Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines

Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines Document Number Version Ratified By & Date Name of Approving Body(s) & Date(s) FPE-004 V1 Safety and Effectiveness Sub-Committee Safety and Effectiveness Sub-Committee Job Title of Document Author Corporate Performance and Information Lead Name of Responsible Committee Safety and Effectiveness Sub-Committee Executive Director Director of Finance and Resources Date Issued December 2014 Expiry Date (Maximum Two Years) December 2016 Target Audience All staff involved in booking appointments and staff that conduct appointments This document may be made available in a different format By contacting the Author of the Document

Version Control Review and Amendment Log Version Type of Change Date Description of Change V1.0 Document Update 20.02.2014 Update policy following V1.1 Feedback from initial consultation and User and Patient Forum V1.2 Further feedback following above revision V1.3 Feedback from Safety & Effectiveness Sub- Committee V1.4 Feedback from Commissioners and User Forum feedback from Commissioners 01.04.2014 Updated policy into Trust Policy format. 25.04.2014 Update policy following comments regarding feasibility of offering two appointments 02.05.2014 Change to 6.2.3 from six weeks to three weeks 26.08.2014 Changes following feedback from Commissioners and User Forum Page 2

DOCUMENT SUMMARY Document Title DNA/Cancellation Policy Document Status New X Revision Date of Publication 9 April 2014 Key Points The length of time that a patient waits for an appointment or treatment can impact on their experience with the Partnership Trust. It is also an important quality issue and is a visible public indicator of the efficiency of the Partnership Trust. The NHS constitution provides patients with the right to access services within maximum waiting times. Commissioners have also identified a number of local targets whereby patients must be offered an appointment and seen within a set number of weeks. Contractual penalties can be imposed should the Partnership Trust fail to meet these targets. The Partnership Trust will seek to ensure that all patients/service users are seen as early as possible during their pathway. However, one of the major obstacles to this is when a patient/service user Does Not Attend (DNAs) their appointment. This results in an inefficient use of clinical time and also the slot to go unused rather than it being offered to another patient. The Partnership Trust has a contractual target that DNA s account for no more than 7.5% of appointments. Currently, in 2013/14 the Partnership Trust is within its target at 4.7%, however, this equates to 81k DNA s out of 1.7M appointments. Using an average shadow cost and volume tariff, this would equate to lost revenue of 5M+ across the whole Partnership Trust area. The policy provides the process for dealing with patients/service users who DNA/cancel appointments by: Advising how patients/service users should be dealt with should they DNA their first or subsequent appointment. It also details when patients/service users continually cancel or rearrange their appointments Clarifying the exceptions to the policy Complying with all national Referral to Treatment (RTT) Guidance Detailing how the rules of the policy affect the RTT and local waiting time clocks The guiding principle of this policy is to support the treatment of all patients/service users and so, therefore, flexibility will be maintained where the clinical judgement is that it is in the best interests of the patient to refrain from any part of the policy Available Support Professional Leads Performance Team Page 3

Contents 1. Introduction... 5 2. Purpose... 5 3. Explanation of Terms... 6 4. Duties and Responsibilities... 6 5. Exceptions... 7 6. Quick Reference Guide... 7 7. Training and Resource Implications... 9 8. Consultation, Approval and Ratification Process... 9 9. Equality Analysis Summary... 10 10. Monitoring Compliance with the Document... 11 11. References and Supporting Documents... 11 12. Policy Review... 11 Appendix 1 - Equality Analysis... 12 Page 4

