Managing Waiting Lists and Handling Referrals Nickie Yates, Head of Information & Contracting

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1 Trust Policy and Procedure Document Ref. No: PP(13)138 Patient Access Policy For use in: For use by: For use for: Document owner: Other Contributors Status: Trust Wide All Staff Managing Waiting Lists and Handling Referrals Nickie Yates, Head of Information & Contracting General Managers, Access Team Reviewed Policy INTRODUCTION The successful management of patients who are referred and wait for all appointments or elective treatment is the responsibility of a number of key individuals and organisations. These include commissioners, General Practitioners, Hospital Doctors, Primary Care Trusts, Hospital Trust staff and Patients themselves. Treating patients and delivering a high quality, efficient and patient-focussed service is the core responsibility of the hospital and the wider local health community. Access to appropriate treatment regardless of setting is an important quality issue and is a visible and public indicator of the efficiency of services provided by all healthcare commissioners and providers. Service commissioners must ensure that service agreements are established with sufficient capacity to ensure that no patient waits for more than the guaranteed maximum time specified by the NHS. All hospital clinical staff, managers, secretarial and clerical staff have an important role in treating patients, delivering a high quality, efficient and responsive service and keeping waiting times to a minimum. This policy is a reference document which applies to the management of referrals and activity at West Suffolk Hospital NHS Trust inpatient, day case, outpatient, therapy and diagnostic services, and must be adhered to by all staff. It complies with all national policies and data standards, and is in line with the national Referral To Treatment guidance. It should be read in conjunction with procedure documents. Access to hospital services is managed in the context of the whole health community and there is recognition of the role of primary care. The policy will be available to all those involved in access to services at the West Suffolk Hospital including the general public. Stephen Graves Chief Executive Source: Head of Info & Contracting Status: Approved Page 1 of 27

2 PURPOSE OF THIS DOCUMENT The policy and procedures have been written to ensure an efficient and consistent way of managing patients who are waiting for diagnosis or treatment, particularly as Electronic Booking and the Choose and Book processes are implemented. It is intended as a statement of the policy for management of waiting lists and is backed up by operational guidance documents. The policy and its associated procedures will form part of the induction of staff. AIMS This Policy aims to provide information and guidance to ensure a comprehensive and positive approach to the handling of referrals, both electronic and manual, and to managing waiting lists. It will also ensure fair and equitable access to hospital services within the maximum Referral To Treatment times, and the appropriate allocation of resources. OBJECTIVES This Policy is intended to ensure that the Trust: minimises the time patients wait for treatment and will offer appointments which guarantee the maximum outpatient waiting time is met. does NOT unnecessarily cancel patient admissions, operations or appointments and minimises the risk of patient non-attendance. offers dates to Patients of the same clinical priority for appointment or treatment within chronological order, based on the number of days remaining on their RTT pathway, with the exception of patients showing flexibility to accept short notice. operates systems for the management of patients on waiting lists which will be equitable and transparent. maintains Trust Waiting List information (including patient data) which is accurate and up to date, so that the PAS system and Waiting List processes provide a safe and reliable support for patients. remains on the choice menu for local referring GP s. gives Patients reasonable notice, which is defined within the policy. encourages Generic referrals wherever possible provides appropriate and effective booking systems across all specialties. Maintains accurate and up to date information about the outpatient and direct access services provided by the Trust on the Choose and Book, Directory of Services (DoS). The Policy should provide a practical and easy to follow guide for those charged with managing the day-to-day administration and clinical management of waiting lists; because the document cannot predict every eventuality, common sense will be required for cases that fall outside the policy. However, decisions made outside the policy will need to be justified Source: Patient Access Manager Status: Approved Page 2 of 27 2

3 EXECUTIVE SUMMARY Choice and the length of time a patient waits for hospital treatment are important quality issues and a visible and public indicator of the efficiency of the hospital services provided by the Trust. This policy is designed to ensure that our services are delivered in a timely and patient centred way. The successful management of patients who are waiting for diagnosis or elective treatment is the responsibility of a number of key individuals and organisations including commissioners, General Practitioners, Hospital Doctors, Primary Care Trusts and Hospital Trust Managers. If patients who are waiting for appointments or treatment are to be managed effectively it is essential for everyone involved to have a clear understanding of their roles and responsibilities. Patients also have responsibilities for complying with the booking systems. This policy defines those roles and responsibilities and establishes good practice guidelines to assist staff with the effective management of all waiting lists and referral arrangements managed by the West Suffolk Foundation NHS Trust inpatient, day case, outpatient, therapies and diagnostic services. The policy should be read alongside procedure documents which give details of how the policy is to be applied. These documents are available on the intranet. The executive lead for this policy will be the Chief Operating Officer. The Patient Access Development Manager will review this policy at least annually. ROLES AND RESPONSIBILITIES