Implementation of the right to access services within maximum waiting times

Implementation of the right to access services within maximum waiting times Guidance for strategic health authorities, primary care trusts and providers

DH INFORMATION READER BOX Policy HR / Workforce Management Planning / Performa Clinical nce Document Purpose Gateway Reference Title Estates Commissioning IM & T Finance Social Care / Partnership Working Action 13676 Implementation of the right to access services within maximum waiting times Author Publication Date DH 8 Mar 2010 Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs, Medical Directors, Directors of Nursing, PCT Chairs, NHS Trust Board Chairs, Special HA CEs, Directors of HR, Directors of Finance, Allied Health Professionals, GPs, Communications Leads, IS Providers, Care Trust CEs Circulation List #VALUE! Description Guidance on implementing the new patient rights to access services within maximum waiting times (18 weeks for non-urgent consultant-led elective care, and 2 weeks for urgent cancer referrals, from GP referral) Cross Ref Superseded Docs Action Required Timing Contact Details The NHS Constitution, The Handbook to the NHS Constitution, 18 Weeks rules suite, the NHS Cancer Plan, the Cancer Reform Strategy, The Government response to consultation on new patient rights and The NHS Constitution: a consultation on new patient rights N/A Relevant organisations to implement Directions Implementation of new patient rights by 1 April 2010 NHS Constitution team Room 601 Richmond House 79 Whitehall SW1A 2NS 0 nhsconstitution@dh.gsi.gov.uk For Recipient's Use

Implementation of the right to access services within maximum waiting times Guidance for strategic health authorities, primary care trusts and providers Crown copyright 2010 First published 8 March 2010 Published to DH website, in electronic PDF format only. http://www.dh.gov.uk/publications

Contents 1. Executive summary 2 2. Implementation of the right to start treatment within 18 weeks 4 Scope of directions 4 What does the right cover? 4 Services excluded 4 Patient exclusions 5 When does the right come into effect? 6 18 weeks referral to treatment 6 18 weeks maximum waiting time standard 6 What has changed 6 Patient awareness of maximum waiting time rights 7 Dedicated point of contact 8 Alternative providers for patients who wish to be seen more quickly 8 Step-by-step process 9 Nationally Commissioned Services 10 Roles 11 Performance Reporting 12 3. Implementation of the right to be seen within 2 weeks for all suspected cancers 14 Scope of Directions 14 What does the right cover? 14 Services excluded 14 Patient exclusions 14 When does the right come into effect? 14 2 week urgent referral for suspected cancer 15 What has changed? 15 Patient awareness of maximum waiting times rights 15 Dedicated point of contact 16 Alternative providers for patients who wish to be seen more quickly 16 Step-by-step process 17 Roles 18 Performance reporting 19 Useful actions 19

1. Executive summary 1.1 The NHS Constitution sets out the following right for patients: You have the right to access services within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of alternative providers if this is not possible. The waiting times are described in the Handbook to the NHS Constitution. 1.2 This means patients have the right to start consultant-led treatment within 18 weeks from referral, and be seen by a specialist within 2 weeks of GP referral for suspected cancer or, where this is not possible, for the NHS to take all reasonable steps to offer the patient a quicker appointment at a range of alternative providers if the patient makes such a request. New, legally binding Directions from the Secretary of State to primary care trusts (PCTs) and strategic health authorities (SHAs) create this right. They were published on 8 March and come into force on 1 April 2010. 1.3 Waiting times for consultant-led elective treatment and urgent cancer referrals are already covered by established operational standards. Patients should expect to wait no more than 2 weeks from the time they are referred by their GP to the time they are seen by a cancer specialist. And, no one should expect to wait more than 18 weeks from the time they are referred to the start of their consultant-led treatment, unless it is clinically appropriate to do so or they choose to wait longer. The NHS in England is meeting these standards nationally and, in many cases, waits are significantly shorter. 1.4 The Primary Care Trusts and Strategic Health Authorities (Waiting Times) Directions 2010 legally require PCTs, to: make arrangements to ensure providers meet the waiting time standards; take all reasonable steps to ensure that any patients for whom the 18 week or 2 week waiting time is not met are offered a quicker appointment to start treatment at a range of clinically appropriate alternative providers, if the patient requests this; and provide patients on 18 week and 2 week pathways with a dedicated contact point to approach if the maximum waiting time has been, or will be, breached and if they wish to seek an alternative. Some of these obligations fall to SHAs in relation to patients on 18 week pathways for nationally commissioned services. 1 1.5 This guidance describes the duties placed on PCTs and SHAs in the Directions and sets out some of the mechanisms these bodies might want to adopt to fulfil their legal obligations. The guidance also covers actions providers of NHS services could take in order to fulfil their contractual obligations 2. The guidance and Directions come into effect on 1 April 2010. 1 SHAs currently commission services for a small number of very rare conditions - see the National Health Service (Functions of Strategic Health Authorities and Primary Care Trusts and Administration Arrangements) (England) Regulations 2002. In practice, this function is delegated to a lead SHA (currently NHS London). 2 The NHS Standard contract for Acute services states: 4.27 The Provider is under a duty to provide Services so as to comply with any waiting times which the Commissioners are obliged to make arrangements to secure pursuant to directions made under section 8 of the 2006 Act. 2

