Document name: Document type: Did Not Attend And No Access Visits Policy Clinic appointments and cancellation of clinic appointments procedure Routine/scheduled community/home visits Policy and Procedural document What does this policy replace? Staff group to whom it applies: Distribution: How to access: Update of previous policy All medical and clinical staff who undertake clinics and community/home visits, and their administrative support The whole of the Trust Intranet Issue date: September 2016 Next review: September 2019 Approved by: Developed by: Director leads: Contact for advice: EMT Dr P Kumar Medical Director Medical Director www.southwestyorkshire.nhs.uk
Contents Section Page 1 Introduction 4 2 Purpose 5 3 Duties 5 4 Definition of terms used 6 5 Abbreviations 7 6 Principles 7 7 Practice Standards 9 8 Procedure 10 8.1 New referrals 10 8.2 Known service user 11 8.3 Four Steps to safety 14 9 Safeguarding 16 10 Technical issues related to caseload / waiting list etc. 16 11 Cancellation of clinics 17 11.1 Cancellation by service user 17 11.2 Trust cancelled appointment 17 12 Future Developments 18 13 Equality Impact Assessment 18 14 Process for Monitoring Compliance of this Policy 18 15 Process for Reviewing and Approving this Policy 18 16 Dissemination, implementation and access to this Policy 18 17 Document control and archiving 19 18 Associated Documentation 19 2
19 References 19 20 Example letters attached as appendices 19 APPENDICES Page Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 DNA by Service User to Clinic Appointment Flowchart(Mental Health) No Access Visit to Service User/Referred Person Flowchart (Mental Health) Did not attend by Service User to Medical Clinic Appointment (Mental Health) Template of letter to service user/carer to cancel/change clinic appointment Template of letter to service user/carer who failed to keep (outpatient) clinic appointment with doctor Template of letter to General Practitioner/referrer to discharge service user who failed to attend medical clinic appointment 20 21 22 23 24 25 Appendix 7 Equality Impact Assessment Tool 26 Appendix 8 Checklist for the Review and Approval of Procedural Document 29 Appendix 9 Version Control Sheet 31 3
1 Introduction 1.1 This policy is important as it is recognised within all services delivered by the Trust that for some service users, there could be a high clinical risk if they did not attend (DNA) scheduled appointments or access was not available or declined i.e no access visit (NAV). DNA/NAV related issues are common findings in serious incident investigations, whether homicide or suicide, both locally and nationally. 1.2 The Trust will seek to ensure that all service users are seen as early as possible during their pathway. However, one of the major obstacles to this is when a service user fails to attend their appointment. This results in an inefficient use of clinical time and also currently for the slot to go unused rather than it being offered to another service user. The following table provides an estimate of the cost of DNAs to staff time in the Trust for 2014/15. Cost (approximate) of mental health DNA appointments (staff time only) 2014/15 Cost of DNAs ( ) Number of DNAs Service area Child & Adolescent Mental Health Service 145,114 5,333 5,313 Forensics 1,105 82 68 Learning Disabilities 33,654 1,792 1,499 Low Secure Services 3,293 193 161 Older People Services 80,854 5,369 4,012 Working Age Adults 986,631 54,270 48,762 Grand Total 1,250,651 67,039 59,815 DNA appointment hours 1.3 This policy and procedural document was originally developed in 2010 with subsequent iterations following consultation with all services delivered through the Trust and builds on the review of existing policies, procedural and practice guidance. This will support the delivery of consistent good practice across the Trust. Consultation took place with: Directors Assistant Directors Medical staff Clinical Governance representative Risk representative 4
Information Governance representative Administrative Managers Service Users representatives Legal opinion was also sought and the feedback incorporated as appropriate Relevant recommendations following Serious Incident (SI) investigations over time have been incorporated over time. This document is an update of the original policy and procedural document. 2 Purpose This policy identifies the core values and principles which apply to all services and is intended to clarify responsibilities in each of those service areas. Many services, for example psychology, district nursing, musculoskeletal community service have their own tailored protocols that incorporate the core values and principles in this document. This policy document will clarify:- 2.1 The clinical responsibility and the procedure to be followed when service users fail to attend their scheduled appointments. It is intended to apply to new referrals, including those which are referred through the single point of access and from other members of the multidisciplinary team (MDT), as well as those who are well known to any of the services provided by the Trust 2.2 Procedures around cancellation of clinic appointments. 2.3 A framework which promotes the exercise of sound clinical judgement, thereby ensuring DNAs and NAVs are managed 2.4 A framework that ensures that when a person DNAs or there is a resulting NAV at a first or any subsequent appointments the appropriate referrer is informed. 2.5 A framework that ensures DNAs and NAVs are responded to appropriately by the clinician responsible for the care of the service user based on knowledge and understanding of the service user, and best practice in managing risk within the clinical delivery systems and frameworks such as that of CPA/Standard Care. 3 Duties 3.1 The lead Director (currently the Medical Director) is responsible for ensuring the policy is reviewed, approved and monitored by the appropriate Trust group(s). 3.2 The appropriate Trust groups, currently the Executive Management Team will provide policy approval and ratification. 5
