PATIENT ACCESS POLICY & USER MANUAL

PATIENT ACCESS POLICY & USER MANUAL Controlled document This document is uncontrolled when downloaded or printed. Reference number Version 16 Author & Job Title WHHT: C056 Jane Shentall, Director of Performance Approved by/date RTT Programme Board/ June 2017 Ratified by Quality and Safety Group Date ratified 20 th July 2017 Committee/individual responsible RTT Programme Board Consultation Policy & Guideline Review Group/11 th July 2017 Issue date July 2017 Review date April 2019 Target audience Key Words Previous Policy Name Equality Impact Assessment All staff with responsibility for patient pathway events or the administrative management of 18 week pathways 18 weeks, RTT, waiting times, Access policy, pathway Outpatient and Inpatient Waiting times & Patient Access Policy Completed April 2017

CONTRIBUTION LIST Key individuals involved in developing this version of the document Name Designation Jane Shentall Director of Performance Lynne McGrory Head of RTT Access Team Mark Currie Associate Director for Performance & Information Sue Daniels Radiology Services Manager Approved by Committee RTT Programme Board- 29.06.17 Ratified by Committee Quality and Safety Group- TBA Change History Version Date Author Reason V1 October 2013 Piers Young Updated in line with national guidance V2 December 2013 Piers Young Further updates added in line with national guidance V14 January 2014 Piers Young Further updates added in line with national guidance V15 October 2015 Jane Shentall Updated in line with national guidance. More user-friendly format. V16 May 2017 Jane Shentall Updated in line with national guidance Author: Jane Shentall Review date: April 2019 Page 2 of 66

CONTENTS 1. EXECUTIVE SUMMARY & POLICY STATEMENT... 4 2. INTRODUCTION... 5 3. NATIONAL STANDARDS... 6 4. NATIONAL PERFORMANCE MEASURES... 7 5 KEY PRINCIPLES... 11 6. OUTPATIENT WAITING LISTS... 16 7. INPATIENT WAITING LISTS... 29 8. PRE-OPERATIVE ASSESSMENT (POA)... 39 9. DIAGNOSTICS AND IMAGING APPOINTMENTS... 43 10. THERAPIES, ORTHOTICS etc... 51 11. PATIENT LETTERS... 54 12. APPENDICES... 56 12.1 GLOSSARY OF TERMS... 56 12.2 18 WEEK REFERRAL TO TREATMENT CODES... 58 12.3 PROCESS FOR PAEDIATRIC DNAs... 59 13. EVALUATION MEASURES... 62 14. RELATED POLICIES... 63 15. EQUALITY IMPACT ASSESSMENT... 63 16. POLICY AND PROCEDURE SIGN-OFF SHEET... 64 Policy Ratification Form... 65 Author: Jane Shentall Review date: April 2019 Page 3 of 66

1. EXECUTIVE SUMMARY & POLICY STATEMENT The purpose of this document is to both outline and define how the Trust and its staff manage access to its key services, ensuring fair treatment for all patients. The successful management of patient waiting lists is fundamental to achieving NHS England s objectives in reducing waiting times and improving patient choice. This policy describes the processes to be followed to ensure transparent, fair and equitable management of waiting lists. It includes guidelines and procedures to ensure: that waiting lists are managed effectively a high quality of service to patients is maintained optimum use is made of resources at all locations within the Trust. This document is intended to be used by all staff in the local health economy dealing with waiting list management. It will ensure that patients will be treated in order of clinical priority, and that patients of the same clinical priority will be seen in turn. It will also help provide equity of access within specialties across sites throughout the Trust. The policy is not intended to replace local and departmental operational policies and procedures including defined Patient Administration System processes set out in Clinicom user guides, but act as a framework to support them. It will be reviewed annually to ensure that it accurately reflects changing local, regional and national priorities The Director of Performance is accountable for ensuring services have the frameworks, policies and processes to support delivery of operational standards relating to the provision of elective care, diagnostic and cancer services. Divisional General Managers, Assistant Divisional Managers, outpatient and inpatient scheduling staff, Head of RTT Access and the RTT Access team have overall responsibility for implementing and ensuring adherence to the policy within their areas. Where issues arise with any member of staff complying with the policy, the issue will be resolved between that individual s line manager, the relevant Assistant Divisional Manager and Divisional General Manager and the individual concerned. Any failure to reach agreement will be referred to the Director of Performance. Any failure to reach agreement at that stage will be referred to the Chief Operating Officer. Failure to adhere to this policy will be dealt with through the Trust s disciplinary process. Author: Jane Shentall Review date: April 2019 Page 4 of 66

2. INTRODUCTION This Patient Access & Waiting Times Policy for West Hertfordshire Hospitals NHS Trust has been developed and reviewed following investigation of best practice together with consultation and good practice throughout the local health economy. This has included partnership working with Clinical Commissioning Groups (CCGs), and the Patient Access Team. The aim of this document is to establish a consistent approach to patient access across the Trust to ensure that national and local standards of care are met through clarity of definition and procedure to provide an operational guide for all areas to work to consistently, in conjunction with local operational procedures, which cover the detail of day-to-day administrative processes. This policy does not replace local operational procedures but seeks to support them. Medical staff, managers and administrative staff have an important role in managing waiting times effectively. Treating patients and delivering a high quality, efficient and responsive service, ensuring prompt communications with patients is a core responsibility of the Trust, each hospital site, all staff and the wider local health community. Staff must ensure that national standards are met and that all notification rules are adhered to. These are detailed throughout the policy and summarised below for ease of reference. Author: Jane Shentall Review date: April 2019 Page 5 of 66

