PATIENT ACCESS POLICY

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1 V 9.1 PATIENT ACCESS POLICY Reference Number: POL- COR/1825/11 (OLD REF NO.COR/2011/002 Version / Amendment History Version: 9.1 Status: Draft Author: Roger McBroom Title: Head of Patient Access and Administration Version Date Author Reason Dianne Prescott Introduction of National 18 week rules Dianne Prescott Comments from MAC 3 3/ 2011 Dianne Prescott Updated 4 July 2012 Gayle Halliday Cancer Centre Updates 5 August March November 2014 Helen Scott-South Helen Scott-South Roger McBroom Organisational change and Internal Audit Recommendations Revision following discussion at MAC in December 2012 and with Strategy and Partnership (Dianne Prescott) Revision following recommendations from an IMAS report on the management of 18-week Referral to Treatment December 2013 and implementation of Lorenzo 7.1 February Roger McBroom Emphasis on patient 2 1 of 29

2 2015 DNA before referral back to primary provider 7.2 June 2015 Roger McBroom Link included to Single Source of Truth. Inclusion of 6-week diagnostic reasonable offer guidance. Declaration that if a patient cancels their appointment twice, they may be discharged back to their GP 8.0 May 2016 Roger McBroom In addition to a number of minor amendments, key updates, which have been left highlighted for ease of reference, include: Overseas visitors Accessible Information Standard RTT Patient transport Referral review times Interpreters Records management Monitoring requirements 9.0 June 2017 Roger McBroom Amendment as a result of routine review and specifically, feedback from NHS Improvement. 9.1 December 2017 Sarah Morgan (Data Quality Team) Amendment as a result of routine review of delays for elective admissions. Highlighted for ease of reference Training and Dissemination: All Staff associated with patient access and who use the Lorenzo patient administration system must undergo training, including awareness of this policy and any associated SOPs. This will be delivered to all new applicable staff as part of their induction and as part of their essential-to-role training prior to issue of their smartcards. 2 of 29

3 To be read in conjunction with Trust Policies: See key References section In consultation with and date: Head of Operations 19 June 2017 Elective Care Delivery Group 13 June 2017 Head of Information 2 June 2017 Medical Advisory Committee 1 June 2017 Patient Access Group 2 February 2017 RTT Education Team 16 January 2017 NHS Improvement 6 December 2016 EIRA stage One Completed - Yes Stage Two Completed - NA Approving Body and Date Approved Chief Operating Officer 21 June 2017 Date of Issue 21 June 2017 Review Date and Frequency Contact for Review Executive Lead Approving Executive Annually by Chief Operating Officer Head of Patient Access and Administration Chief Operating Officer Chief Operating Officer 3 of 29

4 Derby Teaching Hospitals NHS Foundation Trust Patient Access Policy 1 Introduction 1.1 This policy has been produced collaboratively with the local health community and sets out the standards for the Trust, referrers and patients by which we manage our access to services. A user guidance section for staff (see paragraph 28) describes how they are to achieve this using the Trust s electronic patient administration system (PAS). This policy also gives Trust staff clear direction and expectations on all aspects of patient access in line with patient rights as set out in the NHS Constitution and Accessible Information Standard. The Trust will use this policy to demonstrate how rules are applied fairly and with equity in the provision of planned care. This policy should be read in conjunction with other related policies, which can be accessed via the links provided at the end of this document. 1.2 This policy aims to inform patients, their relatives and carers of their rights and what they can expect from the Trust in terms of access to services by outlining relevant rules, responsibilities and actions by which the Trust will manage patients through their pathways, specifically: The national 18-week Referral to Treatment (RTT) pathway, which is about improving patients experience of the NHS, ensuring all patients receive high quality elective care without any unnecessary delay. National Cancer Waiting Times for all suspected and diagnosed cancers. 1.3 Everyone has the right (by law since 2010) to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible. This includes a right to: start consultant-led treatment within a maximum of 18 weeks from referral for nonurgent conditions; and be seen by a cancer specialist within a maximum of two weeks (2WW) from General Practitioner (GP) referral for urgent referrals where cancer is suspected. 4 of 29