The Chief Executive and Trust Board will be responsible for ensuring that this policy is implemented effectively. The Chief Operating Officer is the executive lead for this policy and the Patient Access Manager is operationally responsible for implementing the Policy and ensuring that an annual review is conducted. The Access Team is responsible for ensuring that any issues relating to the Policy or the Trust s ability to meet waiting time standards are met or escalated. The Head of Information and Contracting has the responsibility for ensuring that mechanisms are in place to enable the Trust to report data accurately and ensuring that systems are available to do so. Waiting List management is the collective responsibility of clinicians and managers. Individual staff members - including clinicians - are responsible for ensuring that their practices are consistent with the policy and that the systems are in place to support effective waiting list management. This Policy will develop over time, and departments should feed suggested amendments and improvements through their representatives on the Access Team. Within Choose and Book there are number of instances in which clerical and administrative staff are designated as proxy for clinicians, and can accept or reject referrals. In this role, staff must only comply with clinicians specific instructions since responsibility for those actions will not move from the clinicians. Patients are responsible for complying with booking arrangements, attending appointments and ensuring that the Hospital is informed of any relevant changes in circumstances. Under the NHS Constitution, patients have the right to request an earlier date (at the Trust or elsewhere) if they are likely to breach national Waiting Time commitments. In the normal course of events issues will be resolved between the patient and TAC, Waiting List Office or the Rapid Access team. For referrals received after 1 April 2010, patients should be referred to a Trust Point of Contact if they have unresolved issues about potential breaches of Waiting Time standards. The formal Point of Contact at the Trust is the Patient Access Development manager. GENERAL PRINCIPLES The Trust has a duty to ensure all patients who are referred and listed are offered the service they require within the waiting time standards. All cancellations, additions to or removals from waiting lists must be made in accordance with this policy. The policy will be applied without exception across the Trust to ensure that all patients are treated equitably, consistently and according to clinical need. Source: Patient Access Manager Status: Approved Page 3 of 27 3

4 The words Waiting List are customarily understood to refer to those patients who are waiting for an appointment date. In practical terms there are no Waiting Lists for Outpatients or Inpatients as such because patients have their appointment date agreed within two weeks of their referral. However the administration of patients is conducted using the Waiting List Module of PAS whether they are waiting for a date or for an appointment which has been agreed. The words Waiting List in this policy are used in this latter context. Referrals and Waiting lists will always be managed according to clinical priority. Patients with the same clinical priority should be seen or treated in strictly chronological order unless the patient has chosen a later date. Where the Trust is required to operate multiple systems for dealing with referrals and it is not possible to rigidly control the flow of patients, the Trust will strive to maintain equity of access within clinical priority. The principles of Choice will be applied in that patients will be offered a choice of date and time, and where possible, location. The Trust provides services at a number of locations, and when demand exceeds capacity the Trust will actively endeavour to provide extra capacity which reflects geographical demand. However there are also likely to be issues of efficiency and practicality and the Trust cannot guarantee first choice location if it jeopardises waiting times for other patients. While the Trust may not always be able to provide additional clinics at other locations, all replacement clinics or appointments must be where the original was arranged. The 18-week commitment is made to all patients including prisoners and military personnel to the extent that a PCT or CCG commissions their care (18 weeks does not apply to MOD-commissioned care unless stated in commissioning agreements). Military personnel and prisoners are excluded from the government s Choice policy and a protocol is in place for the treatment of prisoners at local HM Prison Service establishments. However these specific arrangements should neither advantage nor disadvantage any patient in terms of clinical priority. At the time of attendance patients can agree the date of their next appointment, or admission if appropriate. The process of referral and waiting list management should be transparent. Communication with patients should be informative, clear and concise. Patients will have access to this policy and should be aware of their responsibilities. The Waiting List Module of the Patient Administration System (PAS) must be used to administer all Waiting Lists, supported by reports produced by the Trust s Information team. The Outpatient module, linked to Choose and Book software (and other systems developed to support the efficient management of outpatient services) will also be used to administer all outpatient referrals. Written operational procedures and protocols and appropriate user training will support this policy. Plans to achieve and maintain waiting times as set out from time to time in Department of Health (DH) targets and those agreed with commissioners will be based on collaboration between organisations and staff within the local health system, based on a full understanding of the demand and capacity issues, and subject always to clinical priority. The contents of the policy are consistent with current Service Level Agreements and are in line with the standards within the contracts. Generic referrals will be encouraged in accordance with current DH guidance. The Trust has limited capacity and financial constraints. If activity exceeds that which commissioners have agreed to pay for, the Trust s ability to treat other patients is jeopardized. While capacity is the responsibility of commissioners, Managers and Clinicians will work with the PCT and CCGs to ensure that they are aware of the nature and extent of risks when demand may exceed capacity. One measure put in place by the PCT to regulate demand is the list of Treatments of Limited Value. Given that different PCTs have different lists, the onus is on referring GPs to apply rules put in place by their respective PCTs. However, to mitigate the risk of dispute and anxiety to patients, clinicians should not accept referrals where there is reasonable doubt that commissioners will sanction or pay Source: Patient Access Manager Status: Approved Page 4 of 27 4

