from a set of reasonable options; or
The treatment is no longer necessary.
Guidance relating to the NHS constitution indicates that the Trust should;
work with the relevant commissioner to identify a range of alternative providers if one cannot be
sourced through locally agreed arrangements
keep patients informed, including about their length of wait if they choose not to accept the offer of
having treatment with an alternative provider, and making it clear that they (the original providers)
remain responsible for patient care
contract with alternative providers and agree any specific operational details and requirements (e.g.
format for transmission of tests and reports, turnaround times, transmission of any relevant past
diagnostic images and reports)
notify their Commissioners and NHS England if an alternative provider has failed in its duties, and
Work with the relevant commissioner to ensure cost of treatment is properly reconciled.
A formal process for dealing with NHS constitution requests has been set up in the Trust and is identified in
section 1.
4.2 TIME STANDARDS TO BE ADHERED TO BY ALL STAFF
This section describes the waiting time standards to be adhered to by all staff in relation to;
Clock starts
Clock stops
Waiting List Management, including referral to treatment (RTT), cancer patients, diagnostics and Ex-Military
Service Personnel.
Sources of referral that
commence 18 week clock
clock)
A waiting time clock starts when a referral is made by any care professional or service permitted by an English NHS commissioner to make such referrals. A referrals from the following may start an 18-week clock: General practitioners (GPs) General dental practitioners (GDPs) General practitioners (and other practitioners) with a special interest
(GPwSIs) Hospital consultants Optometrists and orthoptists Accident and emergency (A&E) Minor injuries Units (MIU) Walk in Centres (WiC) Genitourinary medicine clinics (GUM) National screening programmes Specialist nurses or allied health professionals where CCG’s have approved
these Self-referrals if this has been verified by the patient’s GP Prison health services Referral from private practice
Referrals to services from
Primary Care which start
an 18 week clock
Referrals from primary care to the following services start 18 week
clocks:-
Medical or surgical consultant-led services irrespective of setting including: Referral-management centres (this covers arrangements known as clinical
advisory centres, integrated clinical assessment and treatment services, interface services etc)
Cancer services (for which a 62 day cancer-target clock also starts) Rapid Access Chest Pain Clinics (for which a 14 day waiting time target for
first outpatient/assessment applies) Diagnostic services provided the patient will be assessed and might, if
appropriate, be treated by a medical or surgical consultant-led service, before responsibility is transferred back to the referring health professional (i.e. ‘straight-to-test’ scopes etc).*
Practitioners with special interests if they are part of the referral management arrangement as defined above
Referrals to services from
start an 18 week clock
In some circumstances an 18 week clock will start in a secondary care setting.
Consultant to consultant (or consultant-led services) referrals do start a clock,
specifically for:
A different condition newly identified by the consultant and unrelated to the original condition for which the patient was referred (e.g. cardiology problem identified at assessment following Orthopaedic referral).
A consultant to consultant referral for the same condition continues the 18 week clock that commenced in primary care (e.g. clinician refers to a colleague who may sub specialise in the management of specific conditions).
A patient may attend A&E/Assessment services and it is identified that they require to commence an elective pathway within a medical or surgical specialty*
In cases where a patient has been initially admitted as non-elective and it is identified that they require further treatment as an elective patient (e.g. patient admitted with acute cholecystitis who is listed for cholecystectomy at a future date)
In some cases where a patient has not been on an 18 week pathway (e.g. may have been on active monitoring) and a new decision to treat within a medical or surgical consultant-led service is made.
Where a Patient has been seen privately by a Clinician but now requires a follow up appointment in the NHS, the referral must be treated as a new referral to the Trust and seen in chronological order (unless clinical priority dictates) within the guaranteed waiting times. A new Referral to treatment time clock will start at the point the patient is referred into the NHS. Where the patient has already had treatment in the private sector and the NHS care is for postoperative follow up or active monitoring only, this referral will not start a new RTT period.
*This does not apply to fracture or to anticoagulant clinics since this is a
continuation of a non-elective pathway.
Referrals that do not
commence an 18 week
clock
Referrals from primary care to the following services do not start the week clock:
Allied Healthcare Professionals (e.g. physiotherapy) healthcare science (e.g. audiology) or mental health services that are not medical or surgical consultant-led (including multidisciplinary teams and community teams run by mental health trusts) irrespective of setting.
Diagnostic services if the referral is part of a ‘straight-to-test’ arrangement.* Primary dental services provided by dental students in hospital settings. Private patients or patients under the care of a non-English commissioner.
Note: Referrals from primary care to diagnostics*
Direct Access – the GP refers for diagnosis reasons and upon receiving the result/s will make the decision
whether or not to refer the patient on to secondary care. The direct access diagnostic does not start an 18 week
clock since the GP has not yet determined if the patient requires onward referral for further
investigation/intervention.
The information below describes, once a clock is to be started, at which point it should do so. For the majority of
referrals the clock automatically starts when a referral is added to Sigma. Therefore, it is crucial that referral dates
put onto the Sigma system or sourced via Choose & Book (or its replacement) are accurate and consistent with
this policy.
starts
In the case of a referral from primary care or a self-referral, the clock start is recorded as the date when the referral is received at the provider.
In the case of eRS the clock is recorded as the date that the patient converted their Unique Booking Reference Number (UBRN)
If a patient is booked via the Telephone Appointment Line (TAL) the clock start is recorded as the date the patient made contact with TAL.
If the referral is from an interface service or another acute provider, then clock start details must be obtained from the referring organisation. This will be carried out by the RTT data entry team. Clock start details should be provided from the referring provider via an Inter-Provider Transfer Minimum data set (IPT MDS).
If the interface service provided a first definitive treatment that was subsequently determined to be unsuccessful or if the patient is referred on following active monitoring then the clock start will be when Aintree Hospitals NHS Trust receives that referral.
If the referral is from one consultant-led service to another for a different condition (e.g. cardiology problem identified at assessment following orthopaedic referral) the clock starts when the consultant communicates the decision to refer to the patient. This also applies when a clinician in A&E/Assessment service makes a referral to a specialty requesting that the patient is reviewed on an elective basis.
