Elective Services Access Policy Access to Elective Care Pathways

SH CP 152 Elective Services Access Policy Access to Elective Care Pathways Version: 2 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: The policy reflects current national standards, data definitions and guidance and should be read in conjunction with national Referral To Treatment Guidance. This policy aims to set out clearly the rules and definitions for referral to treatment waiting times to ensure that each patient has fair access to services. Elective Services, Elective Care Pathways, Referral to treatment, Scheduled Care, Access to Treatment. All clinical and non-clinical staff involved with the booking, management care of and performance of elective pathways. Next Review Date: November 2018 Approved and Ratified by: ISD West Governance Group Date of meeting: 12 Date issued: Author: Director: Sarah Olley, LNFH Clinical Services Manager Su Harvey, Operations Manager Hannah Thompson, Assistant Operations Manager Chris Ash, Director of Integrated Services (West Hampshire) 1

Version Control Change Record Date Author Version Page Reason for Change Sept 2015 S. Olley S. Harvey 2 Policy review Reviewers/contributors Name Position Version Reviewed & Date Lorinda Cope Selena Hughes Chris Brown Sarah Olley Katie Wooldridge Jackie Street Lance Beatty Lyrain Ford Emma Chalk Julia Lake Peter Hockey Head of Business and Performance Access Centre Coordinator (18 weeks) Business Analyst, Community Hospitals Clinical Services Manager Business and Performance Manager Admin Manager (MSK services) Clinical Services Manager Administrative Manager (Elective Services) Surgical Admissions supervisor Head of Professions Clinical Director 2

Contents Page 1 Introduction 4 2 Scope 4 3 Definitions 4 4 Duties / Responsibilities 5 5 Access to Treatment, Including 18 Week RTT Pathway 5 5.1 Stages of Treatment Waiting Times 5 5.2 Data Definitions and RTT Terminology 6 6 Management of Patient Pathway General Principles and Referred National Guidance 8 6.1 Management of Non-admitted Pathway 8 6.2 Misdirected Referrals 8 6.3 Offer of Appointment 9 6.4 Outpatient Clinic and Directory of Service (DOS) Templates 9 6.5 Reasonable Offer 9 6.6 Patient Declining Two Reasonable Offers 10 6.7 Transfer to Another Secondary Care Provider (Inter Provider Transfers IPT) 10 6.8 Patient Does Not Attend (DNA) or, for Paediatrics, Was Not Brought (WNB) 10 6.9 Patient Initiated Cancellations 11 6.10 Pre-Operative Assessment Service 11 6.11 Patients Who Walk-out 12 7 Management of Admitted Pathway 12 7.1 Decision to Admit 12 7.2 Planned Schedule 12 7.3 Booking Patients for Inpatient or Day Case Procedures 13 7.4 To Come In (TCI) Cards 13 7.5 Bilateral Procedures / Surgery 13 7.6 Patients Listed for More Than One Procedure 14 7.7 Patients Medically Unfit for Treatment 14 7.8 Patient Does Not Attend (DNA) or, for Paediatrics, Was Not Brought (WNB) 14 7.9 Diagnostics 14 8 Cancellations 15 8.1 Cancellations by the Trust 15 9 Policy Exemptions 15 9.1 Children 15 10 Training Requirements 16 11 Monitoring Compliance 16 12 Delivery of Policy and Support 17 13 Policy Review 17 14 Associated Documents and Supporting References 17 Appendices A1 Definitions 18 A2 Training Needs Analysis (TNA) 19 A3 Equality Impact Assessment (EqIA) 21 3