5 for treatment. If referrals do not make it clear that a patient meets exception or qualifying criteria (e.g. BMI not shown), or do not have the appropriate documentation attached, the GP should be asked to re-refer with more complete information. Explicit referral guidelines will be agreed between services and those who make referrals. These guidelines will reflect national guidance and should be explicit in the Directory of Services within the Choose & Book system. They should also be maintained on the Pink Book website. The Trust will work with the commissioners and patient representatives to ensure that any letters routinely sent to patients are subjected to the widest practical consultation to achieve the clarity of both message and language. GPs should be using the Choose and Book system. The Trust will, as far as possible, make sure capacity is available on the Choose & Book system, including access to Rapid Access (suspected malignancy) slots. While the Trust will actively encourage the use of Choose and Book, GPs cannot and will not be prevented from using paper referrals. GPs will be encouraged to use generic Dear Colleague letters or two week wait pro-formas which can be allocated to an appropriate Consultant with the shortest waiting time. The Trust does offer Named Consultant appointments on Choose and Book, and GPs and patients have the right to be referred to the clinician of their choice where there is clinical advantage for the patient. In these cases referrals should explain the reason for referral to a specific Consultant. Where a referral letter is addressed to an individual Consultant (whether on the Choose and Book system or as a paper referral) the named Consultant will be shown the letter and decide if there is a clinical reason that they should see that patient; if there is no valid clinical reason the patient will be given a generic appointment. Each Specialty must have a system which ensures that a Consultant views all referrals and distributes them appropriately. In some Specialties where an agreed process is in place, an appropriate Nurse Specialist may view and distribute referrals. GPs and Patients may continue to request an appointment with a specific Consultant for clinical or any other reason; however it must be understood that where an individual Consultant's waiting times jeopardise Trust targets or even its capacity, the Trust may (with appropriate clinical supervision) redistribute referrals among other Consultants within the same Specialty. The Trust will, wherever possible, agree an appointment with the patient at the time of referral or at any step in their pathway. Waiting Lists are therefore a record of appointment or admission arrangements rather than a list of those waiting to agree an appointment or admission. However whilst the term Appointments or Admissions List better describes what is happening, usage and the constraints of the Trust s current clinical systems mean that the term Waiting List will continue to be used. All referrals received must be registered on the Hospital PAS System by the Telephone Appointments Centre (TAC) within one working day of receipt. Where any paper referral for appointment are sent directly to Consultants or PAs they must be taken or sent immediately to TAC. All additions to or removals from Waiting Lists must be made in accordance with this policy. There must be no hidden waits. Patients with the same clinical priority will be treated on a "first come first served" principle. The single exception to this is for those identified by Referrers as covered by the Priority Treatment for War Pensioners arrangements, but preference is limited to patients of similar urgency with similar conditions. The arrangements do not allow a change of clinical priority. Source: Patient Access Manager Status: Approved Page 5 of 27 5

6 Patients should only be added to a waiting list if: the patient is ready for consultation or treatment, and there is an expectation of consultation or treatment within maximum waiting times. All patients should be offered appointments to hospital within the published maximum waiting times. The Trust will work with Suffolk PCT and other Commissioners to ensure that contractual arrangements support this process. Where the Trust is directly involved in offering appointments, such offers will always be reasonable. This means three attempts will be made to contact a patient, and for Routine appointments a choice of three dates will be given with at least three weeks notice. For cancer patients, this is classed as any offered admission between the start and end point of the 31 or 62 day standards. Appropriate training programmes should support staff with special regard given to newly recruited and temporary staff. All staff involved in the implementation of this policy, clinical and clerical, will undertake initial training and regular updating. To ensure and maintain standards, all staff who use the PAS system to make or alter appointments for Inpatients, day cases or Outpatients may be required to revalidate against a series of criteria. They are required to follow standard operating procedures (SOPs) which are available on the intranet and which will be regularly updated PRIVATE PATIENTS The Trust will neither advantage nor disadvantage Private Patients. Private patients may transfer to the NHS for treatment; they pick up the timing of the other patients at that point in the pathway. Practically that means if a patient starts from the beginning, the clock starts when the referral is received from the GP if they join at the Pre-Assessment stage they join those who have had their Outpatient appointment and diagnosis. In