Note: this is the date that the consultant communicates the decision to the patient and not the date when the referral is received. If the referral is from one consultant-led service to another for the same condition
(e.g. clinician refers to a colleague who may specialise in the management of a specific condition), the clock start is the date the initial referral was received from primary care.
Consultant to consultant referral for the same condition does not start a new 18 week clock but continues the existing clock. The consultant receiving the referral for specialist management or advice, should be made aware of current patient clock times and encouraged, where clinically appropriate, to expedite the advice or management in order to ensure compliance with the overall treatment waiting time for the primary condition.
In cases where a patient has been initially admitted on a non-elective pathway
and it is identified that they require further treatment as an elective patient (Patient admitted with acute cholecystitis who is listed for cholecystectomy at a future date).
The start of the 18 week clock would be recorded as the date that a decision to list was communicated to the patient. In those circumstances where a decision to list cannot be made during the non-elective episode e.g. the team caring for the patient need to refer to another specialty for further advise or carry out the procedure) the 18 week clock would start on the date on which the patient was informed that referral to the other consultant led clinical team was being made.
If a patient has been on active monitoring and a decision is made that medical or surgical consultant led intervention is required then a new 18 week clock would start at the time the clinician identifies further intervention is required and communicates this to the patient.
Bilateral procedures An 18 week clock would have commenced at the point at which the patient was
referred for the first stage of treatment. When the first stage of treatment has
been completed the 18 week clock would stop. Upon completion of the first stage
of treatment, a new 18 week clock would start when the patient becomes fit and
ready for the second stage procedure.
4.2.2. Clock stops
The information below describes the decisions and points at which an 18 week patients RTT clock would stop.
Decisions that stop an
18 week clock
The 18 week clock stops when First definitive treatment begins. This could be: Treatment provided by an interface service Treatment provided by a consultant-led service When a clinical decision is made that treatment is not required When a patient chooses to decline treatment (permanently) When a period of active monitoring is commenced A decision is made to add a patient to a transplant list. A decision is made to return the patient to primary care for non-consultant-led
treatment in primary care.
18 week clock stops
Clock stop (see above for details of clock stops)
First definitive treatment – the clock stops on the date that the patient receives the first definitive treatment intended to manage his or her condition. For inpatient or day case admission, the clock stops on the day of admission. For treatment provided in an outpatient setting, the clock stops on the day the
patient attends and is treated A clinical decision that treatment is not required – the clock stops on the date
that the clinical decision is communicated to the patient. Patient choice to decline treatment – the clock stops on the date that the
patient declines treatment, having been offered it. Active monitoring – the clock stops on the date that the clinical decision to
commence active monitoring is made and communicated to the patient. Patients may initiate the start of a period of active monitoring themselves (for
example by choosing to decline treatment to see how they cope with their symptoms) and therefore the clock would stop. Except in cases where a
patient wants to have a particular diagnostic test/ appointment or other intervention, but wants to delay the appointment for a period of no greater than 6 weeks.
Decision to return the patient to primary care for non-medical/surgical consultant-led treatment in primary care – the clock stops on the date that this is communicated to the patient.
A patient DNA’s their 1st appointment following initial referral that started their waiting time clock, provided that the Trust can demonstrate that the appointment was clearly communicated to the patient.
A patient DNA’s any other appointment and is subsequently discharged back to the care of their GP, provided that: The Trust can demonstrate that the appointment was clearly communicated to
the patient Discharging the patient is not contrary to their best clinical interests Discharging the patient is carried out according to local, publicly
available/published, policies on DNA.
Outpatient treatment (or medical or surgical consultant-led treatment irrespective of setting) if no subsequent inpatient or day-case admission is expected.
First-line treatment – less intensive treatments or medical management attempted with the intention of avoiding more invasive procedures or treatment.
Inpatient or day-case treatment. Diagnostic tests turned into therapeutic procedures during the investigation. The fitting of a medical device. Therapy (for example physiotherapy, speech and language therapy, podiatry,
counselling) to healthcare science interventions (e.g. hearing aid fitting) if that is what the medical or surgical consultant-led service decides is the intervention intended to manage the patient’s disease, condition or injury and avoid further intervention.
Interventions that do
clock
The following examples do not stop the patients clock:
Administration of pain relief before a surgical procedure takes place or other steps to manage a patient’s condition in advance of definitive treatment.
Treatment for MRSA where this is not the reason why the patient was referred to the hospital.
Consultant-to-consultant referrals where the underlying condition remains unchanged. In this case, where an external tertiary referral is made, an Inter- provider transfer Minimum Data set must be completed by the medical secretary.
The act of making a tertiary referral or a referral from one provider to another. The clock does not stop if a provider rejects a referral, stating that their
service is not appropriate for this patient. The referrer must re-refer the patient to an appropriate service without delay*
*Note: This means that Aintree University Hospital NHS Foundation Trust (AUH)
will inherit waits from other providers (e.g. ICATS, GMSC, Acute Trusts) if patients
are rejected as unsuitable. In addition if AUH rejects referrals sent via eRS then
the GP is able to use the same UBRN number to book the patient into another
service. The clock will start at the point the original referral was made.
Planned Patients
1. Bilateral Procedures
A bilateral procedure is a procedure that is performed on both sides of the body at
matching anatomical sites. Examples include cataract removals and hip or knee
replacements.
Consultant-led bilateral procedures are covered by 18 weeks with a separate
clock for each procedure. The 18-week clock for the first consultant-led bilateral
procedure will stop when the first procedure is carried out (or the date of
admission for the first procedure if it is an inpatient/day case procedure). When
the patient becomes fit and ready for the second consultant-led bilateral
procedure, a new 18 week clock will start.
*Notes*
We should record each episode as it happens which means that patients can
have the appropriate elective Method of Admission of WL. The second procedure
should only be added to PAS once the patient is fit and able to have it. Our
reporting would then report 2 separate pathways.