1 Introduction 1.1 SHFT as per the NHS Constitution, will ensure patients have the right to access services within maximum waiting times, or will take all reasonable steps to offer a range of suitable alternative providers if this is not possible. 1.2 SHFT will collect and submit monthly referral to treatment (RTT) data to NHS England and will monitor waiting times performance against the standards set out in the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 1. 1.3 Southern Health Foundation Trust is committed to efficient management of waiting times, offering timely, fair and equal access to services for all patients (SHFT, Equality, Diversity and Equal Rights Policy) and to providing patient choice, in accordance with NHS Constitution (July 2015) and Department of Health Referral to Treatment Consultant Led Waiting Time Rules Suite (Oct 2015). 1.4 This Policy details the way in which SHFT will manage patients who are referred to SHFT for scheduled care services. Fundamentally, every process will be clear and transparent to patients and partner organisations and must be open to inspection monitoring and audit. 1.5 As per RTT rules (Oct 2015) SHFT will give priority to clinically urgent patients and treat everyone else in turn. 1.6 This document also defines the accountabilities and responsibilities of those involved in the processes detailed in this policy. All staff are responsible for understanding the rules and guidance which apply, ensuring their practices are consistent with the requirements of this policy. 1.7 This document replaces all previous Patient Access or Waiting List policies relating to Elective Care Pathways. 2 Scope 2.1 This policy covers all aspects of the scheduled Care Pathway management ensuring patients are treated in a timely way and includes: booking notice requirements, patient choice and waiting list management for all stages of referral to treatment pathway for scheduled patients including inpatients, outpatients, day case patients, planned care and diagnostic services. 2.2 The Scheduled Care Pathways are for those patients who are not an emergency but have been referred to a consultant led service with the intention that the patient will be assessed and treated prior to referral back to the referring health professional or GP and require planned procedures or surgery. 3 Definitions See Appendix A1 4

4 Duties / Responsibilities 4.1 Heads of Service are responsible for delivery of operational and performance standards, accountable to and monitored by the Business and Performance Manager. 4.2 Regular monitoring will ensure compliance with standards, efficient use of resources and ensure best quality service to patients. 4.3 Waiting list administrators, be they clinic staff, booking staff, secretaries or reception staff are required to be compliant with this access policy and their responsibilities towards the day to day management and support the achievement of Referral To Treatment consultant led access targets. 5 Access to Treatment, Including 18 Week Referral to Treatment (RTT) Pathway The National Operating Standards, set by the Department of Health, are as follows: 95% of non-admitted patients will receive their first definitive treatment within 18 weeks of their referral. (A non-admitted pathway does not require the patient to be admitted to hospital to receive their first definitive treatment i.e. treatment is given or prescribed in an outpatient setting) 90% of admitted patients will receive their first definitive treatment within 18 weeks of their referral. (An admitted pathway is where patient requires admission to hospital, as either a day case or an inpatient, to receive their definitive treatment). The tolerances reflect good reasons why not all patients can or are able to receive their treatment within 18 weeks, namely clinical reasons, patient choice and cooperation between patient and service provider (e.g. DNA). SHFT will still monitor at 18 weeks to ensure the NHS Constitution is still met. 5.1 Stages of Treatment Waiting Times Patients should not wait longer than 13 weeks (91 days) from receipt of referral to date of new outpatient appointment. No patient should wait longer than 6 weeks for any diagnostic test or image (and the 6 weeks diagnostic test occurs within the 18 week pathway). The Trust does not operate as a 14 day pathway service and cannot accept referrals from GP or other consultants for suspected cancer or breast symptoms. SHFT are responsible for referring back to the original referrer. In line with the Monitor compliance framework, 92% of patients on an incomplete pathway will not wait longer than 18 weeks. As part of an integrated service model the Trust will work with community partners to ensure patients commence an elective care pathway in a timely manner. 5

5.2 Data Definitions and RTT Terminology Each step along the elective care pathway must be recorded on the Electronic Patient Record System (EPR) and must include: clock start, ongoing activity (i.e. clock ticking) clock stop or clock pause (activity not part of an RTT period). The routing or clinic outcome sheet is the tool used by staff to map the stages of the patient pathway. Outcome sheets must be used for all outpatient and diagnostic attendances. Where patient is on more than one pathway, separate RTT timelines are required and are monitored individually. 5.2.1 RTT Clock Start 1) A waiting time clock starts when any care professional or service permitted by an English NHS 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. 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 consultant-led; 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; e) when a patient rebook their appointment following a first appointment DNA that stopped and nullified their earlier clock. 5.2.2 RTT Clock Pauses From 1 October 2015, there is no provision to pause or suspend an RTT waiting time clock under any circumstances. See guidance under clock starts and stop points. 5.2.3 Active Monitoring / Watchful Waiting Active monitoring / watchful waiting is when a patient s condition is being clinically monitored or a treatment plan observed, without clinical intervention or diagnostic procedure. This can be initiated by the patient or the clinician and would result in the RTT clock being stopped. 6

