Waiting List Management and Patient Access Policy

Transcription

1 Waiting List Management and Patient Access Policy Document Reference Document status Target Audience OP.WL.V5.0 Final Clinical Directors, Consultants, Nurses, Directorate Managers, Waiting List Managers, Booked Admission Officers, Senior Secretaries and Administration Managers, Medical Secretaries, Outpatient Services staff, All Cancer Clinical Leads and Multi-disciplinary team members, Cancer Services Department, Sunderland CCG Date ratified 9 March 2017 Ratified by Policy Committee Release date 1 April 2017 Review date March 2020 Sponsor(s) Sean Fenwick, Director of Operations Version Date of Amendment Author(s) Update comments 5.0 April 2017 Alison King Updated in line with national guidance 4.1 August 2015 Laura Bond / Amy Johnstone / Vicky Parkin / Marie Walls / Alex Curtis / Denise Inskip 4.0 August 2015 Laura Bond / Amy Johnstone / Vicky Parkin / Marie Walls / Alex Curtis / Denise Inskip Final amendments following policy committee Regular Review Update to national 18 week policy Meditech implementation Cancer Pathway Policy Veron Thompson 18 weeks, C&B Veron Thompson First edition.

2 Contents Section Page 1 Introduction 4 2 Purpose & Scope 5 3 Duties/Responsibilities 6 4 Definitions 9 5 Management of Patient Pathways 5.1 Entitlement to NHS Treatment 5.2 War Veterans 5.3 Patients Transferring from the Private Sector 5.4 Patients Transferring from NHS to Private Sector 5.5 Patients Requiring Commissioner Approval (prior approval) 5.6 Booking and Choice 5.7 Hospital Cancellations Monitoring Compliance/Effectiveness of the Policy 14 7 Dissemination, Implementation and Training 15 8 Consultation, Review and Approval/Ratification 15 9 References Associated Documentation 17 Appendices Appendix 1 Waiting List Reports Appendix 2 RTT Standards Appendix 3 Key elements of RTT Appendix 4 Best Practice Guide Waiting List Management

3 1. INTRODUCTION City Hospitals Sunderland (CHS) NHS Foundation Trust is committed to ensuring that patients receive treatment in accordance with national standards and targets. The Trust s Waiting List Management and Patient Access Policy outlines the general principles and standards expected with regards to managing patient access to secondary care elective services from referral to consultant led treatment, and for maintaining new consultant outpatient, diagnostic, inpatient and day case waiting times. The Policy covers the processes for booking, cancellations, notice requirements, patient choice and waiting list management for all stages of the referral to treatment (RTT) pathway. This policy should be read in conjunction with the reference documents in Section 9. The Trust will ensure that the management of patient access to services is transparent, fair, equitable and managed according to clinical priority. As set out in Everyone Counts: Planning for Patients and NHS Constitution, patients have the right to start consultant-led treatment within a maximum of 18 weeks. Since December 2008 no one will have to wait more than 18 weeks (127 days) from referral to first definitive treatment. This includes all the stages that lead up to treatment, including outpatient consultations, diagnostic tests and procedures. People with Leaning Disabilities (PWLD) and Mental Illness (MI) will have equal access to treatment and care packages within the Trust. Their views and opinions will be respected, care plans will be personalised and reasonable adjustments to care packages and the environment will be made. The specific needs of PWLD and MI, such as communication, information, use of advocacy services, involving carers according to the patient s wishes, must be taken into consideration when these patients are accessing elective and acute services. All procedures, including consent to treatment will be in accordance with the Mental Capacity Act The Trust went live with the former Choose & Book electronic booking system in January 2007 allowing patients to have a choice of the time and place of their outpatient appointment. Most specialties are now available for GPs to access and book appointments on line. 2. PURPOSE & SCOPE The purpose of this policy is to ensure the appropriate management of patients on an 18 week RTT pathway or a 2 week wait suspected cancer pathway. It sets out the roles and responsibilities, processes to be followed and best practice guidelines to assist staff with the effective management of patients who need to attend the Trust for treatment as an outpatient, inpatient, day case or to receive diagnostic investigations. 3

4 The policy will ensure a consistent approach is used with regards to all aspects of waiting list management throughout the Trust and ultimately that patients have a choice of appointment/procedure date and are seen by the right professional in the shortest time possible. The broad principles of the policy apply to all departments who deliver elective services: outpatient, inpatient, diagnostics and therapies. The most recent National Waiting Times Guidelines (currently Referral to Treatment consultant-led waiting times: Rules Suite October 2015) will be followed (for 18 weeks elective pathways). The Trust is committed to provide good access to high quality health care to the community it serves and is committed to the following: To establish a consistent, integrated approach to patient access across Sunderland and other local health economies. All patients will be treated according to clinical need within the resources available. The Trust will endeavour to achieve all national targets set regarding waiting list/waiting times. All letters sent to patients with details of attendances will clearly state a point of contact should the patient have any queries around their appointment or procedure The language of all patients will be recorded upon receipt of referral and patients will be provided with the help of an interpreter when necessary. Any communication requirements of patients will be recorded. Any patient identified with different needs will be supported to ensure they have access to services Ensuring effective communication channels between patients, their GP and the Trust To provide high quality information to assist in the monitoring and management of waiting lists/waiting times both internally and externally Continual improvement in the effectiveness and efficiency of current services dependent upon resources The policy only applies to new outpatients who are placed on a waiting list and not to review appointments once treatment has commenced. Review outpatient appointments are not subject to national waiting time targets and appointment date/times are generally agreed between the patient and consultant responsible, timeliness of follow up is based upon the clinical need of the patient. However, the timeliness of review appointments is critical to enable the majority of patients to have started their treatment within 18 week of being referred. 3. DUTIES/RESPONSIBILITIES This policy should be adhered to by all staff within the Trust who are responsible for referring patients, managing referrals, adding to and maintaining waiting lists (outpatient or inpatient), scheduling of appointments for the purpose of progressing a patient through their treatment pathway. 4