1.6 This guidance is not intended to be an extensive source of rules and definitions or information on 18 weeks or cancer services; there are other sources referenced throughout the guidance that set these out in greater detail. The guidance should be read alongside the corresponding Directions, and PCTs and SHAs should satisfy themselves they are complying with the legal obligations in the Directions. 1.7 Ultimately, organisations will need to be able to demonstrate, if challenged, that they have met patients rights and fulfilled their legal obligations. The guiding principle should, therefore, be one of openness and transparency in implementing these requirements, alongside clear and unambiguous communications at all times. 3

2. Implementation of the right to start treatment within 18 weeks Scope of Directions What does the right cover? 2.1 The right applies to patients who are referred from 1 st April 2010 by any GP, general dental practitioner or person approved by arrangements with the PCT or SHA commissioning the service or by the consultant or service accepting the referral. The right applies unless patients choose to wait longer or it is clinically appropriate for them to do so (amongst other exceptions which are set out below). 2.2 From 1 April, PCTs are under a duty to make arrangements to ensure providers of services to their patients meet the waiting time standards 3. In addition, for any patients for whom they are the responsible commissioner and who are not able to access services within the maximum waiting times, the PCT is required to take all reasonable steps to offer those patients a range of alternative providers if this is what the patient wishes. It is for the patient, or someone lawfully acting on their behalf (such as a parent, guardian or carer), to request that alternative arrangements are sought in their case. 2.3 The current maximum waiting time that applies to consultant-led services in England is 18 weeks from referral to start of treatment. 2.4 Nationally-commissioned consultant-led services are also included in the scope of the 18 week referral to treatment standard. The same basic principles should be observed for these services (currently commissioned by NHS London on behalf of all SHAs) as for PCT-commissioned services: treatment should start within 18 weeks of referral and, if this is not possible, all reasonable steps should be taken by the SHA to offer patients a range of alternative providers. Services Excluded 2.5 The following services are excluded from the right: Maternity services (referrals of healthy pregnant women are not covered by the 18 week operational standard or this right. Pregnancy referrals should only start an 18 week clock when there is a separate condition or complication, which does not arise in the ordinary course of pregnancy, requiring medical or surgical consultant-led attention); and 3 NHS Operating Framework 2009/10 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_091445 4

Any healthcare services which are not consultant-led Patient Exclusions 2.6 This right does not apply to: patients who are not on an 18 week pathway. patients who are registered with a GP in Northern Ireland, Scotland or Wales. This policy only applies to England and the right applies to patients referred to a service commissioned by an English PCT or SHA. patients who do not attend (DNA) an agreed appointment, or rearranged appointment, without giving prior notice where the date of the original appointment offered was reasonable. While the NHS should make every effort to treat these patients within the waiting time standard and offer redress if this is not met, it is not possible to guarantee this in these cases. Commissioners and providers should ensure local access policies, detailing the consequences of not turning up to appointments, should be available to all patients and published. These policies should be consistent with the national 18 weeks rules suite. Patients who give prior notice when cancelling or rearranging their appointments in advance should not be classed as DNAs. patients who refuse treatment. The reasons for the refusal of treatment by the patient, or someone acting lawfully on their behalf, should be recorded. patients who choose to wait longer than 18 weeks for their treatment, 4 and they had been offered a reasonable date to attend an appointment at the provider. patients who are unable to commence treatment within 18 weeks (for reasons not related to the relevant commissioner or provider) where they had been offered a reasonable date to attend an appointment at the provider. This exclusion should apply in limited circumstances only, for example, a reservist posted abroad who was unable to commence routine treatment. patients for whom it is not clinically appropriate to start treatment within 18 weeks. patients who do not require treatment following clinical assessment. patients who are referred back to primary care services to receive treatment. patients who require active monitoring following assessment. patients who are placed on a national transplant waiting list following assessment. 2.7 Prisoners and people detained under the Mental Health Act are not excluded from the right. 2.8 If a patient moves home and changes providers between referral and starting treatment, their waiting time clock should continue to run until they start their consultant-led treatment. These patients should not be treated as exclusions. 4 Where patients on an admitted pathway have chosen to pause their clock for social or personal reasons PCTs should try to ensure that these patients are treated within the maximum waiting times + any clock pause in accordance with 18 weeks guidance 5