3. NATIONAL STANDARDS 3.1 The NHS Constitution for England From April 2010 patients have had the right to: start their consultant led treatment within a maximum of 18 weeks from referral for non-urgent conditions. Be seen by a cancer specialist within a maximum of 2 weeks from a GP referral for urgent access where cancer is suspected. For English Patients (from an individual patient perspective) the current maximum waiting times for elective care are set out in the NHS Constitution and the handbook to the NHS Constitution. This can be found at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/48048 2/NHS_Constitution_WEB.pdf Handbook to the NHS Constitution for England (July 2015) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/47445 0/NHS_Constitution_Handbook_v2.pdf In addition to the individual patient rights as set out in the NHS Constitution (and its supporting handbook) there is a set of waiting time performance measures for which the NHS is held accountable for delivering by NHS England. These measures are set out in the current NHS England document: Everyone Counts: Planning for Patients 2014/15 to 2018/19. This can be found at: https://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf 3.2 NHS Operational Planning & Guidance 2016/17 2018/19 This document describes nine must do national priorities, covering the following: STPs Finance Primary Care Urgent & Emergency Care Referral to treatment times and elective care Cancer Mental Health People with learning disabilities Improving quality in organisations The guidance states that Commissioners and Providers must have plans to demonstrate how they will deliver these priorities. Author: Jane Shentall Review date: April 2019 Page 6 of 66

It also describes the seven NHS England 2020 goals, one of which is to maintain and improve performance against core standards, including the RTT 92% incomplete pathway standard. https://www.england.nhs.uk/wp-content/uploads/2016/09/nhs-operational-planningguidance-201617-201819.pdf Author: Jane Shentall Review date: April 2019 Page 7 of 66

4. NATIONAL PERFORMANCE MEASURES 4.1 REFERRAL TO TREATMENT (RTT) In June 2015 NHS England announced changes to the tracking of RTT waiting times, with a focus on open pathways. Therefore the only national reporting of RTT waiting times will be as follows: 92% of patients on open pathways (waiting for treatment) should be waiting less than 18 weeks from referral. The current (October 2015) Recording and reporting referral to treatment (RTT) waiting times for consultant-led elective care rules and guidance can be found at Further information can be obtained from the updated (May 2016) Recording and reporting referral to treatment (RTT) waiting times for consultant-led elective care: Frequently Asked Questions, which can be found at https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04/recordingand-reporting-rtt-guidance-v24-2-pdf-703k.pdf https://www.england.nhs.uk/statistics/wpcontent/uploads/sites/2/2013/04/accompanying-faqs-v7.2.pdf 4.2 CANCER WAITING TIMES The headline performance measures are against a minimum threshold of 93% of patients referred by a GP (GMP or GDP) for suspected cancer will be seen within 2 weeks from referral 93% of patients referred with breast symptoms (where cancer is not suspected) will be seen within 2 weeks from referral 96% of patients will receive first definitive treatment within 31 days of the decision to treat (DTT) 94% of patients will receive treatment within 31 days of the DTT where that is a second or subsequent treatment(s), including those diagnosed with a recurrence, where the subsequent treatment is surgery. 98% of patients will receive treatment within 31 days of the DTT where that is a second or subsequent treatment(s), including those diagnosed with a recurrence, where the subsequent treatment is drug treatment. Author: Jane Shentall Review date: April 2019 Page 8 of 66

94% of patients will receive treatment within 31 days of the DTT where that is a second or subsequent treatment(s), including those diagnosed with a recurrence, where the subsequent treatment is radiotherapy. 85% of patients will receive first definitive treatment within 62 days of urgent GP (GMP or GDP) referral for suspected cancer. 90% of patients will receive first definitive treatment within 62 days of urgent referral from an NHS Cancer Screening programme (breast, cervical and bowel) for suspected cancer. Patients will wait a maximum of 62 days from a consultant upgrade of urgency of a referral to first treatment currently no operational performance standard. Patients will wait a maximum of 31 days from urgent GP referral to first treatment for children s cancer, testicular cancer and acute leukaemia (monitored within the 62 day standard but no separate operational standard). The National Cancer Waiting Times Monitoring Dataset Guidance version 9.0 (October 2015), can be found at https://digital.nhs.uk/media/896/national-cancer-waiting-times-monitoring-dataset- Guidance Further detailed information can be obtained from the Delivering Cancer Waiting Times, A Good Practice Guide (updated July 2016), which can be found at https://improvement.nhs.uk/uploads/documents/delivering_cancer_waiting_times_up date_july_2016.pdf 4.3 DIAGNOSTIC WAITING TIMES Speed of diagnosis is a significant factor in the quality and timeliness of care. 99% of patients will have a maximum wait of 6 weeks for a diagnostic test (see section 8). National guidance can be found at https://nhsenglandfilestore.s3.amazonaws.com/stats/dm01-guidance-v-5.32.doc Details of frequently asked questions can be found at https://nhsenglandfilestore.s3.amazonaws.com/stats/dm01-faqs-v-3.0.doc 4.4 NON-CLINICAL ON THE DAY CANCELLATIONS Where a patient is cancelled on the day of admission or day of surgery, he/she must be rebooked within 28 days of the original admission date. Two reasonable offers Author: Jane Shentall Review date: April 2019 Page 9 of 66

must be made to the patient within 28 days of the date of cancellation. The patient may choose not to accept a date within 28 days. If the Trust cannot offer the patient a date within 28 days of the cancellation, the Trust must offer to fund the patient s treatment at the time and hospital of the patient s choice where appropriate. Author: Jane Shentall Review date: April 2019 Page 10 of 66

