Patient Access Policy

Transcription

1 Patient Access Policy SPONSOR (Information Asset Owner): Chief Operating Officer AUTHOR (Information Asset Administrator): Gina Quantrill Associate Director Elective Care RATIFIED BY: Document Management Group TBC APPROVED BY: Access Board 06/11/17 TARGET AUDIENCE: All staff involved with patient appointments and pathway DOCUMENT NUMBER: CM31 DOCUMENTCATEGORY: Corporate Management (CM) This document is available in large print format and alternative formats. Should you or someone you know require this in an alternative format please contact us on x6455 or

2 Patient Access Policy / CM31 / v7 Date Version Details of changes Review Date No Mar Detail changes Mar 2004 Aug Detail changes Aug 2006 Jun Detail changes Jun 2008 Oct Full review inclusive of 18 week target Oct 2013 Oct Full review, inclusive of new guidance, Oct 2016 NHS structures & Trust s CM-52 format Oct Full review following NHSI input. Revised and updated DNA, cancellations, service restriction policy requirements, individual funding requests Oct 2019 (or earlier if material changes to RTT)

3 Patient Access Policy / CM31 / v7 Contents 1 Introduction 1 2 Purpose 2 3 Scope 2 4 Definitions 3 5 Duties 6 6 Entitlement to NHS treatment 7 7 Transfer of Private Patients 8 8 Outpatients 8 9 Methods of Referral 9 10 Inappropriate Referrals Registration week RTT Booking Timescales Ministry Of Defence Patients Private Patients HM Prison Patients (HMP) Attendance Overseas Visitors Clinic Management Diagnostics Elective Inpatients and Day Cases Outcomes of Admission Offers Transfer of Treatment to another Consultant Active Monitoring Referrals which do not start a clock Procedures which require funding from CCGs Training Requirements Monitoring of compliance Associated Documents Equality Impact Assessments References 33

4 1 Introduction The best interests of the patient are foremost and the Trust intends to ensure efficient and equitable handling of referrals in line with waiting time standards and the NHS Constitution. The Constitution sets out your rights as an NHS patient. These rights cover how patients access health services, the quality of care you will receive, the treatments and programmes available to you, confidentiality, information and your right to complain if things go wrong. The constitution can be found by going to Individual Patient Rights The NHS Constitution clearly sets out a series of pledges and rights stating what patients, the public and staff can expect from the NHS. A patient has the right to the following: The choice of hospital and consultant team (where available). To commence their treatment for routine conditions following a referral into a consultant led service, within a maximum waiting time of 18 weeks to treatment. To be seen by a cancer specialist within a maximum of two weeks from a GP referral for urgent referrals where cancer is suspected. The NHS has to take all reasonable steps to offer a range of alternatives if this is not possible. The right to be seen within the maximum waiting times does not apply if: the patient chooses to wait longer. delaying the start of the treatment is in the best clinical interests of the patient (note that in both of these scenarios the patient s RTT clock continues to tick). it is clinically appropriate for the patient s condition to be actively monitored in secondary care without clinical intervention or diagnostic procedure. The purpose of this policy is to outline the Trust and Commissioner requirements and operating standards for managing patient access to secondary care services for patients from referral to treatment, and discharge to primary care. This policy has been produced in collaboration with the CCG to reflect local and national standards. The policy covers the processes for booking, notice requirements, patient choice and waiting list management for all stages of a referral to treatment pathway. Giving patients more choice about how, when and where they receive treatment is one that requires us to offer a more responsive service to our patients needs through quality assurance. The length of time a patient waits for hospital treatment is an important quality issue and is a visibly and public indicator of the efficiency of the hospital services provided by the Trust. This policy provides the basis for giving patients equitable access to health care, whilst applying agreed rules and conditions that will help facilitate the delivery of Page 1 of 36

5 National targets and local contractual requirements. All targets defined within this policy are in line with National standards. The Trust will ensure that the management of patient access to services is transparent, fair and equitable and managed according to clinical priority. The policy will be applied consistently and without exception across the Trust to ensure equity amongst its patients whilst taking account of their clinical need. This policy applies to all administration and clinical prioritisation processes relating to patient access, including outpatient, inpatient, day case, therapies and diagnostic services. Treating patients, delivering a high quality and efficient service, as well as ensuring prompt communication with patients are core responsibilities of the hospital and the wider local health community. 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 for the purpose of progressing a patient through their treatment pathway. 2 Purpose The purpose of this policy is to: Establish a clear and consistent approach for patient access by defining the means by which patients may be referred to Trust services. Describe how the Trust will manage access to its services and ensure that the pathway to treatment is fair for all and is compliant with the 18-week Referral to Treatment (RTT) rules. Ensure that patients receive treatment according to their clinical priority; both suspected cancer patients and routine patients with the same clinical priority are treated in chronological order, thereby minimising the time a patient spends on the waiting list and improving the quality of the patient experience. Support the reduction in waiting times, reduction in cancelled operations and the achievement of relevant waiting time targets. Improve the patient experience by reducing DNA s (Did not attend) and cancellations. Provide a framework by which administration of waiting lists and bookings will be managed. Ensure that all the information relating to the number of patients waiting, seen and treated is accurate and recorded on PAS (Patient Administration System). The advice given in the policy is, at all times, consistent with the national 18 Week rules. Provide a framework by which administration of waiting lists and bookings will be managed. 3 Scope This policy only applies to the management of elective episodes of care. For the management of Cancer pathways and access standards please refer to the Cancer Access Policy (available on the intranet). Page 2 of 36