When does the right come into effect? 2.9 The Primary Care Trust and Strategic Health Authorities (Waiting Times) Directions 2010 come into effect on 1 April 2010. As such, the right applies to any patients who are referred on or after 1 April 2010. It does not apply to patients who were referred prior to 1 April 2010. 18 weeks Referral to Treatment 18 weeks maximum waiting time standard 2.10 18 weeks applies to pathways that do or might involve consultant-led care (with a medical consultant), setting a maximum time of 18 weeks from the point of initial referral up to the start of any treatment necessary for all patients, where it is clinically appropriate and where patients want it. The operational standards of delivery for the NHS are: 90 per cent of pathways where patients are admitted for hospital treatment should be completed within 18 weeks; and 95 per cent of pathways that do not end in an admission should be completed within 18 weeks. These operational standards allow for patients choosing to wait longer and for clinical exceptions. The requirements of the contract reflect the operational standard. 2.11 Details of the scoped definition of 18 weeks are set out in the national 18 Weeks Rules Suite: http://www.dh.gov.uk/en/publicationsandstatistics/statistics/performancedataandstatistics /18WeeksReferraltoTreatmentstatistics/DH_089757 What has changed? 2.12 The NHS has made great progress in achieving this standard nationally. However, there are still some patients who are waiting longer than 18 weeks for reasons other than choice or clinical exception. The Primary Care Trusts and Strategic Health Authority (Waiting Times) Directions 2010 are intended to help reduce the number of patients inappropriately waiting longer. The following sections provide detail on how the Directions apply to PCT-commissioned services. SHAs will need to take similar steps and should consider the guidance in a similar way. More detail is provided in the section on nationally-commissioned services. 2.13 The new right places a duty on PCTs to: 1) make arrangements with providers to ensure they meet the waiting time standards; and 6

2) take all reasonable steps to offer patients who request it an opportunity to start treatment sooner at a range of suitable alternative providers, if they have not been, or will not be, treated within 18 weeks, and the PCT or provider is satisfied this request is valid. 2.14 The 18-week standard should already be met for every patient, in every specialty and in every organisation (unless the patient chooses otherwise or it is not their best clinical interest). Now, PCTs will also have to take all reasonable steps to offer a range of alternative providers where the standard is not met, if this is what the patient requests. 2.15 It is also good practice to use information about unnecessary waits over 18 weeks to understand the reasons for unnecessary waits and ensure they are addressed. The right does not require PCTs or providers to actively seek out patients for the purpose of offering them quicker, alternative appointments: the patient must approach them first. However, once the patient has approached them, the PCT or provider, should act quickly to take all reasonable steps to offer a range of alternative providers to all patients who will not be seen within the waiting times and who express their wish to start treatment more quickly. 2.16 Guidance to the NHS 5 has set out that providers should review waits longer than 18 weeks. This information should continue to be reported by providers to their Board and their PCT(s). PCTs should continue to identify systemic problems in an organisation or a local health community to eliminate any unnecessary waits. SHAs should do the same for nationally commissioned services. Patient awareness of maximum waiting time rights 2.17 It is good practice for PCTs and providers to make patients aware of their rights and of the steps they need to take should their rights not be met. Possible actions could include: Making sure all patients on an 18-week pathway are given the 18-week treatment planner ( Your Treatment Planner ), so they are aware of when their clock starts and stops; Providing an insert to be included with Your Treatment Planner 6 giving sources of further information on patient rights; Including information on waiting time rights in patient appointment confirmation letters; Working with Local Improvement Networks (LINks) and Patient Advice and Liaison Services (PALS) to develop ways to support patients in exercising their rights; and Working with local GP practices and clinical champions to raise awareness of the NHS Constitution and its benefits for patients and staff. 2.18 PCTs should take these steps for all patients who they are responsible for 7, including those referred for SHA-commissioned services. 5 Reviewing patients who have waited longer than 18 weeks and reporting any unnecessary waits (breaches of the 18 weeks standard) Gateway 12620 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_107378+ * 6 Available from www.orderline.dh.gov.uk quoting 301873/Your treatment planner 7 Who Pays? Establishing the Responsible Commissioner Gateway 8448 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_078466 7