5 3.1 Board of Directors The Board of Directors is responsible for ensuring that there is a robust system of Corporate Governance within the organisation. The Board of Directors review waiting list performance at Trust and speciality level, against national targets to seek assurance on performance. 3.2 Chief Executive The Chief Executive is ultimately responsible for ensuring effective corporate governance within the organisation. 3.3 Director of Planning and Business Development The Director of Planning and Business Development is accountable for ensuring the Trust achieves the RTT and Cancer Waiting Time standards as outlined in this policy. 3.4 Director of Operations The Director of Operations has overall accountability for overseeing the operational implementation of the principles outlined in this policy. 3.5 Divisional General Managers The Divisional General Managers are responsible for overseeing the operational management of waiting lists to ensure the principles outlined in this policy are applied by Directorate staff. 3.6 Directorate Managers and Clinical Directors Directorate Managers and Clinical Directors for each Directorate have overall responsibility for implementing and ensuring adherence to the policy within their area. Directorate Managers and Clinical Directors are responsible for: Ensuring that overall specialty capacity meets inpatient, outpatient and daycase demand within the constraints of the waiting times targets and agreed contracting levels linked to consultant job planning. Management of patients on the waiting lists supported by directorate waiting list teams and Outpatient Appointments staff. Management of inpatient and daycase waiting lists. The day to day management of waiting lists may be delegated. The Directorate Manager must ensure that Directorate administrative staff co-ordinate and actively participate in Trust procedures involving the validation of inpatient and daycase waiting lists. Ensuring that staff are trained in line with this policy and that annual training records are up to date. 5

6 Ensuring that staff participate in regular audit activities and respond to emerging patterns and themes. 3.7 Directorate Waiting List Managers/ Secretaries/Divisional Administration Managers/Administrative Staff/Patient Pathway Coordinators (Surgery)/Outpatients staff These staff are responsible for: Accurately recording referrals within 2 working days of receipt including the accurate management of tertiary referrals. Checking every patient s eligibility to receive free NHS care by asking the question have you lived in the UK lawfully for the past 12 months? at the point of registration. Ensuring that for procedures requiring prior funding approval that agreement to undertake that particular treatment or care is in place prior to listing the patient for treatment. Ensuring available data sets and reports as outlined in the monitoring table in Section 6 and Appendix 1 are reviewed on at least a weekly basis (outpatients, diagnostics, inpatients, 18 week RTT reports, patient tracking lists, cancer waiting time reports). Manage waiting lists and patient pathways in line with the RTT standards included in Appendix 2. Maintain accurate and up to date waiting lists (both outpatient and elective inpatient/day case) through ongoing review Highlighting capacity shortfalls in a timely manner to avoid patient wait times being compromised. Providing patients with earliest reasonable offer, providing a choice of dates and relevant notice. Ensuring outcomes are recorded using an accurate RTT code in real time at key stages in the patient pathway 3.8 Consultants It is a Consultant s responsibility: To review all patient referrals (including C&B advice and guidance services), allocating clinical priority and accepting / rejecting referrals, within 2 (of their) working weekdays of the referral being available to the consultant. Cover arrangements should be in place to ensure that urgent referrals are reviewed on a working daily basis. This excludes 2 week wait (2ww) referrals which are automatically accepted. To support the directorate manager in reviewing demand and capacity for outpatient, inpatient, day case and diagnostic services to ensure patients are seen by their latest date and that all RTT 18 week and Cancer 62 day targets are met. Coordinating medical staff to ensure that scheduled outpatient clinics and operating theatre sessions are held to avoid the need to cancel patient treatment. 6