2. Other Planned Procedures
This means an appointment /procedure or series of appointments/ procedures as
part of an agreed programme of care which is required for clinical reasons to be
carried out at a specific time or repeated at a specific frequency. Planned activity
is also sometimes called “surveillance,” “re-do” or “follow-up”. Examples include 6-
month repeat colonoscopy following removal of a malignancy, tumour, or polyp.
Patients should only be included on planned waiting lists if there are clinical
reasons why the patient cannot have the procedure or treatment until a specified
time. Once the patient is clinically ready for treatment to commence, the patient
should be transferred to the active waiting list and an 18 week clock should start.
In many of these cases the patient is planned because they have already had their
First Treatment and so the planned activity will not be measured against 18 Weeks.
There will be some patients, though, who are planned but waiting for their First
Treatment, e.g. a child who can only have the procedure at a certain age. In these
cases we should be measuring one RTT period up until the decision to treat and
then another one when the patient is clinically ready to have their treatment.
4.2.3. Adjustments & Delays
Beyond a certain point, patient initiated delay makes it unreasonable or impossible for the Trust to provide
treatment within 18 weeks. The way in which patient initiated delays, either through deferment of treatment,
failure to attend for treatment or repeated cancellation of agreed appointments, is detailed within this section.
Legitimate exceptions
and delays
There is nothing in the 18 week pathway equivalent to the pauses suspensions or
clock resets which were allowed under the previous measurement of RTT
pathways.
Pauses cannot be applied to any element of an RTT pathway, regardless of
whether appointment dates offered are reasonable or not.
*Note: It is crucial that all offers of admission are recorded on Sigma to provide an
audit trail of notice periods and admission offers made.
Consultant Upgrade Consultant upgrades are a mechanism which allows consultants (specialists) to
“upgrade” a patient at any time from when the referral was received until the
decision to treat, but not after.
Upgrading a referral does not convert it into a Two-Week Wait (2WW) referral.
The 62 day “clock” starts when the consultant makes a decision to upgrade and
not when the original referral was received.
Reasonable offer of
appointment
The current definition of a “reasonable offer” is that it gives the patient a minimum
of 3 weeks’ notice for outpatient and diagnostic appointments and 3 weeks for
inpatient and day case procedures with a choice of 2 different dates if the offer is
made verbally. This information must be clearly documented on Sigma and it is
the responsibility of the staff member offering the TCI to do this (Medical
Secretary, waiting list coordinator, Patient Appointment Centre staff etc.).
Patients who choose
pathway
Some patients will turn down reasonable appointments because they prefer, for
example, to go on holiday or because of work commitments. Beyond a certain
point, patient initiated delay like this makes it unreasonable or impossible for the
NHS to provide treatment within 18 weeks.
Prior to referral onto an 18 week pathway GPs should ensure that patients are
ready and available to receive treatment within this timeframe. In such instances
where patients cannot make themselves available for a period of 6 weeks the
patient should, if clinically appropriate, be referred back to their G.P with
appropriate communication giving rationale for the return of the referral.
Additions to the
waiting list
Patients can only be added to the in-patient/day case waiting lists following a pre-
operative assessment which has deemed them medically fit to undergo their
intended routine procedure. Patients who are not fit for routine treatment should
not be listed. These patients should be referred back to the GP unless
optimisation is expected to take less than two weeks.
This needs to be a clinical decision based on the time it will take to optimise the
patient and the likely gap between decision to admit and date of admission.
Examples of patients that will not be optimised within two weeks are as follows:
Patients with high blood pressure Patients needing to lose weight Patients with cardiac or respiratory problems
Patients requiring a diagnostic test before a definitive decision to admit can be made
The decision to proceed with these types of patients lies entirely with the
consultant anaesthetist/consultant surgeon who, following a review of all clinical
information will make a decision whether to proceed with or defer treatment. The
responsible consultant must ensure that such decisions are discussed with the
patient, and/or carer, and clearly documented in the medical record.
In those circumstances where the patient’s condition is deemed to be
clinically urgent and the hospital consultant needs to seek advice /
intervention of another consultant, the 18 week clock will continue until
such time as the patient received their first definitive treatment or they are
returned to the care of the GP and asked to re refer the patient when fit
for surgery.
admission as an
inpatient/day case
Some patients will choose to delay their routine treatment/surgery because of
personal circumstances. Where a decision to admit for treatment has been made
(i.e. the patient is listed for treatment as an inpatient/day case) and following this
the patient wishes to defer treatment for a period less than 6 weeks then this
should be noted on Sigma. The 18 week clock cannot be paused.
If a patient wishes to defer routine treatment for a period in excess of 6 weeks the
patient records should be reviewed by the responsible clinician with a view to
discharging the patient back to the GP or referring clinician. In the event of the
patient remaining on their treatment pathway the responsible clinician will need to
decide if the time period that the patient wishes to wait would compromise the
treatment plan and whether the patient would require further clinical or pre-
operative assessment prior to attending for surgery.
If the clinician decides that further assessment would not be necessary then the
patient should be listed for surgery and the date they wish to make themselves
next available for treatment must be recorded on SIGMA.
In circumstances where the clinician decides that deferral of routine treatment
would require the patient to be reassessed at a later date e.g. return for further
follow up, the patient should ideally be returned to the care of their GP and re--
referred at a more appropriate time.
If the patient has declined two reasonable offers of admission for routine
treatment the patient should ideally be referred back to their GP or, if appropriate,
their referring clinician with appropriate communication giving rationale for the
return of the referral.
Exceptions to this are; Clinically very urgent referrals including cancer, or active surveillance for
cancer and other critical illnesses. Children of 16 years and under or vulnerable adults In instances where reasonable notice and/or patient choice cannot be
demonstrated on the patient administration system (PAS). Discharging the patient is not in their best clinical interests
Where circumstances were beyond the patient’s control, the Trust will endeavour to be as flexible as possible.