Dedicated point of contact 2.19 PCTs are under a duty to ensure patients are provided with two dedicated points of contact and to take reasonable steps to ensure that the patient is made aware of these contacts. Some communication routes are suggested above but PCTs should ensure that these are robust and are advised to seek patient feedback on them. These contact points should be able to deal with patients requests for an alternative provider, should they not be treated within 18 weeks. 2.20 The first point should be at the provider and the second should be at the PCT. 2.21 The contact point at the provider should be able to help the patient with any concerns about the length of their wait and, where necessary, should be able to investigate alternative provision if this is what the patient requests. It is for the provider to decide the most appropriate arrangements but, for illustrative purposes, the role could be carried out by the booking manager or the relevant medical secretary. 2.22 A second contact also must also be provided at the PCT. This contact should be able to help the patient if they are unsatisfied with the way the provider has handled their request. This point of contact should be able to act on the patient s behalf to secure them alternative provision if this is available 2.23 Whatever arrangement is put in place should be easily accessible for patients. For example, PCTs or providers could arrange for a dedicated phone line to be available to patients at convenient times with sufficient cover. 2.24 Patients referred for treatments commissioned by an SHA can access the contact points at their local PCT or at the provider that they have been referred to in the same way as any other patient on the 18 week pathway. Alternative providers for patients who wish to be treated more quickly 2.25 The dedicated contact should be able to provide details to patients on request regarding how long their 18 week clock has been running. Where patients are about to breach, or have breached their maximum waiting time, qualify for the right, and wish to be treated more quickly, the provider should take all reasonable steps to offer a range of alternative appointments to start treatment elsewhere at suitable providers. Options for alternative providers to the patient include other NHS providers or private providers providing NHS services through an NHS Standard contract, Foundation Trust contract, an extended choice or free choice network agreement, or independent sector treatment centre contract. 2.26 Where this is not possible, the reasons should be explained to the patient. It is good practice to keep a record of this conversation to inform any subsequent review of the patient s case. 8

Step-by-step process 2.27 Where a patient, or someone acting on their behalf (such as a parent, guardian or carer) makes a legitimate request to seek an alternative provider, the original provider could take the following steps: Try to find the patient a quicker appointment to start treatment earlier either at the same or a different site (at the original provider) or with other providers with whom original provider has local arrangements; If this is not possible, the original provider could work with the patient s PCT to where possible - identify a range of alternative providers which can start the patient s treatment more quickly. It is good practice for the original provider to determine with the patient where they would be willing to travel in advance of seeking alternatives; If suitable alternative providers are identified that can start the patient s treatment more quickly, the patient should be offered appointment dates at those providers. The patient does not have to accept an alternative offer and may choose to remain at the original provider. This is not, however, classified as choosing to wait longer than 18 weeks for the purpose of performance reporting and the patient s waiting time clock should continue to run until they start their treatment; The steps taken when seeking alternative providers should ensure that any alternative provider is able to provide appropriate and suitable aftercare for the patient; If more timely offers to commence treatment are not available at any other provider, this should be explained to the patient and the patient offered an apology. The original provider should then treat the patient as soon as possible; Records should be kept of all conversations with the patient regarding this waiting time right; and Original providers should ensure that their PCTs are made aware of patients who choose to be treated in an alternative provider as PbR costs/payments will need to be adjusted to reflect any patient transfers. (Tariff will follow the patient and the PCT will only be obliged to pay for one episode of care.) 2.28 PCTs are responsible for ensuring this process works effectively. Where providers fail to meet their obligations, PCTs should take action under the usual contractual arrangements. PCTs should also act on the patient s behalf to secure alternative provision if the provider has failed to take all reasonable steps to do so or if the patient requests this. 2.29 Suitable alternative providers must be: Clinically appropriate in the view of the patient s clinician; Able to commence the patient s treatment more quickly than the original provider; and Able to provide services on the same mandatory terms and conditions as other similar NHS services. 2.30 When taking all reasonable steps to offer an alternative provider certain general principles should be observed: 9