5 1.4. We also provide a range of patient information publications on a range of conditions, procedures and services and these are available to patients in the respective departments and via the Trust s website. 2 Purpose and Outcomes 2.1 This policy sets out how this Trust will manage 18-week RTT pathways and suspected cancer referrals in line with national targets and guidance. Application of the policy will ensure that each patient s RTT clock starts and stops fairly and consistently in accordance with an agreed structured methodology. Treatment decisions will be fair and transparent and at an operational level this translates into the adoption of the following key principles: The management of patients will be fair, consistent and transparent and communication with patients will be clear and informative and will be consistent with the Human Rights Act 1998 and the Equality Act Patients seen in outpatients, diagnostics or admitted as inpatients/day cases will be seen firstly according to clinical priority and then in chronological order based upon the 18- week RTT pathway. We will attempt wherever possible to agree appointment dates to suit patients personal circumstances. In the event that, due to a lack of capacity, the hospital cannot expect to treat patients within the mandated timescale, patients and their GP will be notified of this. Patients will also be presented with a range of alternative providers that will be able to treat them within those timescales should they wish to take up this offer. 2.2 Consultant-to-Consultant and Consultant-to-GP referral criteria are: a. Direct referrals will be appropriate for: Suspected or diagnosed cancer. Urgent problems for which delay would be detrimental to the patient s health. The expectation here would be that the patient needs to be seen within 2 weeks. Referral as part of the same clinical problem. Part of the recognised pathway of care for the condition or as part of a preoperative assessment. Transfer of responsibility of care for an on-going condition, when it would be more convenient for the patient to be seen in a different location. b. Referral back to GP will be appropriate for: Conditions that are unrelated to the presenting problems and do not require urgent referral. 5 of 29

6 Incidental findings; conditions that can be dealt with by the Clinical Commissioning Group (CCG) or GP. Those patients who Did Not Attend (DNA) their appointment twice, subject to clinical agreement (it is anticipated that these cases will be reviewed in a timely manner, ideally at the end of the relevant clinic). Those patients who cancel their appointment twice, subject to clinical agreement (it is anticipated that these cases will be reviewed in a timely manner, ideally at the end of the relevant clinic). Staff should also satisfy themselves that the weight of cause is biased towards the patient and not for example due to the fact that the hospital may have cancelled the patient first and offered a new appointment that is inconvenient for the patient. c. Referral Queries: If there is any doubt as to whether a patient needs to be managed by the hospital or whether a patient should be offered another choice of hospital, consultant or treatment option, the responsible Consultant should contact the patient s GP to discuss the case. Patients should only be added to a waiting list when fit and ready for treatment and in the case where a patient is unfit; they should be reviewed by a clinician or GP and added when appropriate. 3 Responsibilities, Accountabilities and Duties See Appendix Outpatient Referrals 4.1 With the exception of cancer 2WW and urgent screening referrals, all referrals (electronic and paper) will be reviewed and prioritised within 7 working days of receipt, except for visiting consultants, where alternative arrangements are to be agreed locally by the Business Unit Clinical Director. 4.2 Cancer 2WW and cancer screening urgent referrals must be reviewed and prioritised within 24 hours of receipt. 4.3 Processes around the use of the NHS e-referral Service Advice & Guidance (A&G) service (designed to support GPs with referral queries) must be standardised across the Trust and, in accordance with contractual requirements, 95% of A&G requests should be responded to within 3 working days of the request (for urgent) or 5 working days (for routine). As the NHS e-referral Service system only supports one response, a holding message must not be used and such messages are not considered by the commissioner to be an appropriate response under the contract s requirements. 6 of 29

7 4.4 If a 2WW referral is deemed inappropriate from the information provided, consultants must contact the GP to discuss the referral further. If, after that discussion, the GP agrees to downgrade the referral, the GP must re-refer the patient using a standard urgent or routine letter or pro-forma through NHS e-referral Service. The consultant must note the date, time and outcome of the discussion on the 2WW form, which must be filed in the case notes and the Cancer Centre Manager informed. A new referral with a new patient pathway identifier will start a new pathway weeks (21 days) notice must be given to the patient when agreeing an appointment date. The only exceptions to this are: Where it is clinically urgent (e.g. cancer 2WW referrals). Urgent referrals for screening appointments i.e. bowel, breast and ovarian cancer screening. For a diagnostic test/procedure, where a reasonable offer is 10 days or more. Where patients make themselves available at short notice. 4.6 Referral Queries - If there is any doubt as to whether a patient needs to be managed by the hospital or whether a patient should be offered a choice of provider it will be advisable for the consultant to contact the GP to discuss the case. 5. Inpatients / Day Cases / Active Waiting List / Planned Waiting List 5.1 Patients must only be added to an active elective admission access plan or booked for surgery when they are ready and able to come in (TCI) for their appointment/treatment. 5.2 Cancer patients must be given the earliest possible TCI date, within their 31 or 62 day target, whichever is the earliest. Clinical staff should refer to the Cancer Centre team for the cancer target date information. 5.3 A TCI form must be used by all Consultants and must be completed for each patient, including those who have been seen at peripheral and private hospitals. 5.4 Any conversations with patients agreeing to dates offered and declined need to be recorded and documented together with the reason(s). 5.5 Patients may choose to delay their inpatient treatment, in this case, their 18wk RTT clock will continue to tick and they must remain on an active waiting list. If this results in a breach, these patients fall into the allowed tolerance level above the RTT national target. You should however inform the clinician of any patients who have requested a delay that is longer than agreed guidelines in case this is detrimental to their condition, as well as the Assistant General Manager if the delay will result in a breach. 5.6 A decision to treat letter must be sent to the GP. 5.7 Patients with the same priority will be treated in chronological order in line with their RTT pathway, unless the patient has specifically chosen a later date themselves. 7 of 29