3.3 The Business Delivery Units will review compliance of the policy by analysis of data collected through incident reporting and by the Trust informatics systems 3.4 Each consultant/clinical team leader/clinical manager will plan and oversee his/her team system to implement this procedure ensuring appropriate linkages with relevant clinical and administrative staff. 3.5 Consultants will decide whether it is appropriate to delegate decisionmaking about response to DNAs/NAVs to other doctors in the team. Junior doctors should be closely supervised (for example, bringing DNAs/NAVs to the attention of the consultant weekly, or immediately in some cases). Decisions about response to DNAs/NAVs may be delegated to more experienced trainees and SAS (Specialty and Associate Specialists) doctors. 3.6 Each consultant/clinical team leader/ team manager will ensure that new medical and non-medical clinical staff and relevant administrative staff are familiar with the arrangements for DNAs and NAVs. 3.7 All staff will ensure that DNAs and NAVs that occur in all settings are brought to the attention of the clinician responsible for the care provided. 3.8 A decision about what action to pursue will be made by the consultant or their delegated medics on the basis of the principles outlined, and conveyed and recorded in a clear way. Care Co-ordinators and clinicians through agreed contingency plans, consultation with line managers and supported through clinical supervision/case Management. 4 Definition of terms used 4.1 The term outpatient from national performance perspective is used to identify consultant led clinics that receive direct referrals from General Practitioners (GP) rather than team referrals. It also dictates the compliance with several national targets that are not possible for a secondary Mental Health and learning disability provider to meet as many service users are seen by a variety of health professionals. Hence, the term clinic will be used throughout this procedural document. 4.2 DNA is defined when a service user fails to keep their scheduled/agreed appointment with any clinician or support staff within a healthcare delivery environment without notifying the Trust* prior to the commencement of the appointment. Any notification prior to the appointment commencement time is recorded as a cancellation* 6
4.3 NAV is defined when a service user fails to keep their agreed appointment with any clinician or support staff within the community or within their home environment without notifying the Trust.* * when an individual notifies the Trust of intent not to attend a clinic or scheduled/agreed appointment the individual who this appointment was made with (this may be a Consultant Psychiatrist, delegated medic, Psychologist, Community Psychiatric Nurse, Social Worker members of mental health teams, support services teams and specialist services within the trust) in consultation with the Care Coordinator, Lead clinician when applicable needs to give careful consideration to the appropriateness of such action and base their response on an understanding of individual risks, contingency plans and information made available from other services and partners including primary care. 4.4 A clinician is any professionally qualified individual delivering physical and mental health services on behalf of the Trust. 4.5 Support staff describes any individual who supports the role of the clinician. This will include Support Workers, Support, Time and Recovery Workers, Community Support Staff and Administrative Staff. 5 Abbreviations used in this policy CPA GP MDT SI Care programme approach General Practitioner Multi-disciplinary team Serious incident 6 Principles 6.1 The key principle to this procedural document is to ensure that all staff within the Trust are aware that service users should not be declined or not offered Trust services as a result of not attending an appointment and the standards relating to this. 6.2 All DNAs and NAVs (including cancellations) will be reviewed on an individual basis and any subsequent action influenced by the needs of the individual based on an assessment of risk and prior knowledge / understanding whenever possible. 6.3 All efforts must be made to maintain contact with high risk individuals who continuously DNA and NAV, through creative means, e.g. Agree a minimum contact schedule with the individual Agree to meet at a time convenient for the individual but at the same time staff must ensure their safety 7
Maintain contact by phone (if appropriate) Arrange with the person and agree alternative facilities to attend as a point of contact e.g. group or venue 6.4 It is important that processes around DNAs and NAVs are clear to all involved. For medical staff, decisions should be made by the medical team under the leadership of the consultant. 6.5 Assessment of risk and of the level of urgency of service users clinical needs (on the basis of the information available) are key elements guiding decisions. This must be based on an up-to-date assessment of risk, or a review of the current risk assessment 6.6 Actions to be taken include the seeking of further information, particularly from the referrer. 6.7 Consultants, Care Co-ordinators, Lead professionals and clinicians should seek the support and collaboration of other members of the MDT as appropriate. (Team meeting/review of care). 6.8 Liaison with the carer (with service user s permission) as well as reference to existing advanced decisions may be appropriate for some service users. 6.9 No automatic follow up appointment is given until the clinician has decided on that this action is to be taken following DNAs/NAVs. 6.10 All reasonable effort will be made to ensure communication with service users, including those with disabilities and language barriers in a way that they can access and understand, and identify and provide any communication support that they need consequent to any disability, impairment or sensory loss in keeping with the Accessible Information Policy. 6.11 For service users with no fixed abode or frequent change of address, all necessary attempts will be made to contact with them in collaboration with referrer, GP and /or other members of the MDT. These will include Visiting establishments known to be frequented by the service user Arrange a visit at an agreed location i.e. GP Practice Using electronic means, i.e. mobile phones, text messages, e- mail Clear documentation of all attempts should be made in the service user s clinical record. 8
