Access Policy Scheduled Care Name of Author and Job Title: Name of Review/Development Body: Ratification Body: Date of Ratification/Effective from: Luigi Federico RTT Lead ELT Clinical Quality Governance Committee February 2017 Review Date: February 2018 Reviewing Officer: Luigi Federico - RTT Lead Commissioner Sign Off: Niki Baier Guildford & Waverley If this document is required in an alternative language or format, such as Braille, CD, audio, please contact the author or company secretary.
VERSION CONTROL SHEET Date Nov 2015 Feb 2017 Feb 2017 Feb 2017 Review Type (please tick) Minor amendment 1 Full Review Version No. Author of Review 1.2 Luigi Federico 1.3 Luigi Federico 1.3 Luigi Federico 1.3 Luigi Federico Title of Author RTT Lead Date Ratified Dec 2015 Ratification Body Clinical Quality Governance Committee Page Numbers (where amended) Line Numbers (where amended) Details of change Inserted RTT Lead 20 Updated Trust web address for TWR referral forms RTT Lead 21,22 Updated Oasis Referral Sources Deleted RTT Lead 27,39,40,41 Wording amendment to clarify national guidelines 1 Where there is a full review, amendment details are not required in the version control sheet.
CONTENTS VERSION CONTROL SHEET... 2 1. INTRODUCTION / BACKGROUND... 6 2. PURPOSE AND OBJECTIVES... 6 2.1. Objectives... 6 2.2. Information Governance... 6 3. SCOPE... 8 3.1. Inclusions... 8 3.2. Exclusions... 8 3.2.1 National Access Target and Key Elements of RTT 8/9/10 Cancer Waiting Times Standards. 9 3.3. Glossary... 12 4. DUTIES & RESPONSIBILITIES... 16 4.1. Key Duties and Responsibilities of Committees... 16 4.1.1. 18 Weeks Group [weekly meeting]... 16 4.2. Key Duties and Responsibilities of Staff... 16 4.2.1. Director of Operations and Their Deputies... 16 4.2.2. Specialty Managers and Their Deputies, Heads of Departments and Line Managers of Staff... 16 4.2.3. Outpatient, Admissions Staff [Including Non RSCH staff], Medical Secretaries, 18 Week Validation Team and Clinicians... 16 5. SUBJECT MATTER OF WORKING DOCUMENT... 17 5.1. SECTION A: OUTPATIENT REFFERALS TO THE RSCH... 17 5.1.1. Robust Clinical Information... 17 5.1.2. Patient Details... 17 5.1.3. E-Referrals... 18 5.1.4. Manual, [Paper etc], Routine/Urgent/Cancer Referrals... 19-21 5.1.5. Referral Sources on Oasis... 21 5.1.6. Rejecting Referrals and Inappropriate Referrals... 22 5.1.7. Overseas Visitors... 23 5.1.8. Minimum Data Sets [Incoming Referrals]... 24 5.1.9. Example of the Referral Process... 25 5.2. SECTION B: BOOKING PROCESS... 25 5.2.1. Receipt and Registration of Referrals... 25 5.2.1.1. Consultant Referral Triage Process... 25 5.2.2. Adminstration Processes For Incoming Referrals... 25 5.2.2.2. Clock Continuation... 26 5.3. SECTION C: PATIENT CHOICE... 26 5.3.1. Ensuring Choice Throughout the Booking Process... 27 5.4. SECTION D: PATIENT ACCEPTANCE OF THEIR APPOINTMENT. 28 5.4.1. Patient Agreement to Date/Time Offer... 28 5.4.2. Effective Record of Patient Choice and Offers... 28 Page 3 of 60
5.4.3. Transport Guidelines and Eligibility... 28 5.5. SECTION E: PATIENT VARIANCES PART 1... 29 5.5.1. Patient Is Unable to Agree Date/Time Within Timescales... 29 5.5.2. Patient Cancellations and Rebookings... 29 5.5.3. Outpatient Did Not Attend Protocol... 30 5.5.4.1 Persistent DNA s... 31 5.5.4.2 Financial Impact... 32 5.5.5. Private Patients Referrals to and From NHS Care... 32 5.5.6. War veterans. 32 5.6. SECTION F: HOSPITAL VARIANCES PART 1... 33 5.6.1. Clinician Leave Management Process... 33 5.6.2. Hospital Clinic Cancellations... 33 5.6.3.1. Rescheduling of Appointments New Patients... 34 5.6.3.2. Reschedule Standards... 34 5.6.3.3. Rescheduling of Appointments - Follow Up Appointments... 34 5.6.4. Outpatient Slot Management... 35 5.6.5. The Appointments Slots Issue Process [ASI]... 35 5.6.5.1. Booking Appointments Through E-Referrals... 36 5.6.5.2. Booking Appointments Directly Into PAS... 36 5.6.5.3. Hospital Recieves Appointment Request Details... 37 5.6.5.4. Reviewing Appointment Request Details... 37 5.6.5.5. Check Appointment Availability... 37 5.7. SECTION G: PATIENT ATTENDS APPOINTMENT... 37 5.7.1. Outcome of Clinic Appointment... 37 5.7.2. Further Outpatient Appointment Required... 37 5.7.3. Diagnostic Test Required... 37 5.7.3.1. Supspensions... 38 5.7.3.2. Cancellations/DNA... 38 5.7.3.3. Appointments Declined... 38 5.7.3.4. Return to GP... 38 5.7.4. Decisions To Admit and Pauses... 39 5.7.4.1. Adding Patients to the Waiting List... 39 5.7.4.2. Clock Pauses... 39 5.7.5. Bilateral Procedures... 40 5.7.6. Pre-Screening and Pre-Assesment... 40 5.7.7. Low Priority Procedures... 40 5.8. SECTION H: PATIENT VARIANCES PART 2... 41 5.8.1. Choice To Wait Longer For Treatment (Specific Consultant)... 41 5.8.2. Patient Cancellations and Rebookings... 41 5.8.3. Inpatient Did Not Attend DNA Protocol... 42 5.8.3.1. Adults [Pre Assessment]... 42 5.8.3.2. Adults [TCI/Admission]... 42 5.8.3.3. Clinically Intiated Delays [Or Patient Unfit For Treatment]... 42 5.8.4. Planned Admissions... 43 5.9. SECTION I: HOSPITAL VARIANCES PART 2... 44 5.9.1. Subsequent Appointments... 44 5.9.2. Theatre Capacity... 44 Page 4 of 60
5.9.3. Hospital Inpatient Cancellations... 44 5.9.4. Preoperative Assesment... 45 5.9.5. Removal From the Admitted Waiting List... 45 5.10. SECTION J: DEFINITIVE TREATMENT GIVEN... 45 5.10.1. Admit For Definitive Treatment... 45 5.10.2. Referred For Further Treatment... 45 6.1 TRAINING... 47 6.2 INTERNAL INFORMATION REPORTING SUITES... 47 7. IMPLEMENTATION.... 47 8. MONITORING COMPLIANCE WITH & EFFECTIVENESS OF THE DOCUMENT... 48 9. REVIEW, RATIFICATION AND ARCHIVING... 48 10. DISSEMINATION AND PUBLICATION... 48 11. EQUALITY IMPACT ANALYSIS... 49 12. ASSOCIATED DOCUMENTS... 49 13. REFERENCES... 49 14. APPENDIX 1 CLINIC BOOKING ITEMS AND USAGE CATEGORIES... 49 15. APPENDIX 2 CANCER PATIENT ACCESS STANDARDS..51 Page 5 of 60
1. INTRODUCTION / BACKGROUND This policy is intended to support staff and management, regarding access to services at The Royal Surrey County Hospital. The Trust is committed to low waiting times, patient choice and providing an excellent level of patient care. This policy will support the development and implementation of local access issues and addresses the management of waiting lists and reasonableness. This policy provides guidance for: Outpatient, Diagnostic and Inpatient elective [day surgery and main theatre] access. Cancer pathways Appendix 2 covers Cancer Patient Access Standards It excludes emergency care This policy has been based on the guidance published by the Department of Health and previous local NHS South East Coast Strategic Health Authorities Guidance published in June 2008 as well as the 2013/2014 Choice Framework and Cancer Waiting Times Guidance. This guidance applies to all groups of patients including children and vulnerable adults [but with the exception of Obstetrics]. 2. PURPOSE AND OBJECTIVE The aim of this policy for the Royal Surrey County Hospital NHS Foundation Trust (RSCH) is to provide clarity and uniformity of practice, definitions and process throughout the Trust. 2.1. OBJECTIVES: The main objectives of this Policy are to: Set out to document and guide the patient pathway for accessing services at The Royal Surrey County Hospital NHS Foundation Trust for Outpatients and Inpatients Describe the process of the mandatory information required to process patient attendances Describe the responsibilities of our commissioners to support their patients during their 18 weeks/rtt/cancer pathways. Describe the responsibilities of patients during their 18 weeks/rtt/cancer pathway. Provide guidance for hospital staff regarding the rules relating to 18 weeks/rtt/cancer pathways. 2.2. INFORMATION GOVERNANCE The Royal Surrey County Hospital NHS Foundation Trust recognises the importance of reliable information, both in terms of the clinical management of patients and the efficient management of services and resources. Information Governance (IG) gives assurance that the Trust handles personal and nonpersonal information (both manual and electronic) efficiently, securely, effectively Page 6 of 60