5. KEY PRINCIPLES This policy will be applied consistently and without exception across the Trust. This will ensure that all patients (including prisoners) are treated equitably and according to their clinical need. All staff employed by West Hertfordshire Hospitals NHS Trust will adhere to the Waiting Times and Patient Access Policy. All stakeholders including, CCG s, Area Teams, patient representatives, patients and others will have access to this policy Patients will be treated in strict order of clinical priority and chronological waiting time. Patients of the same clinical priority will be seen in turn according to Trust Targets and standards. Patients will be invited to choose an appointment date/time within the defined booking period. Patients will agree at the time of attendance the date/time of their next appointment. The following symbols appear throughout this document to allow easy identification of clock events and data entry. This symbol indicates a CLOCK START / STOP event This symbol indicates a DATA ENTRY requirement 5.1 REFERRAL TO TREATMENT PRINCIPLES As a general principle, the Trust expects that before a referral is made for treatment, the patient is clinically fit for assessment and treatment. The patient must be available for treatment within 18 weeks of referral. The Trust will work with GPs, CCGs and other primary care services to ensure patients have a full understanding of this before starting an elective care pathway. 5.2 REASONABLE OFFERS A reasonable offer is an offer of a time and date three or more weeks from the time the offer was made. If a patient accepts an offer with less than 3 weeks notice, that will be considered a reasonable offer should the patient subsequently cancel. Author: Jane Shentall Review date: April 2019 Page 11 of 66

5.3 RTT CLOCK STARTS An RTT clock starts when any health professional (or service permitted by an English NHS Commissioner to make such referrals) refers to a consultant-led service. The RTT clock start date is the date that the Trust receives the referral. For referrals received through NHS e-referral, the RTT clock starts on the patient converts their unique booking reference number (UBRN). A new RTT clock should be started when a patient becomes fit and ready for the second of a consultant-led bilateral procedure. 5.4 RTT CLOCK STOPS FOR TREATMENT An 18-week clock stops when: A patient receives treatment in an outpatient setting; this could be medication, advice, fitting of a brace or appliance, or the initiation of a therapy treatment plan The patient is admitted for treatment. Where the treatment requires day case or inpatient admission, the clock stops on the day of admission. It does not stop where admission is for diagnostic tests only. A diagnostic procedure that turns in to a therapeutic procedure or the fitting of a medical device also stops the RTT Clock. CLOCK STOP: First definitive treatment DATA ENTRY Use code 30 date of admission/treatment 5.5 RTT CLOCK STOPS FOR NON-TREATMENT An RTT clock stops when the patient and subsequently their GP are informed that: It is clinically appropriate to return the patient to primary care for nonconsultant-led treatment in primary care. A clinical decision is made not to treat. A patient DNA (did not attend) results in the patient being discharged. A patient declines treatment having been offered it. Author: Jane Shentall Review date: April 2019 Page 12 of 66

A decision is made to start the patient on a period of watchful wait / active monitoring. CLOCK STOP: DNA (33) / Decision not to treat (34) / Patient declined treatment (35) DATA ENTRY Use code 33 / 34 / 35 the date the decision is made and communicated to the patient and GP 5.6 ACTIVE MONITORING / WATCHFUL WAITING In many pathways there will be times when it is clinically appropriate to start a period of active monitoring without further clinical intervention or diagnostic procedure. The clock stops when this decision is made and communicated to the patient. CLOCK STOP: Active monitoring / watchful waiting DATA ENTRY Use code 32 the date the decision is made and communicated to the patient and GP Some clinical pathways require patients to undergo regular monitoring/review diagnostics as part of an agreed programme of care. These events would not of themselves indicate a decision to treat or a new clock start. It is not appropriate to stop a clock for a period of active monitoring if some form of diagnostic or clinical intervention is required in a couple of days time, but it is appropriate if a longer period of active monitoring is required before further action is needed. If a decision is made to treat after a period of active monitoring / watchful waiting, a new RTT clock would start on the date of decision to treat (DTT). CLOCK START: Active monitoring end DATA ENTRY Use code 11 the date the decision to treat is made Author: Jane Shentall Review date: April 2019 Page 13 of 66