Did Not Attend (DNA) and Cancellation Policy and Operational Guidelines 1. Introduction This Policy ensures that all relevant staff (including admin / clerical) employed by Staffordshire and Stoke-on-Trent Partnership NHS Trust (Partnership Trust) apply a clear and consistent approach to dealing with patients/service users that DNA or cancel their appointment. This policy is disseminated to patient/service user groups so that there is maximum awareness of the implications of the policy. 2. Purpose The policy aims to inform all relevant staff and patients/service users about how the Partnership Trust will respond when patients/service users DNA, cancel or postpone an appointment. It adheres to the principles of the RTT national guidance and aims to ensure that all patients receive treatment in accordance with the NHS Constitution. The guiding principle of the policy is to support the effective treatment of patients/service users through their respective pathways. Whilst it is acknowledged that there are many reasons for appointments to be moved, regular postponements, particularly at short notice, can hinder a patient/service user s treatment/support. Along with DNAs, this can lead to unused appointment slots which is both an inefficient use of staff time and delays the treatment of other patients/service users. The NHS constitution states that patients have the right to access certain services commissioned by NHS bodies within maximum waiting times. The Partnership Trust also has a number of contractual waiting times for access to services. There are penalties for failure to meet these waiting times. Patients/service users often choose to wait longer for an appointment/treatment and the Partnership Trust is keen to support patient/service user choice. However, it is essential that procedures are in place to ensure that the Partnership Trust is not penalised for supporting this patient choice, should this impact on waiting time performance. Therefore, the policy also includes reference to how DNAs and cancellations impact on various waiting time clocks. The Partnership Trust should also ensure that it considers ways to reduce DNAs where possible by utilising technologies to send reminders prior to Page 5

appointments and ensure that patients/service users are contacted in the most appropriate manner taking into account the diverse needs of patients/service users. 3. Explanation of Terms For the purpose of this document, the following terms apply Term Explanation Patient/Service User The term patient and service user refers to all adults aged 16years and over DNA Where a patient/service user does not attend an appointment, without giving prior notice Cancellation Where a patient/service user gives prior notice that they are unable to attend a previously agreed appointment RTT The time waited from Referral to Treatment (Consultant-led and Allied Health Professional) Clock Each patient on a pathway has a waiting time clock, which counts the time from referral to clock stop. Depending on the particularly pathway, the clock can be stopped at the first appointment, commencement of treatment, or nontreatment such as a DNA. Discharge The discharge of a patient/service user out of the Trust s services and back to the referring agency Vulnerable Adult A person aged 18 years and over who is or may be in need of community care services by reason of mental or other disability, age or illness; and Including some people who may have capacity as well as those who do not. Who is or may be unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation 4. Duties and Responsibilities It is the responsibility of all professionals to ensure documentation, and information for patients is legible and free of abbreviations, dated and timed, and signed with their name and designation clearly printed. Any information given to patients should be made available in the appropriate language and format preferred by the patient. Interpreters should be engaged where necessary to ensure patients have as full an understanding as possible as to the implications of this policy. It is the responsibility of all staff that arrange or conduct appointments with patients/service users to ensure that they are familiarised with the requirements of the policy and that they are assured that these requirements have been conveyed to patients/service users. Page 6

5. Exceptions Flexibility will be maintained where the clinical judgement is that it is in the best interests of the patient to refrain from any part of the policy (other than a DNA for a first appointment). Other exceptions include children and young persons, vulnerable adults, cancer pathways, offender health and sexual health. A Vulnerable adult is defined in accordance to the Department of Health (2000) No Secrets: As a person aged 18 years and over who is or may be in need of community care services by reason of mental or other disability, age or illness; and Including some people who may have capacity as well as those who do not. Who is or may be unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation Procedures will be developed for these excepted areas and included as appendices to this policy. 6. Quick Reference Guide 6.1 DNA 6.1.1 First Appointment for all service types Patients/Service Users who DNA their initial appointment will automatically be discharged. This will be communicated to the patient and also the referrer within five working days. It is important that the Partnership Trust can demonstrate that the appointment was communicated to the patient/service user therefore this must be recorded within the patient/service user record. The patient/service user is removed from the waiting list with immediate effect and the 18-week clock nullified. However, if there are clinical reasons why another appointment should be offered, then a second offer will be made and a copy sent to the referrer advising them of the initial failure to attend. This would commence a new 18- week clock start. 6.1.2 Follow-Up Appointment for all service types Patients/Service Users who DNA any subsequent appointment will be discharged unless there are clear clinical reasons otherwise. This will be communicated to the patient and also the referrer within five working days. It is important that the Partnership Trust can demonstrate that the appointment was communicated to the patient/service user therefore this must be recorded within the patient/service user record. Should the patient/service user still wish to receive treatment, then they must be re-referred and this starts a new clock. Page 7