and in accordance with relevant legislation, with the objective of delivering the best possible care and service. PRINCIPLES Within this policy, it is the responsibility of all the staff working in these areas to action the required policy within their scope of their role. It is the responsibility of the staff and their Speciality Business Unit teams to implement these changes within their normal working practices, or highlight concerns and issues to the relevant staff. Page 7 of 60
3. SCOPE 3.1. INCLUSIONS This Policy applies to: All substantive and temporary staff who have contractual obligations to the Royal Surrey County Hospital NHS Foundation Trust 3.2. EXCLUSIONS This policy does not cover, in detail, the following: Local Department Standard Operating Policies [SOP s] Non 18 weeks/rtt patients pathways [E.g. Direct access diagnostics, therapies, planned/follow-up review patients and maternity patients]. NB there is further explanation of planned patients in section 5.8.4. Referrals from primary care to diagnostics or therapies can take one of the following routes, and will not start an 18 week clock: o Direct Access - the GP refers for diagnosis reasons and upon receiving the results makes the decision whether or not to refer the patient on to secondary care. o Straight to test - the GP refers the patient to a secondary care consultant and refers for the test at the same time. o Therapy, healthcare science (e.g. audiology) or mental health services that are not medical or surgical consultant-led (including multidisciplinary teams and community teams run by mental health trusts) irrespective of setting o Direct Access to Physiotherapy services information directory for GPs here - http://www.royalsurrey.nhs.uk/adx/aspx/adxgetmedia.aspx?docid=143 8,110,6,1,Documents&MediaID=c28ac9d8-8036-4d0b-bf22-19a4476ca167&Filename=Royal+Surrey+Physiotherapy+Service+Dire ctory+2013.pdf 3.2.1 NATIONAL ACCESS TARGETS AND KEY ELEMENTS OF REFERRAL TO TREATMENT (RTT) WITHIN 18 WEEKS AND CANCER WAITING TIMES STANDARDS (See Appendix 2: Cancer Patient Access Standards) No one should wait more than 18 weeks (126 days) from referral to the start of hospital treatment. This includes all the stages that lead up to treatment, including outpatient consultations, diagnostic tests and procedures. The 18 Week Patient Pathway does not replace other waiting times, targets or standards where these are shorter than 18 weeks (126 days). This includes waiting times for cancer patients. No patient will wait longer than 6 weeks for a diagnostic test or image. The diagram below shows the internal milestones for 18 weeks patients: Page 8 of 60
CANCER WAITING TIMES STANDARDS: Two week wait (2WW) standard - 93% of patients to be seen within two weeks of an urgent GP referral for suspected cancer - 93% of patients to be seen within two weeks of a GP referral with breast symptoms (where cancer is not suspected) 31 day standards [Decision to Treat to Treatment] - 96% of patients to receive their first definitive treatment for cancer within 31 days of the decision to treat - 94% of patients to receive subsequent treatment for cancer within 31 days of the decision to treat/earliest clinically appropriate date to start a second or subsequent treatment where that treatment is surgery - 98% of patients to receive subsequent treatment for cancer within 31 days of the decision to treat/earliest clinically appropriate date to start a second or subsequent treatment where that treatment is an anti-cancer drug regime - 94% of patients to receive subsequent treatment for cancer within 31 days of the decision to treat/earliest clinically appropriate date to start a second or subsequent treatment where that treatment is a course of radiotherapy Page 9 of 60
. 62 day standards [Referral to Treatment] - 85% of patients to receive their first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer. Maximum wait of 31 days from urgent GP referral to first treatment for children s cancer, testicular cancer and acute leukaemia - 90% of patients to receive their first definitive treatment for cancer within 62 days of referral from an NHS Cancer Screening Service (breast, bowel and cervical) The diagram below shows the cancer waiting times operational standards and the internal milestones : (See Appendix 2: Cancer Patient Access Standards) Cancer Standards and Trust internal milestones GP Breast Symptomatic referral (cancer not suspected) Diagnostic phase (CT, MRI, endoscopy, biopy etc) and MDT Staging tests Pre-asssessment Treatment Planning etc Pre-asssessment Treatment Planning etc GP/GDP Urgent TWR referral for suspected cancer Receipt of GP/GDP referral Date first seen OPA or first test Decision to treat made First treatment Decision to treat made Subsequent treatment (Anti-cancer drug, radiotherapy and surgery) Two week wait ( 14 days) 62 days first treatment 31 Days to first treatment 31 days subsequent treatments Referrals from NHS Cancer Screening Programmes Screening referral Date abnormality reported 62 days first treatment Consultant Upgrade - Note: can occur at any point in patient pathway Consultant decides to upgrade patient 62 days first treatment Key Elements of RTT The following points summarise the key elements of the standard: All patients will be managed according to their clinical urgency, and within the 18 week Referral to Treatment (RTT) standard. Performance will be judged against the following waiting time standard: Incomplete operational standard of 92% the percentage of incomplete pathways within 18 weeks should equal or exceed 92%. Page 10 of 60
