Elective Access Policy

Elective Access Policy Version: 1.0 Date Effective: January 2014 Author: Assistant Director of Clinical Services (Access and Performance) Equality Impact 31 st December 2013 Assessment: Consultation: Divisional teams, Trust Access Group Approved by and Trust Access Group January 2014 date: Ratified by and date: TME 24 th January 2014 Where available: Trust Internet for patients and Intranet for Trust staff Target audience: All Trust Staff Next review date: 31 st March 2015 Responsible for Assistant Director of Clinical Services (Access and Performance) review: Page - 1 - of 41

REVIEW AND AMENDMENT LOG Version Date Author Type of Change 1.0 10 th January 2014 Assistant Director of Clinical Services Merged version of legacy Access Policies Description of Change Merged version of legacy Access Policies Page - 2 - of 41

CONTENTS Section Content Page No. 1.0 Introduction 4 2.0 Policy Purpose 4 3.0 Roles & Responsibilities 4 4.0 Definitions 7 5.0 Access Arrangements 11 5.1 National Operational Standards 11 5.2 Principles of Referral-To-Treatment (RTT) Pathways 12 5.3 RTT Rules and Definitions 13 5.4 Capturing Patient s Treatments and Clinic Outcomes 16 5.5 Process for Non-Admitted Pathways 18 5.6 Process for Diagnostic Pathways 22 5.7 Process for Admitted Pathways 23 5.8 Patients Entitled to NHS Treatment 28 6.0 Consultation, Approval & Ratification Process inc EIA 29 7.0 Review and Revision Arrangements inc Document Control 29 8.0 Dissemination and Implementation 29 9.0 Document Control inc Archiving Arrangements 30 10.0 Monitoring Compliance with and the Effectiveness of this Policy 31 11.0 References 32 12.0 Associated Documentation 32 APPENDICES A Equality Impact Assessment 33 B Local RTT Codes for Trust PAS Systems 34 C National RTT Codes and Definitions 36 D 18 Week Monitoring Reports 41 Page - 3 - of 41

1 Introduction 1.1 The purpose of this policy is to outline the Trust and Commissioner requirements and the operating standards for managing patient access to secondary care services from referral to treatment, then discharge to primary care. The Trust is required to have an Elective Access Policy that is agreed between the Trust and Commissioners and is available to patients and published on the Trust s website. 1.2 The Trust will ensure the management of patient access to services is transparent, fair and equitable and is managed according to clinical priority and waiting time. 1.3 The policy covers the principles and processes for booking, notice requirements, patient choice and waiting list management for all stages of a referral to treatment (RTT) pathway. This policy should be read in conjunction with the Cancer Operational Policy which sets out arrangements for the management of patients with suspected and confirmed cancer. 1.4 This policy applies to all administration and clinical prioritisation processes relating to patient access to elective services managed by Lewisham and Greenwich NHS Trust, including outpatient, diagnostic, inpatient, and day case services. 1.5 This policy should be adhered to by all staff within the Trust who are responsible for referring patients, managing referrals, adding to and maintaining waiting lists for the purpose of taking a patient through their treatment pathway. 1.6 This policy refers to Trust Patient Administration Systems (PAS) which are used to record patient referrals, waiting list entries and patient pathways. The Trust uses PIMs at the Lewisham site and HISS at the Greenwich site both of these systems are due to be replaced in 2014 with icare QEH and icare UHL which is the Cerner Millennium System. This policy refers generally to Trust PAS systems which would be the system in place at the time of reading the policy. 2 Purpose 2.1 This policy sets out the access and management arrangements for access to elective services at Lewisham and Greenwich NHS Trust. This covers all services including outpatients, diagnostic, day case and inpatient services. The application of the arrangements in this policy should be set out within departmental standard operating procedures and workflows. 2.2 This policy covers all patients referred electively to the Trust although excludes patients on an emergency, antenatal/maternity pathway and those patients referred with suspected or confirmed cancer. The arrangements for cancer patients are set out within the Cancer Operational Policy. 3 Roles and Responsibilities 3.1 The Director of Nursing and Clinical Services is responsible for ensuring patient access through the operational delivery of the waiting times standards described in this policy and responsibility for the governance and performance monitoring processes that underpin the Policy. It is the role of the Director of Nursing and Clinical Services to ensure this is done transparently and without contravening this policy. Performance and delivery against these standards is reported monthly through Trust scorecards to both the Trust Management Executive (TME) and Board. Page - 4 - of 41