6 All patients (except those on a cancer pathway) must be seen, diagnosed and treated within 18 weeks from Referral to Treatment (RTT). Wherever possible for patients on an 18 week pathway, the principles of partial and full booking will be applied and patients will be encouraged to agree their appointment and admission dates and times in advance of their booking arrangements. The Trust recognises that recommendations for good practice specify the notice period to patients for these arrangements should where possible be a minimum of 3 weeks with two dates offered. The Trust will therefore expect that referring clinicians will have alerted their patients to the appropriate pathway rules before the referral is made. They will further highlight to their patients the importance of them being available for any such appointments, tests and admissions that may be required along the pathway. Full booking applies to any new patients contacted and booked within 48 hours of their referral into the Trust and also applies to rapid access patients. It also applies to any patient who agrees the booking of their follow-up appointment when they leave the department after their clinic appointment. Wider and more detailed information on procedures is available through a range of Patient Information Leaflets that are produced by the Trust for the patient. The following national operating standards apply to all patients: 92% of open pathways will be under 18 weeks (this has become the sole measure of elective performance nationally) There is no provision to pause or suspend an RTT waiting list clock under any circumstances. No patient will wait any longer than 6 weeks for a diagnostic test or procedure from the date the decision is made. 4 Definitions A 18 week RTT (Referral to Treatment) Active monitoring Active Waiting List Patients Admission 18-week Referral to Treatment (RTT) is the period of a consultant led treatment from referral for non-urgent conditions. A patient s RTT clock may be stopped where it is clinically appropriate to start a period of monitoring in secondary care without a clinical intervention or diagnostic procedures at that stage. A new clock would start when a decision to treat is made following a period of active monitoring (in previous guidance also known as watchful waiting). Where there is a clinical reason why it is not appropriate to continue to treat the patient at that stage and to refer the patient back to primary care for ongoing management, then this constitutes a decision not to treat and should be recorded as such and also stops a clock. Patients awaiting elective admission for treatment and are currently available to be called for admission. The act of admitting a patient for a day case or inpatient Page 3 of 36

7 C D B Admitted Pathway Bilateral (procedure) Care Professional Chronological Booking procedure. A pathway that ends in a clock stop for admission (day case or inpatient). A procedure that is performed on both sides of the body, at matching anatomical sites. For example, cataracts (both eyes). A person who is a member of a profession regulated by a body mentioned in section 25(3) of the NHS Reform and Health Care Professions Act Refers to the process of booking patients for appointments, diagnostic procedures and admission within date order of their clock start date. Clinical Decision A decision taken by a clinician or other qualified care professional, in consultation with the patient, and with reference to local access policies and commissioning arrangements. Clock Start Clock Stops Consultant Consultant- Led Date Referral Received (DRR) Day cases Decision to Admit The RTT clock starts when any healthcare professional (or service permitted by an English NHS Commissioner to make such referrals) refers to a consultant led service. The RTT clock start date is the date that the Trust receives the referral. For referrals received through NHS e-referral, the RTT clock starts on the day the patient converts their unique booking reference. A referral is received into a consultant led service, regardless of setting, with the intention that the patient will be assessed and, if appropriate, treated before clinical responsibility is transferred back to the referrer. A referral is received into an interface or referral management assessment centre which may result in an onward referral to a consultant led service before clinical responsibility is transferred back to the referrer. An RTT clocks stops when: First definitive treatment starts Or A decision is made not to treat A person contracted by a healthcare provider who has been appointed by a consultant appointment committee. He or she must be a member of a Royal College or Faculty. The operating standards for referral to treatment exclude non-medical scientists of equivalent standing within diagnostic departments. A consultant retains overall clinical responsibility for the service, team or treatment. The consultant will not necessarily be physically present for each patient s appointment, but he/she takes overall clinical responsibility for patient care. The date on which a hospital receives a referral letter from a GP. The waiting time for outpatients should be calculated from this date. Patients who require admission to the hospital for treatment and will need the use of a bed but who are not intended to stay in hospital overnight. Where a clinical decision is taken to admit the patient for either a day case or inpatient procedure. Page 4 of 36