Patients seeking an alternative should not be treated more quickly at the expense of another patient of the same or greater clinical priority already waiting at the alternative provider; and Any care provided by an alternative provider must not be at above tariff costs. 2.31 If a patient accepts the offer of an alternative provider, the provider should also consider making appropriate arrangements for the patient's travel and accommodation to enable them to access services at the alternative provider without being financially disadvantaged. 2.32 The duty does not mean an alternative must be found in every case. The duty means that all reasonable steps must be taken to find a range of alternatives. There may be a small proportion of cases where this is not possible. However, providers and PCTs are advised to record details of attempts to find clinically appropriate alternative providers where patients are seeking quicker treatment, as patients may seek judicial review if they believe their PCT has not met its obligations. 2.33 The availability of this redress mechanism does not mean that providers can ignore their contractual obligations to meet the existing 18 week waiting time standards for each specialty. Nationally-commissioned services 2.34 In relation to nationally-commissioned services SHAs must: make arrangements to ensure providers of services to their patients meet the 18 weeks waiting time standard; and take all reasonable steps to offer patients a range of alternative providers when they request this and qualify for alternative provision. 2.35 SHAs should work together with original providers to identify alternative providers and to ensure patient care is not compromised or delayed. 2.36 Patients will be able to access the points of contact established by PCTs and providers in same way as other patients. The points of contact should be able to investigate alternative provision, if this is what the patient wants, involving the relevant SHA where necessary. 2.37 PCTs are under a duty to inform the relevant SHA if a patient contacts them with a legitimate request for alternative provision. SHAs must then take all reasonable steps to offer a range of alternative providers which can treat the patient more quickly. 2.38 When sourcing alternative provision, the step-by-step process outlined in the relevant section above provides guidance on steps which could be taken, with the SHA fulfilling the roles of the PCT. 2.39 SHAs are responsible for ensuring this process works effectively. Where providers fail to meet their obligations, the relevant SHA should take action under the usual contractual 10

arrangements. SHAs should also act on the patient s behalf to secure alternative provision if the provider has failed to take all reasonable steps to do so. 2.40 Original and alternative providers should carry out their roles, as described elsewhere in this chapter, to keep patients informed and to ensure the provision of high-quality, safe and appropriate care. Roles 2.41 Arrangements for identifying alternative providers should be determined locally by health economies and by original providers needing to offer patients appointments to start their treatment more quickly. 2.42 PCTs must: make arrangements to ensure providers of services to their patients meet the 18 weeks waiting time standard; take all reasonable steps to offer patients a range of alternative providers when they request this and qualify for alternative provision; ensure patients on an 18 week pathway are provided with two dedicated points of contact as described above and ensure that patients are made aware of these contacts; and notify the relevant SHA, in relation to nationally commissioned services, if a patient referred for such services requests an alternative provider. 2.43 PCTs should: inform patients that they are entitled to expect all reasonable steps to be taken to offer a range of alternative providers if they have to wait in excess of the 18 weeks maximum waiting time (where they have not chosen to wait longer or it is clinically appropriate to do so); work together with original providers to identify alternative providers; ensure communications with patients about their rights reach all members of the community, including those who are seldom heard; ask patients about their experience of the process in surveys; ensure patients are aware of their rights and responsibilities; and ensure regular reports are presented to Boards on how patient rights are communicated and whether patients are content with steps taken to offer redress. 2.44 PCTs and original providers should work together to ensure patient care is not compromised or delayed. 2.45 In relation to prisoners and people detained under the Mental Health Act, providers and commissioners should consider the practicalities, safety and security requirements, including the associated costs, of each individual case when taking reasonable steps to offer appointments at alternative providers. 2.46 Original providers should: work with the relevant commissioner to identify a range of alternative providers if one cannot be sourced through locally agreed arrangements; 11