5.7 CLINICALLY INITIATED DELAYS (Patient not fit for treatment) If a patient is listed for surgery but is identified, or self-reports, as unfit for that procedure, the nature and duration of the clinical issue should be ascertained. If the clinical issue is short term (3 weeks or less) and has no impact on the original clinical decision to undertake the procedure (eg cough, cold), the patient must be offered a new TCI date within their 18 week breach date. The clock will continue running during this time. If the clinical issue is expected to last for 4 weeks or more the patient must be removed from the waiting list and advised accordingly. This will be a clock stop event. CLOCK STOP: Active monitoring / watchful waiting DATA ENTRY Use code 32 the date the decision is made and communicated to the patient and GP The patient should be re-listed and a new clock started when confirmation is received from either the GP or the relevant clinician, that the patient is fit to undertake the procedure. The treating consultant must review the case and indicate whether the patient needs to be reviewed in outpatients or whether they can be added directly to the inpatient waiting list. CLOCK START: Active monitoring end DATA ENTRY Use code 11 the date the patient is added to the waiting list or the date of the new referral if the patient requires outpatient review first 5.8 NEW CLOCK STARTS If a decision is made to start a substantively new or different treatment that does not already form part of that patient s agreed care plan this will start a new RTT pathway clock and the patient shall receive their first definitive treatment within a maximum of 18 weeks from that date. CLOCK START: First activity in RTT period DATA ENTRY Use code 10 the date the decision is made and communicated to the patient and GP Author: Jane Shentall Review date: April 2019 Page 14 of 66

This will include all patients whose pathway has been stopped previously but who are then added to an elective waiting list for surgery or other therapeutic intervention. Author: Jane Shentall Review date: April 2019 Page 15 of 66

6. OUTPATIENT WAITING LISTS 6.1 REFERRAL LETTERS All routine and urgent referral letters should be sent to the outpatient booking office. Referrals are received by the Trust in either paper form or electronically in the form of an NHS e- referral. Both fall into two categories: Open referrals to pooled waiting lists in a given specialty Consultant specific referrals. Where clinically appropriate, referrals should be made to a service (an open/generic referral) rather than a named clinician. This is in the best interests of patients as it promotes equity of waiting times and allows greater flexibility in terms of booking appointments. As a general principle, generic referrals will be sent to the consultant with the shortest waiting time in that specialty. However, it is the patient s right to request a named consultant. 6.2 MANAGEMENT OF REFERRALS All outpatient waiting lists must be managed using the PAS / NHS e-referral systems. 6.2.1 Paper Referrals All paper referrals must be date stamped upon receipt at point of entry to the Trust. Details of the referral will be entered onto PAS at this point reflecting recorded date by the Trust. For patients referred by paper referrals this is the point that the Referral to Treatment (RTT) clock starts on waiting time standards and 18-week pathway. CLOCK START date referral received by the Trust DATA ENTRY Referral details entered on PAS Referrals will be sent to Clinical teams for prioritisation. Prioritisation should be recorded as Cancer (where a 2ww pro forma has not been used), Urgent or Routine'. Author: Jane Shentall Review date: April 2019 Page 16 of 66

Patients should be given appointments within the agreed maximum timeframe for each specialty (agreed by clinical specialties and at Executive Level). Appointments must be made in chronological order and on a first come first served basis to ensure equity of access. This process should take no more than five working days. 6.2.2 NHS e-referrals All NHS e-referrals must be reviewed and accepted / rejected within 24 hours for an urgent referral and 48 hours for a routine referral by Clinical Teams. Where there is a delay in reviewing these referrals this will be escalated to the relevant clinical team and actions agreed to address this. Where possible the Trust will endeavour to provide an NHS e-referral appointment at the hospital site of the patient s choice. If this is not possible the patient will be offered an appointment at one of the other sites within the Trust. If a patient s appointment has been incorrectly booked on the NHS e-referral system into the wrong service by the referrer, the NHS e-referral team will redirect the patient to the correct service and a confirmation letter of the appointment change will be sent. If a NHS e-referral referral is received for a service not provided by the Trust, it will be rejected back to the referring GP advising that the patient needs to be referred elsewhere. If there are no slots available for the selected service, the patient will appear on the Appointment Slot Issue (ASI) work list. Patients on this list must be contacted within 14 days and offered an appointment as soon as one becomes available. If they cannot accept the appointment offered they will stay on the list until another is available. If the patient cannot accept the second appointment offered the patient should be advised that the relevant clinician will review the referral and confirm whether a further appointment should be offered or if the patient should be discharged back to their GP. If the patient advises that the appointment is no longer required, they will be removed from the waiting list and discharged back to the GP. The 18 week clock will be nullified. CLOCK STOP the pathway is nullified on the date the patient advises the referral is no longer required Author: Jane Shentall Review date: April 2019 Page 17 of 66