8 5.8 When selecting patients for listing, it is essential to make that selection based on clinical grounds and length of wait only. 5.9 DNAs where safeguarding issues (Adults and Children) are a factor must be alerted to the GP, the Health Visitor Liaison Nurse (based in CED) and Family and Children s social care as necessary Patients may need to be added to a planned waiting list following treatments, diagnostics resulting in watchful wait or additional admissions for a planned sequence of care. Examples of this would be repeat colonoscopies, repeat injections, or multiple sessions of lithotripsy for kidney stones. Patients will only be placed on a planned list if they have undergone initial treatment/diagnostic test and a period of time is required to elapse before the next stage of treatment is commenced. Planned patients will be given an approximate date, for the second and any subsequent admissions at the time of their first treatment or when the diagnostic results are communicated. Patients on a planned list are outside of the scope of 18 weeks; however, these patients will still be treated in a timely manner and within clinically appropriate timescales. When patients are added to the planned list they will be allocated an expected appointment/admission date for the clinically appropriate time. This Trust manages overdue planned patients separately rather than moving them onto the active waiting list at over 4 weeks. 6. NHS e-referral Service 6.1 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 guidance states that the responsibility for the effective implementation of NHS e-referral Service should be shared between organisations. For example: Providers are responsible for ensuring that services are made available on NHS e- Referral Service and that patients can book into appointments using the system Referrers are responsible for using NHS e-referral Service effectively to find suitable services for their patients Commissioners are responsible for ensuring that services available on the system accurately represent the clinical needs of their patient population and that those referrers and providers use the system effectively for the benefit of all patients. 6.2 Until this option is formally closed as part of a paperless strategy in the future, the option for paper referrals via post or fax machine remains. 7. Referral to Treatment (RTT) Rules 7.1 The NHS Constitution confirms that all patients have the legal right to start NHS consultantled treatment within a maximum of 18 weeks from referral, unless they choose to wait longer or it is clinically appropriate that they wait longer. The national standard for 18 week RTT is those on an 8 of 29

9 incomplete pathway whose clock is still running; 92% of those on the waiting list should not have waited more than 18 weeks. 7.2 Consultant-led treatment includes treatments where a consultant retains overall clinical responsibility for the treatment. This could include treatments provided by the service or team led by the consultant. The setting of the consultant-led treatment, whether hospital-based or in a community-based clinic, will not affect a patient s right to start treatment within 18 weeks. 7.3 If a patient cannot be seen within the maximum waiting time, the organisation that commissions and funds the treatment (CCGs or NHS England) must investigate and offer a range of suitable alternative hospitals or community clinics that would be able to see or treat the patient more quickly. The local CCG or NHS England must take all reasonable steps to meet the request. 8 RTT Measurement 8.1 Clock Starts. A clock start is the date that the Trust receives notice of the referral in to any service (consultant led, interface or assessment service) via the NHS e-referral Service or when the Defer to Provider functionality is used in the NHS e-referral Service. Where a paper referral is sent, the clock start is the date on which the referral is received by the Trust or the receiving consultant for consultant-to-consultant referrals. 8.2 Clock Continues The clock continues while tests and investigations are taking place. 8.3 A clock does not automatically stop when a patient DNAs a follow-up appointment. 8.4 The clock does not stop when a patient gives more than 24 hours notice that they are unable to attend an appointment. 8.5 An in-patient or day-case admission for a diagnostic procedure only will not necessarily stop an 18-week clock; the decision on whether it does rests with the Consultant if it is felt that Watchful Wait/Active Monitoring is appropriate or there is no decision to treat and the patient is being discharged. 8.6 Clock Stops The 18-week clock stops when first definitive treatment is given surgically or non-surgically, for example advice or medication. The clock may also stop for non-treatment provided communication is given, without undue delay, to the patient and their GP and/or other referring practitioner. These clock stops could be: A clinical decision is made to start a period of active monitoring/watchful wait. A patient declines treatment having been offered it. A clinical decision is made not to treat. A patient DNAs their first new appointment in their RTT pathway following the initial referral that started their 18-week clock, provided that the provider can demonstrate that the appointment was clearly communicated to the patient. 9 of 29