7 To assist the directorate manager/waiting list team in monitoring of waiting lists, and working with appropriate management colleagues to proactively plan additional capacity as and when required. To bring inappropriate cancer referrals to the attention of the Directorate Clinical Governance Lead and to provide feedback to the relevant GP. To ensure all outpatient activity is completed with an accurate RTT code (the task can be delegated). For patients who require treatment this includes an indication of how long individual patients can defer treatment without clinical review. 3.9 Outpatient Services Manager The Outpatient Services Manager is responsible for the co-ordination and scheduling of outpatient clinics and maintaining the clinician schedules, highlighting areas of pressure to the Directorate Managers as well as supporting the provision of management information where required, in conjunction with Information Services. The management of theatre capacity and booking of inpatients is undertaken by Directorates Performance Team The Performance team is responsible for: The ongoing performance monitoring and management of delivery of the 18 week standards and cancer waiting times. This includes producing early warning reports/dashboards to address risks as they arise. Reporting performance against national waiting time standards to NHS England and internally to the Board of Directors Information Services The Information Services team will: Provide advice and support to all staff in the effective implementation of this policy. Ensure information reported to NHS England is compliant with guidance. Ensure that information is available to Directorates via the Data Repository and Intranet Launchpad which support the overall mangement of waiting times All Staff All staff including locums, agency staff and staff on honorary contracts and volunteers (where appropriate), are responsible for ensuring that the principles outlined within this policy are appropriately applied. All staff will ensure that any data created, edited, used or recorded on the Trust s Patient Administration System (Meditech) is accurate, timely, relevant, valid, complete and fit for purpose. Staff must keep themselves updated and informed by reading and understanding this policy and other associated policies and guidance, cited in Sections 9 and 10. 7

8 4. DEFINITIONS The Trust adheres to the definitions set out in the NHS data manual which can be found on the NHS web site and are summarised below. The Trust will implement Information Standards Notices (ISNs) and Data Set Change Notices (DSCNs) as required by the Standardisation Committee for Care Information (SCCI) where these are applicable to the management or recording of waiting list information. 4.1 RTT Standards In England, under the NHS Constitution, patients have the right to access services within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of alternative providers if this is not possible. NHS England collects and publishes monthly RTT performance which is used to monitor NHS waiting times performance against the standards set out in the NHS Operating Framework. Delivery of RTT standards in Appendix 2 by Trusts is overseen by NHS Improvement Appendix 3 outlines the key elements of the RTT standards (18 weeks elective pathway and for patients with suspected cancer) which should be adhered to in line with this policy. 4.2 RTT Clock The RTT clock measures the length of time which a patient has been waiting for treatment. 4.3 NHS e-referral Service The NHS e-referral Service is a national electronic referral service which gives patients a choice of place, date and time for their first outpatient appointment in a hospital or clinic. The majority of referrals to consultant led services are received via this route. 4.4 The Intranet Launchpad The Launchpad is available via the Trust s Intranet home page. It has been created by the Information Services Department to provide up-to-date information to directorates for the management of RTT processes including capacity and demand management and to support the governance of waiting list management. 4.5 Latest Date A latest date is the date attached to an outpatient, inpatient, diagnostic or therapy pending appointment (waiting list entry). This is the latest date that the patient should be seen in outpatients clinic or that a procedure should be performed. This date can relate to a gateway on the RTT 18 week pathway e.g. the latest the first appointment should take place or it may relate to the clinical priority of the patient 8

9 e.g. the latest that a planned procedure should be performed or when a 6 month outpatient review should take place. 4.6 Did Not Attend (DNA) A DNA is defined where a patient does not attend a scheduled appointment or admission without prior notice. 4.7 Polling Range Each service on the NHS e-referral Service has a polling range. The polling range indicates how far in advance appointment slots are available for patients to book into. In order to achieve the 18 week RTT target, these should be constantly monitored. 4.8 To Come In date (TCI) When a patient is given a date to attend for their planned surgical treatment this is called the TCI date. 5. MANAGEMENT OF PATIENT PATHWAYS There are a number of different activities which may occur during a patient s treatment pathway and each is defined according to whether they start, continue or stop an 18 week RTT pathway. The details of this are included in Appendix 3. This section covers the general principles for managing patients on RTT and non- RTT pathways. Appendix 4 provides best practice guide to waiting list management. 5.1 Entitlement to NHS Treatment The Trust has a legal obligation to identify patients who are eligible for free NHS treatment. The NHS provides healthcare for people who live in the United Kingdom. People who do not normally live in the UK are not automatically entitled to use the NHS free of charge regardless of their nationality, whether they hold a British Passport or have lived and paid National Insurance contributions and taxes in this country in the past. The following NHS treatment is available to anyone: Treatment in an emergency (but not follow up treatment). Treatment of certain communicable diseases. Compulsory psychiatric treatment. All NHS Trusts have a legal obligation to: Ensure that patients who are not ordinarily resident in the UK are identified. 9