theory there is a potential disadvantage in that the 18 week clock starts when a patient joins the pathway, but the overriding principle is that patients will be seen and treated in the same chronological sequence as other patients with similar clinical priority at similar points on the pathway. Patients seen privately for diagnostic assessment must be referred (usually by Consultants to themselves) and attend an outpatient / pre-admission appointment. Private patients may join or leave the NHS system at any stage, but may not bounce between the two systems. Some Private Providers offer consultation and treatment under NHS arrangements for commissioning and payment. They must offer similar services to NHS providers and, again patients must be neither advantaged nor disadvantaged. The Trust will treat NHS patients with a Private Provider in exactly the same way as those with NHS providers, regardless of the clinician involved. If a patient is seen as an NHS outpatient at a Private Provider but that organisation could not offer the treatment required, then the patient must be offered choice and a new referral and new clock start must be provided and the patient will follow the pathway of any other patient, including (another) outpatient appointment. Trust Consultants may and do see NHS patients at Private Provider organisations. However they may not have an executive role with a Private Provider, nor must they must offer services which they can or will not provide for the Trust. The Trust will cooperate with commissioners and others to ensure the principle of equity for all patients is maintained and, if necessary, enforced. 18 WEEK REFERRAL TO TREATMENT PATHWAYS The Department of Health (DH) mandates NHS organisations to report waiting list information via an 18 week Referral to Treatment (RTT) pathway. The Trust has developed and will maintain systems to record and report waiting times from referral to treatment that follow this policy framework. This Policy describes the processes that support the local programme delivery. Source: Patient Access Manager Status: Approved Page 6 of 27 6

7 The NHS overall is committed to providing all patients (except those undergoing fertility or obstetric treatment) with an 18 week maximum wait from referral to first effective treatment (RTT). The Trust recognises this as a positive step and has been among the first nationally to achieve the standard. The principles and definitions of the 18 week target count the referral to treatment (RTT) waiting times in totality; there is no scope for change within the 18 week principles and definitions. It therefore impinges on the way the Trust manages every aspect of outpatient, diagnostic and elective activity and every department must take account of these definitions and principles. Standard Operating Procedures which deal with procedural arrangements are approved by the Access Group and are to be found at These are reviewed regularly and updated by the Health Records department and approved by the Access Team. OUTPATIENT WAITING LIST MANAGEMENT Outpatient waiting lists will be managed in accordance with the 18 week guidance and with the procedures contained within or referred to by this policy. Standard Operating Procedures which deal with procedural arrangements are approved by the Access Group and are to be found at These are reviewed regularly and updated by the Health Records department. OUTPATIENT REFERRALS There are four pathways for referrals from Primary Care: - Rapid Access (RA) Referrals Choose and Book (C&B) Referrals Written Referrals SOS Referrals From time to time Commissioners may require referrals to be handled either in a specific way or through third parties. The Trust will cooperate with such schemes provided that the mechanisms (including those for payment where applicable) are evidenced in writing and have been agreed as clinically safe and in accordance with contractual arrangements. Rapid Access (RA) referrals are for patients with a suspicion of cancer who meet pre-defined criteria using Rapid Access Proformas. These patients are referred by agreed protocols and must be seen within 14 days of the receipt of the referral or from conversion of the Unique Booking Reference Number (UBRN) for C&B referrals. The process for RAcP patients within the Trust is the same as for patients with suspected malignancy. Choose and Book (C&B) represents both a software package and a process. It allocates a Unique Booking Reference Number (UBRN) to each patient and enables patients to choose where they wish to attend for an outpatient appointment, and to book a date and time of their choosing, from those available. It therefore offers choice at the point of referral. The Trust uses the full Electronic Booking Service. C&B allows referrals to be managed generically in order to offer the first available appointment slot to the patient. Once the booking is made, the GP attaches the electronic referral letter which is then available on the C&B system for the Trust s clinician to review. As bookings are not visible to the Trust until the referral is attached by the GP to the booking, Urgent referral letters should be attached within one day and a routine referral generated within three days of the decision to refer or at the time of booking. Source: Patient Access Manager Status: Approved Page 7 of 27 7

8 Written referrals. GPs who use written referrals should use generic Dear Colleague letters which can be allocated to an appropriate Consultant in order to maintain balance of capacity within a specialty. Each Specialty must have a system which ensures that a Consultant views all generic referrals to ensure appropriate distribution. While the Trust will actively encourage generic referrals, GPs and patients may continue to request an appointment with a specific Consultant for clinical or any other reason; however it must be understood that where an individual Consultant's waiting times jeopardise national targets the Trust may (with appropriate clinical supervision) redistribute referrals among other Consultants within the same Specialty. SOS referrals. For some patients it is appropriate to discharge them but their condition may alter and a further appointment is warranted. For these specific conditions, where the Consultant has alerted the patient (and the GP) to signs and symptoms which may trigger an SOS