Active monitoring ends and a new clock will start when: a patient becomes fit and ready for a second bilateral procedure a decision is made to treat, in either an in-patient of outpatient setting a patient is referred for diagnostics or specialist opinion with the intention of commencing treatment. 5.2.4 RTT Clock stops 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 of 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 2) 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 nonconsultant-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; 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 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. 7

6 Management of Patient Pathway General Principles and Referred National Guidance. The Trust adheres to NHS general principles in relation to progress through the patient pathway including but not limited to: Patient Entitlement to NHS Treatment NHS Constitution Access to Health Services for Military Veterans Exceptional Case Approval via Commissioning Organisations Patient referrals from Private Sector to NHS and vice versa The general principles the management of referrals, outpatients, pre-operative assessment and elective admissions are summarised below. 6.1 Management of Non admitted Pathway Patients should only be referred into the Trust if the referring clinician deems them to be fit, willing and able to commence an 18 week pathway and receive treatment. All referrals should contain a robust clinical set of information, along with the relevant patient details, to ensure that patients are allocated appropriate clinic slots i.e. urgent or routine. All outpatient referrals will be reviewed as appropriate within 5 working days to determine appropriateness and urgency. Routine practice will see patients referred to a service rather than a named clinician. Any inappropriate referrals should be returned to the referrer with an explanation or forwarded to the appropriate Provider within 2 working days. If patients are referred to a specific Consultant who has a waiting list nearing the maximum target this should be brought to the attention of the Operations Manager. In discussion with the Consultant the Operations Manager should arrange for such patients to be seen by another Consultant with a shorter wait. The patient and GP will be informed of the planned change of consultant by letter. Consultants do not have the right to refuse to transfer patients to colleagues with a shorter waiting time. The exception would be in cases where clinical care could be compromised by denying access to sub speciality opinions. 6.2 Misdirected Referrals Misdirected E Referrals (e.g. where the GP has requested an inappropriate service or clinic for the patient) should be returned back within 24 working hours with an appropriate instruction to ensure that the appointment is cancelled or rebooked appropriately. 6.2.1 Rejecting Referrals A referral may be rejected under the following conditions: Clinical decision that the patient does not need a specialist opinion this decision must be made by an appropriate senior clinician The patient s needs cannot be met by the service offered this decision must be made by an appropriate senior clinician 8

If the patient has not replied to the invitation letter asking him/her to phone in and book an appointment, within 7 working days. This rule does not apply to vulnerable adults as defined in SHFT Safeguarding Adults Policy or children. Inappropriate referral e.g. SHFT do not provide service admin, refer back to GP with letter. In all instances the patient and referrer must be advised by letter that the referral has been rejected. The Outpatient Department is responsible for ensuring this happens. 6.3 Offer of Appointment Patients will be offered the choice of an appointment at their preferred hospital site or in the earliest available appropriate clinic. The Trust endeavours to offer appointments in a reasonable timescale. Wherever possible, patients should be given a minimum two weeks notice of appointments. Where the offer is being made verbally (e.g. under E Referral) the patient must be given two reasonable offers of appointment. A second offer should be given to patient and patient advised that in accordance with Stages of Treatment to attain 18 weeks they will be discharged to GP if they decline the second date. Where it has not been possible to contact the patient within 72 hours, patients should be contacted by letter to ask the patient to make contact within 7 working days. Where patients do not make contact they will be returned to their GP. For urgent patients and specialities where there is capacity available at less than three weeks notice an appointment can be offered with less than three weeks notice. A patient can turn down an offer of a short-notice appointment without it affecting their waiting time. If a patient chooses to accept an earlier appointment and provided they have received written confirmation detailing their responsibilities and the consequences of not attending, the DNA or cancellation procedures will still apply. A letter confirming appointment details should be sent to the patient within 24 working hours of the appointment being created. The Trust does not accept referrals for patients on a two week wait (2WW) pathway. If a 2WW referral is received it will be redirected to the original referrer without delay. The Trust aims to see all patients for their first appointment within 6 weeks of referral receipt. 6.4 Outpatient Clinic and Directory of Service (DOS) Templates Clinic and DOS templates will be agreed between the clinician, E Referral / Clinic Coordinators and the Operational Manager. These will be reviewed on a quarterly basis by the Operational Manager to ensure that there is adequate capacity to meet demand. 6.5 Reasonable Offer For an offer to be considered reasonable it is required that the patient is offered a date that is at least three weeks from the time that the offer was made. Should a 9