10 Assess liability for charges in accordance with Department of Health Overseas Visitors Regulations. Charge those liable to pay in accordance with Department of Health Overseas Visitors Regulations. The Human Rights Act 1998 prohibits discrimination against a person on any ground such as race, colour, language or religion. The way to avoid accusations of discrimination is to ensure that everybody is treated in the same way. The Trust needs to check every patient s eligibility. An NHS card / number does not give automatic entitlement to free NHS treatment. Therefore, every time a patient begins a new course of treatment at the hospital, registration staff must ask the question have you lived in the UK lawfully for the past 12 months? If the answer is no or raises doubt about the patient s status then staff should contact the SRH main reception and a member of that team will attend to interview the patient to assess eligibility. 5.2 War Veteran Patients All War Veterans should receive priority access to NHS secondary care for any conditions which are likely to be related to their service, subject to the clinic needs of all patients. War Veteran patients, identified at referral, should be given priority for both outpatient and inpatient care. The regulations regarding veterans indicate they should be given priority over patients with similar medical problems - not that they should be seen in preference to other patients whose medical condition is more urgent. This therefore requires an assessment of the clinical needs of other patients who are already in the system before greater prioritisation of an individual veteran's appointment can be made. 5.3 Patients Transferring from the Private Sector to the NHS Patients can choose to move between NHS and private providers at any point during their treatment without prejudice. Patients wishing to transfer from a private provider to the NHS must be referred back to their GP to be offered choice and then referred on to an NHS provider. No patient should be referred directly to the Trust from the private provider. This includes patients who have been diagnosed with or are suspected to have cancer. The private service must contact the patient s GP and the GP must fax an urgent referral to the outpatient appointments team or create an urgent referral under the 2 week rule via the NHS e-referral service. This excludes patients who are referred in an emergency. Patients who are referred via their GP from a private provider can be added directly to an NHS waiting list on receipt of the referral. An NHS outpatient appointment is not required if the clinician accepting the referral deems it unnecessary. The RTT 18 week or 62 day for suspected cancer clock will start upon receipt of the referral. 10

11 5.4 Patients Transferring from NHS to Private Sector NHS patients already on an NHS waiting list who opt to have private treatment must be removed from the NHS waiting list. The RTT pathway should be stopped using RTT code Patient Declined Treatment. The referral should be discharged/completed. If the patient is choosing to have private treatment at the Trust, then a new referral must be created on Meditech and Patient Category recorded as Private (rather than NHS). Clinicians engaging in private work must not encourage patients referred to CHS for NHS care to transfer their care to the clinician s private practice. 5.5 Patients Requiring Commissioner Approval (prior approval) Certain procedures for example rare or high cost procedures not routinely commissioned, or where it needs to be demonstrated that patients fit referral criteria, require prior agreement from the responsible Commissioner. Individual commissioners have protocols for Individual Funding Requests and for Prior Approvals. The implications of not having a written approval and/or code may result in the Trust not being paid for the procedures undertaken. It is the waiting list manager/secretary s responsibility to ensure that agreement to undertake that particular treatment or care is in place prior to listing the patient for treatment. 5.6 Booking and Choice In line with the NHS Plan, and as far as practicably possible patients will be offered choice in booking their outpatient appointments and procedure dates. 5.7 Hospital Cancellations Every effort must be made not to cancel/reduce clinical sessions with less than 6 weeks notice. Inevitably, there will be occasions where this is necessary and will need to be approved by the relevant Clinical Director/Directorate Manager. It is likely that in these circumstances that the clinical session should be reinstated within 4 weeks. This would not apply for short notice cancellations in circumstances such as bereavement. It is vital that services take steps to ensure that patient safety is not being compromised as a result of the cancellation. In circumstances where a clinical session is cancelled / reduced with less than 5 weeks notice, then patients must be issued with a letter of apology immediately and at the same time, as far as possible, be advised of their new appointment date and time. This will be the next available appointment. These patients will be given priority over existing patients waiting to be allocated an appointment Acceptable and Unacceptable Reason for Hospital Cancellations (less than 6 weeks notice) 11

12 Acceptable reasons for cancelling clinical sessions include sickness leave and emergencies (trauma/fallow rotas are planned in advance and therefore should not result in clinic cancellations). Unacceptable reasons for short notice (<6 weeks) cancellations include: Annual leave Study leave Exam leave Holding interviews for new staff Changing clinical session e.g. cancelling a clinic to operate in theatre (nonemergency) Attending courses Attending meetings/seminars Authorisation to Cancel a Clinic / Theatre Session It is the Directorate s responsibility to ensure that sessions are not cancelled/reduced with less than 6 weeks notice. It is also the responsibility of the Directorate to ensure that the Schedule Change Team are notified of planned cancellations/reductions at least 6 weeks in advance of the clinic date. The Clinical Director or Directorate Manager must approve all cancellations/reductions. 6. MONITORING COMPLIANCE/EFFECTIVENESS OF THE POLICY The Trust has a comprehensive reporting system to ensure that patient access time and waiting lists are managed effectively. This policy will be monitored in line with the table below. Performance is monitored throughout the Trust by the Performance Team and daily reports are available to Directorate Managers and Waiting List Teams via the Intranet Launchpad. These reports are used on a daily basis by operational staff and discussed at monthly meetings between Directorate Managers and the Performance Team, and actions will be agreed and monitored for any areas of concern. The Performance Team in conjunction with the Trust s Data Assurance Team will undertake validation of compliance of the Trust s Patient Access Policy and the quality of the data held with regard to waiting list information. Element to be monitored Performance against national targets relating to RTT and Cancer waiting times By whom Performance Team Cancer Services Frequency Reporting to Weekly CCG, Monthly Department Quarterly of Health, Monitor Action plan by Directorate Manager Monitored by Operations Committee, Executive Committee, 12