DNA
(Did not attend)
A DNA is defined strictly as a patient failing to give notice that they will not be
attending their appointment. Patients who give prior notice, however small, are
not classed as DNA’s
In line with the Department of Health patient choice agenda, any patient who does
not attend their agreed routine appointment (new or follow up OPD, Pre-
Operative Assessment, in-patient/day case surgery, diagnostic test or direct
access diagnostic appointment) should be automatically discharged back to the
care of their GP, or referring clinician, if the Trust can demonstrate that;
Reasonable notice was given. The patient was offered choice The patient entered into a verbal contract with the Trust, either face to face or
via telephone, and exercised personal choice in agreeing an appointment date with less than 21 days’ notice.
Exceptions to this are;
Clinically very urgent referrals including cancer, or active surveillance for cancer and other critical illnesses.
Children of 16 years and under or vulnerable adults In instances where reasonable notice and/or patient choice cannot be
demonstrated on the patient administration system (PAS). Discharging the patient is not in their best clinical interests Where circumstances beyond the patient’s control can be demonstrated the
Trust will endeavour to be as flexible as possible. If the patient is categorised as an exception and falls into one of the above
categories then the patient must first be contacted to ascertain the reasons for
DNA and ensure compliance to attend a rescheduled appointment. The
rescheduled appointment must be made from the original referral, as it is for the
same condition. However, a follow up patient’s 18 week status will continue.
DNA First Routine OPD Appointment/Direct Access Diagnostic
Any patient who did not attend their first routine appointment, and received a
reasonable offer of that appointment, will have their RTT clock nullified and their
referral returned to the GP (or other referrer). A new clock will start on the date the
provider receives notice of any subsequent re-referral.
In all instances where a decision is taken to discharge the patient following a
failure to attend a routine first outpatient appointment or direct access diagnostic
test the Trust will, within 10 working days, notify the patient and their GP of this
decision in writing to ensure that on-going management of the patient can take
place as appropriate. The patients RTT pathway will be closed.
DNA Routine Follow Up OPD Appointment/Diagnostic/IP or DC Admission
In the event of a patient failing to attend a routine follow up appointment,
diagnostic test, pre-operative assessment or for in-patient/day case surgery the
responsible clinician should undertake a review of the patient’s records to
ascertain if it is clinically appropriate to discharge the patient from the service. In
all instances where a decision is taken to discharge the patient the Trust will,
within 10 working days, notify the patient and their GP of this decision in writing to
ensure that on-going management of the patient can take place as appropriate.
The patients RTT pathway will be closed.
In reviewing the action to be taken when a patient DNA’s an appointment, due
consideration must always be given as to the vulnerability of the individual. Where
doubt relating to any decision to return a referral back to a GP exists, this should
be reviewed by a consultant and if necessary discussed with the referring GP.
Flexibility will be maintained where clinical judgement is that it is in the best
interests of the patient to offer a further appointment and this should be clearly
documented within the clinical records.
Any other DNAs along the pathway which do not result in the patient being
referred back to the care of their GP will not nullify or stop the 18 week clock.
No response following
appointment.
Failure to respond to Trust Invitation of Appointment: First Routine OPD
Appointment/Direct Access Diagnostic
Should patients not respond to the standard Trust invite i.e. 2 letters requesting
contact to arrange a routine appointment, then their referral will be returned to the
GP (or other referrer).
In all instances where a decision is taken to discharge the patient following a
failure to respond to the standard trust invite on 2 occasions the Trust will, within
10 working days, notify the patient and their GP of this decision in writing to
Failure to respond to Trust Invitation of Appointment: Routine Follow Up
OPD Appointment/Diagnostic/IP or DC Admission
Should patients not respond to the standard Trust invite i.e. 2 letters requesting
contact to arrange an appointment, then their responsible clinician should
undertake a review of the patient records to ascertain if it is clinically appropriate
to discharge the patient from the service.
In the event of a patient not engaging with a service by failing to respond to 2
invites for a diagnostic test or pre-operative assessment the relevant service must
inform the responsible clinician within 2 working days. This will allow a review of
clinical information to take place prior to a decision being made concerning the
appropriateness of discharging the patient back to the care of their GP.
It is important to note that patients who have previously engaged with a service
may have outstanding diagnostic results and it is therefore essential that all
available clinical information is reviewed prior to discharging a patient back to the
care of their GP.
In all instances where a decision is taken to discharge the patient the Trust will,
within 10 working days, notify the patient and their GP of this decision, in writing,
to ensure that on-going management of the patient can take place as appropriate.
Due consideration must be given to each case to ascertain the vulnerability of
adults and children. Consultants should also review cases whereby a patient self-
discharges, to ensure vulnerable individuals are not clinically disadvantaged by
this decision. For further information please consult the Trusts safeguarding Lead.
Going further on Cancer waits (v6.7) has specific instructions relating to Cancer
patients these are:
Patients should not be referred back to their GP after 1st DNA (Did Not
Attend) of their first appointment
Patients can be referred back to their GP after multiple (2 or more) DNAs if this is
the agreed local policy.
Hospital Cancellation A hospital cancellation does not stop the clock
Patient cancellation of
appointments.
Patients who cancel an appointment and are offered an alternative date at the
time of cancellation will not have their 18 week clock stopped unless their choice
of a date for a rebooked appointment entails a delay which makes it unreasonable
or impossible for an 18 week care pathway to be achieved i.e. in excess of 6
weeks.
Patients should be discharged back to their GP at this point unless to do so would
compromise their care.
Patient Cancellations: First outpatient attendance
Patients will have the opportunity to cancel, or change their previously agreed first
routine outpatient appointment, once unless extreme personal circumstances
exist which support the need to offer a third opportunity to agree a mutually
convenient date and time. In instances where the patient is discharged back to
the care of their GP the trust must be able to demonstrate, within the PAS, that on
each occasion the Trust complied with guidance on reasonable notice and/or
verbally agreed a date and time which met the needs of the patient at the point of
booking.