3.2 The Assistant Director of Clinical Services (Access and Performance) is responsible for overseeing implementation of this policy, supporting delivery of the operational standards and providing challenge to the Divisions. 3.3 It is however, the Divisional General Managers who are directly responsible for achieving these operating standards and implementing this policy within their Division. 3.4 The Director of IM &T is responsible for the management of the Trust s PAS systems including the HISS, PIMs and Cerner systems on which patient information and waiting lists are held. 3.5 The Head of Information is responsible for producing weekly reports to enable monitoring of the waiting list position and waiting times. List of reports circulated are set out within Appendix D. 3.6 The Directorate Service Managers are responsible for ensuring their staff comply with the policy, are fully trained to enable them to do so and the day to day delivery of this policy covering: Capacity and demand planning for outpatients, day case/inpatient services and diagnostic where appropriate on at least a six monthly basis in support of service management and business planning. Monitor the RTT, outpatient and inpatient patient tracking lists (PTLs) and waiting list position on a weekly basis with particular reference to the management of long waiters and unexpected increases in waiting list numbers and ensure that backlogs are kept to a minimum and manageable within the overall capacity of the service. Compare the actual waiting list position to the planned position, as per the Capacity Plan and notify the General Manager where there is significant variation from the norm. Ensure that accurate and timely data is recorded on Trust PAS systems by the Waiting List Team, and that cancellations are followed up, and plans made for any paused patients. Effectively manage the Waiting List Team providing a timely and efficient service to all users. Instigate an audit of ten randomly selected waiting list patients every six months, to cross-check their medical notes with the data on Trust PAS systems. Ensure that training needs are assessed and updated on a regular basis for those in the Waiting List Team. Escalate to the General Manager where patients cannot be accommodated within the appropriate target timeframes to agree remedial action. Take the lead in the directorate to ensure that Access performance targets and internal milestones are met, escalating any performance concerns where appropriate. 3.7 The Consultants and Clinical Teams are responsible for: Meeting with their respective Admissions Clerks on a regular basis to review and agree TCI dates for patients on their waiting lists, within target waiting time. Communicate leave commitments to the Service Management Team and Waiting List Team, allowing as much notice as possible, (with a minimum of six weeks notice as per Trust annual leave policy) so as to ensure that planned TCI patients Page - 5 - of 41

are not cancelled. In the event of short notice cancellations, review listed patients ensuring a timely and appropriate TCI, based on clinical need. Actively participate in Waiting List Team training in respect of consultant preferences related to case mix/numbers, special equipment requirements and maintaining an accurate consultant requirement pro-forma, including sign-up to the agreed profile for booking lists. 3.8 All staff who book and schedule appointments/patient care (Booking teams) are responsible for the day-to-day adherence to this policy and for using the supporting standard operating procedures in doing so. Staff are accountable to their management teams for the application of this policy including: Non-admitted booking teams: Add patients to the waiting list within one working day of the Decision to Admit (or at least within one week where this is not possible) and record the RTT pathway on adding to the relevant outpatient and/or diagnostic waiting list. Supervisory and management staff to meet regularly with service management teams to review service capacity, escalations and future capacity plans. Ensure patients are given an appointment within the target waiting time for their specialty and inform the Service Manager when this is not possible. Produce appointment letters and information and book transport/ interpreters if necessary. Validate outpatient waiting lists as per instructions by the Assistant Service Manager, either by patient telephone calls and/or validation letters. Admitted booking teams Add patients to the waiting list within one working day of the Decision to Admit (or at least within one week where this is not possible) and validate the RTT pathway on adding to the waiting list. Meet with consultants on a weekly/monthly basis to plan TCI dates for patients on their respective waiting lists. Ensure patients are given a TCI within the target waiting time for their specialty and inform the Service Manager when this is not possible. Produce TCI letters, confirmation letters and information; arrange preassessment and pre-clerking appointments and book transport/ interpreters if necessary. Validate waiting lists as per instructions by the Assistant Service Manager, either by patient telephone calls and/or validation letters. 3.9 All staff are responsible for ensuring that this policy is adhered to at all times. A failure to follow the requirements of the policy may result in investigation and management action being taken as considered appropriate. This may include formal action in line with the Trust s disciplinary or capability procedures for Trust employees; and other action in relation to other workers, which may result in the termination of assignment, placement, secondment or honorary arrangement. 3.10 Patients have a responsibility to attend appointments and to keep the hospital informed of any change in circumstances, i.e. change of address, dates they are not available for surgery or if they no longer require surgery are reported to the admissions co-ordinator. 3.11 The local Clinical Commissioning Groups play a pivotal role in ensuring patients fully understand their responsibilities on an RTT referral to treatment pathway and GPs refer appropriately for secondary care services. Page - 6 - of 41