The Partnership Trust should endeavour to ascertain reasons for DNAs in order to identify any recurring themes and identify any improvements required to the appointment booking process. 6.2 Cancellations/Alterations 6.2.1 Partnership Trust Cancellations for all service types It is important to distinguish between cancellations by the patient/service user and cancellations by the Partnership Trust. Where the Partnership Trust cancels a patient/service user s appointment, this will not stop the clock and a new appointment should be offered to be held within four weeks of their original appointment. 6.2.2 Patient/Service User Does Not Require Appointment for all service types Where a patient/service user cancels their first appointment stating that treatment is no longer required then the patient/service user is removed from any waiting list and their clock stopped. The referrer must be informed of the patient/service user s decision to cancel the referral. 6.2.3 First Appointments Consultant Led/AHP 18 week RTT pathways Upon receipt of a referral, a patient/service user will be offered two appointments within three weeks. For patients who decline these offers, should the patient/service user be available within a further period of four weeks from this appointment then a further offer of an appointment should be made. Should the patient/service user not be available within this four week period, then they shall be referred back to their referrer. Local Waiting Time Targets Upon receipt of a referral, a patient/service user will be offered two appointments within a reasonable timescale. This will be dependent upon the particular target for the service. For services with a local waiting target, the clock will stop following the decline of one offer of an appointment and the decline of a further offer of an appointment within a two week period of the original offer. Should the patient not be available within this two week period, then they shall be referred back to their referrer. 6.2.4 Patient/Service User Alteration of First and Follow-Up Appointments for all service types If a patient/service user wishes to alter their appointment for a period of up to six weeks then a further offer of an appointment will be made. If the patient/service user wishes to alter their appointment for a period in excess of Page 8

six weeks the Trust will discharge them back to the referrer recommending a new referral is made when the patient/service user is able to be seen. Any requests for a second alteration within a pathway will be rejected and, if the patient/service user is unwilling to keep their appointment, then the patient/service user will be discharged back to the referrer unless there is clear clinical objection. 7. Training and Resource Implications A suitable training package is being developed for all appropriate staff to ensure the awareness of the policy and the RTT/waiting times. These are currently covered in the clinical IT system induction training but a more tailored approach is necessary. The RTT/Local Waiting Group will lead on the development of this training, so that the needs of staff can be configured into the training. Understanding the reasons for DNAs and cancellations could require additional resource to record and collate this information, therefore, this will be reviewed following the implementation of the policy. Utilising technologies for appointment reminders will require additional resource, although current clinical IT systems already have the functionality. It is acknowledged, however, that support from the Information management and Technology function of the Partnership Trust will be necessary to facilitate this. The Trusts approach to waiting list management is currently being reviewed with the intention of implementing a Trust-wide Access Policy, of which this DNA/Cancellation policy will form part of. Once the DNA/Cancellation policy is approved it will be necessary to revisit business processes to ensure compliance with all elements. 8. Consultation, Approval and Ratification Process Consultation The draft policy has been shared widely to ensure that the policy is complete, correct and acceptable as a working document. The comments generated from the consultation have been considered by the author and appropriate colleagues. The author of procedural documents has identified relevant stakeholders and the level of involvement for development, consultation or receipt of final procedures. The author has consulted with operational colleagues, commissioners and User and Patient Forums in developing the final version. Page 9

As part of the Trust s commitment to employee involvement and the agreement with staff side representatives, the procedural documents which have an impact on employee practice and their working lives are subject to consultation with staff side representatives. Document Approval & Ratification Committees The Committees reporting to the Trust Board must consider and comment on relevant strategic and policy documents in the context of their terms of reference and provide support and/or suggested change. A report will be provided to the Trust Board at each meeting of the approved procedural documents for ratification, in the form of a report. The aim of this is to provide assurance that procedural documents are in place and available for staff to implement (via the intranet and the Register of Procedural Documents). The Committees are not required to approve guidance, procedures and protocols unless it is deemed appropriate. The Groups and Sub-Groups will approve these documents. The Committee will receive a report for assurance and where necessary ratification at each of its meetings on those documents which have been approved by the Groups. Committee and Group members will be included as appropriate as part of the consultation procedure. 9. Equality Analysis Summary Staffordshire & Stoke on Trent Partnership NHS Trust considers how the decisions it makes affects people who share different protected characteristics (race, disability, sex, gender re-assignment, religion/belief, sexual orientation, age, marriage and civil partnership, pregnancy and maternity). The Trust also recognises that there are groups/communities that are recognised at a local level within society as excluded or disadvantaged in addition to those listed as protected groups above and this document is inclusive to these groups also for example, young teenage parents, homeless people etc. A completed equality analysis is presented at Appendix (1) of this document. Page 10

