DOH Atchieving the 2 Weeks Time

8/6/2019 DOH Atchieving the 2 Weeks Time

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Health Service Circular HSC 1998/242

Health Service CircularExecu t i v eSeries number: HSC 1998/242

Issue date: 22 December 1998Review date: 22 December 1999Category: Performance ManagementStatus: Action

sets out a specific action on the part of the recipient with a deadline where appropriate

BREAST CANCER WAITING TIMES -ACHIEVING THE TWO WEEK TARGET

For action by: Health Authorities (England) - Chief ExecutivePrimary Care Group LeadsNHS Trusts - Chief ExecutivesRegional DirectorsRegional Directors of Performance ManagementRegional Directors of Public HealthRegional Cancer Co-ordinators

For information by Health Authorities (England) - ChairNHS Trusts - ChairCommunity Health CouncilsLocal Medical Committees

Further details Lisa Westallfrom: 306 Wellington House

135-155 Waterloo RoadLondonSE1 8UG0171-972-4817

22 December 1998 Page 1


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Health Service Circular HSC 1998/242Additional copies of this document can be obtained from:Department of HealthPO Box 410WetherbyLS23 7LNFax 0990 210 266It is also available on the Department of Health website athttp://www.open.gov.uk/doh/coinh.htmCrown copyright 1998



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Health Service Circular HSC 1998/242

BREAST CANCER WAITING TIMES -ACHIEVING THE TWO WEEK TARGET

SummaryIn December 1997 The new NHS set out the action necessary to deliver a modern anddependable health service providing prompt access to specialist services with hospitalslinked to local surgeries and health centres to enable speedy and seamless access totreatment and care. It is guaranteed that from April 1999, (for all other cases ofsuspected cancer by 2000) everyone with suspected breast cancer will be able to see aspecialist within two weeks of their GP deciding they need to be seen urgently andrequesting an appointment.ActionThis guidance sets out the necessary action to achieve The new NHS breast cancerwaiting times target and the steps required in the short term for the roll out of thetarget from April. The definitions of the key words of the cancer target are given inAnnex A with the projected timeframe in Annex B.

1. This circular provides information on defining the target and the specific steps necessaryto develop referral pathways and agree criteria for urgent referral. Achievement of the targetwill require action across primary and secondary care. GPs will be responsible for ensuringthat referrals are prompt and appropriate. NHS Trusts will have the responsibility to arrangeappointments within two weeks for urgent referrals. Monitoring and performancemanagement of the target will be by Health Authority working with Primary Care Groupsand will cover both GPs and NHS Trusts.2. The cancer waiting times audit earlier this year covered waiting times for all cancer sitesfor the month of October 1997. Preliminary analysis of this pre-new NHS data shows thatover 70% of patients referred urgently and diagnosed with breast cancer had been seen withinthe two week timescale. NHS Trusts will receive an analysis of their own data shortly. Inaddition, the 10million made available recurrently in 1997 to improve breast cancerservices has enabled substantial progress to be made in reducing waiting times and improvingquality of care. Reports submitted in September 1998 by each health authority and NHSTrust show that over the past year NHS Trusts have used the money to invest in workforce,training and equipment, to develop rapid diagnosis clinics and to improve waiting times.Regional summaries indicate that the majority of NHS Trusts now have an average wait forurgent suspected breast cancer appointments of less than two weeks.