The referral to treatment (RTT) operational standard should be achieved in each specialty and this will be monitored monthly. An admitted pathway means that the patient requires admission to hospital, as either a day case or an inpatient, to receive their first definitive treatment. A nonadmitted pathway means that the patient does not require admission to hospital to receive their first definitive treatment, i.e. that treatment is given or prescribed in outpatients. Patients are managed on a non-admitted pathway until the point at which they require admission for treatment as either a day case or inpatient, at which point they are managed onan admitted pathway. The 18 week clock starts on the date that a referral is received by the Trust; this is the start of an 18 week clock for that patient. That clock then continues to tick until either the first definitive treatment is given, or another event occurs which can stop the clock. An 18 week clock can also start at another healthcare provider and then the patient can be transferred to the Trust, where the clock continues to tick from the original start date. The following can all start 18 week clocks for patients, when referring to a Consultant led service: GPs; GDPs; Optometrists; Orthoptists; GUM services; A&E; Walk In Centre; National Screening Programmes; Prison Health Services; and specialist nurses and AHPs who have primary care authorisation to refer directly to consultants. For patients who are referred using E-Referrals, the 18 week clock starts on the date on which the patient activates their referral (converts their Unique Booking Reference Number, or UBRN, into an appointment). For patients not referred using E-Referrals the 18 week clock starts on the date their referral is received by the Trust. Where a referral goes initially to a Referral Management Service (RMS) the 18 week clock starts on the date on which the RMS receives the referral. Each step along the patient s pathway (outpatient appointment, diagnostic appointment excluding radiology, pre-assessment, admission, discharge, any decision by the patient or clinician to delay further treatment at any stage) must be correctly recorded in the Patient Administration System (PAS). Patients may have more than one 18 week RTT waiting time ticking simultaneously if they have been referred to and are under the care of more than one clinician at any point in time. Each 18 week pathway has to be measured and monitored separately and will have a unique pathway ID number in PAS. There are a number of different activities which may occur during a patient s treatment pathway, and each is defined according to whether they start, stop or continue an 18 week RTT waiting time. Page 11 of 60
Patients not on an 18 weeks RTT pathway The following activity is excluded from the 18 week RTT standard: Emergency admissions Obstetric patients Elective patients waiting for planned procedures (removal of metalwork, procedures related to age/growth, check cystoscopies etc.) Patients receiving on-going care for a condition where the first definitive treatment for that condition has already occurred Patients whose 18 week clock has stopped for active monitoring, and has not yet restarted, even though they may still be followed up by their consultant. Referrals into a non-consultant-led service. 3.3. GLOSSARY 18 weeks Refers to the standard of seeing all eligible patients within 18 weeks from receipt of referral to first definitive treatment as part of the NHS Constitution RTT Referral to Treatment time. Denotes patients on an 18 week clock Non-RTT Denotes patients NOT on an 18 week clock Pathway Choice New Follow Up Choose and Book DNA Cancellation Rebooking/Rescheduling Pre-Screening Pre-Operative The timeline for a patient, this can include consultations, diagnosis, diagnostics, admissions and can include both RTT and Non RTT patients Refers to the standard of all patients being offered their choice of healthcare provider as well as date and time of their appointment The first referral to a new service within RSCH or first appointment. Any subsequent appointment with the same service. An electronic booking system for GP referrals straight into the Trust This denotes a patient who Does Not Attend their appointment without prior notification. This denotes a patient or hospital cancellation of an appointment or attendance which can either be rebooked or the patient discharged. This denotes a patient or hospital rebooking of an appointment where another date/attendance is arranged/required A brief nurse assessment to determine whether a patient is medically fit for surgery Assessment A full assessment of a patient prior to surgery RTT Pathways National 1) A waiting time clock starts when any care Clock Rules: Clock Starts professional or service permitted by an English NHS Page 12 of 60
commissioner to make such referrals, refers to: a) a consultant led service, regardless of setting, with the intention that the patient will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional or general practitioner; b) an interface or referral management or assessment service, which may result in an onward referral to a consultant led service before responsibility is transferred back to the referring health professional or general practitioner. RTT Pathways National Clock Rules: Clock Pauses (not externally reportable from Oct 2015 but needed for internal management) 2) A waiting time clock also starts upon a self-referral by a patient to the above services, where these pathways have been agreed locally by commissioners and providers and once the referral is ratified by a care professional permitted to do so. 3) Upon completion of a consultant-led referral to treatment period, a new waiting time clock only starts: a) when a patient becomes fit and ready for the second of a consultant-led bilateral procedure; b) upon the decision to start a substantively new or different treatment that does not already form part of that patient s agreed care plan; c) upon a patient being re-referred in to a consultantled; interface; or referral management or assessment service as a new referral; d) when a decision to treat is made following a period of active monitoring (see definition of this below); e) when a patient rebooks their appointment following a first appointment DNA that stopped and nullified their earlier clock. A clock may be paused only where a decision to admit for treatment has been made, and the patient has declined at least two reasonable appointment offers for admission. The clock is paused for the duration of the time between the earliest reasonable offer and the date from which the patient makes Page 13 of 60
RTT Pathways National Clock Rules: Clock Stops themselves available again for admission for treatment Clock stops for treatment 1) A clock stops when: a) First definitive treatment starts. This could be: i) Treatment provided by an interface service; ii) Treatment provided by a consultant-led service; iii) Therapy or healthcare science intervention provided in secondary care or at an interface service, if this is what the consultant-led or interface service decides is the best way to manage the patient s disease, condition or injury and avoid further interventions; b) A clinical decision is made and has been communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay, to add a patient to a transplant list. Clock stops for non-treatment A waiting time clock stops when it is communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay that: a) It is clinically appropriate to return the patient to primary care for any non consultant-led treatment in primary care; b) A clinical decision is made to start a period of active monitoring; c) A patient declines treatment having been offered it; d) A clinical decision is made not to treat; Where there is a clinical reason why it is not appropriate to continue to treat the patient at that stage, but to refer the patient back to primary care for ongoing management, then this constitutes a decision not to treat and should be recorded as such and also stops a waiting time clock. e) A patient DNAs (does not attend) their first appointment following the initial referral that started their waiting time clock, provided that the provider can demonstrate that the appointment was clearly Page 14 of 60