4.0 Definitions Referral to treatment (RTT) A Active monitoring The part of a patient s care following initial referral, which initiates a clock start, leading up to the start of first definitive treatment or other clock stop. A patient s RTT clock may be stopped where it is clinically appropriate to start a period of monitoring in secondary care without clinical intervention or diagnostic procedures at that stage. A new clock would start when a decision to treat is made following a period of active monitoring (in previous guidance also known as watchful waiting) Where there is a clinical reason why it is not appropriate to continue to treat the patient at that stage, but to refer the patient back to primary care for ongoing management, then this constitutes a decision not to treat and should be recorded as such and also stops a clock. Admission Admitted pathway B Bilateral (procedure) C Care Professional Choose and Book Clinical decision Clock pause Consultant If a patient is subsequently referred back to a consultant-led service, then this referral starts a new clock. The act of admitting a patient for a day case or inpatient procedure A pathway that ends in a clock stop for treatment as an day case or inpatient admission A procedure that is performed on both sides of the body, at matching anatomical sites. For example, removal of cataracts from both eyes. A person who is a member of a profession regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002. A national electronic referral service that gives patients a choice of place, date and time for their first consultant outpatient appointment in a hospital or clinic A decision taken by a clinician or other qualified care professional, in consultation with the patient, and with reference to local access policies and commissioning arrangements See pause A person contracted by a healthcare provider who has been appointed by a consultant appointment committee. He or she must be a member of a Royal College or Faculty. The operating standards for referral to treatment exclude non-medical scientists of equivalent standing (to a consultant) within Page - 7 - of 41

diagnostic departments. Consultant-led Convert(s) their UBRN D DNA Did Not Attend Decision to admit Decision to treat F First definitive treatment A consultant retains overall clinical responsibility for the service, team or treatment. The consultant will not necessarily be physically present for each patient s appointment, but he/she takes overall clinical responsibility for patient care. When an appointment has been booked via Choose and Book, the UBRN is converted. (Please see definition of UBRN). DNA (sometimes known as an FTA Failed to attend). In the context of the operating standards, this is defined as where a patient fails to attend an appointment/admission without prior notice Where a clinical decision is taken to admit the patient for either a day case or inpatient treatment Where a clinical decision is taken to treat the patient. This could be treatment as an inpatient or day case, but also includes treatments performed in other settings e.g. as an outpatient An intervention intended to manage a patient s disease, condition or injury and avoid further intervention. What constitutes First Definitive Treatment is a matter for clinical judgement, in consultation with others as appropriate, including the patient. Fit (and ready) H Healthcare science intervention I Interface service (non consultant-led interface service) A new patient pathway and clock should start once the patient is fit and ready for a subsequent bilateral procedure. In this context, fit and ready means that the clock should start from the date that it is clinically appropriate for the patient to undergo that procedure, and from when the patient says they are available. See Therapy or Healthcare science intervention All arrangements that incorporate any intermediary levels of clinical triage, assessment and treatment between traditional primary and secondary care. The operating standard/right relates to hospital/consultant-led care. Therefore, the definition of the term interface service within the context of the operating standards does not apply to similar interface arrangements established to deliver traditionally primary care or community provided services, outside of their traditional (practice or community based) setting. Page - 8 - of 41

N Non-admitted pathway Non consultant-led Non consultant-led Interface service O Operational Standards The definition of the term does not also apply to: Non consultant-led mental health services run by Mental Health Trusts. referrals to practitioners with a special interest for triage, assessment and possible treatment, except where they are working as part of a wider interface service type arrangements as described above. A pathway that results in a clock stop for treatment that does not require an admission or for nontreatment Where a consultant does not take overall clinical responsibility for the patient. See interface service We will define success by what our patients tell us, but patients views need to be underpinned by measures of delivery that organisations can report and monitor progress on operationally. We will continue to measure performance against the minimum operational standards of 90 per cent (admitted patients) and 95 per cent (non-admitted patients). P Pause/ clock pause R Reasonable offer These operational standards allow for patient initiated delays (patients who choose to wait longer than the maximum 18 weeks period) and clinical exceptions (patients for whom treatment in 18 weeks is not in their best clinical interests) on referral to treatment pathways. A clock may be paused only where a decision to admit for treatment has been made, and the patient has declined at least 2 reasonable appointment offers for admission. The clock is paused for the duration of the time between the earliest reasonable offer and the date from which the patient makes themselves available again for admission for treatment. Where a decision to admit, as either a day case or inpatient has been made, many patients will choose to be admitted at the earliest opportunity. However, not all will, and it would not be appropriate to pause a clock for patients who cannot commit to come in at short notice. A clock may only be paused therefore when a patient has turned down two or more reasonable offers of admission dates. Page - 9 - of 41