Patients discharged back to the care of their GP will have their clock removed and
may be re-referred when they are ready, willing and able to proceed. A new 18
week clock will start at this point.
Patient Cancellations: Routine Follow Up OPD Appointment, Diagnostic
test, IP or DC Admission
In the event of a patient cancelling consecutive routine follow up appointments,
diagnostic tests, pre-operative assessment or in-patient/day case surgery the
responsible clinician should undertake a review of the patient’s records to
ascertain if it is clinically appropriate to discharge the patient from the service.
In all instances where a decision is taken to discharge the patient the Trust will,
within 10 working days, notify the patient and their GP of this decision in writing to
In reviewing the action to be taken when a patient recurrently cancels their
previously agreed appointment, due consideration must always be given as to the
vulnerability of the individual. Where doubt relating to any decision to return a
referral back to a GP exists, this should be reviewed by a consultant and if
necessary discussed with the referring GP.
Flexibility will be maintained where clinical judgement is that it is in the best
interests of the patient to offer a further appointment and this should be clearly
documented within the clinical records.
If a patient wishes to cancel/change their appointment following a previous
hospital cancellation at short notice within the same speciality, a further
appointment will be offered to the patient; however their RTT status will remain.
Patients who have been referred as urgent suspected cancer or rapid access
chest pain should not cancel their agreed appointment, as the two week pathway
is then unlikely to be met. The clinical teams must take ownership of reinforcing to
the patient the need for attendance as if the patient is discharged back to the GP
their RTT pathway is closed with an outcome of patient declined treatment.
Patients will be informed of the rules around cancelling appointments in the letter
confirming their appointment.
Patient Cancellation of
A Patient cancellation does not stop the clock.
Patients who cancel their own routine elective admission date for reasons other
than sickness/ or extreme personal circumstances at less than 48 hours’ notice,
after receiving reasonable notice of this date (at least three weeks) will be
removed from the waiting list and a review undertaken by the responsible clinician
with a view to discharging the patient back to their GP for any further action in
primary care or re-referral when ready, willing and able to proceed.
Patients, who self-defer for a valid reason, will be informed of the new
arrangements for their future admission and where possible will be given the
opportunity to agree a rearranged date. If a patient chooses to defer routine
treatment for a period exceeding 6 weeks the responsible clinician will undertake
a review of available information with a view to discharging the patient back to
their GP for any further action in primary care or re-referral when ready, willing
and able to proceed.
The patient can be re-referred at the discretion of the GP, by means of a new
referral letter. The patient will then start a new 18 week pathway.
Going further on Cancer waits (v6.7) has specific instructions relating to Cancer
patients these are:
Patients should not be referred back to their GP after a single
appointment cancellation
Patients should not be referred back to their GP after multiple (2 or more)
appointment cancellations unless this has been agreed with the patient –
by cancelling an appointment a patient has shown a willingness to
engage with the NHS.
clinically appropriate
weeks
In some cases, treatment within 18 weeks may prove not to be possible for
clinical reasons. For instance:
If a series of tests must be done in sequence for clinical reasons When a second condition presents itself that needs to be treated before the
first (this should be expedited as clinically appropriate to ensure treatment within waiting thresholds (or referred back if appropriate).
Where the patient and consultant have agreed that the patient should receive a second opinion which despite best efforts adds a critical delay;
Where the patient is medically unfit to be treated Any patient for whom there is genuine clinical uncertainty about the diagnosis
but where active monitoring (and clock stop) is inappropriate.
Patient is not sure
treatment
If a patient is uncertain about going ahead with treatment, it may be appropriate to
discharge the patient and refer them back to their GP, where their on-going care
will continue to be managed within primary care.
The Trust considers a period of 6 weeks to be a reasonable period of thinking
time therefore patients who wish to take longer than this must be referred back to
the care of their GP and If and when the patient feels ready for treatment they can
ask their GP to re-refer them. Referral back to the GP in this scenario would stop
the 18 week clock and a new 18 week clock would start at the point when the
patient and GP agreed to re-refer for treatment.
Patients may also choose to commence a period of “patient initiated active
monitoring” in circumstances where they wish to see how they cope with
symptoms etc. In such circumstances the clock will be stopped and a code 31
recorded.
Incomplete pathway
tracking lists
To assist administrative staff involved in the process of booking patients the Trust
will produce an 18 week PTL (Patient Tracking List). It is essential to note that the
order of patients for treatment may not be the order in which they were scheduled.
i.e. a patient only very recently scheduled may be approaching the maximum 18
weeks target as they may have taken a while to be diagnosed and a decision to
admit agreed.
A patient may have been scheduled for a longer period of time yet has a shorter
overall length of pathway. It is essential that listing is in accordance with clinical
priority or pathway length and not according to the time spent solely on the
waiting list.
All patients waiting above 6 weeks on the PTL must have a comment recorded on
their pathway which demonstrates active management of waiting time standards.
4.3. WAITING LIST MANAGEMENT
With the RTT waiting times the Trust is moving away from the management of the historic ‘stage of treatment’ waiting time standards i.e. the separate waits for outpatients, diagnostics and inpatient/day case treatment. Despite this these distinct waiting lists still represent a positive way of managing the overall referral to treatment waiting times. This means that waiting lists will still have to be managed effectively, in line with waiting time standards and fully compliant with the NHS Constitution.
Active Waiting Lists
Inpatient/Day case
waiting list
All waiting lists must be reviewed and validated on an on-going basis (at least weekly) to
ensure that patients are being managed in line with their clinical priority and within
national or local waiting time standards.
Only patients who have elected to undergo the procedure in question and following a
pre-operative assessment are deemed clinically suitable at the treatment time will be
added to Inpatient or Day case waiting list, the corollary being that patients who are not
fit or willing to be admitted will not be added to the waiting list and their GP advised
accordingly to re-refer the patient when fit.
Hold or Pending File Clinical Business Units will not operate a ‘hold or pending file’. All patients will be either
fully or partially booked into clinics as per Trust policy.