communicated to the patient; f) A patient DNAs any other appointment and is subsequently discharged back to the care of their GP, provided that: i) the provider can demonstrate that the appointment was clearly communicated to the patient; ii) discharging the patient is not contrary to their best clinical interests; iii) discharging the patient is carried out according to local, publicly available/published, policies on DNAs; iv) These local policies are clearly defined and specifically protect the clinical interests of vulnerable patients (e.g. children) and are agreed with clinicians, commissioners, patients and other relevant stakeholders. Active Monitoring A waiting time clock may be stopped where it is clinically appropriate to start a period of monitoring in secondary care without clinical intervention or diagnostic procedures at that stage. A new waiting time clock would start when a decision to treat is made following a period of active monitoring (also known as watchful waiting). Manual Clock Stops If a patient is subsequently referred back to a consultant-led service, then this referral starts a new waiting time clock. A manual clock stop is a clock stop which is recorded on OASIS when an 18 week clock is stopped as an Administrative Event i.e. at a time other than an Outpatient attendance or an Admission. Examples of manual clock stops are: Discharge back to GP following results, a patient s decision not to proceed with treatment e.g. surgery planned in the future or manual administration validation Definitive Treatment Inter Provider Transfer A complete or commencement of the first definitive treatment for the condition for which the patient was referred Examples of definitive treatment are: Discharged from consultant care at appointment, or Surgical/non-surgical procedure. The Inter-Provider Transfer Administrative Minimum Page 15 of 60
Data Set supports the requirement to transfer administrative data to allow the monitoring of a patients progress along an 18 Weeks pathway and Cancer Waits pathway where care has been transferred between providers. The standard mandates the transfer, from the referring provider to the receiving provider, of the administrative data necessary to allow the receiving provider to report on the patient pathway as required. 4. DUTIES AND RESPONSIBILITIES It is the responsibility of the Operational 18 week Lead for the Trust to ensure all relevant staff are aware of this policy, this includes: 4.1. KEY DUTIES AND RESPONSIBILITIES OF COMMITTEES 4.1.1. 18 Weeks Group [weekly meeting] The 18 Weeks group has the responsibility for reviewing data and reports relating to patient waiting lists and processes. Heads of departments and SBU/Support Service Managers are required to attend 18 Weeks as a representative of their services and staff. The department Heads and Managers should ensure that their staff are compliant with the access policy and local SOP s are based on the processes within this document. For cancer meeting see Appendix 2: Cancer Patient Access Standards 4.2. KEY DUTIES AND RESPONSIBILITIES OF STAFF 4.2.1. Director of Operations and Their Deputies Ensuring the compliance for all Trust staff is in accordance with this Policy. 4.2.2. Specialty Managers and Their Deputies, Heads of Departments and Line Managers of Staff Ensuring local departmental SOPs are in accordance with this Policy. Ensuring that the contents of this Policy are disseminated to and adhered to by all staff working under their management 4.2.3. Outpatient, Admissions Staff [Including Non RSCH staff], Medical Secretaries, 18 Week Validation Team and Clinicians Ensuring they are familiar with this policy Responsibility to bring to the attention of their line manager any variation in processes by Trust staff that is not documented in this policy Identify any training needs required to their line manager Responsibility to escalate any PAS issues with implementing this policy Page 16 of 60
5. SUBJECT MATTER OF WORKING DOCUMENT 5.1. SECTION A: OUTPATIENT REFERRALS TO THE RSCH [RSCH LED SERVICES] REFERRAL LETTERS/FORMS 5.1.1. ROBUST CLINICAL INFORMATION All referrals/forms received via any referral route at the RSCH should contain a robust clinical set of information to ensure that patients are allocated appropriately or consideration will be made as to whether the referral will be accepted by the RSCH. This is to also ensure effective triage can be undertaken by the consultant or clinician who manages the service for which the patient was referred. [Robust clinical information should also be included in discharge letters back to the GP to provide the GP with sufficient knowledge of the tests and treatments undertaken in secondary care]. The clinical management of patients should take place in primary care where possible and transfer to secondary care when clinically appropriate, with a view to the care being transferred back to primary care at a later date. 5.1.2. PATIENT DETAILS All referrals should contain relevant patient details, to ensure that patients are able to be appropriately contacted and informed of their appointments through various methods of communication. This will increase our ability to contact patients, especially at short notice and provide appointment reminders. The Trust is required to record this information in order to submit invoices to the relevant commissioners. If the mandatory details are not contained in the referral letter, the RSCH may not accept the referral until these details are provided. This information is referred to as an MDS [Minimum Data Set]. Referrers are required to provide the following mandatory information within their referral: A) GP Practice Information GP Practice Name, address, telephone number, and email (where available) Name of referring doctor Name of registered doctor B) Patient Details Patients Full Name [including title] Date of Birth Gender Address including postcode Telephone contact details (with a minimum of one up to date daytime/mobile telephone number) Page 17 of 60