7. Practice Standards 7.1 Any decision taken must be based on an up-to date risk assessment or review of an existing risk assessment if available. 7.2 Where information is not known to inform actions, then the referrer /GP must be communicated with to identify and agree risks/actions to be taken. In some service areas, for example, Learning disabilities, it would be appropriate to liaise with paid carers/ family carers. 7.3 Telephone communication should be made for timely decision making and risk management. 7.4 All decisions and formulations must be clearly documented in the case record of the individual. However, an entry in the service user s clinical record alone does not necessarily guarantee good communication to all involved agencies and hence, all appropriate modes of communication must be used to ensure that information and decisions are shared timely with the relevant involved agencies, subject to considerations of patient confidentiality. 7.5 Letters must be sent to the GP/referrer clearly identifying actions and responsibilities following agreed decision making. 7.6 Risk assessment which has informed the actions must be documented within the clinical record. 7.7 Do not work in isolation. Report and share concerns and liaise with other MDT members/line manager to help in decision making. 7.8 Never fail to respond to non-attendance and no access visits. 7.9 Consideration should be given to leaving a note, sending a text message, sending an e-mail, contacting a family member etc. This however should be incorporated into a plan to manage the assessed risks and should not be done as an overall response. 7.10 The safety of the individual and others is of primary importance and therefore decision making should be systematic in understanding and managing the risk with clear actions and responsibilities to manage the identified risks. 7.11 Consideration must be given in formulating action plans as to involve other agencies such as the police, safeguarding and child protection as examples. 7.12 A range of interventions must be considered to manage risk including Use of The Mental Health Act 1983 Use of The Mental Capacity Act 2005 Safeguarding Child protection Mental Health and Physical healthcare providers Other services involvement including Police, Local Authority and externally agreed partnerships which support safe practice. i.e. use of specialist accommodation/hospital etc. Family/carer and significant other support Multi-agency Public Protection Agency (M.A.P.P.A.) Multi-agency Risk Assessment Committee(M.A.R.A.C) 9
8. Procedure 8.1 New referrals 8.1.1 In cases of new referrals who DNA or NAV, the consultant / clinician will review the case after considering all available information from a variety of sources including the referral letter, discussion during the single point of entry / any screening that has taken place, or any other additional information including any past history that the same service user may have had with the service. 8.1.2 If risks appear to be low and there is no other reason to indicate a further appointment, the referrer and the GP should be notified, with a request to re-refer if needed. The service user should also be informed. Standard letters are appropriate in most cases (see Appendices 5 and 6 as examples). 8.1.3 In these cases, in accordance with the Records Management: NHS Code of Practice Part 2 (January 2009), the full set of service user notes, if not captured on the electronic patient record or locally agreed recording systems, should be passed to medical records with a note requesting filing for 2 years. 8.1.4 All relevant information supporting decision making and outcomes will be recorded on the electronic patient record or locally agreed clinical recording systems. 8.1.5 When a service user writes or phones to state that they no longer wish to receive the appointment and no concerns are identified, the service team will write to the referrer advising them that the service user is discharged i.e. no further appointment will be sent unless a new referral is made. The service user is discharged on the administrative/it systems. The service user should be copied in to letter to the referrer. 8.1.6 If the consultant / clinician has concerns such as about potential risk in specific area(s), particularly where a service user may be in need of a service but lacks insight into that need and /or lacks mental capacity to make a decision regarding that need, then he or she should liaise with the GP / referrer to seek further information, advise them of the service user s DNA or NAV and agree whether other alternatives are required; for example, a joint home assessment or a Mental Health Act assessment. 8.1.7 The consultant /clinician will bear in mind the possibility of another member of the MDT undertaking the initial assessment. e.g. community psychiatric nurse/ health visitor attending to the service user at their home address. 10