6.3 CANCER 2 WEEK WAIT REFERRALS (INC BREAST SYMPTOMATIC) GPs and GDPs must use the Trust s 2 week wait (2WW) pro forma which can be found at: http://nww.westhertshospitals.nhs.uk/referrals/cancer_two_week_wait_referral s.asp Referrers will ensure that patients are given the information sheet attached to all 2WW referral pro forma that explains the urgency of the referral. Referrals must be faxed by the GP/GDP to the Trust (within 24 hours of the patient being seen) to Central Booking Office at St Albans City Hospital (fax: 01727 897492). The Central Booking Office staff will liaise with the Consultant to ensure that all patients will be offered a date within 14 days. GPs who send referrals under this protocol will receive a faxed back confirmation of receipt of the referral. NHS e-referral 2 week wait referrals will be booked into an appointment slot within 14 days by the GP or patient. In the rare event that no slots are available on The NHS e-referral system, the GP should use the defer to provider function on system to notify the Trust. The NHS e-referral team will liaise with the relevant Assistant Divisional Manager to ensure that all patients are offered a date within 14 days. GP s and GDP s should ensure their patients are able to attend an appointment within the following 2 weeks. If a patient is unavailable, GP s and GDP s should consider whether it is appropriate to defer the referral until such time that their patient can attend an out-patient appointment within 2 weeks of being referred. Patients should not be referred back to their GP because they are unable to accept an appointment within 2 weeks, ie once a referral has been received it should not be returned due to patient unavailability. If difficulty in meeting the booking guidelines is encountered, this must be escalated through the relevant Assistant Divisional Manager and Divisional Manager for action and resolution. The Cancer Unit Manager must also be kept informed. This should remain as it is down to the division to advise on capacity in these circumstances Two week wait referrals can only be downgraded by the GP - if a consultant thinks the 2 week wait referral is inappropriate, it should be discussed with the GP and the GP asked to withdraw the two week wait referral status. GPs should not be asked to downgrade a patient (or withdraw the referral) simply because they are unavailable to accept an appointment within two weeks. Author: Jane Shentall Review date: April 2019 Page 18 of 66

6.3.1 2 week wait first appointment DNAs If a patient DNAs a 2WW first appointment, another appointment should be booked automatically. The patient should not be discharged or referred back to their GP. However, it is good practice to contact the GP to make them aware that the patient DNAd and ask them to find out why. DATA ENTRY Log the DNA on PAS and re-book another appointment log this on PAS Patients can be referred back to their GP after 2 consecutive DNAs. If a patient DNAs their first outpatient appointment for the second time, the responsible clinician will review the patient notes at end of clinic with a view to discharging the patient providing that: Discharging the patient is not contrary to their best clinical interest. The clinical interests of vulnerable patients (see the Safeguarding Adults at Risk Policy and Procedure, or the Child Protection Policy) are protected. If the decision is made not to rebook, the patient will be removed from the outpatient waiting list and an automated PAS letter will be sent to the GP and the patient notifying them of this removal. The patient will be discharged from PAS, and cancelled on NHS e-referral if appropriate.. 6.3.2 2 week wait first appointment cancellations Patients should not be referred back to their GP after a single appointment cancellation. DATA ENTRY Log the cancellation and book another appointment log this on PAS Patients should not be referred back to their GP after multiple (two or more) appointment cancellations unless this has been agreed with the patient by cancelling an appointment a patient has shown a willingness to engage with the NHS. The quality of suspected cancer referrals will be the subject of regular audit, (with appropriate feedback to individual GPs and the CCG). If there is evidence of training needs in general practice in relation to Cancer referrals, or that this route is being misused to secure fast-track appointments, appropriate action will be agreed with the CCG. Author: Jane Shentall Review date: April 2019 Page 19 of 66

6.4 RAPID ACCESS CHEST PAIN CLINIC (RACPC) REFERRALS To meet NHS standards, RACPC referrals must be seen by a specialist within 14 days of the Trust receiving the referral. To ensure that this is achieved: Referrals from GPs will be by referral protocol only. GPs will ensure that appropriate information regarding the RACPC referral is provided to the patient and the importance of being seen quickly communicated to the patient as well. Referrals must be sent by the GP (within 24 hours of the patient being seen) to the RACPC who will liaise with the Consultant to ensure that all patients are offered a date within 14 days. NHS e-referral referrals for RACPC will be booked into an appointment slot within 14 days by the GP or patient. In the unlikely event that no slots are available on NHS e-referral, the GP must send the referral to the appropriate receiving point, who will liaise with the Consultant to ensure that all patients will be offered a date within 14 days. If a patient cannot make themselves available within 2 weeks for an appointment, the GP should delay making the referral until the patient is available to be seen within 2 weeks. DATA ENTRY Log the appointment on PAS, record the cancellation. Offer an appointment the patient can attend and record on PAS If the patient cannot accept the second appointment offered the patient should be advised that the relevant clinician will review the referral and advise whether a further appointment should be offered or if the patient should be discharged back to their GP. The management of patient DNAs will be in line with section 6.15. Where difficulty in meeting the booking guidelines is encountered, this must be escalated to the relevant Assistant Divisional Manager and Divisional Manager for action and resolution. The quality of RACPC referrals will be the subject of regular audit, (with appropriate feedback to individual GPs and the CCG). If there is evidence of training needs in general practice in relation to RACPC referrals, or that this route is being misused to secure fast-track appointments for inappropriate patients, appropriate action will be agreed with the CCG. Guidance is contained in a separate policy. Author: Jane Shentall Review date: April 2019 Page 20 of 66