keep patients informed, including about their length of wait if they choose not to accept the offer of having treatment with an alternative provider, and making it clear that they (the original providers) remain responsible for patient care; contract with alternative providers and agree any specific operational details and requirements (e.g. format for transmission of tests and reports, turnaround times, transmission of any relevant past diagnostic images and reports); notify their PCTs and SHA if an alternative provider has failed in its duties; and work with the relevant commissioner to ensure cost of treatment is properly reconciled. 2.47 The standard acute contract requires providers to comply with any obligations placed on PCTs relating to waiting times, including those under the Primary Care Trusts and Strategic Health Authorities (Waiting Times) Directions 2010. 2.48 Alternative providers should notify original providers of the following to ensure that the patient s record can be accurately maintained and recorded including: Any additional outpatient appointments or diagnostic tests or treatment given; and The date of any treatment start or discharge. 2.49 The alternative provider will also be responsible for ensuring the treatment starts within the timescale agreed with the original provider or commissioner. 2.50 Patients should contact their provider or their PCT using the contact information given if they will not start, or have not started, treatment within 18 weeks. Patients can choose not to accept an offer of alternative provider. The original providers and relevant commissioner will need to review such cases to ensure that patients are being given reasonable offers and also to agree how these patients will start their treatment as quickly as possible. Commissioners and providers should ensure that patients are aware of the importance of attending agreed appointments and giving as much notice as possible if rearranging. 2.51 The NHS Constitution already contains the following responsibility for patients and the public: You should keep appointments, or cancel within reasonable time. Receiving treatment within the maximum waiting times may be compromised unless you do. Performance Reporting 2.52 Where a patient is close to breaching the 18 weeks standard and the patient has accepted the offer of an alternative provider, the original and alternative providers could put in place a local agreement whereby the alternative provider accepts responsibility for the care of that patient but the referring provider continues to report the patient s wait so that performance is not shared between the providers. 2.53 It is likely that this will require manual amendments to the data in the monthly returns prior to submission to UNIFY2 for both the original and alternative providers. 12

2.54 There should be no impact on the commissioner figures as the same commissioner will report the wait throughout. 2.55 Such patients should not be recorded on the performance sharing return. 2.56 Activity should continue to be reported via the Commissioning Data Set (CDS) and in the Monthly Activity return (MAR) by the receiving provider. It is expected that the impact on data completeness will be small. Therefore no adjustments should be required in the data completeness calculations. 13

3. Implementation of the right to be seen within 2 weeks for all suspected cancers Scope of Directions What does the right cover? 3.1 The right applies to all patients who are urgently referred by a GP via an urgent referral for suspected cancer to a specialist for diagnosis or treatment of cancer. From 1 April, PCTs are under a duty to commission services to ensure that the 2 week operational standard is met. PCTs are also under a duty to take all reasonable steps to offer patients an appointment with a specialist at a range of clinically appropriate alternative providers, where they could be seen sooner, if the waiting time standard is not met in their case. It is for the patient, or someone acting on their behalf, to request that alternative arrangements are sought in their case. Services excluded 3.2 Services excluded: Referrals for investigations of breast symptoms where cancer is not initially suspected are not urgent referrals for suspected cancer; therefore, they fall outside the scope of this right. Patient exclusions 3.3 This right does not apply to: patients who do not attend or choose to cancel any agreed appointment, provided they were made aware of the consequences of not attending; or patients who choose to wait longer than two weeks for their appointment. When does the right come into effect? 3.4 The Primary Care Trust and Strategic Health Authorities (Waiting Times) Directions 2010 come into effect on 1 April 2010. As such, the right applies to any patients who are referred on or after 1 April 2010. It does not apply to patients who were referred prior to 1 April 2010. 14