patient accept an appointment earlier than three weeks, then this becomes a reasonable offer. Patients who decline one reasonable offer of an appointment date must be offered at least one further reasonable date. This new refusal should be recorded on EPR. Patients should be warned that after declining one date, only one further date can be offered before they are discharged back to the original referrer. 6.6 Patient Declining Two Reasonable Offers Some patient will turn down reasonable appointment because they have social / work commitments. In accordance with Stages of Treatment to attain RTT target of 18 weeks, patient initiated delays of this kind makes it impossible for the Trust to provide treatment within the RTT target. Prior to referral onto an RTT pathway a GP must establish that patients are ready and available to receive treatment within this timeframe and the patient has clear expectations of RTT timeframes and their responsibilities towards this. If the patient declines two reasonable offers of a date for either a new or follow up outpatient consultation they will be discharged to their GP. This arrangement will be confirmed in writing to the GP. 6.7 Transfer to another Secondary Care Provider (Inter Provider Transfers IPT) Transfers to alternative providers must always involve the consent of the patient and the consultant responsible for their pathway of care. If the patient is transferred to another provider as part of their RTT pathway then their clock keeps ticking. It is the receiving provider s responsibility to achieve the 18 Week Target. Clock start dates must be clearly stated on the onward referral information. Upon receipt of referral the receiving provider takes on the responsibility for the administration of the patient pathway. Where transferring a patient to another Provider, the Trust has a responsibility to make the transfer in a timely manner in order that the receiving organisation has adequate opportunity to meet the 18 Week RTT target for the referred patient. Where a patient is transferred late in their 18 Week pathway and subsequently breaches the RTT target negotiations will take place between the Trust and the receiving organisation to agree who takes responsibility for reporting the breach. The Trust will work with all secondary care providers to ensure all IPT occur in a timely way, ideally within 10 weeks of the patient pathway. The Trust uses Inter-provider Minimum Data set to communicate relevant information. Failure to comply with the provision of the minimum data set, within 3 weeks from first notification of IPT, will be escalated to the 18 Week Programme Manager with the relevant Commissioning bodies. 6.8 Patient Does Not Attend (DNA) or, for Paediatrics, Was Not Brought (WNB) All patients have the opportunity to negotiate their appointment time and date, either through E Referral or via telephone, thereby putting the onus on the patient to attend their appointment. 10

If the patient is on an 18 week pathway the clock will stop on the day of appointment/admission. The 18 Week Pathway will only be nullified when the patient is discharged back to their GP/original referrer following non-attendance for a follow-up appointment, preassessment or elective admission. Such patients will be included in central reporting of 18 Week RTT performance. Exceptions to this rule are: Urgent referrals based on consultant clinical judgement Paediatric referrals or vulnerable adults as defined in SHFT Safeguarding Adults Policy. In these cases the patient should be contacted and another appointment/date for admission agreed within 7 days of the DNA. Where required, the Consultant/Lead Clinician should have the right to review the patient on their individual clinical need before the patient is discharged. Where a patient is on an admitted pathway and is discharged back to their GP following a DNA, systems should be in place to allow the patient to be referred back into the Trust onto an appropriate point of their pathway. 6.9 Patient Initiated Cancellations Where the patient cancels their first New appointment, the Trust aims to offer an alternative appointment within a maximum of 6 weeks of their original appointment date. The RTT clock remains ticking. Patients who cancel on the day of their appointment will be treated as a DNA and referred back to GP, unless they are a vulnerable adult. Alternative appointments will be offered at the same time as the original appointment cancellation whenever possible and full details confirmed in writing. Reason for cancellation must be recorded on the EPR. Patients must be informed that a second cancellation by them will mean that they are referred back to their GP / Referring clinicians and the RTT clock will stop. Any subsequent referral from GP will initiate a new clock start. 6.10 Pre - Operative Assessment Service Where Pre-Operative Assessment is required patients should be pre-operatively assessed as soon as possible after the Decision to Admit is made, to ensure a patient is fit for procedure. Patients will only be added to the waiting list if there is an expectation of treating them and the patient is fit, ready and able to receive their treatment. Some discretion can be applied to DNA where this has a bearing on dates for admission, where admission is already confirmed. The purpose being to prevent the rebooking of any appointment from causing any delays to surgery date or RTT breach dates. 11