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The Process - An Overview3. The responsibility for meeting the two week target is shared between GPs and NHSTrusts. If a GP decides that a patient with suspected breast cancer needs to be seen urgently,they should reflect that urgency by ensuring that the NHS Trust receives the referral within24 hours of making that decision, by using telephone, fax or other electronic media. Thisis consistent with the Information for Health strategy which, as part of the overall agenda formodernizing the NHS, encourages same day direct booking systems by GPs.4. Every referral made under the two week target must be clearly identified as urgentand include the decision to refer data. This will mean that Chief Executives of NHS Trustswill be responsible for ensuring that robust systems are in place to receive and record theurgent referrals and to identify quickly those being made on the fast track. GPs must alsobe absolutely clear about the route into Trusts for these urgent referrals and the way in whichthey should be made. NHS Trusts performance will be monitored on the basis of thesecorrectly made referrals. Good communication between all players is one of the keys to theachievement of the target.5. Achievement of the target is a priority within the National Priorities Guidance and a newmonitoring system will be operational from April 1999. It is important that potentialproblems are identified early and resolved to ensure that all patients referred within thecriteria are seen within two weeks by April 1999. This will require a systematic review ofthe way local services are organised, local agreement between GPs and consultants on thecriteria for urgent referral and an assessment of the state of readiness for each NHS Trust.This process should complement the wider work which NHS Trusts undertake on thedevelopment of local clinical governance arrangements.6. To enable problems in achieving the target to be identified at an early stage, regionaloffices will survey all NHS Trusts in January and agree with the Health Authority and NHSTrust where additional work is required. In addition, from 1 February 1999 to 30 June 1999,NHS Trusts will monitor urgent suspected breast cancer referrals on a monthly basis. Thiswill test out the new reporting instructions and provide an updated monthly return onprogress to health authorities. More detailed guidance will be issued on this in January.Formal quarterly monitoring of achievement of the target will start from 1 April.Referral Pathways from Primary Care7. GPs and NHS Trusts must establish clear referral pathways and criteria so that thosepatients being referred urgently under the two week target can be identified and fast-tracked. In many cases these will be extensions of well developed referral pathways andagreed criteria which are already in operation. Others will need to review their referralprocedures to ensure that patients are referred to the most appropriate team for the initialinvestigation within the two weeks.8. There is some evidence that referrals to clinics are increasing. Good communicationchannels between providers and primary care are essential to minimise problems ofoverloading of rapid referral clinics. National guidance already exists to help local cancernetworks agree criteria for urgent referrals. Guidelines for Referral of Patients with BreastProblems, published in 1996 by the NHS Breast Screening Programme and Cancer ResearchCampaign, helps GPs differentiate between benign and malignant disease. They are currentlybeing updated to incorporate the two week rule and will be sent to GPs, health authoritiesand NHS Trusts early in the new year. NHS Trusts should give regular feedback to



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Health Service Circular HSC 1998/242referring GPs on the specificity of their referrals.Action within NHS Trusts9. It will be the responsibility of Chief Executives of NHS Trusts to ensure that GPs haveclear information about the way in which these urgent referrals are made and that NHS Trustsystems are sufficiently robust to ensure that all urgent referrals are fast tracked. Whicheverreferral method is used locally, it is essential that NHS Trusts are able to identifyimmediately those patients being referred within the target criteria. To ensure localconsistency, GPs and NHS Trusts should develop their own standardised referral formatsgiving the date of decision to refer and outlining the clinical and other information theywish to have included. Each referral should be clearly annotated that the two week targetapplies.10. From 1 February 1999 to 30 June, NHS Trusts will monitor urgent suspected breastcancer referrals on a monthly basis to test out the new reporting instructions andprovide an updated monthly return to Health Authorities of their progress in meetingthe target. This will identify those NHS Trusts with any remaining problems in meeting thetarget and ensure that action plans are strengthened as necessary. Detailed guidance will beissued on this in January.11. Formal quarterly monitoring will start from 1 April. Most NHS Trust informationsystems are not currently able to collect the information required to monitor this target andinitially will need to monitor it manually. The new NHS target will require NHS Trusts tocapture data for all patients referred urgently with a suspicion of breast cancer rather thanonly those with a confirmed diagnosis. The monitoring requirements are being road testedwith NHS Trusts and regional cancer groups during December. In January they will besubmitted to the Committee for Regulating Information Requirements (CRIR) and then toMinisters. A further Health Service Circular will be issued in February that will giveguidance on arrangements for quarterly monitoring.Action Within Health Authorities and PCGs12. The target must be achieved for all patients referred within the agreed criteria. Regionaloffices will work with all NHS Trusts in January to identify where additional urgent workis still needed. Firm action plans can then be developed and agreed with the health authorityto ensure that the target is met by 1 April 1999.