10. Monitoring Compliance with the Document Some groups in society, who are vulnerable to social exclusion, are forgotten simply because not enough is known about their particular circumstances, this is also true of the processes surrounding DNAs and cancellations. The Partnership Trust will monitor the DNA/cancellation process and the functions covered in this policy to ensure that it is implemented fairly irrespective of age, race, gender, sexual orientation, disability or religion. Statutory duties exist under the Equality Act 2010 and, where appropriate, equality data will be published in the Equality and Human Rights Annual Report and to the Trust Board. Compliance with this policy will be monitored by formal Trust groups. Where any monitoring has identified deficiencies, a risk assessment must be included on the appropriate local risk register, with an action plan to address any gaps identified. The action plan will be monitored in accordance with Trust Policy: Risk Management and Assurance Strategy. 11. References and Supporting Documents NHS Constitution - http://www.nhs.uk/choiceinthenhs/rightsandpledges/nhsconstitution/pages /Overview.aspx Consultant-led RTT Guidance https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 198930/Referal_to_treatment_Rules_Suite.pdf Allied Health Professional RTT Guidance https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 215248/dh_131969.pdf 12. Policy Review This policy will be reviewed in two years following ratification or sooner if the necessity arises as part of the Trust-wide Access Policy. Page 11

Appendix 1 - Equality Analysis DNA/Cancellation Policy STEP 1: What is the background and starting point for this policy? How the Partnership Trust deals with patients/service users that DNA/cancel their appointments differs across services. Although there is national guidance on RTT pathways, some of this guidance can only be implemented once it has been agreed locally. In addition, there are many services not applicable to RTT, therefore, local guidance is required for these services. STEP 2: What do we want to achieve? A consistent methodology for dealing with patients/service users that DNA or cancel appointments and to ensure that patients/service users are aware of the implications of such actions. STEP 3: What do we know? Procedural documents should not be developed in isolation and their introduction should be balanced against the priorities of the Trust. The organisation needs formal written documents which communicate standard ways of working. These help to clarify strategic and operational requirements and they can improve the quality of work and increase the successful achievement of objectives. STEP 4: What consultation has been taken: engagement and involvement? Consultation has been undertaken with a number of target audiences in developing this procedural document. An initial draft was communicated to professional leads prior to approval by the Safety and Effectiveness Sub- Committee. Following review by Commissioners, the policy has been revised following liaison with operational staff and patient groups. STEP 5: The policy clearly references (section 10) the importance of ensuring that the consent process is not prejudiced by any factors outlined in the Equality Act (2010). Advice is given to staff as to help individuals receive adequate and appropriate information to make informed decisions. Support will be given by the Performance Team, Professional Leads and Corporate Governance Team for the implementation and supporting of the DNA/Cancellation Policy and process. Support will be in a variety of ways eg face to face meetings, telephone, email or in the form of training and awareness sessions when indicated at a mutually convenient time, day and venue. This policy is explicit that this will not affect the treatment or care of any person or impact upon by race, age, gender, disability, religion or belief, Page 12

STEP 6: Have you identified any actions: The comments received as part of the consultation procedure have been taken into consideration and subsequent amendments have been made as outlined in the Version Control section of this document. Resources are available to provide advice and support on this policy which will be available to all members of staff. STEP 7: How will we know that the policy has been successful? The monitoring and reporting arrangements are provided within this policy. Performance activity is reported monthly as part of the Trust s contractual Key Performance Indicators. An annual audit will be implemented with a report been presented to all relevant Boards, Committees and Groups. STEP 8: Executive Summary The guiding principle of this policy is to support the treatment of all patients/service users and so, therefore, flexibility will be maintained where the clinical judgement is that it is in the best interests of the patient to refrain from any part of the policy. Page 13