Any patient who DNA s on a second pre-operative assessment appointment should be discharged by the responsible clinician. 6.11 Patients Who Walk-out Patients who arrive at clinic and are booked in but subsequently leave before being seen will be recorded and managed as DNA. If the patient walks out of clinic because of unacceptable delays that are the fault of the Trust, the patient should be contacted and offered another appointment without their pathway waiting time being affected. The Trust measures an acceptable delay as 30 minutes maximum (from the scheduled appointment time). 7 Management of Admitted Pathway 7.1 Decision to Admit The decision to add a patient to an inpatient or day case schedule (Decision to Admit) must be made by a Consultant or another clinician who has been given delegated authority to add patients to a schedule. Patients who are added to a schedule list must be clinically and socially ready for admission, as measured by all pre-operative assessment and anaesthesia criteria, on the day the decision to admit is made. For the purposes of the 18 Week Target, the patient s clock starts on the date of referral into the Trust. This usually corresponds with the date of referral into an outpatient appointment. Patients who are not clinically and socially ready for admission on the day the decision to admit is made must not be added to the schedule. They must be discharged back to the GP. Referral back to the GP will stop the 18 week RTT clock. If the patient is ready for surgery less than 4 months after they were discharged back to their GP they can be reinstated onto the schedule at the GP s request in writing to the Consultant. The Consultant can decide to review the patient in outpatients before placing them on the waiting list. The new clock start date will be the date that the revised GP s request is received by the Trust. Patients who are referred for surgery more than 4 months after they were discharged back to their GP will need to be seen in outpatients first. The new clock start date will be the date that the GP referral is received by the Trust. 7.2 Planned Schedule Patients on a planned schedule are outside the scope of 18 weeks. Planned procedures are part of an agreed programme of care which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency. Examples included 6-month repeat colonoscopy following removal of a malignancy, tumour or polyp. Patients must only be included on a planned schedule if there are clinical reasons why the patient cannot have the procedure or treatment until a specified time. 12

Once the patient is clinically ready for treatment to commence the patient must be transferred to the active schedule and a new 18 week clock will commence. 7.3 Booking Patients for Inpatient or Day Case Procedures Patients having day case or inpatient procedures will be added to the waiting list on the EPR within 24 working hours of a decision to admit. Patients must be contacted with an offer of surgery dates within 2 working days of the decision to admit. Offers of a date for surgery can be made verbally or via letter. Verbal offers must be followed up by letter. Patients should have their surgery within 5 weeks of the decision to admit. Therefore, the surgery dates that the patient is offered should be within 6 weeks of the decision to admit. Patients will be added to the schedule according to their 18 Week RTT waiting time, which takes account of any time already spent waiting in outpatients and diagnostics. Patients must be given two reasonable offers of admission that have at least three weeks notice. If the patient rejects both dates offered, they are discharged back the referrer and the 18 Week clock stops. Patients can be offered short-notice admission dates if there is capacity to do so. Patients can reject short-notice offers without it affecting their waiting time. Procedures that are diagnostic or part-diagnostic must be clearly identified on the inpatient or day case waiting list. Diagnostic procedures do not stop the 18 Week Clock unless they are also therapeutic procedures. Diagnostic procedures must adhere to the national 6 week diagnostic target. It is imperative that schedule data including additions, deletions and admissions is entered promptly and accurately. Clinic outcomes should be checked to ensure that all relevant patients have been added to the schedule. 7.4 To Come In (TCI) Cards TCI cards must be completed on the day the decision is made to admit the patient for treatment. TCI cards must be sent to the appropriate administration office on the same day they are completed. Those specialities using ETCI these must be completed by the referring Consultant in clinic immediately after consulting with the patient. 7.5 Bilateral Procedures / Surgery If the referral is for a bi-lateral procedure or surgery, then the clock stops when the first treatment starts. A new referral to treatment clock starts when the patient becomes fit and ready for the second operation. A second referral is not required. 13