8.1.8 The consultant / clinician may delegate this responsibility to another colleague during periods of planned leave. 8.1.9 In any case where the person may be a carer of children or vulnerable individuals and potential safeguarding concerns are identified, this process should involve liaison with appropriate safeguarding agencies. 8.2 Known service user 8.2.1 Where there has been a DNA/NAV, the staff member who was expecting to see the service user at the appointment is responsible for initiating the process of deciding what action to take. Where that person is an unqualified member of staff they will inform a qualified clinician, preferably one involved in the service user s care, who will start the process. Where a care coordinator is identified and is available, they should coordinate the response to the DNA/NAV. 8.2.2 All services should have a system for determining who will respond to a DNA/NAV in the absence of the clinician ordinarily leading the care of the service user or the care coordinator. This may involve another qualified clinician in the team, a duty clinician or a team leader/manager. 8.2.3 Where a service user is in contact only with medical staff, the response should be coordinated under the supervision of the team consultant (or covering consultant in their absence). Doctors in training must always discuss NAV/DNAs with the supervising consultant as soon as practicable. 8.2.4 Administrative systems within a service must be sufficiently robust to ensure that DNA/NAVs are logged, so that the subsequent response (or lack of it) from a service user is then acted upon in a timely way and not overlooked. 8.2.5 In any case where a service user is discharged from a service after DNA/NAV the service user and GP will both be informed by letter. Where the discharge is of a service user known to the service, the GP discharge letter should include advice about potential indicators of relapse or increasing risk, advice about duration of prescribing where relevant, and what action to take should the service user s mental health deteriorate. 8.2.6 If at any stage in the process of responding to a DNA/NAV there is any uncertainty about the level of risk or what action to take, the person responding should consult with another qualified member of the team and/ or the team manager. Advice may also be sought from a consultant where one is linked to the 11
team. It may also be appropriate to discuss the case in an MDT meeting or case review. 8.2.7 The person responding to the DNA/NAV should ensure that sufficient information is gathered to inform a decision about what action to take. This should involve a review of the service user's recent history and the most recent risk assessment if available. Where there is insufficient information to determine the potential risks, consideration should be given to contacting the GP, carers and other family members (taking into account patient confidentiality) and any other agencies involved who might be able to assist (for example social services) with further information. 8.2.8 In any case of DNA/NAV, consideration may be given to referral to another member of the MDT, but only as part of an overall plan and taking into account any identified risks. 8.2.9 Where the current risk to the service user or others is deemed to be low, a letter can be sent to the service user (see appendix 5 as example), advising them about the missed appointment and inviting contact within a specified period (e.g. 3 weeks). If the service user fails to respond, the situation should be reviewed at the end of that period by the care coordinator, the clinician leading the service user s care, the team manager or team consultant, as applicable. This may lead to discharge or other action, depending on the identified needs of the service user. 8.2.10 Where there are potential risks identified, but which are not thought to be serious or imminent, a letter is sent to the service user with a relatively urgent appointment (e.g. for 2 weeks' time). Again, if the service user fails to respond, their case should be reviewed by the care coordinator, the clinician leading the service user s care, the team manager or team consultant, as applicable. This may lead to discharge or other action, for example arranging a visit at home, which might also involve the GP. 8.2.11 Where there are particular concerns, and in all cases of known high risk to the service user or others, an urgent review must be called by the care coordinator or clinician leading the service user s care to consider the next steps. In consultation with other professionals in the team and where necessary with other agencies (e.g. social services), consideration should be given to involvement of the police to assist in finding the person if they are thought to be missing and/or assisting in an urgent assessment, as appropriate. 8.2.12 In any case where the person may be a carer of children or vulnerable individuals and potential safeguarding concerns are 12
identified, this process should involve liaison with appropriate safeguarding agencies. 8.2.13 Where a service user currently receiving care from the Trust declines any further involvement from a service the care coordinator or person otherwise leading the provision of care to the service user must consult with other team members, including the team consultant if there is one, and the GP. Whilst being sensitive to issues of confidentiality, the service user's family and other carers should be consulted. The service user s records, including risk assessments and care plan, must be reviewed with a view to either discharging them or taking other action as appropriate. The risk assessment should be updated to reflect any concerns arising from the service user leaving the care of the Trust. 13