13 Element to be monitored Waiting List Audits By whom Data Assurance Team Frequency Reporting to Monthly Data Quality Sub-group Action plan by Directorate Manager Monitored by Information Governance Group Data quality checks Data quality audits i.e. audit of RTT pathways and ad hoc reviews of interpretation of 18 week rules and cancer waiting time standards Capacity management audits i.e. job plan delivery, clinical session cancellations/ reductions & extra clinical sessions. Information Services Data Assurance Team Information Services Data Assurance Team Director of Operations Monthly Quarterly Quarterly Data Quality Sub-group Data Quality Sub-group Operations Committee Directorate Manager Directorate Manager Directorate Manager Information Governance Group Information Governance Group Executive Committee 7. DISSEMINATION, IMPLEMENTATION AND TRAINING This policy will be disseminated via Team Brief and the Trust intranet. It will be implemented as soon as it is disseminated. Training on application of the RTT rules will be available for all staff directly involved in managing patient pathways (18 weeks and suspected cancer) to ensure accurate and timely data collection/recording to enable the Trust to meet the RTT targets. As a minimum this should include Directorate Administrative staff (secretaries and waiting list staff) and Outpatients staff on an annual basis. It is the Directorate Manager s responsibility to ensure that all staff are compliant with the policy and attend appropriate training as necessary and this is recorded on ESR. 8. CONSULTATION, REVIEW AND APPROVAL/RATIFICATION Consultation and Review Clinical Directors Divisional General Managers and Directorate Managers Waiting List Manager, Senior Secretaries and Administration Managers 13

14 Performance Team Information Services Director of Operations Approval Executive Committee Ratification Policy Committee 9. REFERENCES NHS England Everyone Counts: Planning for Patients 2014/15 to 2018/19 Department of Health NHS Plan July 2000 NHS England Everyone Counts January 2013 Department of Health NHS Constitution 2013 Mental Health, England and National Health Service England, The National Health Service commissioning board and clinical commissioning groups (responsibilities and standing rules) regulations 2012, December 2012, available at: Department of Health, Referral to treatment consultant-led waiting times: rules suite, April 2014, available at: /RTT_Rules_Suite_October_2015.pdf Department of Health NHS Waiting Times for Elective Care in England National Audit Office January 2014 NHS Interim Management and Support Referral to Treatment Pathways: A Guide to Managing Efficient Elective Care (2 nd Edition) NHS IMAS January 2014 NHS Charges for Overseas Visitors Guidance for the Referral of Armed Forces Veterans Access to health services for military veterans priority treatment 14

15 .uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_ pdf NHS England, Recording and reporting referral to treatment (RTT) waiting times for consultant-led elective care, October 2015, available at: content/uploads/sites/2/2013/04/recording-and-reporting-rtt-guidance-v24-2-pdf-703k.pdf Mental Capacity Act Human Rights Act ASSOCIATED DOCUMENTATION Supporting documentation relevant to this policy includes: Data Quality Policy Patient Information Policy Patient Identification Policy Data Protection and Personal Information Handling Policy Consent for Examination and Treatment Policy Guide to Validating 18 week pathways Meditech How 2 Guides RTT Outcomes Dictionary Guide Protocols for specific services (e.g. direct access endoscopy, referral of suspected urgent cancer) 15

16 Appendix 1 Waiting list reports To support effective waiting list management the following should be reviewed on a weekly basis (alongside a number of reports not currently on Intranet Data Launchpad that will be detailed in standard operating documentation) : 1.1 Launchpad Scheduling Capacity and Demand (Ref: OP011) For outpatients: o There are no patients more than 1 month past their latest date o There is a plan in place for all patients past their latest date o There are no un-validated patients with a latest date more than >24 months ahead 1.2 Launchpad Scheduling Appointment Status (Ref: OP002) For inpatients and outpatients: o There should be no patients in a booked status more than 7 days past their appointment date 1.3 Launchpad RTT Waiting List (Ref: WL006) For inpatients: o There should be no patients in a booked status (past TCI report) o There should be no patients without a Latest Date o There should be a plan in place for patients over due o There should be no IP Booked patients on a clock stopped / closed pathway / not applicable or no pathway. 1.4 Launchpad RTT Operational (Ref: RTT001) o There should be no patients on an open 18 week pathway, over 18 weeks, without an Exception recorded against the pathway in Meditech. o There should be a plan in place for all patients who have breached. 16

17 RTT Standards Appendix The following national access targets apply to all patients: 92% of patients on an incomplete pathway (who have not yet started their treatment) should have waited no longer than 18 weeks. The tolerances across the pathway allows for complex diagnostic or treatment pathways or for patients who choose to wait longer than 18 weeks (127 days). All patients will be seen in date order, according to clinical priority and there should be no patients waiting longer than 52 weeks to receive their first treatment. 99% of patients should be seen within 6 weeks for a diagnostic test or image. 2.2 Cancer Waiting Time Standards All patients referred from a General Practitioner (GP) / General Dental Practitioner (GDP) as suspected cancer under the 2 week wait rule will be seen within 14 days of receipt of referral. All patients referred with breast symptoms will be seen within 14 days of receipt of referral. All patients referred by GP/GDP as suspected cancer or breast symptomatic who are subsequently diagnosed with cancer will commence treatment within 62 days of receipt of referral. All patients referred from screening programmes (bowel, breast, cervical) as suspected cancer who are subsequently diagnosed with cancer will commence treatment within 62 days of receipt of referral. All patients that are upgraded by Consultants as suspected cancer will commence treatment within 62 days of the date of the upgrade. All patients diagnosed as a new cancer will receive treatment within 31 days of decision to treat (DTT) irrespective of the treatment. All patients that are having a subsequent treatment for cancer will receive treatment (drug treatments or surgery) within 31 days of the DTT. 17