appointment, the patient is told to contact the Trust and an appointment will be made without the need for a further GP referral. Any SOS appointment needs to be authorised by the consultant and/or his P.A. Any request/telephone call from a patient received in the Telephone Appointments Centre (TAC) for an SOS appointment will be passed on to the consultant s P.A. Once the request is approved, the P.A. will inform the TAC team who in turn will make a New appointment, regardless of the time since discharge.. PRIORITY OF REFERRALS Whichever referral route is used, only four categories for priority apply: Direct Access Following a conversation between the GP and Consultant, some patients, notably certain Orthopaedic and Paediatric patients, will be invited to attend a clinic or other appropriate setting on the same or following day. These patients will bring the referral letter with them. Wherever the appointment takes place, it must be recorded as a first outpatient appointment on PAS. Rapid Access (RA) referrals will be seen within two weeks. Urgent referrals - the definition of an Urgent referral will vary between specialties, and it is essential that each specialty makes its criteria for an Urgent referral clear. Except where national protocols and guidelines apply, the clinician receiving the referral will assess the urgency based on risk to the patient and knowledge of outpatient case mix. If the clinician wishes to change the priority indicated by the GP, an explanation must be given to the GP to pass on to the patient. Urgent referrals may not be downgraded to Routine and should be either: rejected and returned to the Referrer, either for resubmission as Routine or for resubmission as Urgent, in which case the resubmission should include further information as to why the referral should be treated as Urgent. Or the patient should be seen as an Urgent referral, and the GP told (after the appointment) why the Urgent was inappropriate Urgent referrals should be seen as soon as possible but at the most within 5 weeks Routine referrals are all those which do not meet the rapid access or urgent categories described above. Waiting times for Routine referrals should be as short as practically possible given the constraints of 18 week targets and capacity, but at the most 11 weeks. All referrals received must be registered on the Hospital PAS System within one working day of receipt and must be treated in accordance with the general principles and booking procedures described in this policy. All referral letters should be reviewed and accepted, rejected or redirected within five working days. Referrals must not be rejected: on the grounds of the location of the referrer or patient; or on the grounds that there is insufficient capacity at the time of booking to treat the patient within Waiting time standards CLINIC CONFIGURATION Source: Patient Access Manager Status: Approved Page 8 of 27 8

9 Clinic templates should reflect the priority mix of referrals and the need to accommodate necessary Follow-Up appointments. They identify the number of slots available for new and follow-up appointments and specify the time each clinic is scheduled to start and finish. Clinic templates will be reviewed by Directorates at least annually to ensure that capacity meets demand. This review will be supported by all available data on the previous year s performance and take into account the implications of reducing waiting times and the proportion of follow-up appointments needed. All reviews will involve both management and clinicians. The Trust is required to ensure that there are sufficient appointment slots available to meet demand, AND that all clinically appropriate referrals are accepted, regardless of the location of the patient or any pressures on capacity. Clinic templates are also subject to review at any time to meet the C&B objectives, 18 week targets or when other capacity issues arise. Where patients cannot be allocated an appointment or where slots are no longer available on the Choose and Book System within the agreed waiting time, the relevant General Manager / Clinical Director will be notified weekly and will take the appropriate action to ensure the additional capacity is available. It is the responsibility of the Directorate to agree standards for follow-up appointments. These decisions will take account of:- new to follow-up ratios in line with locally agreed targets the need to minimise the long-term surveillance follow-up in preference for an early referral back to primary care; and where appropriate the follow-up care should be provided by an alternative professional i.e. specialist nurses/technical staff. Patients will not be followed-up without a specific reason such as clinical need or patient-led request. Where appropriate, decisions in relation to the patient s care should be made outside a clinic setting and RTT pathways updated accordingly. Any changes to clinic configuration on PAS must not be effected unless they have been approved by the Patient Access Development Manager or their nominated deputy. AD HOC CHANGES AND CLINIC CANCELLATIONS Every effort should be made NOT to cancel clinic appointments. A minimum of six weeks notice of planned clinic cancellation, reduction or additional capacity must be given by all clinical staff, together with the reason. Any changes to clinic configuration, including reduction or cancellation which are within the six weeks notice period must be authorised by the General Manager and will only be approved in emergency or in exceptional circumstances. All proposed clinic reductions and cancellations should be discussed with Clinical Directors and all possible cover arrangements explored to prevent clinic cancellations taking place. Only in exceptional circumstances, when all possible cover arrangements have been explored, should patients be cancelled. In these instances medical staff must review the case notes. The clinic appointments will be reviewed initially by the TAC to ensure that no patients breach the waiting time targets as a result of cancellation/reduction. Any potential RTT breaches caused as a result of clinic cancellation will be brought to the attention of the Chief Operating Officer for advice or direction. Where cancellations are initiated by the Trust, patients should be re-booked at the time the cancellation takes place and given at least three weeks notice from their original appointment date (unless the patient agrees a convenient appointment with less than three weeks notice). Source: Patient Access Manager Status: Approved Page 9 of 27 9