8. 3 Four Steps to Safely Managing Missed Appointments, Did Not Attends and No Access Visits Step 1 Identify Recognise non-attendance. This may be non-attendance at: clinic appointment assessment clinic screening clinic not available at a planned or urgent home visit Step 2 Take responsibility The individual recognising the non-attendance must take action. This may be: The medical staff / Psychologist leading the clinic The clinician leading on assessment / screening clinics The clinician / care co-ordinator / support staff where the service user individual has not attended a planned/routine contact at a Trust Venue or the service user s home Step 3 - Take action based on assessed risks Identify and take action to minimise risk to the client and /or others: If the service user is known all relevant information relating to risk should be used to formulate an action. This may involve existing care plans, contingency and crisis plans and relapse signatures. If the service user is not previously known to services or additional information may be required to formulate an action then the referrer/gp must be contacted to identify potential risks and to agree any actions This may include formal approaches to assessment under the Mental Health Act 1983 and/or assistance/engagement with other agencies such as the Police. Step 4 Communication. All outcomes and actions must be fully communicated. These must be recorded in the clinical record; an entry in a clinical record on its own does not necessarily guarantee or imply good communication with all. A letter must be sent to the referrer / GP clearly identifying actions and who has responsibilities Ensure full communication with all key individuals, e.g. Care coordinator Where identified, telephone calls to key individuals when actions require immediate communication. 14
IDENTIFY THE NON- ATTENDANCE COMMUNICATE TO ALL TAKE RESPONSIBILITY TAKE ACTION ON ASSESSED RISKS AND IF NOT KNOWN FIND OUT? NEVER DO NOTHING 15
9 Safeguarding 9.1 The role of the carer/parent is critical in ensuring that children, individuals with a learning disability and other instances where individuals are assessed as mentally incapacitous to give consent or make informed decisions/choices, are able to attend appointments/assessments. 9.2 Where it is known that the individual is supported by a carer /parent and non- attendance is the outcome, communication with the parent/carer must be made to identify the reason for non-attendance. 9.3 If for any reason the carer(s)/ parent(s) are not able to support attendance, alternative arrangements should be made wherever possible and the carer/ parent supported. 9.4 In circumstances where the parent/ carer refuses support the attendance of a child / vulnerable or mentally incapacitous person or refuses admission to their home or environment where the person is cared for, safeguarding procedures should be considered and acted upon. 9.5 When assessing the risk following DNA/NAV, consideration is to be given to any potential risks to children, and vulnerable or mentally incapacitous persons through failure to attend appointments. Good communication with services is fundamental in enabling Health Care professionals and Social Care professionals to access, assess and monitor any perceived risks. 10 Technical and legal issues 10.1 New referrals, although not technically users of the Trust s services do fall under the Trust s duty of care from the time the referral is received and for the purpose of SI reporting it is important to capture problems that potentially occur between referral and assessment. As such, it may be appropriate to follow the SI process for people who have been referred but not seen. A discussion with the referring agency may help to establish if the Trust should log the incident and to identify which organisation would be best placed to lead the investigation. 10.2 Secretarial/administrative processes must be sufficiently robust that service users who have not yet got an appointment but are not discharged are not disregarded and lost. This may require a clearly planned system /arrangement between the consultants and their secretary/administrative support staff that both are aware of. 10.3 Assistance from the GP can be limited as the nature of GP work relies on service users to consult them rather than the other way round. 16
11 Cancellation of clinics 11.1 Cancellation by service user 11.1.1 If a service user contacts by phone to cancel an appointment, it will often be possible to negotiate a mutually acceptable replacement during the phone contact. A range of alternatives can be offered. The cancellation, with reasons, should be recorded in the appropriate service user records. 11.1.2 If the cancellation is done by letter/answerphone etc., a further appointment will be offered. The appointment letter will include contact details so that appointment timing can be negotiated with the service user. 11.1.3 Where the communication of a cancellation is taken by a member of Medical Records staff, they will contact the appropriate Consultant s secretary to inform them of the cancellation and any action taken e.g. new appointment made. The secretary will then inform the medical team and an informed decision can then be made regarding any further action required and an entry made in the appropriate service user records. 11.1.4 When a service user cancels two or more successive medical appointments (medical appointments refer to those when the only involvement is with a doctor), consideration should be given to discharging them. The usual process of assessment and notification will be followed i.e. consultant or senior doctor (SAS or higher trainee) led examination of risks, then informing GP/referrer and service user. With complex cases, a nonconsultant doctor will discuss with the appropriate consultant. 11.2 Trust cancelled/changed appointment 11.2.1 The Trust strives to avoid cancelling clinic appointments and will only undertake this as a last measure in unforeseen circumstances after considering options including but not limited to exploring availability of alternative clinician / medical input such a junior doctor (or another doctor who is not familiar with the service user) undertaking the clinic. 11.2.2 Annual leave and study leave planning for medical staff require a minimum of six weeks notice. However, even with this length of notice there is a chance of the need to cancel some clinic appointments as often follow up appointments are booked months in advance. ( Planned cancellations.) 11.2.3 Unexpected leave and the need for cancelling (for example during sick leave): In such circumstances, every effort should be made to provide cover by other clinical members of that team 17