18 2.3 Exclusions patients not on RTT pathway The following activity is excluded from the 18 week RTT standard: Emergency admissions when a patient is admitted as an emergency, they are not part of the RTT pathway and their status should be recorded as Activity not Applicable. However, if the patient s condition is only stabilised as part of the emergency admission and treatment is required at a later date, then the clock would start for this patient at the point the decision was made that future elective therapeutic treatment will be required. Obstetric patients (an 18 week clock should only start when a separate condition or complication requiring medical or surgical consultant led intervention is required). Elective patients undergoing planned or surveillance procedures (e.g. removal of metalwork, procedures related to age/growth, check cystoscopies). Patients receiving ongoing care for a condition where first definitive treatment for that condition has already occurred (and a further care plan procedure is undertaken) or repeat of same treatment for the same condition (excludes unplanned repeat operations / deeper excisions). Patients whose 18 week clock has stopped for active monitoring, and has not yet re-started, even though they may still be followed up by their consultant. GP referrals into a non-consultant led service (excludes Audiology and Physiotherapy). Tertiary referrals into a non-consultant led service where the patient has already received first definitive treatment (opinion only). Diagnostic services if the referral is not part of a straight-to-test arrangement or no secondary care consultation is required. Where patients DNA s their first appointment following the initial referral that started their RTT clock, their RTT clock should be nullified provided that the appointment was clearly communicated to the patient. 18

19 Key elements of RTT Appendix The referral to consultant-led treatment waiting times rules are as follows: What causes a clock start? When does the clock start? Any eligible professional that refers a patient: directly to a consultantled service or to an intermediary service offering clinical assessment and, or treatment. Patient rebooks after failing to attend a first appointment A self-referral (where locally agreed) A decision to treat following a period of active monitoring A patient becomes fit and ready for the second of a bilateral procedure A decision to start substantially different treatment Upon a patient being re-referred into a consultant-led, interface or referral management or assessment service as a new referral For paper referrals: When the referral is received by the Trust, if directly referred to a consultant-led service. If through an intermediary service when received by that service For NHS e-referrals: When the patient s unique booking reference number is converted to a hospital appointment Where there are no appointments available, when the UBRN appears on the ASI work list When a patient re-books following a first appointment that they failed to attend and that nullified their clock: The date the patient contacts the Trust and rebooks their new appointment For self-referrals The date the self-referral is received by the provider After a period of active monitoring/for a substantially different treatment/when patient becomes fit for treatment: The date the decision to treat is made and communicated to the patient For bilateral procedures The date the patient becomes fit and ready for the second bilateral procedure Substantially different treatment When the subsequent decision to treat is made and communicated to the patient. Where a patient is referred for diagnostic or specialist opinion with a view to treatment it may be more appropriate to start the clock at the point of the onward referral For re-referrals When the referral is received or UBRN converted 19

20 What causes a clock stop? When does the clock stop? The first definitive treatment (intervention to manage a patient s condition and avoid further action) When a patient declines treatment A period of active monitoring starts A clinical decision not to treat is made A patient does not attend their first outpatient appointment and the trust can demonstrate that the appointment was clearly communicated to the patient (which nullifies the clock) A patient does not attend a subsequent appointment subject to all the conditions in the rules suite being met The date the first definitive treatment starts; for example, admission to hospital, or date that physiotherapist starts treatment if this is considered first definitive treatment The date: A patient informed a Trust that they did not want treatment A decision is made to start active monitoring A decision is made not to treat a patient A decision is made to add a patient to the transplant list and that is communicated to the patient The date a patient is transferred back to the care of their GP It is clinically appropriate to return the patient to primary care for any non-consultant led treatment in primary care A clinical decision is made and has been communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay, to add a patient to a transplant list Non-outpatient clinical outcomes such as: Diagnostic test results are normal and this is communicated to the patient via telephone or letter; patient on an RTT pathway dies 3.2 Ongoing Clocks A patient has an on-going clock if they have had a clock start but have not yet had either their first definitive treatment or decision not to treat or been placed on active monitoring. These patients should be monitored robustly via diagnostic test tracking procedures or active waiting list management. Tests and results need to be followed up as these patients should be progressed in a timely manner to enable first definitive treatment or a decision not to treat. 20