10 A patient DNAs any other appointment twice and is subsequently discharged by a clinician back to the care of their GP provided that: o The Trust can demonstrate that the appointment was clearly communicated to the patient. o Discharging the patient is not contrary to their best clinical interests. o Discharging the patient is carried out according to local, publicly available, policies on DNAs, which is as described in this policy If there is a delay in booking a further follow-up appointment because the patient preference makes it impossible or unreasonable for 18 weeks to be achieved for that patient, they will be discharged back to their GP. The Trust measures 4 weeks from the original offer as unreasonable. 8.7 Managing Delays Patients are entitled to wait longer for their treatment if they wish. Patients must be allowed to plan their treatment around their personal circumstances. Delays as a result of patient choice are taken account of in the tolerance of 8% set for achievement of the incomplete pathway waiting time operational standard. This means that a patient wishing to delay their treatment must not be removed from the waiting list or have their RTT clock stopped. There is no blanket rule within the Trust that allows a maximum length to patient-initiated delays to be applied for personal circumstances. Clinicians should provide waiting list staff with guidelines as to how long (in general) patients should be allowed to defer their treatment without further clinical review. Patients requesting a delay longer than the general guideline should have a clinical/notes review to decide if this delay is appropriate. If the clinician is satisfied that the proposed delay is acceptable then the trust should allow the delay, regardless of the length of wait. An approximate timescale for a TCI must be documented within the patient s waiting list on Lorenzo. 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 be agreed. If the patient refuses to accept the advice of the clinician then the responsible clinician must act in the best interest of the patient. In this case the clinician may feel that it is in the best clinical interest of the patient to discharge the patient back to the care of their GP and inform them that treatment is not progressing. This must also be made clear to the patient. This must be a clinical decision, taking the healthcare needs of each individual patient into 10 of 29

11 account. In this scenario the patient would be removed from the waiting list and the RTT clock must be stopped. It is not acceptable to refer patients back to their GP simply because they wish to delay their appointment or treatment. However, it would be acceptable where referring patients back to their GP is in their best clinical interests. Such decisions should be made by the treating clinician on a case by case basis. Clinician Initiated (Patient not fit for Treatment). If a patient is listed for surgery is deemed unfit for the procedure, the decision on whether or not to delay and/or stop the clock is a clinical one, regardless of whether it is the patient self-reporting as unfit or through a clinical review. The nature and duration of the clinical issue should be ascertained, if the patient is expected to be fit for the procedure within 4 weeks the patient must remain on the waiting list and the RTT clock should continue to tick. If the clinical decision is that the patient is not expected to be fit within 4 weeks, then the patient should be removed from the waiting list and the RTT clock stopped. It may be that a period of monitoring will follow in which case a clock stop for active monitoring is appropriate, however where treatment is no longer a viable option and the patient is best managed through primary care, then a decision not to treat should be recorded. The GP and patient should be kept informed of any decision made. 8.8 Active Monitoring will commence when a decision is made (and agreed with the patient) that it is clinically appropriate to start a period of monitoring, possibly whilst the patient receives symptomatic support, but without any specific or significant clinical intervention at this stage. Active Monitoring may be initiated by either a care professional or a patient and stops the RTT pathway. When patient initiated the Active Monitoring/Watchful Waiting, this must still be agreed by a clinician. During Active Monitoring the patient will remain under the care of a consultant or NHS Allied Health Professional Service although the GP will be updated with the progress of their patient. If a decision to treat is made during Active Monitoring, this will end the Active Monitoring and will start a new RTT period. 9. Patients Not Applicable to the 18-week RTT Emergency patients. Patients on planned waiting list or undergoing planned care. Private patients. Obstetrics. Direct GP referrals to non-consultant led services. 10. Refusal of Referrals 11 of 29

12 10.1 NHS guidance states that providers should accept all clinically appropriate referrals made to them. Patients choosing a particular NHS provider must be treated by that provider as long as this is clinically appropriate and in accordance with the patient s wishes. 11. Cancer 11.1 All patients referred with suspected cancer by their GP have a maximum wait of two weeks to see a specialist. This also applies to all patients referred for investigation of breast symptoms, even if cancer is not initially suspected Cancer patients should wait no more than 31 days from the decision to treat to the start of their first treatment or any subsequent surgical, drug and/or radiotherapy treatment. If a patient has been seen at another Trust, the 31-day clock may have already started so a check with Cancer Centre staff for target date is required All patients should wait no more than 62 days from their urgent GP referral to the start of their treatment. This 62-day standard also includes all patients urgently referred from NHS cancer screening programmes (breast, cervical and bowel) and all patients on consultant upgrade pathway. If a patient started their 62-day pathway at another Trust, the clock will have already started This Policy confirms that the Trust will adhere to these standards and any breaches will be reportable to the Board. 12. Patients who DNA and Cancellations by the Hospital and the Patient 12.1 If the Trust cancels a Patient s operation on the day for non-clinical reasons, a new date should be offered and this date should be within 28 days of the date the operation was originally booked for This 28-day standard covers all planned and booked hospital operations, including day surgery, but does not cover minor operations carried out at outpatient appointments or clinics If a patient DNAs two appointments, they should be referred back to their referrer, unless the clinician deems it clinically necessary to offer another appointment. A letter confirming their discharge must be sent to the patient and their GP/referrer. At the end of clinic all DNA records will be collected together and reviewed by each Consultant for their clinic or by a nominated consultant for all clinics. The default position is to discharge after 2 DNAs unless otherwise clinically indicated (excluding cancer, paediatrics and some long terms conditions for which a second appointment is offered prior to Consultant review). If a patient cannot make an appointment, they should contact the clinic as soon as possible to ensure timely rebooking and this may also allow the appointment to be offered to somebody else. It helps if referrers outline to patients prior to referral the patient s own responsibilities to attend appointments and how cancelling or not attending appointments can affect their right to have treatment within 18 weeks of referral With regard to measurement of RTT times, the national guidance states that: 12 of 29