8 E F I N O P Decision to Treat Where a clinical decision is taken to treat the patient. This could be treatment as an inpatient or day case, but also includes treatments performed in other settings eg as an outpatient. Direct Access Where GPs refer patients to hospital for diagnostic tests DNA - Did Not Attend Elective Care ERS First Definitive Treatment Fit (and ready) Full Booking Incomplete Pathways Indirectly Bookable Services Inpatient Non-admitted pathway Non-Consultant Led Nullifed Operational Standards Partial Booking Patient Initiated Delay only. These patients will not be on an open RTT pathway. In the context of the operating standards, this is defined as where a patient fails to attend an appointment or admission without prior notice. Any pre-scheduled care ie operation or diagnostic procedure which does not come under the scope of emergency care. A national electronic referral service that gives patients a choice of place, date and time for their first consultation in a hospital or clinic. An intervention intended to manage a patient s condition, disease or injury and avoid further intervention. What constitutes First Definitive Treatment is a matter for clinical judgment, in consultation with others as appropriate, including the patient. A new patient pathway and clock should start once the patient is fit and ready for treatment. In this context, fit and ready means that the clock should start from the date that is clinically appropriate for the patient to undergo that procedure, and from when the patient says they are available and will be for the foreseeable future. Where an appointment or admission date is agreed with the patient. This is the number of patients who are currently waiting for treatment (admitted and non admitted) at any given time Some provider services are not directly bookable through E- referral so patients cannot book directly into clinics from a GP practice. Instead they contact the hospital by telephone and choose an appointment date. This is defined as an Indirectly Bookable Service. These are patients that have been formally admitted in to the hospital in to a bed. A pathway that results in a clock stop for treatment that does not require an admission or for non treatment. Where a consultant does NOT take overall clinical care for the patient. Where the RTT clock is discounted from any reporting of RTT performance. These are the standards of treatment which we aspire to deliver for our patients. These are waiting time standards, used as a proxy for good clinical care. The core standard for elective care is the incomplete pathway standard. Where an appointment or admission date is agreed with the patient near to the time it is due. Where the patient cancels, declines offers or does not attend appointments or admission. This in itself does not stop the RTT clock. A clinical review must take place following 2 consecutive Page 5 of 36

9 R S T U Patient Tracking List (PTL) Planned Waiting List Reasonable Offers Routine Straight to Test TCI (To Come in) date Therapy Upgraded referrals cancellations when a third is attempted. The PTL is a list of all patients (both inpatients and outpatients) currently on an elective pathway of care Patients who are to be admitted as part of a planned sequence of treatment or where they clinically have to wait for treatment or investigation at a specific time. They are not counted as part of the active waiting list or on an 18 week RTT pathway. Patients on planned lists should be booked in for an appointment at the clinically appropriate time. Should there be a delay, in excess of a month, the patient will be moved across to an active RTT pathway. A choice of two appointment or admission dates with three weeks notice (unless a diagnostic appointment). Any pre-scheduled care which does not come under the scope of emergency care, urgent or potential cancer A specific type of direct access diagnostic service whereby a 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. The offer of admission, or TCI date, is a formal offer in writing of a date of admission. A telephone offer of admission should not normally be recorded as a formal offer unless it is confirmed with a letter as well (if time allows). Where a consultant led or interface service decides that therapy (for example physiotherapy, speech and language therapy, counselling) or healthcare science (eg hearing aid fitting) is the best way to manage the patient s disease, condition or injury and avoid further intervention. Hospital specialists have the right to ensure that patients who are not referred urgently as suspected cancer referrals or through the screening programmes, but who have symptoms or signs indicating a high suspicion of cancer, are managed on the 62 day pathway. This can be achieved by upgrading the patients onto a 62 day upgrade pathway 5 Duties 5.1 Duties within the Trust Committees Access Board to monitor RTT performance and adherence to the rules set out in this policy. Specialty Operational Performance Reviews to monitor compliance with RTT standards. Activity and Performance meetings to monitor RTT performance with specialties weekly. 5.2 Duties of Individuals within the Trust Page 6 of 36

10 Managing Director as the Trust s Accountable Officer, has overall responsibility for ensuring the Trust provides appropriate and timely access to services for its patients as set out in the NHS Plan, NHS Constitution and Operating Framework. Director of Operations has strategic responsibility for the implementation of the Patient Access Policy, monitoring compliance and reporting performance to the Trust Board. Associate Director Elective Care - is responsible for ensuring patient access procedural documents are appropriate, up to date and available when needed and to ensure that the outpatient and admission teams comply with this standard and maintain consistently high data quality. Clinical Directors and Clinical Leads are responsible for ensuring staff are aware of, and adhere to, this policy. Associate Directors and General Managers are accountable for compliance with this policy within their clinical directorates and the delivery of activity to meet the National and locally agreed standards. All Staff involved in the Administration of Patient Appointments are responsible for ensuring they are familiar with and follow the Trust s policy and procedures relating to patient access. 6 Entitlement to NHS treatment The Trust has a legal obligation to identify patients who are not eligible for free NHS treatment. The NHS provides healthcare for people who live in the UK. People who do not normally live in this country are not automatically entitled to use the NHS free of charge regardless of their nationality or whether they hold a British Passport or have lived and paid National Insurance contributions and taxes in this country in the past. An NHS card or number does not give automatic entitlement to free NHS treatment. 6.1 NHS Trusts legal obligations All NHS Trusts have a legal obligation to: Ensure that patients who are not ordinarily resident in the UK are identified 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 6.2 The Human Rights Act 1998 The Human Rights Act 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 the same way. Page 7 of 36