NHS number The following information is not mandatory, although it will assist with the triage and booking allocation for patients: C) Additional details E-mail Ethnicity Any additional requirements, such as: o interpreter needed o learning difficulties o transport requirements o visual or auditory impairment Summary of clinical interventions, diagnostics undertaken in primary care. Assessment of the clinical urgency by which the patient needs to be seen (urgent or routine) Patient registration forms are sent out with appointment confirmation letters in order to confirm and the patient details on our patient administration system, OASIS or other databases used across the Trust. At all appointments, this information should be checked and verified with the patient to ensure the information we hold is up-to-date. 5.1.3. E-REFERRALS At present, the E-Referrals electronic booking system is used for routine and urgent new GP referrals only [Functionality is available for Two Week Rules/TWR]. On the E-Referrals system, GP choose the clinically appropriate services for their patient from Directories of Services listed by multiple healthcare providers. It is the GP s responsibility to ensure they offer the patient choice of provider. The patient should leave their GP appointment with the list [providers refer to these as service names] they have chosen in conjunction with the clinically appropriate services determined by their GP. The patient will also have been given their UBRN [Unique Booking Reference Number]. Some GP practice staff help their patients book and arrange their appointment at the GP Surgery. Others advise the patient to contact the national Telephone Appointments Line [TAL] on 03456 088888 or book their appointment online, using their UBRN and unique password. When appointments are available the patients UBRN will be converted to a booked appointment and the patients RTT clock automatically starts. FOR E-REFERRALS, THE CLOCK STARTS ON THE DATE THE PATIENT CONVERTS THEIR UNIQUE BOOKING REFERENCE NUMBER [UBRN]. Page 18 of 60
In the instance when there are no appointments available on E-Referrals for the patient to book an appointment, the relevant Trust will receive a daily report from the E-Referrals system. This report is known as the ASI, [Appointment Slot Issues]. It is the responsibility of the receiving Trust to identify a choice of appointment dates. The patient s clock start date is the date the patient is added to this report and this information will be manually updated on OASIS when the booking is made. ASI reports indicate a failure to provide sufficient capacity on E-Referrals and should be rectified on the system as soon as possible. THE CLOCK START DATE FOR THESE PATIENTS IS THE DATE THE EMAIL IS RECEIVED INTO THE TRUST. THE APPOINTMENT CENTRE The GP practice team are required to attach a referral letter on the E-Referrals system within ADMINISTERS 48 hours of creating THE BOOKINGS the UBRN. It FOR is only THESE when PATIENTS. this referral letter is attached that the process of administering this referral can begin at the Trust. If there is no letter attached to an appointment request, patients appear on a missing referrals letters list. If the patient has converted their UBRN through the Telephone Appointments Line or online and the GP practice has not attached the letter after 3 days, RSCH will contact the referrer and request the referral details. If the referral letter is still not attached after this point, then RSCH will escalate to the commissioner at day 7. Once the referral letter is attached onto the E-Referrals system, the referral is administered by the Appointment Centre team and the Trust triage process begins. Where e-referral triages have not been accepted by a clinician within 5 days referrals will automatically be accepted. 5.1.4. MANUAL [PAPER, FAX, VERBAL OR E-MAIL] ROUTINE AND URGENT REFERRALS FOR NEW PAPER [NON E-REFERRAL] REFERRALS, THE CLOCK STARTS WITH THE DATE THE REFERRAL IS RECEIVED IN THE TRUST. All Outpatient referrals should be received into the RSCH site Appointment Centre, including for services held at outreach [E.g. Haslemere and Cranleigh Hospital] clinics under the management of the Royal Surrey. Routine and Urgent referrals for are received via the following methods: E-mail Into the Appointments Centre rsc-trapptscentre@nhs.net E-mail is checked daily for incoming referrals Fax Safe haven fax in the Appointments Centre 01483 464848 Fax is checked daily for incoming referrals Page 19 of 60
Post [paper] Directly to the Appointments Centre Post is picked up daily for incoming referrals Address is: Royal Surrey County Hospital Egerton Road Guildford Surrey GU2 7XX Tel: 01483464002 (Appointment Centre) 01483571122 (main switch board) A) Two Week Wait (TWW) Rule Referrals All patients referred with suspected cancer should be seen at the earliest opportunity and offered an appointment within 14 calendar days of receiving the referral letter. The received date for TWR/TWW s is day 0. The Appointment Centre administers the bookings for TWW patients. TWW referrals are sent via the dedicated safe haven fax number below. APPOINTMENTS CENTRE FAX - 01483 408303 FOR TWO WEEK RULES/TWO WEEK WAITS TWW referrals are to be faxed with a proforma front cover sheet, indicating the priority. TWW proformas are available on the Trust website [http://www.royalsurrey.nhs.uk/professionals/two-week-rule-referral-forms/] The Appointments Centre will attempt to contact the patient by telephone at least twice within 24 hours of receipt of the TWW referral to agree an appointment date and time, and send out details of the appointment by 1 st class mail in that timescale. See Appendix 2 Cancer Patient Access Standards for further details B) Symptomatic Breast Patients Symptomatic breast referrals are sent from the referrer to RSCH. Patients will be offered an appointment within 14 calendar days of receive date. C) Triage/prioritisation/clinically appropriate clinic With the exception of TWW referrals, all other incoming referrals are to be triaged by a clinician before an appointment can be arranged for a patient. For E-Referrals, the GP decides the most clinically appropriate service from the Directory of Services. For manual referrals, the Appointment Centre staff use the referral information to send this referral to the correct specialty for triage. The referral should be triaged and sent back to the Appointment Centre within 3 working days of receipt. It is the specialty s responsibility to monitor that systems and processes are in place to ensure clinicians can achieve this particularly Page 20 of 60
during periods of leave and in absence of the clinician. The clinician may alter the clinician or service referred to during the triage process if clinically appropriate to do so. The Appointment Centre staff will administer these changes appropriately. 5.1.5. REFERRAL SOURCES ON OASIS The following referral sources should be entered correctly onto OASIS from the information provided; referrals should not be added to OASIS without specific referral information being provided. For referral sources other than GP referrals the referral source and referral name should also be entered directly onto OASIS [for data quality]. Referral sources not available on OASIS, should be logged with the IT service desk. GP/GDP REFERRAL GP GDP [DENTIST] EXTERNAL REFERRAL [FULL MDS TO BE PROVIDED CONTAINING INFORMATION REGARDING THE PATIENT S DEMOGRAPHICS, CLOCK/RTT AND PATHWAY INFORMATION] A&E TO FRACTURE OTHER TRUST CMHT [COMMUNITY MENTAL HEALTH TEAM] COMMUNITY MEDICAL OFFICE CONSULTANT FROM OTHER PROVIDER FOLLOWING DOMICILIARY VISIT INTERNAL REFERRAL [FULL MDS TO BE PROVIDED CONTAINING INFORMATION ON THE PATIENT S DEMOGRAPHICS, CLOCK/RTT AND PATHWAY INFORMATION] A&E REFERRAL A&E TO FRACTURE/EYES [OWN TRUST] A&E TO REVIEW CLINIC CONSULTANT WITHIN THE TRUST - EXISTING PATHWAY CONSULTANT WITHIN THE TRUST - NEW PATHWAY MSK EXISTING PATHWAY OCCUPATIONAL HEALTH FOLLOWING EMERGENCEY ADMISSION OTHER COMMUNITY REFERRER/DISTRICT NURSE PRIVATE (NO RTT DETAILS REQUIRED) NATIONAL SCREENING PROGRAMME [SHOULD CONTAIN FULL DEMOGRAPHIC DETAILS] NATIONAL SCREENING PROGRAMME Page 21 of 60