13 For first appointments on an RTT pathway: o If the patient DNAs, their RTT clock can be stopped and nullified on the date of the DNA appointment. o If the patient DNAs but the Trust chooses to rebook the patient, then their original RTT clock would be stopped on the date of the DNA appointment and a new clock will start (at zero) on the date that the Trust rebooks the patient. For subsequent appointments on an RTT pathway: o If the patient DNAs twice and the clinician feels it not detrimental to return the patient back to primary care, please see paragraph 12.6 below. Their RTT clock would stop on the date of the second DNA appointment. o If the patient DNAs but the Trust chooses to rebook the patient, then their existing RTT clock would continue to tick If a patient cancels their appointment in advance, even with less than 24 hours notice, this is not a DNA so has no effect on the RTT time; the RTT clock will continue to tick If a patient DNAs their appointment twice, subject to clinical agreement, the following will occur: Adults - where there are no safeguarding issues, the patient will be discharged back to their GP. Where there are potential safeguarding issues, the patient should be offered another appointment. Cancer patients - can be referred back to their GP after multiple (two or more) DNAs if this is agreed with the Consultant. Children - will automatically be offered another appointment. In DNA cases, all Consultants must identify whether safeguarding issues are a factor and whether the DNA constitutes potential neglect of medical needs. Children who fail to attend a second outpatient appointment will be discharged back to their GP and the Health Visitor Liaison Nurse (based in CED) should be informed. For missed follow-up appointments, the lead clinician will decide if there is a clinical need for follow-up in secondary care or whether primary care management would be appropriate. An assessment will be made as to whether the repeated non-attendance of the child could indicate neglect of their health needs and further referrals to safeguard the wellbeing of the child/young person may be made For patients with a series of planned appointments, DNA s will need to be considered on a case-by-case basis by the responsible clinician If a patient DNA s where a face-to-face interpreter has been booked, clinic administration staff are authorised to use that interpreter to attempt to make contact with the patient in order to 13 of 29

14 establish a reason why and to offer a new appointment where that is appropriate in order to maximise the use of the translator resource In the event that an interpreter DNAs a pre-booked appointment, clinics are encouraged to continue with the appointment utilising other methods of communication, including attempting to resource interpretation services via the telephone service. Only if it is deemed clinically unsafe to continue with an appointment should a patient s appointment be cancelled and rescheduled. 13. Records Management 13.1 All staff who handle patient casenotes are responsible for ensuring that each time a set is transferred from one location to another, the volume management module on the PAS is updated. Staff who regularly use this module will have these responsibilities written into their job description. It is imperative that this action is carried out accurately and in a timely fashion to reduce the incidence of casenotes not being able to be located for appointments and the need to create temporary casenotes. 14. General Outpatient Booking and Referral Management Principles 14.1 If the patient was discharged more than 6 months ago, GPs will have to re-refer if an appointment is required for the same condition Open appointments may however, in certain circumstances, still be given by the Trust, but the length of time granted for these varies across specialties and is dependent upon the nature of the service/conditions treated Review of referrals must be completed within 7 working days, except for visiting consultants; this does not include cancer patients Referrals are not expected to be routinely rejected. The NHS e-referral Service Operational Manager will audit rejected referrals on a regular basis and advise on solutions to the issues. The Trust can only reject a referral that hasn't been accepted (to be seen) in the NHS e-referral Service. The rejection process sends the patient back onto a work list at their GP surgery and the appointment is automatically cancelled on the PAS and NHS e-referral Service. It is then the GP s responsibility to notify the patient of their appointment cancellation. As a safeguard, clinics also send out an appointment cancellation letter to the patient advising them to contact their GP. If the clinic area deals with the inappropriate and more appropriate service they will change the service and book a further appointment (in NHS e-referral Service) and notify the patient. If they do not deal with the more appropriate service they will reject it back to the GP for them to re-direct. All inappropriate referrals will be referred back to the GP for them to review the choice of provider prior to the referral being re-directed Outpatient clinic staff will redirect referrals as instructed to the correct service/clinic. 14 of 29