11 7 Transfer of Private Patients 7.1 Patients Transferring from Private to NHS Patients can choose to convert between an NHS and private status at any point during their pathway without prejudice. Patients wishing to transfer from the private service to the NHS must be returned to their GP to be offered choice for onward referral to an NHS provider. A new clock start will be generated for this referral reflecting a zero week wait. 7.2 Patients Transferring from NHS to Private NHS patients already on a waiting list opting to have a private procedure must be removed from the NHS waiting list. A new referral must be created NHS to private and a waiting list entry as private patient must be entered. 8 Outpatients 8.1 Outpatient stages Patients are administrated through the outpatient part of the RTT (Referral to Treatment) pathway in three main stages. They are Registration, Booking and Attendance. 8.2 Compliance with procedures It is the function of all staff involved in the booking of appointments to ensure that procedures are followed in order to appropriately record and code each of the three stages; ensure compliance with the RTT rules and ensure that the Trust discharges its clinical obligations within the appropriate time scales. 8.3 First appointment internal standard The key outpatient internal operating standard is for no patient to have to wait more than 8 weeks to first outpatient appointment. 8.4 The General Principles for Outpatients are that: Patients are seen in the order of clinical priority and date on the PTL. Patients have a single point of contact at the Trust call centre for outpatients and the specialty service manager for inpatients and day cases. All referrals should be registered on PAS at the point of receipt of letter. Referrals should be accepted or rejected as appropriate within 5 working days by the consultant and amended on PAS and e-referral if required. Where patients have been seen and discharged with the option that they may have a follow up appointment from the date of discharge, it is the patient s responsibility to contact the hospital if they wish to be seen providing it is within 6 months. Where patients who have been seen and discharged with the option that they Page 8 of 36

12 may have a follow up appointment from the date of discharge, it is the patient s responsibility to contact the GP to make a new referral if it is after 6 months Staff must abide by the parameters of the clinic structure (template) available, unless vacancies occur thereby swapping new and follow up slots accordingly to ensure full utilisation is maintained. This must only be done in conjunction with the outpatient booking teams and the consultants. Cancelled slots must be given to the next longest waiting patient. The Trust will operate a waiting list system based on taking patients in turn except for emergencies and cancer patients. Patients should be given appointments in date order to ensure equity of access. When making the appointment, the booking on PAS must be linked to the appropriate referral which has already been logged. Staff must ensure that duplicate referrals are not created as this will cause double counting and miscalculation of a patient s waiting time. The patient will be sent a confirmation letter or contacted by telephone regarding their booked appointment. The letter must be clear and informative and should include a point of contact to call if they have any queries or concerns. The letter should explain clearly the consequences should the patient cancel or fail to attend at the designated time. Where cancellations are initiated by the Trust, patients should be rebooked as close to their original appointment as possible, ie within the Trust s internal milestones. The policy of the Trust is that 6 weeks notice of clinic cancellations must be given. General Managers and Clinical Leads must give authorisation for cancellations of less than 6 weeks. 9 Methods of Referral 9.1 Non-electronic Referral Letters Non-electronic referral letters may be ed or faxed to the Call Centre from GPs, Allied Health Professionals, Optometrists and Dentists where a hospital service is not available via the e-referral System or where they do not have access to the e- referral facility. Submission of the full set of patient demographic details is required including home, work and mobile numbers. Unless clinically necessary, referrals should not be addressed to a named Consultant as this could create an unnecessary delay with the processing of the referral. All referral letters must be date stamped and registered on Medway on receipt. The clock start date recorded on the PAS will be the date the referral letter is received by Southend University Hospital NHS Foundation Trust. 9.2 Electronic Referral System (ERS) From June 2018 the only route of Referrals from GPs will be via ERS. Bookings made via this means will be received on the basis that the clinical letter will follow the referral via the Electronic Referral Service (ERS), if not immediately, within 5 Page 9 of 36