OPTICIAN [SHOULD CONTAIN FULL DEMOGRAPHICS AND BE SENT ON A B52] OPTICIAN SELF REFERRAL [SHOULD CONTAIN FULL DEMOGRAPHICS] SELF REFERRAL TEST ONLY [SHOULD CONTAIN FULL DEMOGRAPHICS] TEST ONLY FROM GP TEST ONLY FROM OTHER PROVIDER TEST ONLY WITHIN TRUST PRIVATE PRIVATE REFERRALS SHOULD BE RECORDED ON OASIS [SHOULD CONTAIN FULL DEMOGRAPHICS] PRIVATE REFERRAL 5.1.6. REJECTING REFERRALS E-referrals can be rejected and sent back to the work lists of the GP practices (NB this does not include Two Week Rule Referrals See Appendix 2 Cancer Patient Access Standards). Reasons for rejection include RSCH booking for a service not provided, a patient is referred for a procedure that the commissioners have not authorised e.g. cosmetic surgery. The full reason for rejection should be provided by the Trust via E-Referrals and recorded on the footnote of the appointment request record. The trust will send patients an information letter detailing the reason for an appointment redirection to another service. In the case of a referral rejection this will be communicated directly to the GP/Referral Management Service who are then responsible for informing the patient and action. The GP practice should then consider the referral rejection. For manual referral rejections, the Royal Surrey County Hospital is responsible for sending a letter to the GP and the patient regarding the reason for the rejection. Rejected referrals will stop the patient s clock and pathway. INAPPROPRIATE REFERRALS If a referral is clinically appropriate and the trust provides the relevant service then the referral must be accepted. All referrals are logged on receipt. Where a referral is received without the minimum data set (MDS) necessary to record a clock start the referrer will be contacted for additional information. However, the RTT clock will remain running. If a referral is considered clinically inappropriate upon triage then it will be returned to the referring GP, accompanied by a note advising that the patient will need to be reassessed or referred elsewhere if the referral is for a service not provided by the trust and/or is not in line with the agreed clinical criteria protocols. It is the responsibility of the clinician to inform the appointments team Page 22 of 60
in relation to the onwards movement of the referral letters, i.e. diagnostics or direct admission, if not returned to the appointments centre. In the case of Two Week Rule Referrals, please see Appendix 2 Cancer Patient Access Standards) 5.1.7. OVERSEAS VISITORS For patients from SCOTLAND, NORTHERN IRELAND AND WALES: If a patient comes in through A&E and is admitted, the A&E activity is paid by the host CCG. All inpatient and outpatient activity connected to that A&E activity is paid for by the relevant local health board in Scotland, Ireland or Wales. For elective care, ALL appointments must have funding approved BEFORE the appointment takes place. Application for this funding must be sought EVERY time the patient has an appointment. For patients from EUROPE If a patient is from one of the 30 members of the European Union plus Switzerland and Norway they should be asked for their EHIC [European Health Insurance Card] when they present at the A&E Reception Desk. A&E print the front page of the CAS card, attach the ID and put it in the Overseas Tray on the A&E desk. If the patient does not have an EHIC, it is imperative that A&E staff ask for an ID card (all Europeans have them) and ask the patient to write their home address on a separate piece of paper and attach to the copy Cas card. A&E should then notify the Overseas Visitors Manager as soon as possible. If this is out-of-hours, then please leave a message on the answer phone extension 6885 or email Lynda.Fernandez@nhs.net. If the patient does not have an EHIC or an ID card, as a trust, we are obliged to charge them directly for all inpatient and outpatient activity, not their A&E treatment. This will be arranged by the Overseas Visitors Manager when you inform them of the patient s arrival. The Overseas Visitors Manager can attempt to obtain a PRC (Provisional Replacement Certificate) from the patient s country which ensures payment and avoids having to charge the individual patient. From 1 st October a hospital Trust will be paid a bonus of 25% over tariff for all European patients provided an EHIC is obtained. This allows the Department of Work & Pensions to claim monies back from each individual state. All overseas patients presenting for treatment should always be asked for their PERMANENT address and a temporary address in the UK along with telephone/email details. This must be asked in a clear manner. All overseas patients should be asked to produce their passport or Identity Card and Insurance details if applicable which should be photocopied put into the Overseas Visitors tray on the A&E desk. Overseas patients are not normally booked through C&B. If a patient is identified as overseas, please contact the Overseas Visitors Manager so they can check the patient s eligibility. An appointment should only be made before eligibility confirmed if the appointment is a Two week rule or urgent appointment. Page 23 of 60
PATIENTS FROM OUTSIDE EUROPE If a patient presents from a country outside Europe they should be asked for their passport and insurance details. Staff are aware of those countries we have bilateral agreements with and have a list of all those countries and the evidence they are required to produce. Bilateral agreement patients are not charged personally, the charge for their treatment is billed to Guildford & Waverley CCG. It is important, once again, that staff members obtain the patient s permanent address in their own country, the temporary address in the UK plus contact details, phone numbers, email addresses. Staff contact the Overseas Visitors Manager on ext 6885 or by email Lynda.Fernandez@nhs.net 5.1.8. MINIMUM DATA SETS [INCOMING REFERRALS] The Minimum Data Set (MDS) is the best practice standard for referral information throughout England and will provide important information for 18 weeks/cancer and demographic information. In addition it is required for referrals between healthcare providers to be made without delay, i.e. electronically to support the joint responsibility for delivering 18 Weeks Referral to Treatment (RTT) and Cancer treatments in accordance with cancer standards targets (See Appendix 2 Cancer Patient Access Standards) The following information is required: Unique pathway identifier [RTT pathway ID/number] Treatment required [treatment commenced] Original referral date 18 week clock start date/two Week Rule clock start date/31 or 62 day start date Current RTT Status All organisations involved in the patient s 18 week pathway and the cancer standards pathway. It is the RSCH s responsibility to validate [internal referrals] or obtain MDS information [external referrals] for any incomplete referrals before they can be processed on OASIS. This process is operated though the Appointments Centre with the exception of Oncology. In the case of Inter-provider referrals, if the referring provider fails to provide the above information within 2 days of transferring the patient s care, the receiving provider will need to ask for them with an email to the Inter-provider mailbox (rsch.interprovider@nhs.net) for RSCH. The Inter-provider will then contact the relevant Points Of Contact (POCs) to obtain the missing information and reply back. Failure to provide the missing information within 2 days of this request will result in the escalation of the case to Senior Management for both the care providers. Page 24 of 60