7.6 Patients Listed for More Than One Procedure If the patient has been referred in for two entirely separate procedures the patient will be on a separate 18 week pathway for both. If the completion of one pathway results in the patient not being clinically or socially ready for treatment on the second pathway then the patient must be discharged back to the GP for re-referral onto the surgical schedule when they are ready. 7.7 Patients Medically Unfit for Treatment Patients who are known to be unfit at the time the decision to admit is made should not be added to the waiting list. Patients may become unfit whilst on the waiting list for surgery. This may be picked up at pre-operative assessment or the patient/gp may inform the Trust that they are unwell or unfit. If a patient becomes unfit for surgery, a clinical assessment must be made on the likely duration of the period of unavailability. Short term period of medical unfitness (3 weeks or less) must be absorbed into the overall patient waiting time and will not affect the patient RTT status or breach date. For patients medically unfit for over 3 weeks the responsible consultant / anaesthetist can remove the patient from the waiting list and discharge them back to the care of their GP and the RTT 18 Week Clock is stopped. When they become fit for surgery they can be referred back to the Trust by the GP. 7.8 Patient Does Not Attend (DNA) or, for Paediatrics, Was Not Brought (WNB) See section 6.8 7.9 Diagnostics Many patients require diagnostics to determine the appropriate diagnosis and therefore subsequent treatment of a patient examples of diagnostic tests are: a blood test, an endoscopy procedure, a scan or an x-ray. Diagnostic tests must be performed within 6 weeks of request for the test, to ensure delivery of the national operating standards. If a patient cancels or DNAs an appointment for a diagnostic test/procedure, then the diagnostic waiting time for that test/procedure is set to zero and the waiting time starts again from the date of the appointment that the patient cancelled/missed. Similarly, if a patient turns down reasonable appointments, then the diagnostic waiting time for that test/procedure can be set to zero from the first date offered. Please note: only the diagnostic waiting time can be reset. The overall RTT waiting time will continue, in line with RTT rules. GP requested diagnostics Where a GP requests a diagnostic test to determine whether onward referral to secondary care or management in primary care is appropriate, then this does not start an RTT clock. The patient must have the diagnostic procedure within 6 weeks of referral. If the GP subsequently refers the patient to secondary care, then the patient commences on a pathway in line with the operating standards and the clock commences on the date the referral is received. Where a GP refers a patient for a diagnostic prior to an Outpatient appointment with a consultant, as part of an agreed pathway, then the patient is on an RTT pathway 14

and the clock starts on receipt of the referral. The patient must have the diagnostic procedure within 6 weeks of referral. Note it is the GPs responsibility to be clear on the referral whether they are sending the patient for treatment or to request a diagnostic to make a decision regarding treatment. 8 Cancellations Appointments can be cancelled by the patient, GP, referring Consultant or the Trust. 8.1 Cancellations by the Trust The Trust is committed to offering certainty to patients as well as choice in arranging their care. Every effort will be made to avoid cancelling patients' appointments and operations. The patient s target waiting time will not be affected by the Trust cancellation of a clinic or theatre list. Cancellation of theatre lists and clinics can only be authorised by a member of staff who reports directly to a Head of Service. Cancellations must be kept to an absolute minimum and will be monitored on an ongoing basis. Theatre lists should not be cancelled except under exceptional circumstances Wherever possible, patients that have been previously cancelled should not be cancelled a second time. If an outpatient appointment or operation is cancelled by the Trust for non-clinical reasons, a new appointment date or date for surgery must be booked within five operational days and with reasonable notice. If the Trust cancels a patient s surgery on the day of admission the patient must be given a firm date for admission that is within 28 days of the cancelled date, as per the national standard. If this is not possible, the patient is entitled to have their operation performed by an alternative provider and on a date of their choice, funded by the Trust. Patients who are not to be offered a date within 28 days must be escalated to the attention of the Service Manager and Business and Performance Manager. In order to minimise the need to cancel clinics, a minimum of five weeks written notice must be given of planned annual, professional or study leave. This applies to all personnel employed by the Trust, whether through a substantive contract or through service provision arranged with other Organisations for services delivered on behalf of the SHFT. 9 Policy Exemptions 9.1 Children The policy rules apply to children except where there are safeguarding issues and as long as any decision in relation to the patient s pathway of care is in line with the Children s Act (2004). 15