13 working days for routine referrals, 1 day for Fast Track referrals, of the creation of the Unique Booking Reference Number (UBRN). The referral letter will be sent as an attachment to the electronic referral within ERS. A paper copy is therefore not required and should not be sent to the Trust. The recognised RTT start date in this instance is the date the UBRN is converted to an appointment by the patient and is done automatically on PAS. Clinicians should review, accept or reject referrals within 5 days of receipt of the e- referral letter appearing on their e-referral work list. Clinicians are encouraged to nominate a deputy to undertake review of e-referrals in their absence however, if this is not carried outpatients will be booked a clinic appointment for attendance and must be seen. Where a UBRN cannot be converted into a booking, it can be deferred to the Trust and become an Appointment Slot Issue (ASI). This happens in real time and a slot must be found by the Trust so that it can be booked as soon as possible. Patients will be contacted within 2 weeks to inform them that the Trust is actively seeking an appointment for them. The 18-week clock starts the day the UBRN was deferred to the Trust. ASI lists are distributed from the Call Centre to specialties twice weekly. Note: E-referrals may only be rejected on clinical grounds; if an e-referral is rejected the GP/CAS (Clinical Assessment Service) will, in turn, notify the patient. 9.3 Clinical Assessment Service (CAS) Referrals are sent from the GPs electronically via ERS to the CAS. Referrals are then triaged within the specialty. The patient will be informed of the contact method for the service, either to ring in after a certain period or the service will contact the patient directly. Confirmation of appointment will be sent from the service/call centre. 9.4 Consultant Referrals to other Trusts Referrals to other Trusts must only be made when directly related to the original referral reason. It must be made using the interprovider transfer form ensuring that all data (MDS) is completed. The process will be monitored through the Southend University Hospital NHS Foundation Trust Call Centre. 9.5 Consultant Referrals from other Trusts Page 10 of 36

14 Referrals may only be received from other Trusts if the following two fundamental pieces of information are submitted:- The referral to the Trust is directly relating to the reason for the original referral to the referring consultant. Full set of demographic details, RTT clock start date and patient s current RTT status on the Minimum Data sent (MDS). Clock start dates for referrals received from other Trusts will be dependent on the referring consultant explaining whether the reason for this referral is due to either an existing condition; treatment has been started on an existing condition or, a new condition 9.6 Consultant to Consultant Referrals within this Trust It has been agreed with commissioners that consultant-to-consultant referrals can occur in line with the existing agreed policy (C2C Protocol dated September 2017/18). Referrals may be submitted to the receiving consultant in an appropriate referral letter. It must be made clear on the referral letter that this is a continuation of an existing RTT pathway and not for a newly identified condition unless the following have been identified: The patient is under the age of 19 years For investigation, management or treatment of cancer, or suspected cancer, in line with criteria for referral (2 week waits) Where symptoms or signs suggest a life threatening or urgent condition that requires the patient be seen in less than 4 weeks Where there exists suspected adult or child safeguarding concerns The consultant considers that the patient has a non immediate need for treatment or care, which is in scope of the services and which is directly related to the condition or symptoms for which the patient was referred for initially, with the exception of referrals to pain management 9.7 Consultant to Consultant Exclusion Criteria within this Trust It would be safe to make a referral back to primary care or to a community service (where a community service exists that can provide an alternative to secondary care management) A patient reveals symptoms unrelated to the referring condition or incidental findings which do not require urgent referral. The consultant should write in the discharge or clinic letter to the GP and advise of the findings. The letter should not include a recommendation to refer the patient back into acute services A patient requires an onward referral to pain management. All patients being considered for a referral to pain management should be either: o Discharged to primary care or o Referred to the CATS service, in line with the agreed pain pathway Page 11 of 36

15 10 Inappropriate Referrals When a consultant deems a referral to be clinically inappropriate, it must be sent back to the referring GP with an explanation why. The referral decision must be updated and discharged accordingly. Where a referral has been made and the special interest of the consultant does not match the needs of the patient, the consultant should re-direct the referral to the appropriate colleague in the same service or reject back to the GP to refer to the correct service. 11 Registration All referrals will be checked against the Patient Master Index (PMI) on PAS. If the patient is already registered on PMI the details must be checked and amended accordingly. Full details will be entered on to PAS to allocate a hospital number if the patient is not registered on PAS. Referrals with no NHS number should be checked on the National Summary Care Record by department staff. The GP and/or Data Quality Team should be contacted for clarity on any details. Patients referred via E-referral where an NHS number cannot be found will be allocated a Y number on PAS registration. The original copy of the referral letter will be held within the Southend University Hospital NHS Foundation Trust Call Centre for the use and ease of reference of the Consultant involved. Referrals will be scanned and forwarded to the relevant Specialty for Consultant grading. This is to be actioned within 7 days on receipt of the referral week RTT Booking Timescales All referrals will be received into the Southend University Hospital NHS Foundation Trust Call Centre to establish whether there is an RTT clock start or not and, where necessary, establish the clock start date. The Southend University Hospital NHS Foundation Trust call centre team will scan the letter and send electronically to the relevant specialty for acceptance/clinical prioritisation within 2 working days from receipt. The referral is then returned electronically to the call centre for booking or held and booked within the specialty. Communication with the patient will be initiated as soon as the clinician has indicated the relevant pathway. Where possible, patients should be offered the earliest available mutually convenient appointment date adhering to target timeframes, clinical priority and in turn. Relevant comments are to be recorded in the comments field on PAS. Any patients that cannot be contacted on two separate occasions are sent a first available appointment and asked to ring in and confirm attendance where possible. Page 12 of 36