15 14.6 The Date Request Received in the PAS constitutes a clock start for those patients on an active 18-Week RTT pathway. This is the date an attempt was made to convert a Unique Booking Reference Number into a booking for NHS e-referral Service patients and the date the referral letter was received into the Trust for paper referrals Internal consultant-to-consultant referral criteria are: Direct referrals will be appropriate for: o Suspected or diagnosed cancer. o Urgent problems for which delay would be detrimental to the patient s health. The expectation here would be that the patient needs to be seen within 2 weeks. o Referral as part of the same clinical problem. o Part of the recognised pathway of care for the condition or as part of a preoperative assessment. o Transfer of responsibility of care for an on-going condition when it would be more convenient for the patient to be seen in a different location. Advice communicated back to the referrer will be appropriate for: o Conditions that are unrelated to the presenting problems and do not require urgent referral. o Incidental findings, except cancer. o Conditions that can be dealt with by the CCG. If there is any doubt as to whether a patient needs to be managed by the hospital or whether a patient should be offered a choice of other provider or treatment, the consultant should contact the GP to discuss the case Agreeing the dates of appointments/admissions with patients rather than notifying them of an appointment is the preferred option in order to avoid the risk of patient cancellations or DNAs. 15. Summary of Guidelines for Managing New Referrals 15.1 A new referral will be required for: A new condition, even if within the same specialty. Same condition where previous referral was discharged over 6 months ago An assessment should have been undertaken by the referring clinician to determine any need for special considerations at the next level of care and this should then be recorded on the PAS to alert staff. If any new or changed requirements are identified during any treatment episode, then this information should be captured and the PAS updated. 15 of 29

16 15.3 An assessment should also be made, utilising the Pre-attendance Form, if the patient meets the criteria for NHS funding. If not, the Overseas Office should be contacted immediately by the member of staff who first reviews that form to initiate any fee recovery process. 16. Follow-up Appointments 16.1 Patients will only be followed up where there is a specific clinical need following the specialty protocol Fully Booked will only be recorded when booking a further appointment at the time of leaving clinic Partially Booked will be recorded at all other times e.g. when booking from an Outpatient access plan / review Patients who fail to respond to the partial booking process (including patients with a suspected or diagnosed cancer) within 3 weeks will be discharged from the Outpatient access plan, reviewed and referred back to the consultant for a clinical decision to be made regarding on-going clinical care. The GP will be advised accordingly. 17. Changing/Cancelling Appointments at Patient s Request New and Follow-up 17.1 Patients have an additional option to cancel and change their outpatient appointment on line, via the Derby Teaching Hospitals website; these requests will be actioned by the Outpatient Referrals Office. NHS e-referral Service appointments must be cancelled and changed using the NHS e-referral Service telephone appointments line or website In the event a patient cancels a 2WW appointment, a further appointment must be given within 14 days of the original date request received/ubrn conversion. If this is not possible and the new appointment is over 14 days, this must be escalated to the General Manager If patient requests a rearrangement or cancellation within 24 hours of the appointment time it must be recorded as a patient cancellation and the 18-Week RTT clock will continue ticking and the reason for cancelation must be recorded If a patient is unable to attend due to being a current Inpatient, this must be recorded on PAS as a change/cancellation by patient and the reason for cancelation must be recorded If a patient cancels their appointment they should be advised that this may have a detrimental effect on their health and thus should attempt whenever possible to keep their appointment. In the event that this is not possible, a new appointment should be given as soon as possible and the responsible clinician should be made aware as they may wish to review the patient to confirm any resultant risk Patients can change NHS e-referral Service appointments at any time; this is out of the Trust s control. 16 of 29

17 17.7 All patient cancellations must be dealt with immediately to ensure they are not recorded as a DNA If a patient has to leave a clinic prior to being seen (clinic over-running or other circumstance), their appointment must be changed to ensure that they are not penalised in the 18- week cycle as the clock will continue ticking If a child s appointment is cancelled twice, the issues/concerns associated with this must be reviewed and assessed by the consultant, referring to the Trust policy for Safeguarding Children. 18. Hospital Cancellations New and Follow-up Appointments 18.1 New appointments can be changed by clinic administrative staff providing there is no breach to the waiting time targets. Potential breaches must be brought to the attention of the appropriate General/Assistant General Manager for advice and resolution before they become a breach Appointments will be re-booked with the patient s agreement as close to their original appointment date as possible. Only in exceptional circumstances will a patient be cancelled twice A Cancer 2WW appointment cannot be cancelled without the authority of a General/Assistant General Manager. 19. Communication 19.1 Under the Human Rights Act, the Equal Opportunities Acts and anti-discrimination legislation, the Trust has a duty to provide interpreters for appointments when requested and to ensure reasonable adjustments are made for those patients and their families. Additionally, a legal requirement has been identified as part of the NHS Accessible Information Standard that directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. This information must now be recorded onto our Patient Administration system and it is the responsibility of any member of staff who is in receipt of this information to record this directly onto Lorenzo or ensure the information is given to a Lorenzo user to record. This will allow us to be able to better anticipate the needs of those affected patients Interpretation can be managed via the telephone interpretation service or face-to-face with an interpreter present British Sign Language can be accessed via the Interpreter Office on-site at Derby Teaching Hospitals, who will book a suitable date and time Where the patient has a learning disability, the consultant should contact the Learning Disability Liaison Nurse to support the team and the patient with reasonable adjustments or other requirements 20. Ambulance Transport 17 of 29