If a cancer referral is received with insufficient information to process it then the referrer must be contacted immediately to minimize delay to the patient. Referrals must not be rejected for this reason or the pathway paused or delayed Failure to provide the missing information within 1 day of this request will result in the escalation of the case to Senior Management for both the care providers 5.1.9. EXAMPLE OF REFERRAL PROCESS Referral arrives in the Trust Referral date stamped. Appointment Centre team load the referral onto OASIS Information is assessed and sent to the right consultant and clinic where possible. Referral sent to Consultant for triage Returned within 3 days of receipt with triage notes and instructions. Sent back to the Appointment Centre From receipt, Appointment Centre team administer triage instructions within 48 hours. 5.2. SECTION B: BOOKING PROCESS BOOKING AND WAITING TIMES 5.2.1. RECEIPT AND REGISTRATION OF REFERRALS For E-Referrals, the receipt of referral occurs when the referral letter is attached. For manual referrals it is the date the letter arrives in the Trust. For TAL referrals, it is the date the email is sent. For all these referrals, the Appointment Centre team administer the information onto OASIS to check for completeness. 5.2.1.1. Consultant Referral Triage Process If referrals are re-directed, the clock continues. The Appointments Centre will action the required changes and amend OASIS to reflect the change. An amendment will most frequently be a redirection of the referral to a more appropriate clinician within the Trust in which case the referral will be redirected on OASIS for the appropriate clinician to triage. If referrals are accepted the clock continues, Clinicians will also complete request forms for diagnostics if appropriate. 5.2.2. ADMINISTRATION PROCESSES FOR INCOMING REFERRALS Once referrals have been triaged and accepted by an appropriate Clinician, the Appointments Centre will complete and confirm the booking. Where E-referrals are amended at the clinical triage stage, the Appointments Centre will contact the patient to explain the reason for the change and remake their appointment if necessary. The clock continues. Page 25 of 60
New outpatient appointments are booked via the Appointments Centre [with the exception of Oncology and Haematology] and once booked with the patient, are communicated via postal letter. For specialities with clinic capacity issues, the appointments centre team will add the patient to the outpatient waiting list and communicate an acknowledgement/holding letter to advice of the approximate waiting time and the booking process. Assuming sufficient clinic capacity, the RSCH aims to book, all new appointment dates within 4 to 8 weeks of the date the referral was received within the Trust. If a patient is not able to agree [declines two appointment dates with at least 3 weeks notice] an appointment the patient may not initiate a delay to their pathway at this stage and they will be discharged back to their GP if clinically appropriate to do so. This will be decided with the responsible clinician, led by the specialty manager, according to local procedure. They may be re-referred at a future point when they are able to commence their 18 week treatment pathway. Reporting should be available for SBU leads where patients are unable to book due to capacity. These should be reviewed in capacity and demand forums or Performance meetings. 5.2.2.2. Clock Continuation It is the responsibility of the Speciality Manager/Department Lead to ensure the Trust plan their clinic capacity to meet clinical needs and access targets such as TWW/TWR s and RTT. The patient will not be disadvantaged due to issues with outpatient capacity. There are no clock pauses for patients on non-admitted/outpatient clocks. 5.3. SECTION C: PATIENT CHOICE CHOICE DEFINITIONS Choice is fundamental to the delivery of a truly patient-centred NHS by empowering people to get the health and social care services they want and need leading to improved health and well-being [Choice at Referral: Supporting Documentation, Department of Health]. Since April 2008, patients have been able to choose any hospital in the NHS or independent sector for their treatment. People should also be free to choose their GP. The NHS Choices website provides much more information to help patients make decisions about their care [http://www.nhs.uk/pages/homepage.aspx]. Choice inevitably has certain boundaries to ensure clinical safety and achievement of other required patient driven standards. This guidance details the systems and processes by which a patient s choice is applied within the RSCH. Page 26 of 60
5.3.1. ENSURING CHOICE THROUGHOUT THE BOOKING PROCESS For all outpatient appointments agreed along the pathway, reasonable offers should be made with a minimum of three weeks notice and two dates should be applied, although earlier dates can be offered if available [these cannot affect patient clocks if dates are declined]. For admission TCI dates, these should be made with a minimum of three weeks notice and two dates applied, although earlier dates can be offered if available [these cannot affect patient clocks if dates are declined]. For patients with a decision to admit for treatment, where available, patients can be offered with less than 3 weeks notice dates, e.g. when waiting lists are shorter than 3 weeks or unallocated slots / appointments are available, however patients will have the opportunity to decline without any adverse effect on their waiting times or 18 week clock. Patients should be offered the first available date and, where this is not acceptable, should be able to agree a date for their appointment within a three week window. Where the patient cancels an appointment, a further appointment must be offered, within three weeks of the original appointment. When a patient cannot agree a new appointment within this timeframe, the patient will be discharged back to the GP and re-referred if clinically appropriate to do so. For Cancer Patients see Appendix 2 Cancer Patient Access Standards If a patient chooses to delay their pathway at any time, no adjustments can be made to the patient s 18 week RTT clock for patient choice at any stage of the pathway. N.B. From 1 October 2015, although there will no longer be a requirement to report patient pauses externally, internally they must still be noted on the Oasis PAS to reflect patient choice. Page 27 of 60