Appointment Slot
Issues (ASI’s)
ASI’s occur when a patient is unable to be given an outpatient appointment at the time that they contact the Trust to activate their UBRN. If patients are left on the ASI work list and their referrals are not processed by the provider then the following significant patient safety effects can occur:
Some patients, who may have serious medical problems, may not receive
appointments within reasonable timescales. In some cases, this delay to care
could pose a serious danger to their health and wellbeing.
Patients without an appointment will have had no clinical review of their referral,
as referral information only becomes visible to the provider once an appointment
is booked in eRS. This means that providers will not have had the opportunity to
change the priority of a referral, e.g. to upgrade it where the reviewing clinician
feels that the problem is more urgent.
Patients who have been referred into an inappropriate service will not have
been identified and there will have been no opportunity to re-direct them into a
more appropriate service.
eRS guidance suggests that patients on an ASI work list should always be dealt with using eRS by being contacted within four days of being placed on the work list and, wherever possible, be offered a choice of date and time of appointment. It is the Trusts aim to deliver this standard and all Clinical Business Units must actively
work with the Patient Appointment Centre to ensure that sufficient eRS capacity exists
within specialties and that robust processes are in place to ensure that all patients who
appear on an ASI lists can be contacted within 4 days and a formal offer of appointment,
based upon clinical urgency, made.
Offer of TCI All patients should be selected for TCI (or offer of TCI) in accordance with their clinical
priority. Within that priority they should then be broadly selected for TCI based on length
of wait (i.e. longest waiter within clinical priority first). This ensures fair access to their
operation for all patients (Theatre list time and team skill allowing).
Where secondary care clinicians agree that a veteran’s condition is likely to be service -
related, they are asked to prioritise veterans over other patients with the same level of
clinical need. However veterans should not be given priority over other patients with
more urgent clinical needs.
Confirmation of listing All patients should receive a communication confirming that they have been added to a
waiting list and in addition, the General Practitioner must be notified.
Hospital Cancellation of
procedures.
The Trust will make every effort to ensure that they do not cancel patient’s
appointments.
If the hospital cancels an operation/procedure after admission or on the day of
admission for non-medical reasons, the patient must be given a rearranged date within
28 days of their original date. This should be noted on the waiting list record to ensure
that this patient is not cancelled again and is rebooked within the 28 day time frame.
If a patient operation or procedure is cancelled or rescheduled twice by the Trust this will
need to be escalated immediately by the relevant Clinical Business Manager to their
respective Divisional Director of Operations.
Where this is unavoidable the Trust will contact the patient and rearrange their
appointment.
If the cancellation is within two weeks of the appointment date, the patient will be
telephoned. If the cancellation is outside of the timeframe, the patient will be contacted
by letter. Appointments will be made as close to the original appointment as possible.
This is particularly important when patients need to re-attend for test results or to review
medication. The patients 18 week pathway status will remain.
Validation and Review All targeting lists and waiting lists should be validated on a continuous cycle (weekly)
and comments added to demonstrate that validation has taken place. The minimum data
set required is Date of validation, action taken and initials of the validator.
The management and monitoring of validation exercises is the responsibility of the
appropriate Clinical Business Manager.
reductions
The Trust is committed to offering certainty to patients as well as choice in arranging
care. As such, every effort will be made to avoid cancelling patient’s appointments and
every effort made to backfill absent clinicians by the speciality. The cancellation of a
patient’s outpatient appointment will be a last resort and only and only take place if all
other avenues to prevent a cancellation have been exhausted. Clinics should not be
cancelled or reduced for any purpose unless exceptional circumstances exist.
A minimum of six weeks written notice of planned annual, study or professional leave
must be given when a doctor or other professional requires a clinic to be cancelled or
reduced.
Wherever possible patients that have been previously cancelled should not be cancelled
a second time. Such occurrences require immediate escalation to the Clinical Business
Manager who must notify their respective Divisional Director of Operations, or
.
When clinics have to be unavoidably cancelled/reduced at short notice this must be
approved by the Divisional Director of Operations or nominated Deputy. Liaison with
Nursing staff, OPD Service Manager, Booking Team and Medical Records is essential.
This cancellation should only be made after all efforts have been exhausted to substitute
a suitably qualified clinician.
Booking Capacity
Where the number of patients on the outpatient waiting list outweighs the number of
slots available, the operational/business manager responsible for the service must be
informed and must make appropriate arrangements to align capacity with demand.
Follow Up waiting lists The management of follow up patients can be complex and all staff should refer to the
Management of Patient Follow Up Appointments policy for further details, Three key
principles are identified in that policy, these are:
All patients who require a follow up or surveillance appointment shall be offered one within a timescale that is deemed clinically appropriate and cognisant of best practice guidelines.
This process shall be closely monitored by the business unit to ensure no patient waits beyond a clinically appropriate time.
Decisions to reappoint patients or to transfer them back into the care of their GP, is the responsibility of the clinical teams, taking into account patient choice.
There are strong clinical governance and safety reasons why patients’ planned care should not be deferred and all organisations should treat patients at the right time and in order of clinical priority. A significant proportion of ‘planned’ activity is associated with
surveillance of high risk groups of patients who are at risk of significant clinical deterioration if not managed correctly. The Management of Patient Follow Up Appointments Policy sets out the approach and operating procedures for the management of patients where clinicians identify that patients require some form of follow up, long term surveillance or monitoring, prior to their transfer back into the care of their General Practitioner. It is the responsibility of the Clinical Business Manager to monitor, at least on a weekly
basis, the number and waiting times of patients on the follow up waiting list and this
should be supported by an escalation process, from the Patient Appointment Centre and
Consultant Secretaries, which identifies capacity constraints preventing a patients
appointment being booked within the clinically agreed timescale.
Clinically inappropriate
referrals
If the referral is clinically inappropriate, the consultant may not accept the referral. If this
is the case, the reason for the decision will be communicated to the referrer, with a
patient copy of the letter being sent within 15 working days of receipt by the Trust.