16 Following confirmation with the patient of their appointment this is then verified on PAS. When patients have been referred on to the outpatient waiting list they may not be expedited unless there is a late notice cancellation or consultant agrees to expedite. 13 Ministry Of Defence Patients All Ministry of Defence (MOD) referrals sent to Southend University Hospital NHS Foundation Trust Call Centre are processed as other referrals. Priority will be given where GPs state that the patient is a war veteran. 14 Private Patients Private patients are recorded on PAS under the referral as PP for a Private patient, then the appointment type as P for a new appointment or OP for a review appointment. Where a patient has been seen privately, either in this Trust or at a private hospital they may be referred by letter in the usual way by either the consultant or their GP. The referral will be treated as a new referral and the patient pathway will reflect a zero week wait at referral. It is important to ensure that the parameters of equity are observed and patients who have transferred from the private sector are not disadvantaged and are allowed to enter the RTT at the appropriate part of the pathway as a new clock start. 15 HM Prison Patients (HMP) Referral for HMP patients are processed via the same means as any other manual referral. However, the Healthcare Department is contacted by telephone and the first convenient appointment arranged in order to minimise the risk of cancellations. 16 Attendance On attending the outpatient clinic demographic details including current GP, address and updated contact telephone/mobile number will be checked with the patient by the clinic reception staff. 17 Overseas Visitors An overseas visitor is defined as: - a person who is not ordinarily resident in the UK. Residency is defined as Living lawfully in the UK. Treatment is free at point of contact for all patients in an A&E department. However, once a patient is referred to an outpatient clinic (or added to an elective Page 13 of 36

17 waiting list) or admitted as an emergency to a ward, this treatment is no longer free for an overseas visitor unless evidence can be shown that they have a reciprocal agreement entitling them to free healthcare. All patients without exception should be asked Have you lived in the UK for the past 12 months and asked to provide evidence of residency in the UK to prove entitlement to free NHS treatment within secondary care for example; a contract of employment if employed; u tility bill; t enancy agreement or b ank s tatement along with their passport or identification card for EU Citizens. The above question must be asked of all patients at each point of contact within the Trust. This is a legal responsibility of the Trust and is therefore the responsibility of all who have first line contact with patients, be it in outpatients or on a ward. Where a patient has not lived in the UK for the past 12 months or cannot provide evidence of residency, the Private Patient and Overseas Patient Office (PPOP) must be contacted to interview the patient before treatment commences (unless this treatment is clinically urgent). 18 Clinic Management 18.1 Booking Capacity Where the number of patients referred exceeds the available capacity within a speciality the General Manager will be ed on a twice weekly basis by the Call Centre manager. The Call Centre will contact the Associate Director of the specialty to agree a resolution if no response is received within a week 18.2 Notice Periods Patients should be given choice in their appointment date and therefore full use of the available pathway time must be used. In accordance with the national guidance a reasonable offer of appointment involves giving a patient the offer of 2 dates with at least 3 weeks notice of their appointment. Urgent patients may be offered one reasonable notice date (the other offers may be under 3 weeks) All dates offered are recorded on PAS Where a patient declines 2 reasonable offers within 18 weeks and, in agreement with clinician, the patient may be removed from the waiting list and referred back to the GP 18.3 Clinic Cancellations/Reductions/Reinstatements Clinic cancellations should be initiated by the relevant specialty using the appropriate Clinic Cancellation electronic form. The Consultant will be advised of the impact of such changes prior to authorisation. Page 14 of 36

18 The necessary changes will be implemented within 2 working days of receipt of the authorisation Notice of Annual Leave and Study Leave A minimum of 6 weeks notice of annual leave, study leave, professional leave or Consultant of the week commitments must be given when a clinician requests a scheduled clinic to be cancelled or reduced. However, in all circumstances a Clinic Cancellation/Reduction must be requested by completing the template proforma, stating the impact this cancellation will have, and sent to the Clinical Lead to be authorised. No clinics are to be cancelled at less than 6 weeks notice without both the General Manager s and the Clinical Lead s approval. All leave taken with less than 6 weeks notice must have a contingency plan for seeing patients, ie another clinic or doctor. It is only after these actions have been completed that the authorised request should be forwarded to the call centre or specialty outpatient booking department. Where patients have to be cancelled at short notice, the clinician must be able to offer alternative dates to the patient without significantly lengthening the waiting time standard pertinent at that time. Evidence of discussions should be recorded on the clinic cancellation form Template Management Clinic templates are co-ordinated centrally by the PAS team. In order to accurately record patient activity and properly attribute work undertaken by clinicians in the outpatients service, it is vital that a minimum of 6 weeks notice for changes to clinic templates and/or services are provided by the General Manager and, where appropriate, engagement takes place during the planning stage so that transitional periods may be dealt with effectively. All Template request forms must be approved by the General Manager for either amendment to existing templates or the creation of new templates. New templates involving the creation of new outpatient capacity assigned for previously booked patients will require 6 weeks notice for administrative workload to phase in the new schedules. New templates involving the creation of new capacity to book patients not previously assigned appointments will be initiated within 48 hours of receipt of approval. Amendments to existing templates should be given 6 weeks notice and will be initiated on receipt of approval from the General Manager. The changes will be phased in 6 weeks ahead. Page 15 of 36