10 POST ADMISSION APPOINTMENTS All patients requiring follow up appointments following an in-patient stay will be given the opportunity to arrange a mutually convenient appointment. The Ward Book entry is completed and delivered to the TAC or the Fracture Clinic, who will contact the patient to confirm the appointment. The booking will be as a New patient unless the patient was admitted under the care of the same specialty responsible for an unclosed Outpatient episode, in which case the booking will be as a follow-up. PATIENTS WHO DO NOT ATTEND AN OUTPATIENT APPOINTMENT Patients who were given choice at the time of agreeing their appointment (through any booking system) and then do not attend (DNA) will be removed from the Outpatient Waiting List. This applies to all referral methods. If, due to extraordinary circumstances, a fixed appointment has been sent and the patient DNAs, a second appointment will be offered; however if they fail to attend this appointment they will also be removed from the Outpatient Waiting List. The letter inviting patients for outpatient appointment will clearly state that if the patient fails to attend they will be referred back to their GP. Notification of their removal from the waiting list will be sent to the patient and their GP; the patient may be re-referred at the GP s discretion. In the clinical interests of vulnerable and paediatric patients non-attendance will result in the offer of a further appointment without GP involvement. The consultant will review DNAs of Urgent patients and may - if clinically appropriate - issue a further outpatient appointment without referring back to the GP. If an Urgent priority patient is re-instated at the request of the consultant, they may be put back on the waiting list in the same place as when they were removed - reasons for the reinstatement must be recorded in the clinical notes. If the patient fails to attend this further appointment they will be referred back to the GP. Any Routine priority DNA must be removed from PAS and the patient re-referred by their GP. Breast symptomatic patients and patients referred under the cancer two-week wait who fail to attend their appointment should be offered another appointment within 14 days from the DNA d appointment date. If they fail to attend this they will be returned to the care of their GP. The 18 week clock would stop on the date of the DNA. PATIENTS WHO CANCEL AN OUTPATIENT APPOINTMENT The letter to patients confirming an outpatient appointment will clearly state that the patient can only cancel and rearrange once, subsequent cancellations will result in removal from the waiting list and their GP will be informed. This applies to all referral methods. Consultants should be informed on a regular basis of those patients who have been removed through cancellation and can ask to review the referral letter and case notes. Those patients cannot be reinstated, but the GP concerned may be invited to re-refer. Patients who cancel their appointment MUST be given an alternative date at the time of cancellation. Where a patient refuses an appointment, they will retain their original RTT clock start date. A patient will be offered an alternative convenient appointment as soon as possible that minimises the chances of the patient breaching the RTT target. Where a patient cancels/changes a second appointment (that was agreed as convenient) they will be removed from the Out-Patient or Diagnostic Waiting List. The referring consultant will be notified that the patient has been discharged back to the care of their GP. A letter would be sent to the GP informing them of the removal. The 18 week clock will stop. Source: Patient Access Manager Status: Approved Page 10 of 27 10

11 A patient may refuse the offer of a reasonable appointment (at least 3 weeks notice and in line with patients expectations of place and personnel) for social or medical reasons and indicate that they still require the appointment; this allows the clock to be stopped from the first date offered. These patients must be offered a further appointment when they are available, and a new clock starts at the appointment date. Patients can only be allowed to self defer twice before being returned to the care of the GP. CHOOSE AND BOOK The Trust will comply with national C&B guidance and, as far as is possible while preserving safety, equity and capacity, work towards the C&B model described in Responsibilities and Operational Requirements for the Correct Use of Choose and Book. The Trust will continue to work with Commissioners to ensure that C&B issues are addressed as quickly as possible. According to C&B guidance, all patients who need a referral to hospital (or suitable alternative provider) for first diagnostic or outpatient appointment can expect: - to be offered a choice of 4-5 hospitals or suitable alternative provider to receive the information and support required to make informed choice and to be able to pre-book the date/ time of their appointment following GP/ GDP referral The Directory of Services (DoS) provides clinical information about each service offered by the Trust, and guides the referrer to the appropriate service and clinic for the patient s condition. The Trust will continue to work with Commissioners to ensure that a robust and accurate DoS and care pathways (including decision trees) are in place to minimize inappropriate referrals. While commonly the referring GP does not have time to complete an electronic booking during the patient consultation, the booking can be made by the practice s reception/admin staff. Alternatively the patient could go home to think about the choices and either access the internet or call the Choose and Book Appointment Line (CABAL) operated by NHS Direct to complete their booking of date and time. If patients choose a service where no slots are available they will be asked to contact the National Telephone Appointment Line which will be responsible for forwarding the referral on to the Trust. If the National Telephone Appointment Line fails to find a suitable Appointment, they will generate an to The Trust. This is known as a TAL. TALs are received by the Trust s Telephone