and in some cases (only if it is safe and practically possible) by colleagues from another team when clear cross-cover arrangements have been agreed. Failing that, the service user must be advised to consult their GP in the interim. 11.2.4 Every attempt should be made to avoid or reduce the number of cancelled appointments whilst ensuring the safety of the service user when making any alternative arrangements. 11.2.5 Where an appointment has to be cancelled / changed, the service user must be notified as soon as possible; see Appendix 4 for a letter template. 12 Future Developments The Trust will continue to explore ways of how it can assist service users to attend their appointments e.g. text reminder service and how required template letters, forms etc. can be incorporated into the electronic patient record. 13 Equality Impact Assessment The organisation aims to design and implement services, policies and measures that meet the diverse needs of the service, population and workforce, ensuring that none are placed at a disadvantage over others. The Equality Impact assessment tool has been utilised to ensure equality has been assessed within this procedural document. See Appendix 7. 14 Process for monitoring compliance of this procedural document The Business Delivery Units will review compliance of the policy by analysis of data collected through Incident reporting and by the Trust informatics systems. 15 Process for reviewing and approving this document This document will be reviewed biennially or whenever national policy or guidelines changes are required to be considered (whichever occurs first). The document will be reviewed primarily by the Medical Director following which it will be subject to approval and ratification by the Executive Management Team. 16 Dissemination, implementation and access to this document This document will be accessible to staff in read-only format via the Document Store on the Trust intranet. Staff will be alerted to the approved policy via the weekly electronic update. Each consultant / clinician / clinical team will plan and implement this procedure ensuring appropriate linkages with relevant clinical and administrative staff. 18
17 Document control and archiving This policy will be accessible via the Trust s intranet in read only format. Once approved by the Integrated Governance Manager will be responsible for ensuring the updated policy is added to the document store on the intranet and is included in the staff brief. The policy will be reviewed, three years after approval. Appendix 9 details the version control. 18 Associated documents This procedural document links to other policies, procedures and clinical practice within the Trust, the key ones being: Clinical Risk Assessment, Management and Training Policy Non Adherence with Treatment Policy Care Programme Approach and Care Coordination policy and procedures Guidance Notes on Medical Staff Cross Cover Arrangements Medical Staff Study/Professional Leave Procedure Discharge and Transfer of Service User Policy Policy and Procedures on the Protection, Safeguarding and Promoting the Welfare of Children (incorporating the Safeguarding Children Supervision Guidance and Guidance on Child Visiting) Safeguarding Adults at Risk from Abuse or Neglect Care Records Management Policy Accessible information Policy It also links to other policies and procedures which are more in the domain of performance and information as it impacts on how the Trust s clinical activity is recorded and monitored by external agencies, for example booking and waiting list policy. 19 References Safety First: Five year report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Department of Health 2001) National Confidential Inquiry into Suicide and Homicide by People with Mental Health Illness. July 2014. Annual report University of Manchester 20 Example letters attached as appendices The attached letters appendices 4-6 are good practice examples and are available to use. Some clinical teams have designed their own letters which are being used. Copies of such letters should be placed in the clinical record. 19
APPENDIX 1 DNA BY SERVICE USER TO CLINIC APPOINTMENT FLOWCHART All case notes/list of DNA service users for all clinic appointments to be given to the clinician responsible for the appointment or authorised deputy Known to service New service user On CPA/Standard Care and with Care co-ordinator Not on CPA/Standard Care No care co-ordinator (Initial contact) Check referral letter and any MDT/Single Point of Access discussion and other information Identified Initial contact clinician to review follow-up requirements Decision on basis of discussion with care co-ordinator High Risk Urgent Low Risk Not urgent High Risk and/or urgent Letter to service user, GP and care co-ordinator confirming next step Write to service user with copy to GP/referral agent to make another appointment or state wish to be discharged within agreed time ( ) Speak to GP/referral agent and any other source to consider alternatives: joint visit, Mental Health Act assessment etc. Communication with the service user will take into consideration their known disabilities as well as language barriers. Collaborative effort made and documented when attempting to reach those service users with no fixed abode. 20