Patient cancellation of
outpatient
appointments.
Patients who cancel an appointment and are offered an alternative date at the time of
cancellation will not have their 18 week clock stopped unless their choice of a date for a
rebooked appointment entails a delay which makes it unreasonable or impossible for an
18 week care pathway to be achieved i.e. in excess of 6 weeks.
Patients should be discharged back to their GP at this point unless to do so would
compromise their care.
Patient Cancellations: First outpatient attendance
Patients will have the opportunity to cancel, or change their previously agreed first
routine outpatient appointment, once unless extreme personal circumstances exist
which support the need to offer a third opportunity to agree a mutually convenient date
and time. In instances where the patient is discharged back to the care of their GP the
trust must be able to demonstrate, within the PAS, that on each occasion the Trust
complied with guidance on reasonable notice and/or verbally agreed a date and time
which met the needs of the patient at the point of booking.
Patients discharged back to the care of their GP will have their clock removed and may
be re-referred when they are ready, willing and able to proceed. A new 18 week clock
will start at this point.
Patient Cancellations: Routine Follow Up OPD Appointment, Diagnostic test, IP or
DC Admission
In the event of a patient cancelling consecutive routine follow up appointments,
diagnostic tests, pre-operative assessment or in-patient/day case surgery the
responsible clinician should undertake a review of the patient’s records to ascertain if it
is clinically appropriate to discharge the patient from the service.
In all instances where a decision is taken to discharge the patient the Trust will, within 10
working days, notify the patient and their GP of this decision in writing to ensure that on-
going management of the patient can take place as appropriate. The patients RTT
pathway will be closed.
In reviewing the action to be taken when a patient recurrently cancels their previously
agreed appointment, due consideration must always be given as to the vulnerability of
the individual. Where doubt relating to any decision to return a referral back to a GP
exists, this should be reviewed by a consultant and if necessary discussed with the
referring GP.
Flexibility will be maintained where clinical judgement is that it is in the best interests of
the patient to offer a further appointment and this should be clearly documented within
the clinical records.
If a patient wishes to cancel/change their appointment following a previous hospital
cancellation at short notice within the same speciality, a further appointment will be
offered to the patient; however their RTT status will remain.
Patients who have been referred as urgent suspected cancer or rapid access chest pain
should not cancel their agreed appointment, as the two week pathway is then unlikely to
be met. The clinical teams must take ownership of reinforcing to the patient the need for
attendance as if the patient is discharged back to the GP their RTT pathway is closed
with an outcome of patient declined treatment.
Patients will be informed of the rules around cancelling appointments in the letter
confirming their appointment.
Attend (DNA’s)
A DNA is defined strictly as a patient failing to give notice that they will not be attending
their appointment. Patients who give prior notice, however small, are not classed as
DNA’s
In line with the Department of Health patient choice agenda, any patient who does not
attend their agreed routine appointment (new or follow up OPD, Pre-Operative
Assessment, in-patient/day case surgery, diagnostic test or direct access diagnostic
appointment) should be automatically discharged back to the care of their GP, or
referring clinician, if the Trust can demonstrate;
Reasonable notice was given. The patient was offered choice The patient entered into a verbal contract with the Trust, either face to face or via
telephone, and exercised personal choice in agreeing an appointment date with less than 21 days’ notice.
Exceptions to this are;
Clinically very urgent referrals including cancer, or active surveillance for cancer and other critical illnesses.
Children of 16 years and under or vulnerable adults In instances where reasonable notice and/or patient choice cannot be demonstrated
on the patient administration system (PAS).
Discharging the patient is not in their best clinical interests Where circumstances beyond the patient’s control can be demonstrated the Trust
will endeavour to be as flexible as possible. If the patient is categorised as an exception and falls into one of the above categories
then the patient must first be contacted to ascertain the reasons for DNA and ensure
compliance to attend a rescheduled appointment. The rescheduled appointment must be
made from the original referral, as it is for the same condition. However, a follow up
patient’s 18 week status will continue.
DNA First Routine OPD Appointment/Direct Access Diagnostic
Any patient who did not attend their first appointment, and received a reasonable offer of
that appointment will have their RTT clock nullified and their referral returned to the GP
(or other referrer). A new clock will start on the date the provider receives notice of any
subsequent re-referral.
In all instances where a decision is taken to discharge the patient following a failure to
attend a routine first outpatient appointment or direct access diagnostic test the Trust
will, within 10 working days, notify the patient and their GP of this decision in writing to
ensure that on-going management of the patient can take place as appropriate. The
patients RTT pathway will be closed.
DNA Routine Follow Up OPD Appointment/Diagnostic/IP or DC Admission
In the event of a patient failing to attend a routine follow up appointment, diagnostic
tests, pre-operative assessment or in-patient/day case surgery the responsible clinician
should undertake a review of the patient’s records to ascertain if it is clinically
appropriate to discharge the patient from the service. In all instances where a decision is
taken to discharge the patient the Trust will, within 10 working days, notify the patient
and their GP of this decision in writing to ensure that on-going management of the
patient can take place as appropriate. The patients RTT pathway will be closed.
In reviewing the action to be taken when a patient DNA’s an appointment, due
consideration must always be given as to the vulnerability of the individual. Where doubt
relating to any decision to return a referral back to a GP exists, this should be reviewed
by a consultant and if necessary discussed with the referring GP.
Flexibility will be maintained where clinical judgement is that it is in the best interests of
the patient to offer a further appointment and this should be clearly documented within
the clinical records.
Any other DNAs along the pathway which do not result in the patient being referred back
to the care of their GP will not nullify or stop the 18 week clock.
Cashing up of Clinics All attendances within the Trust must have an attendance (administrative) outcome, a
clinic outcome and an RTT outcome.
Where appropriate the outpatient procedure outcome must be recorded. Cashing up
must be done on the day of the clinic at the end of each clinic appointment. The
operational/business manager who is responsible for the administration staff that run the
clinic are responsible for ensuring all clinics are cashed up as appropriate and
performance will be monitored via the Trust Operational Performance Meetings.