Appointments Centre (TAC) team who will contact the patient within 4 days of the referral being received to agree an appointment date and time. Once the booking has been made the referrer attaches an electronic referral letter via C&B, and that booking and referral letter is then available for the Trust s clinicians to review. Guidance for GPs is that referrals should be attached as follows: Rapid Access the same day Urgent within 24hours Routine - within three days Although the patient has a time and date arranged, the Trust may reject the referral (and ask the GP to cancel the booking) if it is either clinically inappropriate or carries a higher priority than appears appropriate. In terms of the patient s RTT period, the 18week clock start is receipt of referral. With C&B however, a patient is on the system from the date of booking, but not visible until the referral is attached. The Trust will not routinely attempt to adjust clock start dates but will, with the cooperation of Suffolk PCT, monitor the delay between booking and attaching the referral. In extreme cases of delay the clock start date may be adjusted. Clinic capacity will be reviewed on a continuous basis and slot poll times will be adjusted to facilitate choice. Source: Patient Access Manager Status: Approved Page 11 of 27 11

12 The Trust s processes for handling referrals will be constantly reviewed to ensure equity and efficiency. As C&B software develops and GPs use of the system improves to provide adequate safeguards and audit trails, the Trust will work with individual clinicians towards a paperless referral system. Commissioners will be responsible for reviewing existing capacity and determining the future capacity required to support choice at the point of referral. The Commissioning Framework Project Team is developing national Policy guidance. The Trust will work closely with Suffolk and other PCTs to plan and monitor the capacity of slots that are available to the C&B system, allocating an appropriate number to urgent and routine appointments. Best practice guidance and benchmarking information will be applied to such allocation. The Trust has agreed to offer advice only services via their DoS. Advice & Guidance is an electronic exchange of letters where the intention is to advise the GP on treatment action rather than to generate a referral. Local PCTs will fund such services as part of the Choice menu. PCTs and the Trust will review this aspect of Choose and Book regularly. MANAGEMENT As C&B becomes the main access route for referrals, the Trust s ability to flex capacity within existing clinics will be reduced. All activity has to be included in available slots. Overbooking of clinics cannot be supported in a C&B environment. Within PAS and the C&B system the Trust can add slots and review profiles for a clinic (i.e. change the ratio of urgent to routine slots) and the Trust has arrangements in place to monitor clinic capacity on an ongoing and regular basis to ensure capacity reflects referral patterns and demand. Referrals will be generally addressed on a service basis to ensure that patients are seen in chronological order. The Trust has been required to make available the Named Consultant Led Service facility on C&B, which means that a lead Consultant s name will appear against every service where this is possible. However unless the referral is specifically addressed to a Consultant and there is a specific clinical or administrative reason, referrals will be treated as addressed to the service, rather than to any individual Consultant. As a general rule, GP Practices should avoid the use of fax machines for referrals. GP Practices must not fax or send a paper copy of letters attached to an electronic booking. Where the referral letter is not received within a reasonable time (which depends on the Waiting Time for the specialty concerned), the relevant PCT will be asked to intervene and ensure that the booking is cancelled. The Trust may cancel appointments not supported by timely and appropriate clinical information. Once the referral has been received, current practice is that the referral letter will be printed and given to the reviewing consultant who will decide whether to accept or reject the referral. All referral letters should be accepted, transferred or rejected within 3 (Urgent) or 5 (Routine) working days of attachment on the C&B system. The time and date of appointments booked via C&B will automatically be deemed reasonable as the Trust is not involved in the patient choice of time and date. The consultant should accept all clinically appropriate referrals. If the patient needs to be seen sooner than the planned appointment the referral should be upgraded. Downgrading is not an option in Choose & Book. When reviewing referrals, consultants are asked to make it clear which of the following categories apply to the referral. Accepted - no further comment is required. Source: Patient Access Manager Status: Approved Page 12 of 27 12

13 Upgrade the consultant believes that there are grounds for the patient to be seen urgently. The referral should be rejected with the comment that the Trust will be contacting the patient to arrange an earlier appointment. Wrong service (misdirected) the referral should be rejected with a comment that the Trust will be contacting the patient in order to make an appointment with the appropriate service. Inappropriate the referral should be rejected with a comment which explains why it is inappropriate (e.g. missing fundamental tests). In accordance with guidance, a referral must not be rejected on the grounds of: location of the referrer or the patient insufficient capacity at the time of booking If the clinician decides to reject the referral, it is no longer visible on the system, so that in every case the referral must be printed before rejection. The system requires a reason for rejection, and it is important that such explanations are clear, giving both the reason for rejection and where possible offering an alternative course of action for the GP. Once a referral has been rejected and the GP has received notification it will be the responsibility of the GP practice to notify the patient. The appointment will have automatically been cancelled on the C&B and PAS systems. If for any reason a patient presents at hospital for an appointment that has been rejected the Patient