21 If a patient is referred from one provider to another as part of the RTT period, their 18 week clock should keep ticking. The originating provider should ensure that the patient s initial RTT clock start date and Pathway ID forms part of the onward referral information. In some instances these patients will be returning to the originating Trust with the clock continuing to tick. 3.3 Clock Stops DNAs If a patient DNA s their first appointment that started the RTT clock, provided that the provider can demonstrate that the appointment was clearly communicated to the patient and is discharged back to the care of their GP, this will nullify the RTT clock. If a patient DNA s at another point on the RTT pathway this will not stop the clock unless it is in the patient s best clinical interest to be discharged back to the care of their GP. This is provided that: The appointment was clearly communicated to the patient Discharging the patient is carried out according to local policies on DNAs which protect the clinical interests of vulnerable patients Discharging the patient is not contrary to their best clinical interests, which may only be determined by a clinician 3.4 Cancelled and rearranged appointments A cancelled or rearranged appointment, either patient initiated or provider initiated will not in itself stop an RTT clock. If a patient or provider cancels, rearranges or postpones their appointment, this has no effect on the RTT clock, which should continue to tick. Any referral back to the GP should be a clinical decision based on the individual patient s best clinical interest. 3.5 Patient thinking time Where a patient requires thinking time, the effect on the RTT clock will depend on the individual scenario. If the thinking time is short i.e. a few days then the clock should continue to tick. If a longer period of thinking time is agreed, then active monitoring is more appropriate e.g. for surgical intervention where a patient is not keen on invasive surgery at this stage. A new RTT clock would start when a decision to treat is made following a period of active monitoring. 3.6 Patient initiated delays Patients are entitled to wait longer for their treatment if they wish. Delays as a result of patient choice are taken into account in the tolerance of 8% set for achievement of the incomplete pathway waiting time operational standard. There is no provision to adjust pathways for delays however patient initiated delays should be recorded to aid good waiting list management and ensure patients are treated in order of clinical priority. 21

22 There are no blanket rules that apply a maximum length to patient initiated delays. Clinicians should indicate how long (in general) patients should be allowed to defer treatment without clinical review. If the clinician is not satisfied that the proposed delay is appropriate then the clinical risks should be clearly communicated to the patient and a clinically appropriate TCI date agreed. If the patient refuses and the clinician feels that it is in the best clinical interest of the patient to discharge the patient back to the clinical care of their GP, the patient must be informed that treatment is not progressing. This is a clinical decision, taking into account the healthcare needs of each individual patient. Open-ended delays should be avoided and an available date should be secured from the patient. Where a patient initiated delay can be considered as patient thinking time rather than a declared period of unavailability, it should be considered whether it is clinically appropriate to start a period of active monitoring. 22

23 Appendix 4 Waiting List Management Best Practice Guide 4.1 Strategies for Effective Waiting List Management How do we deliver consistent 18- week RTT performance? Maintain capacity and demand balance Pathway management to reduce journey times Operational processes on patient pathways Scheduling and booking Tracking and validation Performance management system Leadership and focus 1. Balance underlying supply and demand (each stage) 2. Create pre-agreed flexible supply options 3. Define shape and size of waiting list and monitor both 4. Analyse and manage capacity / demand down to subspecialty level 5. Root cause analysis of failing pathways 6. Systematically remove admin, delays and unnecessary steps 7. Staged wait reduction where bottlenecks occur 8. Agree ideal pathways and escalate trigger points 9. Redesign of clinical care processes, order of activities 10. SOPs for referral triage and addition to waiting list 11. Widespread knowledge on clock stops 12. Decision to admit processes clear and documented 13. Frequent outpatient template review, clear clock stop process 14. Widespread training in scheduling and booking 15. Written rules on classification of urgents and booking in turn 16. High quality access policy, regularly reviewed 17. Monitoring of treat in turn and urgent levels 18. Dedicated tracking and validation of resources linked to specialities 19. Use patient tracking lists (PTL) at all stages: IP, OP and diagnostic 20. Track patients at staged triggers untreated breeches 21. Systematic maintenance of data quality reports 22. Measure adherence to access policy and adherence to rules 23. Publish the right measures and use measures at all levels 24. Good performance conversations with actions, feedback 25. Clarify and implement incentives and consequences 26. Senior input (Board and CEO) to performance conversations 27. Board and directorate-level reporting on predictive measures 28. Support for training, validation and scheduling functions 29. Communication and coordination with commissioners Adapted from: Elective Care Intensive Support Team Referral to Treatment Pathways: A Guide to Managing Efficient Elective Care (2 nd Edition) 2014 Further information to support each of the 29 elements is provided in the reference document. 23