18 20.1 A patient is only eligible for provision of transport (including escort) if considered necessary by a Health Care Professional. 21. Patient Transport Service 21.1 Patients who qualify and require non-emergency transport to attend a hospital appointment are to arrange it themselves through the provider that serves their General Practitioner. 22. Diagnostics and Imaging 22.1 In accordance with national maximum waiting time guidance, imaging appointments will be booked within 6 weeks. The exception to this is interventional radiology procedures, which follow the RTT 18-week pathway The diagnostic waiting time starts when the request for a diagnostic test or procedure is made. For referrals via the NHS e-referral service, this is the time that the UBRN is converted, i.e. when the patient has accepted an appointment 22.3 The diagnostic waiting time stops when the patient receives the diagnostic test/procedure but the RTT clock could still be running If a patient cancels or DNA s an appointment for a diagnostic test/procedure, then the diagnostic waiting time for that test/procedure is set to zero and the waiting time starts again from the date of the appointment that the patient cancelled/missed, if the offer is deemed as Reasonable. A Reasonable Offer in relation to this scenario is anything over ten days. This does not mean that an offer cannot be offered with less than ten days-notice. 23. Referrals 23.1 The Imaging Service receives internal requests, referrals from GP s and other external sources. The Department starts the 2 or 6-week diagnostic wait time for each referral source as follows: Paper date received in department. Electronic date referral is made Referrals will be accepted in Imaging according to internal protocols and Ionising Radiation Medical Exposure Regulations Rejected referrals will be returned to the referring clinician and the diagnostic wait time stopped Resubmitted referrals will start a new diagnostic wait time Where such patients require non-specialist care to improve fitness they will be discharged back to their GP to be re-referred into the service when they are ready for treatment Staged bilateral procedures, where commissioned by the CCG, will be listed for the second side once the patient is fit and ready. The patient will be prioritised for urgency as with any other listing. 18 of 29

19 24. Transfers from/to Private Providers 24.1 A patient may choose to change their inpatient stay in this Trust to private care. In this case, this means transferring them with a new private referral so that the patient can be switched to an RTT Not Monitored pathway. Many private hospitals see both private and NHS patients; therefore either of these patient groups may be transferred/referred to this Trust. These transfers will be either: Private to NHS - this will constitute a new clock start with an auto allocated pathway ID. If the referral is for follow up, a clock start must still be recorded. The clock will then be stopped at the outcome of the appointment with either treatment not required or active monitoring. Where requests are received for previously treated private patients to have a long-term follow up appointment with a timescale greater than 18 weeks, these must be added to a review list, booked as a follow up and excluded from 18- weeks. NHS (from a private provider) to NHS (NHS provider) 18-week details must be used when entering the patient activity on PAS. If no 18-week details are sent with the referral the referring provider must be contacted. Private-to-Private - these patients are excluded from the 18-week RTT. A Pathway ID must still be auto allocated with a treatment status of 98 for as long as they remain a private patient. 25. Inter Provider Referrals 25.1 A transfer of clinical care to an alternative provider will be initiated using an Inter Provider Transfer Administrative Minimum Dataset form (IPT/AMDS) There are two routes that an IPT/AMDS form can come into the Trust: From community (e.g. Ripley, Ilkeston, St.Oswalds, Heanor, Long Eaton and Babington) and all other hospitals (including private providers treating NHS patients) via NHS net account dhft.interprovidertranfers@nhs.net; and From telephone referrals. It should be noted that Pathway ID, 18-week clock start date and status are required in order to record on to the PAS. The referring organisation must confirm this referral with an IPT/AMDS form within 48 hours If an IPT/AMDS is received by any other method, then contact must be made with the sender to inform them of the correct NHS net address. This is managed by the Referral Process Office in Records Management. 26. Overseas Visitors 26.1 Not all patients that attend this Trust are eligible for free NHS treatment and currently some visitors to the UK are receiving hospital treatment which they are not entitled to as they are not 19 of 29