2 week urgent referral for suspected cancer Two week standard 3.5 The two-week standard applies to the waiting time between an urgent referral for suspected cancer from a GP (or general dental practitioner) to the date a patient has been seen by a specialist. What has changed? 3.6 Performance against the current two week wait standard has been sustained at a high level by the NHS. This builds on the existing standard by giving patients a legally binding right. 3.7 The right places a duty on PCTs to commission services to meet the 2 week waiting time standard or, if the 2 week waiting time is not, or will not be, met in an individual case and the patient wishes to be seen more quickly, to take reasonable steps to find the patient a quicker, clinically appropriate appointment elsewhere. 3.8 PCTs should already be ensuring delivery of the standard for all patients in all organisations from which services are commissioned (unless the patient chooses otherwise). Now, they must also take reasonable steps to offer patients an alternative appointment in the small number of cases where the standard is not met. PCTs and providers therefore need to understand and act upon the reasons for any remaining unnecessary waits. The right does not require them to actively seek out patients for the purpose of offering them quicker, alternative appointments: the patient must approach them first. However, once the patient has approached them, the PCT or provider should act quickly to support patients who express their wish to seek an alternative and whose request is valid. 3.9 To better meet the needs of patients and deliver the two-week standard for all patients who wish to benefit, PCTs should continue to review any waiting times longer than two weeks (breaches) and seek to address these. Access policies should be in line with the principles and rules of centrally published guidance. (Full guidance, definitions and rules on cancer waiting times can be found at http://www.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation) Patient awareness of maximum waiting times rights 3.10 It is good practice for PCTs and providers to make patients aware of their rights and of the steps they need to take should their rights not be met. Possible actions might include: Ensuring patients have information on the new right, how it relates to their referral for suspected cancer and the latest date they should expect to be seen by unless they 15

elect to wait longer. Centrally produced information for patients and GPs are available for PCTs and providers to disseminate within their LHCs; Providing this information on patient appointment confirmation letters or when patients call up to book their appointments; Working with LINks, PALS or other local advocacy service to develop ways to support patients in exercising their rights; and Working with local GP practices and clinical champions to raise awareness of the NHS Constitution and its benefits for patients and staff. Dedicated point of contact 3.11 PCTs are under a duty to ensure all patients with an urgent GP referral for suspected cancer are provided with two dedicated points of contact, at or shortly after the point of referral. Some communication routes are suggested above but PCTs should ensure that these are robust and are advised to seek patient feedback on them. These contact points should be able to deal with patients requests for an alternative provider. In order to support patients who have not or will not be seen within the maximum waiting times and who wish to consider a quicker appointment, PCTs are under a duty to ensure they have appropriate mechanisms in place to provide dedicated support. This support should be easily accessible, for example, a dedicated phone line available to patients at convenient times with sufficient cover and capacity to meet demand. 3.12 The first dedicated contact should be at the provider which the patient has been referred to. This point of contact should be able to help the patient with any concerns about the length of their wait and should be able to investigate alternative provision, if this is what the patient requests. It is for the provider to decide the most appropriate contact point, but for illustrative purposes it could be the booking manager or the relevant medical secretary. A second dedicated contact must be based at the PCT and should be able to help the patient if they are unsatisfied with the way the provider has handled their request. This person should be able to act on the patient s behalf to secure them alternative provision if it is available. Alternative providers for patients who wish to be seen more quickly 3.13 The dedicated contact should be able to provide details to patients on request regarding their waiting time. Patients who are about to breach/have breached their maximum waiting time, who qualify for the right, and who wish to be seen more quickly can request to be offered an alternative provider or appointment from the dedicated contact. 3.14 PCTs should take all reasonable steps to offer patients earlier appointments at a range of alternative providers if the patient requests this. Where possible, the alternatives should include NHS providers and private providers. Alternative providers must be able to provide services on the same mandatory terms and conditions as other similar NHS services. PCTs and providers may wish to take advice from the local Cancer Network when seeking to identify appropriate alternative providers. 16