19 Changes and additional Nurse Led clinics will be approved by the Head of Nursing for the service Follow up appointments The Trust operates on the basis that: Patients should not be recalled for follow-up appointments unless absolutely essential. The Trust operates two methods of follow up booking, partial and full booking. Patients should leave clinic with a follow up appointment agreed for services operating a full booking system Partial Booking The Trust operates a Partial Booking system for some services. All appointments where the patient is to be seen in 6 weeks or under are booked at the reception desk when the patient leaves clinic. The same applies for vulnerable patients and those where their medical condition requires a firm appointment or series of appointments to be booked The only exception is where clinic capacity does not exist. A patient that remains undated beyond 6 weeks of the due by date is reviewed by the clinician to assess the clinical risk of delay. Patients must be added to the Partial Booking review list on PAS. Patients requiring appointments over 6 weeks ahead are added to a waiting list and an appointment 6 weeks prior to their due date is arranged where capacity allows. Where a patient does not attend their follow up appointment, the clinician will review the notes in the clinic setting and decide if a further appointment should be booked. However, if the review appointment is considered non-urgent, after clinical review, a further appointment may be offered. Where the clinician decides that an urgent review is still required, a further appointment will be offered. This decision must be made immediately to ensure that the appropriate outcome is recorded Did not Attend Where the clinician, on review of the notes at the end of the clinic, decides that the patient is clinically required then a further appointment will be offered to the patient. The RTT clock continues during this period, unless this was a first outpatient attendance. The RTT clock is nullified if this was a first outpatient appointment. The outpatient clock will restart from the date the Trust and patient agree on a new appointment date if a further appointment is offered. Page 16 of 36

20 Where the clinician, on review of the notes at the end of the clinic, decides that the patient does not clinically require the appointment, and reasonable notice was given, the patient will be discharged back to the GP and the clock stopped. The only exception for the above is children under the age of 18 or people in care (Vulnerable Adults) or on a cancer pathway, another appointment will be offered. Subsequent DNA s will be discussed with the clinicians and safeguarding teams if appropriate. The clinician must record the outcome before the clinic ends either the patient is discharged or must be offered another appointment This decision must be made immediately to ensure that the appropriate RTT outcome is recorded on PAS. Where the patient is subsequently re-referred by their GP this will constitute a new RTT clock start. New referral patients from other referring clinicians (eg consultant to consultant) will also be referred back to the original referrer. E-referral patients who DNA follow the same pathway Patient Initiated Cancellations Where the patient gives any prior notice that they cannot attend their appointment (even if this is on the day of clinic), this should be recorded as a cancellation and not a DNA. The Trust will make every effort to reschedule patient appointments at the convenience of the patient. Patients can choose to postpone or amend their appointment or treatment if they wish, regardless of the resulting waiting time. Such cancellations or delays have no impact on reported RTT waiting times. However, clinicians will be informed of patient initiated delays (where two concurrent cancellations have already been made and a third is requested) to ensure that no harm is likely to result from the patient waiting longer for treatment (clinicians may indicate in advance, for each specialty or pathway, how long it is clinically safe for patients to delay their treatment before their case should be reviewed). Where necessary, clinicians will review each and every patient s case on an individual basis to determine whether: The requested delay is clinically acceptable (clock continues) The requested delay is clinically acceptable, but the clinician believes the delay will have a consequential impact (where the treatment may fundamentally change during the period of delay) on the patient s treatment. The patient should be contacted to review their options this may result in agreement to the delay (clock continues) or to commence a period of active monitoring (clock stops) The patient s best clinical interest would be served by discharging them to the Page 17 of 36