24 4.2 Prioritisation of patients Each referral, booking and pending appointment/procedure will be given a Priority as follows: Priority 3 Patient is on a Cancer Pathway or cancer is suspected (patient must be seen/treated within 2 weeks) Priority 2 Urgent (patient must be seen/treated within 6 weeks) Priority 1 Routine (routine review of cancer patients is Priority 1 an * alongside the priority within Meditech indicates that the patient is on a Cancer Pathway) NB: Diagnostics tests are the exception to the rule and should be prioritised as follows: Priority 3 Patient is on a Cancer Pathway or cancer is suspected (patient must be seen within 7 days) Priority 2 Urgent (patient must be seen within 2 weeks) Priority 1 Routine (patient must be seen within 6 weeks) To ensure that all patients on the waiting list are seen in priority order, each pending appointment/procedure will be given a Latest Date. This is the latest that the patient should be seen. This is: Clinically driven date (for Priority 3 and 2 patients and those patients on a planned/closed pathway) Before the patients RTT target date (polling range for first appointment and 16 weeks for TCI) for routine patients on an open pathway 4.3 Critical data fields It is imperative that all patients have a named consultant overseeing their pathway of care. Ensuring that the named clinician is correct in the referral will enable accurate data reporting each time an appointment or procedure is added to a waiting list or booked. The accuracy of this data should be checked during the Consultant Action routine on Meditech. The visit type must be appropriate to the patient s visit: If attending for the first time the visit should be a New visit type and new appointment type. All other visits should be a Follow-Up Type. The only exception to the rule is when a patient is reviewed in outpatient clinic for the first time following an emergency admission the visit type should be classified as New on a review appointment type. Patients changing consultants (for example consultant leaving the Trust) can also be classified as New visit type. Each step along the patient s pathway (outpatient appointment, diagnostic appointment, pre-assessment, admission, discharge, any decision by the patient or clinician to delay further treatment at any stage) must recorded on Meditech as either a clock start, on-going activity of an already open pathway/ticking clock, a clock stop, 24

25 or as an activity which is not part of an 18 week pathway. A code exists for each type of activity and this code must be recorded in Meditech at each point during the pathway. The RTT codes with descriptions can be found in the RTT Outcomes Dictionary guide. 4.4 Appointment / TCI Booking and Choice No choice is given when an appointment (new or follow-up) or TCI date is booked and sent to the patient, without any negotiation with the patient. As far as possible systems will be developed to provide patients with a choice of date and time. Within the RTT guidance: Partial booking refers to a system where: The patient is contacted by telephone/face to face and an appointment (new, follow up or procedure) is agreed, or A letter is sent to the patient requesting the patient telephones the Trust to agree a mutually convenient appointment date, or The patient is given the opportunity to agree a mutually convenient TCI date outside of one working day of the decision to admit them. Full booking refers to a system where: The patient is given the opportunity to agree a mutually convenient new appointment date within one working day of the decision to refer, or A patient agrees a mutually convenient follow-up or PREP appointment date directly after a clinic attendance, or A mutually convenient admission date within one working day of the decision to admit the patient (i.e. add them to the waiting list) is agreed Patients who have had the opportunity to agree a date within 1 working day but chose to wait longer than 1 day to agree the date, should still be counted as a fully booked patient. The appointment booking system type must be recorded each time a TCI is agreed with a patient or sent to a patient. Within the outpatient setting choice is provided for new appointments via the Choose and Book system for patients referred via that route. For patients referred to consultant led services via other routes the patient is provided with an appointment date and time via letter and asked to contact the outpatient appointments team if they wish to rearrange that appointment. For review appointments a patient is fully booked if the follow up is required within 6 weeks. For longer term reviews no choice is provided: the patient is provided with 25

26 an appointment date and time via letter and asked to contact the outpatient appointments team if they wish to rearrange that appointment. NHS England guidance indicates that to offer patient choice attempts must be made to phone the patient more than once and at least once out of working hours. Records of each attempt must be made on Meditech in the waiting list comments field. The appointment / TCI letter can then be sent which includes the paragraph We are attempting to offer you choice, enclosed is our first offer. This can then be recorded as a partial booking patient as every effort has been made to offer the patient choice. 4.5 Reasonable Verbal and Written Notice/Offer Reasonable notice for a verbal offer of an outpatient appointment or diagnostic test, is two dates with the earliest a minimum of one calendar week (7 days) away and for a written offer is a date with a minimum of two calendar weeks away. Reasonable notice for a verbal offer of an elective admission for is two dates with the earliest a minimum of three calendar weeks (21 days) away and a written offer is a date with a minimum of three calendar weeks away. All offers of dates to patients for outpatient, diagnostic or inpatient treatment must be recorded on Meditech at the time the offer is made. The aim of the clinic and admissions booking staff will always be to find a date appropriate for a patient s clinical priority which is convenient for the patient. Therefore, three attempts to contact every patient by telephone will always be made if an appointment or admission date is less than one week away, one of the attempts must be after 6 pm and the attempts will fall on different days. These contacts must be recorded on Meditech. In relation to cancer 2 week wait referrals, patients must be contacted within 48 hours following receipt of the referral and they must be given reasonable notice and a choice of at least 2 options for any appointment offers. For 2 week wait referrals, if a patient is unable to attend an appointment within 2 weeks of a GP referral, despite the GP giving the appropriate information relating to the urgency of their referral, the GP may defer referring until the patient will be available. As the patient s best interests should be first and foremost, the Department of Health guidance advises that the patient should be referred at the earliest opportunity and therefore deferred referrals are not recommended, however there is nothing within the guidance to indicate that immediate referral of the patient is necessary nor that delaying a referral would be unsafe. Therefore, agreeing with the patient to delay the referral, if the patient advises they are unavailable for over a 2 week period, is acceptable. Should General Practitioners be informed by their patients of their inability to attend within 2 weeks of referral these should only be referred when the patient is available to be seen, which should be documented in their GP 26