Step-by-step process 3.15 Where a patient, or someone acting on their behalf, makes a legitimate request to seek an alternative provider, the original provider should consider taking the following steps: try to find a quicker clinically appropriate appointment either on the same or a different site (at the original provider) or with other providers with whom original provider has local arrangements. When doing this, original providers will need to check that an equivalent level of service is offered, e.g. one-stop clinics. If this is not possible, the original provider should work with the commissioning PCT to identify a range of suitable alternative providers. It is good practice for the original provider to determine with the patient where they would be willing to travel in advance of seeking an alternative. Any provider on the Extended or Free Choice Network can be considered an alternative. If alternative suitable providers are identified (suitable alternatives should be able to offer a clinically appropriate appointment) that can see the patient, the patient should be offered these appointments. The patient does not have to accept any alternative offer and may choose to remain at the original provider. This is not, however, classified as choosing to wait longer for the purpose of performance reporting and will be recorded as a breach within the published statistics. If more timely appointments are not available at any other provider, this should be explained to the patient and the patient should be offered an apology. The original provider should ensure the patient is seen as soon as possible. Records should be kept of all conversations with the patient regarding the waiting time right. Original providers should ensure that their PCTs are made aware of patients exercising their right to be offered alternatives, as PbR costs/payments will need to be adjusted to reflect any patient transfers. Tariff will follow the patient and the PCT will only be obliged to pay for one episode of care. 3.16 PCTs are responsible for ensuring this process works efficiently, and the standard NHS contract requires providers to support PCTs in achieving this. Where providers fail to meet their obligations, PCTs should take action under the usual contractual arrangements. 3.17 When taking all reasonable steps to offer an alternative provider, certain general principles should be observed: Patients seeking an alternative provider should not be seen more quickly at the expense of another patient of the same or greater clinical priority already on a waiting list at the alternative provider; Any care offered by an alternative provider must not be at above tariff costs. 3.18 The duty does not mean an alternative must be found in every case. There may be a small proportion of cases where it will not be possible to find an alternative provider. Providers and PCTs are advised to record details of attempts to find clinically appropriate alternative providers where patients are seeking quicker appointments, as their actions may be subject to judicial review. 17

3.19 The availability of this redress mechanism does not mean that providers can ignore their contractual obligations to meet the existing two week waiting time standards. Roles 3.20 Arrangements for identifying alternative providers are to be determined within the LHC and by original providers needing to offer patients quicker appointments. 3.21 PCTs must: make arrangements to ensure providers of services to their patients meet the 2 week waiting time standard; take all reasonable steps to offer patients a range of alternative providers when they request this and qualify for alternative provision; and ensure patients are given details of dedicated contact points. 3.22 PCTs should: ensure that there are no compromises or delays for patients and inform patients that they are entitled to expect all reasonable steps to be taken to offer an appropriate appointment with alternative providers; work closely with original and alternative providers to identify alternative providers; ensure communications with patients about their rights reach all members of the community, including those who are seldom heard; ask patients about their experience of the process in surveys; ensure patients are aware of their rights and responsibilities; and ensure regular reports are presented to Boards on how patient rights are communicated and whether patients are content with steps taken to offer redress. 3.23 PCTs and original providers should work together to ensure patient care is not compromised or delayed. 3.24 In relation to prisoners and people detained under the Mental Health Act, providers and commissioners should consider the practicalities, safety and security requirements, including the associated costs, of each individual case when taking reasonable steps to offer appointments at alternative providers. 3.25 Original providers should: work with their PCT to identify a range of alternative providers if options cannot be sourced through existing locally agreements; inform patients of the right, giving them information about their expected length of wait if they choose not accept an offer of being seen at an alternative provider, and explaining that they (the original provider) remain responsible for the patient s care; contract with alternative providers and ensure a service equivalent to that which would have been received in the originating provider s clinic; 18

agree responsibility for patient transport, following rules they have locally set for offering transport when patients wish to go to an alternative provider; notify their PCTs if an alternative provider has failed in its duties; and report activity as specified in the standard contractual arrangements. 3.26 Alternative providers should maintain communications with original providers to ensure that the patient s waiting list record and clinical records are accurately maintained. 3.27 Patients can choose not to accept an offer of an alternative provider. PCTs and the original providers should review such cases to ensure that patients are being given reasonable alternative offers. Performance Reporting 3.28 All reporting on cancer waiting times should be via the Cancer Waiting Times Database following the mandate specified in Data Set Change Notice (DSCN) 20/2008. 3.29 Activity should continue to be reported via CDS and via the Cancer Waiting Times Database by the provider commissioned to receive care to support wider commissioning process and PbR. It is expected that the impact on data completeness negligible. Useful Actions 3.30 To ensure that patients are aware of their rights and that they are at the centre of the process, PCTs might wish to take the following actions to engage with patients: Publish the local access policy; Ensure communications with patients reach all members of the community; Ask patients about their experience of the process in surveys; and Ensure patients are aware of their rights and responsibilities. 19