If a child is not available to attend an appointment, does not attend an appointment or cancels an appointment for a second time they may be discharged back to the GP as set out in the guidance above. However, discharge back to the GP should only occur once the appropriate clinician has determined that there are no safe guarding issues. Where it is not appropriate for the child to be discharged back to their GP, every attempt will be made to still meet the 18 Week RTT target. These patients will not have their 18 week clock stopped unless their re-booked appointment/admission date entails a delay that makes it unreasonable or impossible for 18 weeks to be achieved for that patient. For the following groups of children, another appointment would always be made within 7 days of a DNA or cancellation where possible: Children on the cancer two week wait or undergoing cancer treatment or active surveillance for cancer Urgent referrals based on clinical judgement Vulnerable children 10 Training Requirements All medical and clinical staff must have appropriate training regarding RTT rules and their responsibilities. Evidence of training should be documented within the local induction period. All waiting list administrators, clinic staff, secretaries, booking clerks are required to have regular RTT awareness training relative to their role and responsibilities within the process. The policy will be supported by initial training at new starter induction, with annual and ad-hoc updates to reflect changes to national and local guidance. 11 Monitoring Compliance 11.1 Weekly tracking lists will be produced by the information team for management and monitoring by the Operational Manager and 18 Week Coordinator. 11.2 Appropriate information on current waiting times, 18 Week performance, trends and trajectories will be produced by the information team for routine distribution to Operational Managers, Heads of Service and Performance Managers. 11.3 Weekly and monthly RTT data will be submitted to the Department of Health as required. 11.4 The Head of Information is responsible for ensuring that appropriate staffing is in place to ensure DH data return deadlines are met. 11.5 The Clinical Services Manager is responsible for ensuring that all 18 Week data returns are signed off operationally prior to being submitted to the DH. 11.6 The Business and Performance Manager is responsible for ensuring that all 18 Week data returns are signed off on behalf of the Trust s Care Services Directorate prior to being submitted to the DH. 16

11.7 Summary speciality and clinician waiting times information will be presented to the Trust Executive and Board regularly, in accordance with Monitor reporting requirements. 12 Delivery of Policy and Support 12.1 The Clinical Service Manager has overall responsibility for the delivery of operational standards for their respective service, including local implementation, support, guidance and training to all staff. Records of staff training updates in relation to new guidance will be kept. 12.2 The Business and Performance Manager and the Performance and Information Team will provide advice and guidance for all staff in the implementation of this policy and attainment of all performance standards. 12.3 Accountability for implementation, adherence and delivery of the policy and the standards contained within in sits with the Clinical Services Manager Area Director. 13 Policy Review The policy will be reviewed every 3 years or in line with changes to local and national operating standards. 14 Associated Documents and Supporting References 14.1 Department of Health Operating Framework 2012/13 14.2 NHS data Standards and Information Standards Notifications 14.3 Monitor Compliance Framework 2012/13 14.4 Department of Health Referral to Treatment consultant led waiting Time - Rules suite January 2012 17

Appendix A Definitions Active Monitoring Active monitoring / watchful waiting is when a patient s condition is being clinically monitored or a treatment plan observed, without clinical intervention or diagnostic procedure Breach Patient episode which would over-run the maximum wait time of 18 weeks from referral to first treatment, excludes cancer and rapid chest pain as these have shorter targets Bilateral (Procedure) Procedure performed on both sides of the bod, at matching anatomical sites. CAMIS / ecamis Electronic Booking system integrated with RTT pathway Day Case Patient who requires admission for treatment without the intention to stay overnight DBS Directly Bookable Services (E Referral) DH Department of Health DOS Directory of Services (E Referral) Decision to Admit The point at which a Consultant agrees with the patient that day (DTA) case or inpatient admission is required Did not attend (DNA) Patients who did not attend for admission or outpatient appointment without notifying the hospital in advance Decision to Treat Clinical decision is taken to treat patient either inpatient/ day case or outpatient SHFT Southern Health Foundation Trust IBS Indirectly Bookable Services (E Referral) Elective Care Those patients who are not an emergency but have been referred Pathway and require planned procedures or surgery. Generic referral A referral to a specialty rather than a named clinician, usually addressed to Dear Doctor or Dear Colleague Outpatient Patient who requires clinical advice or treatment but does not require an admission to the hospital EPR Patient Administration (or Admission) System Patient cancellation Patient who has previously accepted an outpatient appointment time or date for operation and then subsequently notified the hospital that they wish to cancel or change their appointment PTL Primary Targeting List The PTL is a required undertaking to monitor and report weekly on the waiting lists against agreed targets. Reasonable (offer of Patient offered a date that is at least 3 weeks from the time that the appointment) offer was made. RTT Referral to Treatment Target and relates to the 18 Week Referral to Treatment Target Schedules Waiting Lists Patients awaiting elective admission, diagnostic or outpatient appointment and who are currently fit and available to be called for admission or appointment TCI To come in (patient appointment date and time) UBRN Unique Booking Reference Number (E Referral) Was Not Brought in Refers to Paediatric DNA WNB 18