6.5 TRANSIENT ISCHAEMIC ATTACK (TIA) CLINIC REFERRALS To meet NHS standards all high risk TIA patients should be seen and treated as a medical emergency within 24 hours of the first contact with a healthcare professional. All low risk TIA patients should be seen and treated within 7 days of the first contact with a healthcare professional. Referrals from GPs will be by referral protocol only and must be accompanied by a completed ABCD2 score pro-forma. Patient scoring 4 or above on the ABCD2 should be referred to the high risk clinic within 24 hours of the first contact. GPs must contact the TIA referral hotline and an urgent appropriate appointment will be agreed for the patient whilst still in consultation with the GP. Patients who score below 4 on the ABCD2 should be referred as low risk and will be given an appointment in the TIA clinic within 7 calendar days of contact. GPs must fax referrals to the Stroke Office and the patient will be contacted to agree an appropriate appointment date and time. The quality of TIA referrals will be the subject of regular audit, (with appropriate feedback to individual GPs and the CCG). If there is evidence of training needs in general practice in relation to TIA referrals, or evidence that this route is being misused to secure fast-track appointments for inappropriate patients, action will be agreed with the CCG. 6.6 REFERRALS FOR LOW PRIORITY TREATMENTS Requests for admission for some conditions which are classed as low priority treatments are not generally funded by commissioners. These patients must not be added to the inpatient waiting list unless explicit approval has been received on a named patient basis from the commissioning CCG. Once approval has been obtained, the request for admission can be processed in the normal way. The RTT clock will continue while approval for treatment is sought. Patients referred for treatment outside of existing contracting agreements will follow the agreed protocol as laid out in the Host Commissioner s Low Priority Treatment Policy before booking. Author: Jane Shentall Review date: April 2019 Page 21 of 66

6.7 OVERSEAS VISITORS Separate guidance should be referred to when managing the treatment of overseas visitors, as access to the Health Service may be limited. Department of Heath guidance on overseas visitors may be found at: www.dh.gov/overseasvisitors 6.8 MILITARY VETERANS All veterans and war pensioners should receive priority access to NHS care for any conditions which are related to their service subject to the clinical needs of all patients, in line with December 2007 guidance from the Department of Health. Military veterans should not need first to have applied and become eligible for a war pension before receiving priority treatment. GPs should notify the Trust of the patient s condition and its relation to military service when they refer the patient so that the Trust can ensure that it meets the current guidance for priority service over other patients with the same level of clinical need. In line with clinical policy patients with more urgent clinical needs will continue to receive clinical priority. 6.9 CONSULTANT TO CONSULTANT REFERRALS Consultant-to-Consultant referrals should be kept to a minimum wherever possible and should relate to the original referred condition. Consultant-to-Consultant referrals must follow the strict Referral Protocol process as agreed with the CCG. At present referrals may be accepted under the following circumstances: Consultant to consultant outpatient referral or Accident & Emergency to consultant outpatient referral is considered of benefit to the patient when a different specialist consultant opinion is needed to advance the management of the presenting or associated condition When the referral is for investigation, management or treatment of cancer, or a suspected cancer Symptoms or signs suggest a life threatening or urgent condition Surgical assessment of an established medical condition with a view to surgical treatment Medical assessment of an established surgical condition with a view to medical management Anaesthetic risk assessment A&E referrals to fracture clinic Author: Jane Shentall Review date: April 2019 Page 22 of 66

Referrals that are part of the continuation of investigation/treatment of the condition for which the patient was referred. These will continue their existing pathway. Suspected cancer referral. This will be vetted and dated by the receiving consultant and upgraded if deemed necessary. Once upgraded the patient will be treated within 62 days of the date the referral was received by consultant. Management of pain where surgical intervention is not yet appropriate. All other referrals must be returned to the referring consultant for referral back to the patient s GP. Investigation for or treatment of any condition other than the condition for which the patient was originally referred, requires the patient to be referred back to the GP for onward referral to a different specialist. 6.10 INAPPROPRIATE REFERRALS If a referral has been made to a Consultant whose service/specialist interest does not match the needs of the patient, the Consultant should advise the GP promptly so that appropriate treatment can be sought. If the opinion of a different specialty is required this should be made in agreement with the patient s registered GP and an onward referral made. This does not constitute a new referral. The original referral must be changed to reflect the change of consultant. If the referral is for a service not provided by the Trust the referral letter will be returned to the referring GP with a note advising that the patient needs to be referred elsewhere. Such patients will not be registered by the Trust. 6.11 REFERRALS FROM AAU & WARDS Patients who require an outpatient appointment with the Consultant Team that was responsible for their care during their inpatient stay will be booked as follow-up appointments. These patients do not need to be placed on an 18 week RTT pathway. Appointments should be agreed with the patient and booked by the ward before the patient is discharged. Patients who require an outpatient appointment with a different specialty or new Consultant Team following an inpatient admission will be booked as New appointments. These patients fall under the 18 week RTT requirements, and a RTT clock will start at this point. Author: Jane Shentall Review date: April 2019 Page 23 of 66

CLOCK START: Activity following first treatment DATA ENTRY Use code 90 date referral received by new consultant team Waiting times standards as detailed in section 2.1 and 4.3.2 will apply to these patients. Appointments should be agreed with the patient and booked by the ward before the patient is discharged. Patients who require an outpatient appointment with a different specialty or new Consultant Team following an inpatient admission who are already under the care of that Consultant Team for out-patient treatment will be booked as follow-up appointments. The appointment should be booked under the existing outpatient registration for that Consultant Team. The guidance on consultant to consultant referrals (section 5.5.6) must be applied when booking appointments for this group of patients. 6.12 FURTHER APPOINTMENT REQUESTS AFTER DISCHARGE Patients requesting an appointment with the same clinical team after being discharged must seek a new referral from their GP. 6.13 REFERRALS FROM CLINICAL ASSESSMENT & TRIAGE SERVICES (CATS) These services provide intermediary levels of clinical triage, assessment and treatment between traditional primary and secondary care. At the Trust there are CATS for dermatology and musculoskeletal conditions. A referral to CATS starts an 18 week RTT clock. CLOCK START DATA ENTRY date referral received by the CATS service If the patient is referred on to the Trust having not received any treatment or non-treatment clock stop in the service the Trust inherits the 18 week RTT wait for the patient. Author: Jane Shentall Review date: April 2019 Page 24 of 66