5.4. SECTION D: PATIENT ACCEPTANCE OF THEIR APPOINTMENT 5.4.1. PATIENT AGREEMENT TO DATE/TIME OFFER All appointments along the pathway should apply the same offers to all patients. A minimum of three weeks notice and two dates should be applied, although earlier dates can be offered if available, however this will have no effect on their waiting time. Staff are required to record the Earliest Reasonable Offer date (EROD) on OASIS. For Cancer Patients see Appendix 2 Cancer Patient Access Standards. Where patients do not agree dates within reasonable time frames, the general approach should be that a clinical review takes place, and if clinically appropriate to do so the hospital will communicate to the GP that the patient will be discharged back to them for re-referral as appropriate. All appointments, especially those agreed with the patient via telephone should be confirmed to the patient by using OASIS generated letters that are sent to the patient. 5.4.2. EFFECTIVE RECORD OF PATIENT CHOICE AND OFFERS It is essential to ensure patients within all areas of the trust understand the implications of their choices and actions in line with this policy. It is the responsibility of each SBU and Clinical Support Service to ensure all letters, telephone calls and communications must be such that a patient is suitably informed of this guidance and how it could potentially affect them. All records of patient choices and decisions should be effectively recorded and detailed on OASIS to ensure there is an auditable trail of the booking process. 5.4.3. TRANSPORT GUIDELINES AND ELIGIBILITY When booking an appointment or an admission at the Royal Surrey County Hospital (RSCH) or one of the RSCH sites, it is the patient s responsibility to make their own way to and from the hospital. Details of the non-emergency hospital transport are detailed in our Patient Transport Service leaflet. All health professionals and patient requests for hospital transport have to be assessed for eligibility, and we cannot provide patient transport for financial or social inconvenience. All patients will have to go through a strict confidential eligibility questionnaire and will be assessed for eligibility/mobility. All options for patient self or assisted transportation should be sought and excluded prior to the NHS/hospital funded service being considered. Before asking for transport, patients are requested to think about the following: Does their mobility allow them to travel via public transport or independently? Can a friend or family member bring them? Bus and Train travel where applicable Volunteer services in their local communities Wider volunteer services if applicable Page 28 of 60
Alternative transport options, such as Dial-a-ride, Local area services Taxis There are three possible outcomes following transport eligibility assessment: 1. Patient qualifies for NHS funded transport, based on medical need 2. Patient does not qualify for NHS funded transport based on medical grounds need, but public transport fares may be reimbursed because you are in receipt of a qualifying benefit 3. Patient does do not qualify for transport, but assistance will be given for alternative options available If the patient is an outpatient, they need to book their transport via their GP/directly with the booking service. All qualifying inpatient journeys will be booked via the patient transport officers at the hospital. If the patient attends the hospital on a regular basis, they will be assessed for the entire block of treatment and then reassessed once their treatment is complete. All other patients will be reassessed for every appointment 5.5. SECTION E: PATIENT VARIANCES PART 1 For TWW and Cancer Patients See Appendix 2 Cancer Patient Access Standards 5.5.1. PATIENT IS UNABLE TO AGREE DATE/TIME WITHIN TIMESCALES If a patient is referred and subsequently proves unwilling to agree an appointment date, they can be returned to the GP until they are ready to accept an appointment. No adjustments can be made for patient choice at any stage of the non-admitted pathway. 5.5.2. PATIENT CANCELLATIONS AND RE-BOOKINGS Where the patient cancels an outpatient appointment, the clock will continue to tick. All patients should be encouraged to agree a second appointment within three weeks of the cancelled appointment. When a patient cannot agree a new appointment within this timeframe, the patient may be discharged back to the GP, if clinically appropriate to do so. Any reasonable appointment offered by the Appointments Centre, within three weeks of the cancelled appointment, and refused by the patient, must be recorded on PAS by booking and then cancelling the appointment. If the patient cancels a second appointment, a further appointment will not be automatically given unless indicated by the clinician in charge of that patients care. The matter should be raised to the appropriate Specialty Manager for review. If the Specialty Manager, following discussion with clinical colleagues, determines that discharge is not detrimental to the patient s care, the clock stops and the patient is discharged back to their GP, if clinically appropriate to do so as per Section 5.2.2, and may be re-referred at such a point as they are able to commence their treatment. Page 29 of 60
BACK TO GP Patient has an arranged appointment PATIENT CANCELS APPOINTMENT [First time] Patient agrees NEW appt within 3 weeks If Patient does not agree a date REVIEW WITH CLINICIAN Arrange another appointment It is important that correspondence e.g. appointment letters, with the patient explains how to change an appointment and the impact of a cancellation or DNA. Administrative processes in each SBU or CSS must ensure that patients are able to contact the appropriate location to be able to change their appointment and agree a subsequent date. 5.5.3. OUTPATIENT DID NOT ATTEND [DNA] PROTOCOL For TWW and Cancer Patients See Appendix 2 Cancer Patient Access Standards. A DNA [Did Not Attend] is defined as any scheduled appointment, procedure or operation that is missed without prior arrangement with the Trust. For patients who have been manually booked onto our OASIS system, we must demonstrate that the patient was offered choice of their appointment and that the appointment was clearly communicated to the patient within an agreed process and timescales [see Section 5.3]. For patients who have booked through the E-Referrals system via any route [online, telephone, or direct with practice], this will constitute sufficient evidence that the provider has offered choice. However, similar to above, we must demonstrate that the appointment was clearly communicated to the patient within an agreed process and timescales. If the patient has received choice, as defined by above, and the patient has not attended for their appointment, the patients clock will be stopped by the DNA. A new clock will start when contact is made with the patient to agree a new date. This ONLY applies to the first new appointment on the patients pathway. If the patient has been through a primary care assessment service, this cannot be applied to their first appointment in secondary care. A new clock will only start when contact is made with the patient to agree a new outpatient appointment Page 30 of 60