20 lawful residents of the UK. Therefore all new patients will be required to complete a Pre-Attendance Form prior to their appointment or during their admission to a ward area. The attendance form will be sent out with all new patient appointments as well as hard copies being available in all areas. The Pre-Attendance Form is designed to be simple and easy to complete and will help the Trust to identify patients who are not eligible for free NHS treatment Before patients can access any community services, they must have registered with a GP and so will have satisfied eligibility for free NHS care at that time. If not eligible for free NHS care, the GP will initiate a cost recovery process Once a patient has completed the Pre-Attendance Form the receptionist/ward staff are to examine the form and, if necessary, refer it to the Overseas Office. This will result in an interview with a member of the Overseas Team who will assess their residency situation and come to a decision about whether they are or are not eligible for free NHS care. 27. PAP Implementation & Monitoring Arrangements 27.1 Where applicable, Deputy General Managers and Assistant General Managers (or equivalents) are responsible to the Head of Patient Access and Administration for implementing and monitoring compliance with this policy within their areas of responsibility. Governance of this policy will be exercised through the Patient Access Group (PAG) via a set of Key Performance Indicators (KPIs) agreed by the PAG; these may vary from time-to-time. 28. User Guidance Guidance contained within the Single Source of Truth and supporting SOPs describe the processes to be used to achieve a high quality patient administrative experience and should be adhered to by all departments unless it is expressly stated otherwise. 29. Glossary Active Monitoring (Also known as watchful waiting ) Active Waiting List An 18w clock may be stopped where it is clinically appropriate to start a period of monitoring in secondary care without clinical intervention or diagnostic procedures. A new 18- week clock would start when a decision to treat is made following a period of active monitoring. Patients awaiting elective admission for treatment and are currently available to be called for admission. 20 of 29

21 Bilateral Procedure Can Not Attend (CNA) NHS e-referral service Date Referral Received (DRR) Day cases Decision to Treat date (DTT) Did Not Attend (DNA) First Definitive Treatment Inpatients Outpatients A procedure that is performed on both sides of the body, at matching anatomical sites. Patients who, on receipt of reasonable offer(s) of admission, notify the hospital that they are unable to attend. A method of electronically booking a patient into the hospital of their choice. 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. The date on which a consultant decides a patient needs to be admitted for an operation. This date should be recorded in the case-notes and used to calculate the total waiting time. Patients who have been informed of their date of admission or pre-assessment (inpatients/day cases) or appointment date (outpatients) and who without notifying the hospital did not attend for admission/ pre- assessment or OP appointment. An intervention intended to manage a patient s disease, condition or injury and avoid further invention. What constitutes First Definitive Treatment is a matter for clinical judgement, in consultation with others as appropriate, including the patient. Patients who require admission to hospital for treatment and are intended to remain in hospital for at least one night. Patients referred by a General Practitioner or another health care professional for clinical 21 of 29

22 advice or treatment. Patient Tracking List (PTL) Planned List Reasonable Offer Referral to Treatment (RTT) (To Come In) date (TCI) The PTL is a list of patients (both inpatients and outpatients) whose waiting time is approaching the guarantee date, who should be offered an admission/appointment before the guarantee date is reached. for procedures that are part of an agreed programme of care required, for clinical reasons, to be carried out at a specific time or repeated at a specific frequency. For an offer of an appointment to a patient to be deemed reasonable, the patient must be offered the choice of dates within the timescales referred to for outpatients, diagnostics and in patients. The 18-week (RTT) standard addresses the whole patient pathway from referral to the first definitive treatment/or other clock stop. This is instead of focusing upon a single stage of treatment (such as outpatients, diagnostic or inpatients). The offer of admission, or TCI date, is a formal offer in writing of a date of admission or an offer made by telephone confirmed with a formal written offer. 30. Key References Cancer Waiting Times - A Guide (Version 8.0). Available from: < Accessible Information Standard. Available from: < Trust Casenote Tracking Policy. Available from: < NHS e-referral Service. Available from: < 22 of 29

23 Equality Act Available from: < Guide to NHS Waiting Times. Available from: < to%20waiting%20times.aspx> Human Rights Act Available from: < Improving Outcomes: A Strategy for Cancer. Available from: < Information for Visitors to England. Available from: < NHS England General Practice Forward View, April Available from: < Recording and reporting referral to treatment (RTT) waiting times for consultant-led elective care. Available from: < content/uploads/sites/2/2013/04/recording-and-reporting-rtt-guidance-v24-2-pdf- 703K.pdf> Recording and reporting referral to treatment (RTT) waiting times for consultant-led elective care: Frequently Asked Questions. Available from: content/uploads/sites/2/2013/04/recording-and-reporting-rtt-guidance-faqs-v6-2- PDF-164K.pdf Referral to Treatment Pathways: A Guide for Managing Efficient Elective Care. Available from: < ways second_edition_.pdf> Referral to treatment consultant-led waiting times - How to Measure. Available from: < Measure-Jan-2012-Final.pdf> Trust Patient Information Services. Available from: Policy for the Management of Children, Young People and neonates who do not Attend Their Appointments. Available from: < 23 of 29

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