All attendances even for closed RTT pathways must have an outcome against it.
NHS Constitution
All new patient letters must contain an insert advising them of their rights under the new
NHS constitution and providing a contact number for queries.
Non Commissioned
Procedures.
The availability of some healthcare services is determined nationally – for example, under the National Institute for Health and Care Excellence’s technology appraisal recommendations, where all clinical commissioning groups (CCGs) or the NHS Commissioning Board (NHS CB) or local authorities have to fund the recommended drugs and treatments. There are also some services that are commissioned directly by the NHS CB, which will therefore take a national decision on their funding. However, in most cases, decision- making on whether to fund a service or treatment is left to the local CCG or local authority. This is to enable CCGs and local authorities to commission services that best fit the needs of their local population. If a CCG, a local authority or the NHS CB has decided that a treatment will not normally be funded, the patient and appropriate clinical team will decide whether to formally apply, on an exceptional basis, to the appropriate body using the agreed “Individual Funding Request” process.
Managing Tertiary Referrals
Tertiary referrals are those referrals for treatment that are made from Consultant to
Consultant inside the Trust (Internal Tertiary Referrals) and from a Consultant outside
the Trust to an Aintree Consultant (External Tertiary Referral).
The following are proposed as the actions that should be taken in response to tertiary
outpatient referrals received by medical staff at Aintree University Hospital NHS
Foundation Trust. This will apply to consultant tertiary referrals from both within and
outside of Aintree University Hospital NHS Foundation Trust and independent sector
referrals to the NHS. Tertiary Referrals can be made as urgent or non-urgent referrals in
the same way as other requests for an OPD appointment.
Whilst there are no recognised national breach sharing arrangements between providers in relation to 18 Weeks RTT pathways, there is an expectation that departments and providers will work together to develop 18 Week compliant inter-provider pathways. In the case of external tertiary referrals received into the Trust departments and specialties should be aware of particular pathways where it is likely that patients will be referred into the organisation for diagnostics or treatment and ensure that appropriate pathway milestone monitoring is agreed locally between providers. Additionally, there should be clear and timely communication channels between providers to share information relating to the patient’s RTT status and progress along the pathway e.g., clock stops.
Urgent Tertiary Referrals: Urgent referrals will be treated in the same way as urgent
referrals received from GPs, being governed by the same waiting time requirements and
clinical judgement.
Non-urgent Tertiary Referrals for Directly Related Condition: Where a routine
referral for a directly related condition is made, to assist the referring Consultant in the
management of the patient, the referral should be treated in the same way as a routine
GP referral, being governed by the same waiting time requirements.
Non-urgent tertiary referrals for unrelated condition: Where a consultant identifies
that a patient should, in their opinion, be referred to another Consultant but this referral
is not vital to the management of the condition which the referring Consultant is treating
the patient; the referring consultant should not refer to another consultant. Instead, the
referring consultant should refer the patient back to their GP. This is suggested for the
following reasons:
If the patient is referred by the GP the waiting time experienced is likely to be shorter than under a routine tertiary referral arrangement
The GP may already be aware of the condition identified and have the management of the condition in hand. GPs, particularly under Practice based Commissioning, will increasingly want to have more influence and control over patient referrals
The GP will offer the patient Choice – the patient may choose to go elsewhere than where the referring consultant may have chosen to refer the patient
It will help Directorates in managing capacity and waiting times. If a non-urgent tertiary referral for an unrelated condition is received within the Trust, the referral should be sent to the patient’s GP with a copy letter back to the referring consultant advising them of the Trust’s policy.
4.4. TRAINING Trust staff receive training as per the Trust’s Training Needs Analysis. The processes for checking that staff complete relevant training in accordance with the Trust’s Training Needs Analysis and for following up those who fail to attend relevant training are described in the Trust’s Learning and Development Policy.
5.0 MONITORING OF COMPLIANCE
performance management
Job title of individual/ committee
responsible for monitoring
implementation of action plan
RTT Performance at Specialty level (Incl stage of treatment waiting times)
Performance Management
Group
Group
Audit of compliance with Access Policy: Reasonable Notice, DNA etc.
Audit Clinical Business Managers
Group
Review of Incidents
Clinical Business Managers
Divisional Chief Operating Officers
6.0 EQUALITY, DIVERSITY AND HUMAN RIGHT STATEMENT
The Trust is committed to an environment that promotes equality and embraces diversity in its performance both as a service provider and employer. It will adhere to legal and performance requirements and will mainstream Equality, Diversity and Human Rights principles through its policies, procedures, service development and engagement processes. This policy should be implemented with due regard to this commitment. 7.0 REFERENCES Referral to Treatment consultant led waiting times rules http://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-guidance/ Detailed data definitions are available at http://www.connectingforhealth.nhs.uk/datadictionary/websitecontent/navigation/diagramsmenu.asp?shownav=1 Guidance on diagnostic waiting times is available at: http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/ Guidance on Cancer waiting times is available at: http://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/ Calculation of waiting times: http://www.connectingforhealth.nhs.uk/systemsandservices/data/nhsdmds/faqs/cds/admitpat/admpatwait/ 18-week rules suite “How to Measure” guide http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digit alassets/@dh/@en/@ps/@sta/@perf/documents/digitalasset/dh_132485.pdf Referral to treatment consultant –led waiting times – Rules suite, October 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/464956/RTT_Rules_Suite_October_2 015.pdf Delivering Cancer Waiting Times: A Good Practice Guide (2014) http://www.nhsimas.nhs.uk/fileadmin/Files/IST/Delivering_Cancer_Wait_Times.pdf Achieving Cancer Waiting Times – A How to Guide. https://www.england.nhs.uk/wp-content/uploads/2015/03/how-to-guide.pdf The NHS Constitution Handbook http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/handbook-to-the-nhsconstitution.pdf Maximum waiting times: Guidance for Commissioners (Aug 2013) http://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/08/wait-times-guid-comms.pdf Access to he