LEaD (Leadership, Education & Development) Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEAD department (Deputy Head of LEAD or LEAD Strategic Education Lead) before the policy goes through the relevant Expert Committee. Training Programme Referral To Treatment (RTT) Awareness Frequency Course Length Delivery Method Trainer(s) Annually and adhoc in light of changes tolocal / national policy and guidelines Half day / hours/ 1 hour refresher training (depending upon staff group) Local induction Medical staff induction Access Centre Administrator Cascade training from Administration Leads Directorate Division Target Audience Adult Mental Health N/A MH/LD Learning Disabilities Older Persons Mental Health Specialised Services N/A N/A Recording Attendance Course trainer Strategic & Operational Responsibility Vicky White (Strategic) Lisa James (Operational) ICS TQtwentyone Adults Children s & Wellbeing N/A All medical and clinical staff must have appropriate training regarding RTT rules and their responsibilities. (NB Some clinical staff will have received training via their employing organisation e.g. UHST) All waiting list administrators, clinic staff, secretaries, booking clerks are required to have RTT awareness training relative to their role and responsibilities with the process. All medical and clinical staff must have appropriate training regarding RTT rules and their responsibilities. (NB Some clinical staff will have received training via their employing organisation e.g. UHST) 19

All waiting list administrators, clinic staff, secretaries, booking clerks are required to have RTT awareness training relative to their role and responsibilities with the process. Corporate Services Dental All (HR, Finance, Governance, Estates etc.) All medical and clinical staff must have appropriate training regarding RTT rules and their responsibilities. (NB Some clinical staff will have received training via their employing organisation e.g. UHST) All waiting list administrators, clinic staff, secretaries, booking clerks are required to have RTT awareness training relative to their role and responsibilities with the process. Business analysts and Information Team. 20

Southern Health NHS Foundation Trust: Equality Impact Analysis Screening Tool Equality Impact Assessment (or Equality Analysis ) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups. It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law. For guidance and support in completing this form please contact a member of the Equality and Diversity team Name of policy/service/project/plan: Access to Elective Care Pathways Policy Number: SH CP 151 Department: Elective Services SW Integrated Service Division Lead officer for assessment: Lisa James Date Assessment Carried Out: December 2012 1. Identify the aims of the policy and how it is implemented. Key questions Briefly describe purpose of the policy including How the policy is delivered and by whom Intended outcomes Answers / Notes Overall expectations of the staff of SHFT to manage the delivery of elective care pathways, to ensure fair, equitable progression of patients progress along the nationally mandated 18 week pathway. 21

2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources: Demographic data and other statistics, including census findings Recent research findings (local and national) Results from consultation or engagement you have undertaken Service user monitoring data Information from relevant groups or agencies, for example trade unions and voluntary/community organisations Analysis of records of enquiries about your service, or complaints or compliments about them Recommendations of external inspections or audit reports Key questions Data, research and information that you can refer to Trust Wide 2.1 What is the equalities profile of the team delivering the service/policy? 2.2 What equalities training have staff received? Mandatory Training 2.3 What is the equalities profile of service users? Reflects local demographic 2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps? 2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/staff 2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations Staff, information analysts, national guidance Consultation of access policies from partner organisations that reflect service user demographics. 22

In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this: Positive impact (including examples of what the policy/service has done to promote equality) Negative Impact Action Plan to address negative impact Actions to overcome problem/barrier Resources required Responsibility Target date Age Disability Yes Yes Gender Reassignment Marriage and Civil Partnership Pregnancy and Maternity Race No No No No Religion or Belief Sex No No Sexual Orientation No 23

Sign Off and Publishing Once you have completed this form, it needs to be approved by your Divisional Director or their nominated officer. Following this sign off, send a copy to the Equality and Diversity Team who will publish it on the Trust website. Keep a copy for your own records. Name: Designation: Signature: Date: 24