21 care of their GP (clock stops) Where a patient is subsequently re-referred this will constitute as a new clock start, and the patient will be classified as another new referral attendee. When a patient no longer wishes to be seen, they may choose to cancel their outpatient appointment and this will stop the RTT pathway. This will result in discharge back to the care of their GP. The RTT clock will be stopped as a consequence by the person receiving the notification from the patient. It is imperative that PAS is updated immediately using the date that the patient contacted the Trust to cancel their appointment. A letter is sent to the GP to inform them that the patient has been discharged Hospital Initiated Cancellations The clock continues to tick if the Trust cancels a patient s outpatient appointment. For new referral appointments cancelled, the revised appointment must not breach the current waiting time standard. Cancellation of a follow up appointment will result in rebooking and the new date must take account of the clinical prioritisation, whilst also avoiding the potential to breach the RTT standard. Particular attention by specialty teams must be paid to appointments that may potentially be cancelled where clock stopping treatment was planned to be carried out in clinic. This would avoid potential breaches under these circumstances. The Trust standard is for clinicians to provide a minimum of 6 weeks notice for clinic cancellations and, in line with this, every effort should be made to predict clinician absences and therefore reduce the need to cancel outpatient appointments. Wherever possible, patients who have been cancelled once should not be cancelled for a second time unless, as a result of clinical reprioritisation, there is no other option. However, clinicians will be informed of hospital initiated delays (where two concurrent cancellations have already been made and a third is attempted) to ensure that no harm is likely to result from the patient waiting longer for treatment (clinicians may indicate in advance, for each specialty or pathway, how long it is clinically safe for patients to delay their treatment before their case should be reviewed). Where necessary, clinicians will review each and every patient s case on an individual basis to determine whether the delay is clinically acceptable (clock continues). All clinic cancellations require authorisation by the General Manager and Clinician of the service with an approved copy of the clinic cancellation request. No patients are to be cancelled until this form has been sent to the Call Centre or Specialty booking service. When a clinic has to be unavoidably cancelled, it is essential that effective liaison takes place between the Clinician, Lead Manager/Service Manager, outpatient nursing staff, and the Outpatient administration team to ensure capacity is replaced. Page 18 of 36

22 The patient will be contacted by either the Call Centre or Specialty team If an agreed appointment needs to be cancelled in less than 6 weeks who will agree an alternative date and time within the waiting time standard which is pertinent at that time. This will then be recorded on the PAS Attendance Outcome Coding including DNAs and Cancellations It is the responsibility of the clinical staff in the outpatient clinic to accurately report any procedures or treatment undertaken and identify the appropriate referral to treatment (RTT) outcome code on the outcome form. Given the importance of accurate and timely RTT coding responsibility for the process is a collaboration of the multi-disciplinary team. Clinic staff should ensure that at the end of a clinic, all patients have a recorded outcome and the relevant outcome form is signed by the clinician. The receptionist must ensure that all information is accurately entered into PAS and signs the outcome form once procedure has been recorded. The medical secretary will support the outpatient team in addressing missing RTT outcomes and procedures/treatments within 48 hours of the clinic date to enable all cashing up to be completed and updated on PAS. 19 Diagnostics Referral for all diagnostic tests must be made via the electronic systems or by appropriate process set by each department. Where possible, once patients have been referred for a diagnostic test after being seen in the outpatient clinic, they should be able to book their diagnostic appointment before leaving the hospital. The National maximum waiting times for Diagnostic investigations are: Cancer patients - 2 weeks Urgent patients - 4 weeks Routine request - 6 weeks The patient must be contacted by telephone to agree a date for their diagnostic test if a patient is not able to book their diagnostic test prior to leaving the hospital. Where the patient is not available on the first phone contact, a second attempt the following day at a different time is to take place. Where the patient is still not available, an appointment letter (with date and time) will be sent to the patient within 24 hours for all urgent/cancer referrals, and 48 hours for routine, requesting them to ring the department if the appointment is not convenient. Page 19 of 36

23 When offering routine dates to patients for diagnostic tests, the locally agreed reasonable criteria of 2 weeks notice must be given wherever possible with a choice of two dates. Should the patient refuse these dates, this must be recorded on all relevant systems. Patients who cancel an offer of a diagnostic appointment date will be able to discuss another date for their procedure within their RTT pathway. PAS will be updated to reflect the cancelled appointment date. Further dates should be offered to support patient choice and to accommodate the patient s diagnostic test being performed up to the 6 week point in the diagnostic pathway and 2 week rule for cancer patients. The patient will be referred back to the referring clinician or GP (if direct access diagnostic) if a further date cannot then be agreed within the target pathway. Patients who have agreed their appointment date, b u t with short notice (ie less than 2 weeks), but then cancels, a further offer of a date will be made. Where a patient does not attend where the patient has had a choice of date and time of the appointment, the attendance will be recorded as a DNA and the requesting clinician will be informed with a view to the patient being referred back to the GP and discharged. (Excludes cancer patients - see Cancer Access Policy) Where the period of notice provided by the patient for a cancellation is not within a reasonable time ie on the day of the procedure taking place, the cancellation will be recorded and the patient may be returned to the care of the GP and discharged, following review by the clinician. (Excludes cancer patients.) For patients where the requesting clinician is the GP, and the patient is monitored as being within the RTT pathway, the relevant diagnostic department will, after discussion with the clinician, refer the patient back to the GP and the clock will be stopped. For patients where the requesting clinician is the GP, and the patient is not monitored as being within the RTT pathway, the relevant diagnostic department will refer the patient back to the GP. Monitoring of the timeframes is the responsibility of the relevant Lead Manager for the diagnostic area. 20 Elective Inpatients and Day Cases 20.1 Pre-Operative Assessment A core pathway for pre-operative assessment has been agreed and implementation is tailored to each specialty. The majority of patients will complete a health questionnaire prior to being added to the waiting list. The Pre-Operative Assessment team will decide from the Page 20 of 36