APPENDIX 2 NO ACCESS VISIT TO SERVICE USER/REFERRED PERSON FLOWCHART Known to services New service user Attempt all methods of making contact. i.e. telephone, contact known carer or involved professionals On CPA/Standard Care Decision for action based on discussion with Care Coordinator and MDT or Team/Service Manager in absence of Care Co-ordinator. Decision to be based on all known risks Check referral information and any Single point of access or MDT discussion/decision making. Communicate with the referrer and/or GP. Decision to be based on all known risks Low risk assessed High Risk assessed High Risk assessed Low risk assessed Communicate confirmation of next steps to GP, service user, others involved by letter. Any discharge must be as a direct result of a documented CPA/Standard Care Review Speak to GP/referral agent and any other source to consider alternatives: joint visit, Mental Health Act assessment etc. Write to service user, GP, referral agent to make another appointment and to seek confirmation that contact is still required All discussions, decisions and actions must be documented in clinical patient record 21
APPENDIX 3 DID NOT ATTEND BY SERVICE USER TO MEDICAL CLINIC APPOINTMENT (DNA defined when a service user fails to keep their clinic appointment without notifying the Trust) All case notes/list of DNA service users for all team doctors to be given to the consultant or authorised deputy Known to service New service user On CPA/Standard Care and with care co-ordinator Not on CPA No care co-ordinator (Initial contact) Identified Initial contact clinician to review follow-up requirements Check referral letter and any MDT/Single Point of Access discussion and other information Decision on basis of discussion with care co-ordinator Low Risk Not urgent Letter to service user, GP and care co-ordinator confirming next step High Risk Urgent Write to service user, cc to GP/referral agent to make another appointment or state wish to be discharged within agreed time High Risk and/or urgent Speak to GP/referral agent and any other source to consider alternatives: joint visit, Mental Health Act assessment etc. 1. For medical staff, decisions should be made by the medical team under the leadership of the consultant. 2. Assessment of risk and urgency of service user clinical needs (on the basis of the information available) are key elements guiding decisions. 3. Consultants should seek the support and collaboration of other members of the MDT as appropriate. 4. Liaison with the carer (with service user s permission) as well as reference to existing advanced decisions may be appropriate for some service users. 5. No automatic follow up appointment is given until the clinician has decided on the action to be taken following DNAs. 6. All reasonable effort will be made to ensure communication with service users, including those with disabilities and language barriers. 7. Special effort will be made, in collaboration with referrer, GP and other members of the MDT for service users of no fixed abode or frequent change of address. 22
APPENDIX 4 (Template of letter to service user/carer to cancel/change medical clinic appointment to be put on Trust headed paper) Private & Confidential Our Ref: Date Address of hospital/clinic Telephone: Direct line: Fax: NHS Number:.. Name and address of service user/carer Dear (name) (in the case of the letter being sent to a carer, put on behalf of <service users name> ) It has been necessary to change your appointment for Dr.(name) s clinic on (date) Another appointment has been made for you to see one of our doctors at: Dr (name) s clinic at. (address of hospital or clinic).. on (date) at (time).. If this appointment is not convenient for you could you please let us know as soon as possible so that we can rearrange your appointment and offer this one to someone else. Please contact (name and contact details). between the hours of (hours).. If you need to speak to someone sooner please contact (name and contact details). Yours sincerely Name Title 23
APPENDIX 5 (Template of letter to service user/carer who failed to keep (outpatient) clinic appointment with doctor - to be put on Trust headed paper) Private & Confidential Our Ref: Date Address of hospital/clinic Telephone: Direct line: Fax: NHS Number:.. Name and address of service user/carer Dear (name) (in the case of the letter being sent to a carer, put on behalf of <service users name> ) As you did not attend the clinic appointment with: Dr (name). which was scheduled on (date and time) at.(place)..., kindly contact (name) by phone:.(telephone number) between the hours of (hours).. or by letter (see address above) to arrange for another appointment to be made at a more convenient time. Otherwise if you believe you no longer need to receive this consultation please let us and your GP know, within the next 3 weeks from the date of this note. Yours sincerely Name Title cc Referrer 24
APPENDIX 6 (Template of letter to General Practitioner/referrer to discharge service user who failed to attend medical clinic appointment to be put on Trust headed paper) Private & Confidential Our Ref: Date Address of hospital/clinic Telephone: Direct line: Fax: Name and address of GP/Referrer Dear Dr.(Name) This is to let you know that the service user (name) (NHS Number ) you referred on (date) failed to keep his/her clinic appointment on (date and time). On the basis of the information available to us, it is decided that no further appointment will be sent and therefore will be considered discharged. Please re-refer if needed. Yours sincerely Name Title 25
APPENDIX 7 Equality Impact Assessment template to be completed for all policies, procedures and strategies Date of assessment: 24 th March 2016 Equality Impact Assessment Questions: 1 Name of the document that you are Equality Impact Assessing 2 Describe the overall aim of your document and context? Who will benefit from this policy/procedure/strategy? 3 Who is the overall lead for this assessment? 