Minimum Data Set forms must be used to transfer 18 week information about the patient to the Trust. The Trust will ensure these are in place to manage the patient s care. 6.14 PATIENT CONTACT 6.14.1 Booking Outpatient Appointments All patients will be offered appointments within the current guidelines for patient choice and in line with the national guidance for waiting times. Wherever possible, patients are to be contacted by telephone to agree their first outpatient appointment. Three attempts are to be made to contact the patient over a 24 hour period (one attempt to be after 5.00pm). If this is unsuccessful the patient will then be sent a letter requesting that they make contact with the relevant booking team. This is known as partial booking. Where this is not in place, the patient will be sent an appointment. If the patient does not make contact with the relevant team within two weeks (as per the letter), the patient should be removed from the outpatient waiting list and a standard PAS letter sent to the patient and GP confirming the patient s removal. The RTT clock will be nullified. A written appointment to a patient must be deemed reasonable. It is accepted that while all offers have to be reasonable it is possible some patients may be willing to attend at short notice. If a patient accepts a short notice offer, this will be considered a reasonable offer, if the patient subsequently cancels the appointment. However if a patient declines such an offer the patient s 18 week RTT waiting time must continue. Patients who are not referred via NHS e-referral will receive an invitation or acknowledgement letter confirming their first outpatient appointment. Patients will be booked for their first outpatient appointment in line with speciality pathway milestones (where available). NHS e-referral patients will receive a confirmation letter once the referral has been reviewed and accepted by the Clinical Team. 6.14.2 Patients requesting time to consider treatment options (thinking time) Patients may wish to spend time thinking about the recommended treatment options before confirming they are willing and able to proceed. It would not be appropriate to stop the 18 week RTT clock where this amounts to only a few days however, it may be appropriate to stop the 18 week RTT clock (patient active monitoring) where the patient requests a delay of two or more weeks Author: Jane Shentall Review date: April 2019 Page 25 of 66

before coming to a decision, provided the clinician responsible for the patient s care confirms that: that a delay it is not contrary to their best clinical interest. The clinical interests of vulnerable patients (see the Safeguarding Adults at Risk Policy and Procedure, or the Child Protection Policy) are protected. CLOCK STOP: Patient active monitoring DATA ENTRY Use code 31 date patient requested thinking time (and there is a delay of 2 or more weeks before coming to a decision) If the patient subsequently decides to go ahead with the recommended treatment he/she can be added to the waiting list and a new clock started when the patient confirms they willing to proceed. They can be added directly to the waiting list again within a 12-week period. Any delay over 12 weeks will require a new referral from the GP. The consultant in charge of the patient s care may decide to add the patient straight on to the waiting list, or may offer the patient an outpatient appointment. CLOCK START: Active monitoring end DATA ENTRY Use code 11 date patient confirms they are willing to proceed or date new referral received 6.15 DID NOT ATTEND (DNA) 6.15.1 New appointment DNA For patients who DNA their first outpatient appointment for the first time, the responsible clinician and/or outpatient nurse will review the patient notes at end of clinic with a view to discharging the patient providing that: Discharging the patient is not contrary to their best clinical interest. The clinical interests of vulnerable patients (see the Safeguarding Adults at Risk Policy and Procedure, or the Child Protection Policy) are protected. If the decision is made not to rebook, the patient will be removed from the outpatient waiting list and an automated PAS letter will be sent to the GP and the patient notifying them of this removal. The patient will be discharged from PAS, and cancelled on NHS e-referral if appropriate. The 18 week RTT clock is nullified. Refer to section 6.3.1 for Cancer referral DNAs. Author: Jane Shentall Review date: April 2019 Page 26 of 66

6.15.2 Follow up appointment DNA Patients who DNA their follow up outpatient appointment will be discharged back to their GP providing that: Discharging the patient is not contrary to their best clinical interest. The clinical interests of vulnerable patients (see the Safeguarding Adults at Risk Policy and Procedure, or the Child Protection Policy) are protected. This is to be confirmed by the consultant at the end of the clinic and a letter sent to this effect to the patient and their GP. Where the patient is on an active/open pathway a clock stop needs to be recorded on PAS at time of the patient DNA. See section 6.3.2 for guidance on the management of cancer pathway patients who cancel their appointment. CLOCK STOP: DNA DATA ENTRY Use code 33 date of the Dina s appointment and notification to GP 6.16 PATIENT CANCELLATIONS (CNA Could not attend) Patients who cancel their appointment should be given an alternative date at the time of the cancellation. If a patient cancels an appointment on two or more consecutive occasions (and causes delay to their appointment by more than two weeks) or they are unable to re-book their appointment within their breach date, their case should be reviewed by medical staff to ensure there is no clinical risk in not treating the patient and it is agreed that the patient is not considered to be vulnerable (see Safeguarding Adults at Risk policy, Child Protection Policy). Where no risk is identified, patients should be discharged back to their GP. CLOCK STOP: Patient not treated but discharged DATA ENTRY Use code 35 date of the second consecutive patient cancellation See section 6.3.2 for guidance on the management of cancer pathway patients who cancel their appointment. Author: Jane Shentall Review date: April 2019 Page 27 of 66