This circular has been issued by:

Dr Graham WinyardDirector of Health ServicesNHS Executive



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Health Service Circular HSC 1998/242ANNEX A

ACHIEVING THE NEW NHS CANCER WAITING TIMES TARGET: DEFINITIONSThe new NHS guarantees that Everyone with suspected cancer will be able to see a specialistwithin two weeks of their GP deciding they need to be seen urgently and requesting anappointment. By April 1999 for breast cancer and by 2000 for all other cancersi. It is the GP who decides in the light of the new national guidelines whether a patient needsto be seen urgently and requires a specialist outpatient appointment within the two weekperiod. Guidelines for Referral of Patients with Breast Problems published in 1996 by theNHS Breast Screening Programme and Cancer Research Campaign have been shown toenable GPs to differentiate between benign and malignant disease. They are currently beingupdated to incorporate the two week rule and will be disseminated early in the new year. They should form the basis of local agreement between NHS Trusts and GPs on the criteriato be used for an urgent referral.ii. Able permits a degree of patient autonomy. Patient views should be considered whenapplying the two week rule, and monitoring should be able to allow for personal preferencesand patient delay, where social and personal factors may mean that an appointment within14 days is inappropriate. Such factors could include the need for another person toaccompany the patient, a wish to digest the initial information and holidays.iii. A specialist means that person or persons who are most able to progress the diagnosisand treatment in timely fashion or re-refer where necessary. The specialist will be workingin or attached to a multi-disciplinary specialist team, and referral routes to such teams needto be agreed by Primary Care Groups, and widely disseminated within local cancer networks.iv. The GP seeing the patient with the current illness is their GP. The diagnosis of possiblecancer requiring urgent referral should remain the responsibility of the individual GP seeingthe patient. Before deciding to make an urgent referral the GP may use time and appropriateinvestigations in order to refine possibility into probability. This is good clinical practicewhich is unlikely to have a deleterious effect on clinical outcomes, whilst at the same timefocusing cancer resources where most needed, and protecting patients without cancer fromunnecessary anxiety or trauma.v. The two week waiting interval, measured in calendar days, will start from the date thatthe GP decides to refer - the decision to refer - date and will be subject to the GP makingthe referral and the NHS Trust receiving the referral within 24 hours of the decision to referbeing made. This will either be the day the patient sees their GP or because the need forurgent referral may only become apparent on receipt of results of investigations ordered bythe GP, the date the GP lets the patient know that they are going to be referred urgently.The Information for Health strategy encourages same day direct booking systems, either byelectronic media,that NHS Truststarget criteria.

telephone or fax. Whichever referral method is used locally, it is essentialare able to identify immediately those patients being referred within the

Everyonevi. This includesof relapse. Women referred from the breast screening programme will continue to be

all patients referred with a suspected primary cancer and suspected cases



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Health Service Circular HSC 1998/242monitored under existing NHS Breast Screening Programme standards.Failures to attendvii. Monitoring must allow for the fact that social and personal factors may mean that apatient might choose to delay their appointment beyond 14 days. In such cases, the 14 dayperiod would start from the date the patient is offered (and refused) an appointment to thedate the patient is actually seen. This is consistent with existing outpatient waiting timeprocedures.Further Clarificationviii. Advice on data collection and central returns will be given in specific guidance inJanuary and February.



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Health Service Circular HSC 1998/242Annex B

ACHIEVING THE NEW NHS BREAST CANCER WAITING TIMES TARGETProjected timescale of planned action18 December -December -

January -

end January -

1 February -

April -February - June -July

Issue Health Service CircularDraft monitoring guidance field tested with regional cancer groupsand information contacts at NHS Trusts.In early January, monitoring arrangements and guidance forapproval submitted by correspondence to CRIRSpecific guidance issued on state of readiness report requirementsand definitions for monitoring from 1 FebruaryRegional cancer co-ordinators report on state of readiness of NHSTrustsAction plans developed between HAs and NHS Trusts for achievingtargetNHS Trusts begin manual monthly monitoringHealth Service Circular issued to the NHS explaining the quarterlymonitoring requirements and giving guidance for its completion.Quarterly monitoring beginsMonthly monitoring data receivedQuarter 1 monitoring return


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DOH Atchieving the 2 Weeks Time