4 Who else was involved in conducting this assessment? Evidence based answers & actions: Did Not Attend And No Access Visits Clinic appointments and cancellation of clinic appointments procedure Routine/scheduled community/home visits Identifies the core values and principles which apply to all services and is intended to clarify responsibilities in each of those service areas, including: The clinical responsibility and the procedure to be followed when service users fail to attend their scheduled appointments. It is intended to apply to new referrals, including those which are referred through the single point of entry and from other members of the multidisciplinary team (MDT), as well as those who are well known to any of the services provided by the Trust Procedures around cancellation of clinic appointments. A framework which promotes the exercise of sound clinical judgement, thereby ensuring DNAs and NAVs are managed A framework that ensures that when a person DNA s or there is a resulting NAV at a first or any subsequent appointments the appropriate referrer is informed A framework that ensures DNA,s and NAV s are responded to appropriately by the responsible clinician, based on knowledge and understanding of the person and best practice in managing risk within the clinical delivery systems and frameworks such as that of CPA/Standard Care and CAF as examples Service users and carers, clinical and support staff, managerial staff Medical Director Dr P Kumar 5 Have you involved and consulted service users, carers, and staff in developing this policy/procedure/strategy? The policy and procedural document was developed originally following consultation with all services delivered through the Trust and builds on the review of existing policies, procedural and practice guidance. 26
What did you find out and how have you used this information? The policy includes the recommendation of Serious Incident (SI) findings. Consultation took place with: Directors Assistant Directors All medics Clinical Governance representative Risk representative Information Governance representative Administrative Managers Service Users representatives Legal opinion has also been sought and the feedback incorporated as appropriate The document is an update of the original policy and procedural document. Further consultation has taken place with service and medical leads in all specialities and localities across the Trust. 6 What equality data have you used to inform this equality impact assessment? All feedback obtained has been used to inform the update of the policy where appropriate. Breakdown of 2014/15 DNA data by equality characteristics provided by P&I and 2014/15 trustwide equality dashboard. 7 What does this data say? There is no evidence to indicate inequality in access to services. 8 Taking into account the information gathered above, could this policy /procedure/strategy affect any of the following equality group unfavourably: 8.1 Race No /No Evidence based answers & actions. Where negative impact has been identified please explain what action you will take to remove or mitigate this impact. 8.2 Disability No 8.3 Gender No 8.4 Age No 8.5 Sexual orientation No 8.6 Religion or belief No 8.7 Transgender No 8.8 Maternity & Pregnancy No 27
8.9 Marriage & civil partnerships 8.10 Carers (Our Trust requirement) No No 9 What monitoring arrangements are you implementing or already have in place to ensure that this policy/procedure/strategy:- 9a 9b 9c 9d Promotes equality of opportunity for people who share the above protected characteristics; Eliminates discrimination, harassment and bullying for people who share the above protected characteristics; Promotes good relations between different equality groups; Public Sector Equality Duty Due Regard 10 Have you developed an Action Plan arising from this assessment? Each business delivery unit will monitor the DNA rates in their area using the Trust s informatics systems. This policy covers clinical, support and managerial staff working in SWYPFT and all service users who are in contact with Trust services. The policy will be implemented in the same way for everyone regardless of individual s diverse characteristics This policy covers clinical, support and managerial staff working in SWYPFT and all service users who are in contact with Trust services. The policy will be implemented in the same way for everyone regardless of individual s diverse characteristics This policy covers clinical, support and managerial staff working in SWYPFT and all service users who are in contact with Trust services. The policy will be implemented in the same way for everyone regardless of individual s diverse characteristics This policy covers clinical, support and managerial staff working in SWYPFT and all service users who are in contact with Trust services. The policy will be implemented in the same way for everyone regardless of individual s diverse characteristics None identified 11 Assessment/Action Plan approved by (Director Lead) 12 Once approved, you must forward a copy of this Assessment/Action Plan to the partnerships team: partnerships@swyt.nhs.uk Please note that the EIA is a public document and will be published on the web. Failing to complete an EIA could expose the Trust to future legal challenge. Sign: Title: Date: APPENDIX 8 28
Checklist for the Review and Approval of Procedural Document 1. Title Title of document being reviewed: Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is the method described in brief? Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are supporting documents referenced? 6. Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? /No/ Unsure N/A Comments Original policy went to consultation 7. Dissemination and Implementation 29
Title of document being reviewed: Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? 9. Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible implementation and review of the document? /No/ Unsure N/A Comments 30
APPENDIX 9 Version Control Sheet Version Date Author(s) Status Comment / changes 1 Mar 2010 2 January 2011 3 May 2011 4 June 2013 5 Septem ber 2016 Dr Waddington, Prof Read, Phil Tordoff Nisreen Booya Phil Tordoff Nisreen Booya Phil Tordoff Nisreen Booya Phil Tordoff Nisreen Booya Superse ded Draft Superse ded Superse ded Final For review May 2013 To incorporate all services provided by the trust. For review May 2015. Reviewed to reflect recommendations following a serious incident. Review lead by Dr Prem Kumar 31