Access Development Manager will be notified of this attendance, and they will notify the relevant PCT who will address the error with the referring GP practice. If the patient s condition deteriorates or improves during the period between the referral letter being sent and the appointment being held the referring clinician is responsible for informing the Trust s clinician of this alteration. Clinical responsibility for the patient remains with the GP until the receiving clinician has seen the patient. The duty of care then becomes a joint responsibility with any new relevant information being communicated between the clinicians. For some specialties, Suffolk PCT operates a referral management service. If the referral is received from such a Primary care service, the source of referral required on PAS will be entered as GP and 18 week rules apply. WRITTEN REFERRAL LETTERS If referral letters are to be acted on promptly it is important that they are addressed as generic or 'open referrals to a speciality and only to a specific Consultant where this is appropriate. Patients who are referred as generic or 'open referrals to a speciality will be allocated by the clinician responsible for prioritising referrals, to the consultant with the appropriate interest who has the shortest waiting time. All referrals should be directed to the Telephone Appointments Centre (TAC). Referrals received by secretaries without the TAC date stamp must be taken immediately to the TAC for registration. All referrals will be entered onto PAS and the Referrals database upon receipt. The referral letter must include full demographic details including patient s telephone numbers, daytime and evening to ensure that the patient can be contacted promptly. The TAC team will make three attempts over three days to contact the patient by telephone to agree an appointment date and time. The referral letter will then be forwarded to respective departments to be accepted or rejected, and should be returned to the TAC within three working days of receipt. Upon return to the TAC all referrals will be actioned on the Referrals database giving closure to each episode. If a patient cannot be contacted by telephone a call and book letter, which requests the patient to ring the TAC within 5 working days to make their appointment, will be sent. If the patient fails to respond within that time the patient will be returned to the care of the GP. In exceptional circumstances the original referral may be accepted, but the waiting time will be restarted from the date of the acceptance. Source: Patient Access Manager Status: Approved Page 13 of 27 13

14 The same choices and mechanisms apply to the Waiting List Office for the booking of inpatient and daycase activity. The Trust and PCTs will work together to ensure that all referrals are appropriate. If a consultant deems that a referral is inappropriate, it will be returned to the referrer with a clear explanation. Where a referral does not result in an Outpatient appointment e.g. the Consultant rings the GP with advice it must still be returned to the TAC to complete the audit trail. RAPID ACCESS (CANCER) REFERRALS To meet NHS standards, patients referred with suspected cancer must be seen by a specialist within two weeks of the date of receipt of the GP referral. To ensure this: Referrals from GPs will be by referral pro-forma only. The pro-formas will be received by the TAC team, who will ensure that all patients are offered a date within two weeks. Rapid Access Referrals are currently excluded from the Choose and Book process at the WSH. The 'quality' of suspected cancer referrals needs to be subject to regular audit to ensure that this route is being used appropriately. If there is evidence of training needs in general practice in relation to cancer symptoms, appropriate feedback will be given to the GPs and the PCT. MISDIRECTED REFERRALS If a referral has been made and it is clear from the referral that the speciality of the consultant does not match the needs of the patient, the Consultant should cross-refer the patient to the appropriate colleague within the Trust. If it is a written referral the letter may be simply passed across. If the referral is for a service not provided by the Trust then the referral letter will be returned to the referring GP with a note advising that the patient needs to be referred elsewhere. CONSULTANT TO CONSULTANT REFERRALS (INTERNAL) Consultants may wish to refer patients to another Consultant within the Trust, or to another Trust. This may be because the referral from Primary care was misdirected, because of sub-specialisation within a Specialty or where the patient s specific needs can only be met elsewhere. When a decision to refer internally is made the referral letter must be delivered to the TAC within 24 hours of the decision to refer being made. The TAC is responsible for registering the referral on PAS and booking an appointment. Inter Consultant Referrals should only be made for an existing condition where the Commissioners have explicitly agreed the pathway. Where clinical urgency demands or dictates it is appropriate to refer for a new condition. In every case a Consultant to Consultant Referral Form must be attached showing how the criteria are met An internal referral for the same condition keeps the patient s 18 week clock running. In order to meet the Referral to Treatment (RTT) targets, the receiving consultant should ensure that the patient is seen in a timely fashion. A referral to another provider for tests, advice or opinion, where the WSH retains the care of the patient also keeps the clock running. Results or responses should be actioned in order to meet the RTT targets. Mandatory 18 week data must accompany the referral letter. A referral for the same condition made to another provider where the care of the patient is transferred, stops the patient s pathway at the WSH, but the 18 week clock continues to run at the receiving provider. The mandatory 18 week pathway data must accompany the letter of referral. Where a different condition which is unrelated to the original referral is identified, the GP should be informed that a referral to a particular specialty or provider is advised. When the GP makes the new referral, this starts another 18 week pathway for the patient. Source: Patient Access Manager Status: Approved Page 14 of 27 14