6.17 HOSPITAL CANCELLATIONS Patients who are cancelled by the hospital must be offered an alternative date which is within the following two weeks and/or within their 18 week RTT breach date. The only acceptable reason for clinic cancellations is absence of medical staff as a result of planned annual / study leave, audit activities, on call commitments or unplanned sickness absence. A minimum of six weeks notice of planned leave should be given. Clinics should not be cancelled for any other reason unless there are exceptional circumstances and the cancellation has been authorised by the Director of Performance or the Chief Operating Officer or a nominated deputy. 6.17.1 Cancellations with six weeks or more notice Only leave approved by the relevant clinical lead will be actioned. Session cancellation notifications will only be accepted if submitted on the appropriate form, unless there are exceptional circumstances. Session cancellation notification must be passed to the relevant administrative manager for action. Session cancellation requests will be actioned at the earliest opportunity and within a maximum of five working days. Where patients have to be cancelled, the relevant clinician should review clinical priorities and waiting times and identify the rebooking requirement. Patients who have previously been cancelled should not be cancelled a second time. 6.17.2 Cancellations with less than six weeks notice Clinics should not be cancelled with less than six weeks notice unless there are exceptional circumstances. No clinic should be cancelled without the authorisation of the Director of Performance or the Chief Operating Officer or a nominated deputy. When clinics have to be unavoidably cancelled at short notice, liaison with nursing staff, the Outpatient Manager and relevant Assistant Divisional Manager is essential. Identifying appropriate capacity for these patients to be rebooked remains the responsibility of the consultants and the division, not the outpatient department. The identified short notice cancellation clinic code on PAS must be utilised in such circumstances. Author: Jane Shentall Review date: April 2019 Page 28 of 66

7. INPATIENT WAITING LISTS 7.1 PRINCIPLES OF WAITING LIST MANAGEMENT The decision to add a patient to a Waiting List must be made by a Consultant, or under an arrangement agreed with the Consultant. Patients should not be added to the waiting list unless they are fit, ie if a bed was available the following day the patient is medically fit to proceed. Patients who are considered to be insufficiently fit/well enough to proceed must be discharged back to their GP with a full explanation and clear details of the criteria that need to be met in order for the patient to be reconsidered for treatment at a later date. The consultant may choose to continue to review them in outpatient department but take them off the waiting list for surgery. This includes patients with a high BMI, smokers, drug users and heavy drinkers. A decision not to treat or active monitoring clock stop should be applied following the clinician s decision to the patient s 18 week RTT pathway. CLOCK STOP: Decision not to treat DATA ENTRY Use code 34 date of decision not to treat The use of effective early pre-operative clinics (POA) forms the basis of efficient waiting list management. The attendance at a POA clinic following the decision to treat determines the suitability and fitness to treat at an early stage. In cases where fitness is an issue continuing care via POA may be appropriate. 7.2 THE ACTIVE WAITING LIST (PTL) The active waiting list should consist of patients awaiting inpatient or day case admission, who are currently fit and able to proceed with treatment. This includes local anaesthetic procedures and first endoscopic procedures. All patients irrespective of procedure, form part of the elective waiting list and must be treated in line with Department of Health guidance. Clinical priority should be defined as urgent or routine only. Author: Jane Shentall Review date: April 2019 Page 29 of 66

To aid both the clinical and administrative management of the waiting list, elective waiting lists and planned lists will be listed separately but must be managed in line with this policy guidance and the intended management. 7.2.1 Patients requiring Commissioner funding approval When funding prior approval for treatment is required this must be obtained before adding a patient to the active waiting list. The 18 week RTT clock will continue to tick whilst approval is sort. The process for obtaining approval to treat must be followed as outlined in Appendix 3. This applies to NHS Hertfordshire patients only, but may be extended to other Commissioners following negotiation. 7.2.2 Adding Patients to Active Inpatient / Day case Waiting Lists The definition of an inpatient is any patient admitted electively or by other means with the expectation that they will remain in hospital for at least one night, including any patient admitted with this intention who leaves hospital for any reason without staying overnight. The definition of a day case is A patient admitted electively during the course of a day with the intention of receiving care who does not require the use of a hospital bed overnight and who returns home as scheduled. If this original intention is not fulfilled and the patient stays overnight, such a patient should be counted as an ordinary admission. A day case must be an elective admission A Consultant is responsible for the patient s medical care The patient uses a hospital bed for recovery purposes. If a bed or trolley is used for a specific short procedure rather than because of the patient s condition, this does not count as a hospital bed. The patient is not intended to occupy a hospital bed overnight, and does not actually occupy a bed overnight. 7.3 PATIENTS LISTED FOR MORE THAN ONE PROCEDURE If more than one procedure is to be performed at one time by the same surgeon the patient should be added to the waiting list with additional procedures noted. DATA ENTRY List the additional procedures on the waiting list entry If different surgeons will be working together to perform more than one procedure the patient should be added to the waiting list of the Consultant Surgeon for the priority procedure with additional procedures noted. Author: Jane Shentall Review date: April 2019 Page 30 of 66