A reasonable offer is an offer of a time and date three or more weeks from the time that the offer was made. Referral Management or assessment Service If patients decline these offers and decide to wait longer for their treatment, then their clock may be paused from the date of the first reasonable offer and should restart from the date that patients say they are available to come in. Referral management or assessment services are those that do not provide treatment, but accept GP (or other) referrals and provide advice on the most appropriate next steps for the place or treatment of the patient. Depending on the nature of the service they may, or may not, physically see or assess the patient. Referral Management and Assessment Services should only be in place where they carry clinical support and abide by clear protocols that provide benefits to patients. They must not be devices either to delay treatment or to avoid having clinical discussions with GP practices about good referral practice. In the context of the operational standards, a clock only starts on referral to a referral management and assessment service where that service may onwardrefer the patient to a surgical or medical consultantled service before responsibility is transferred back to the referring health professional. S Standard Operating Procedure (SOP) Straight to test Substantively new or different treatment Established departmental procedure(s) to be followed in carrying out a given activity or in a given situation A specific type of direct access diagnostic service whereby a patient will be assessed and might, if appropriate, be treated by a medical or surgical consultant-led service before responsibility is transferred back to the referring health professional. Upon completion of a referral to treatment period, a new pathway and clock starts upon the decision to start a substantively new or different treatment that does not already form part of that patient s agreed care plan; It is recognised that a patients care often extends beyond the 18-week maximum referral to treatment period, and that there may be a number of planned treatments beyond first definitive treatment. However, where further treatment is required that Page - 10 - of 41

was not already planned, a new pathway and clock should start at the point the decision to treat is made. Scenarios where this might apply include: where less invasive/intensive forms of treatment have been unsuccessful and more aggressive/intensive treatment is required (e.g. where Intra Uterine Insemination (IUI) has been unsuccessful and a decision is made to refer for IVF treatment); patients attending regular follow up outpatient appointments, where a decision is made to try a substantively new or different treatment. In this context, a change to the dosage of existing medication may not count as substantively new or different treatment, whereas a change to medication combined with a decision to refer the patient for therapy might. T Therapy or Healthcare science intervention U UBRN (Unique Booking Reference Number) Ultimately, the decision about whether the treatment is substantively new or different from the patients agreed care plan is one that must be made locally by a care professional in consultant with the patient. Where a consultant-led or interface service decides that therapy (for example physiotherapy, speech and language therapy, podiatry, counselling) or healthcare science (e.g. hearing aid fitting) is the best way to manage the patient s disease, condition or injury and avoid further interventions; The reference number that a patient receives on their appointment request letter when generated by the referrer through Choose and Book. The UBRN is used in conjunction with the patient password to make or change an appointment. 5.0 Access Arrangements 5.1 National Operating Standards 5.1.1 The following national operating standards apply to all patients: 95% of non-admitted patients will receive their first definitive treatment within 18 weeks (127 days) of their referral. 90% of admitted patients will receive their first definitive treatment with 18 weeks (127 days) of the referral. 92% of patients still waiting to be within 18 weeks Page - 11 - of 41

No patient will wait longer than 6 weeks for a diagnostic test or image No patient should wait longer than 52 Week targets from referral to treatment. All patients with suspected cancer who are referred urgently by their GP must be seen within 14 days of the GP decision to refer. All patients diagnosed with any form of cancer will receive their first treatment within 31 days of diagnosis. All patients referred through the urgent 14 day cancer referral route and subsequently diagnosed with cancer, will receive their first treatment within 62 days of the date of referral. Patients who are not referred through the urgent 14 day pathway but who have highly suspicious symptoms may be added to the 62 day pathway at the request of a hospital specialist, as will any patients referred from screening services. 5.1.2 For further information regarding management of Cancer patients, please go to the Cancer Operational Policy on the Trust Intranet. Tolerances 5.1.3 There are important reasons why not every patient can, or should, be treated within these operating standards: Patients for whom it is not clinically appropriate to be treated in 18 weeks (CLINICAL REASONS). Patients who choose to wait longer for one or more elements of their care (CHOICE). Patients who (choose not to) do not attend appointments (CO-OPERATION) 5.1.4 These patients are taken into account in the tolerance set as part of the delivery standard: 5% non-admitted patients and 10% admitted patients 5.2 Principles of Referral-To-Treatment Pathways 5.2.1 Patients have the right to start consultant-led treatment within 18 weeks from referral and be seen by a specialist within 2 weeks of GP referral for suspected cancer or, where this is not possible, for the NHS to take all reasonable steps to offer the patient a quicker appointment from a range of alternative providers if the patient makes such a request. 5.2.2 The NHS Constitution sets out the following right for patients: You have the right to access services within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of alternative providers if this is not possible. The waiting times are described in the Handbook to the NHS Constitution. 5.2.3 Patients have the right to start consultant-led treatment within 18 weeks from referral, and be seen by a specialist within 2 weeks of GP referral for suspected cancer or, where this is not possible, for the NHS to take all reasonable steps to offer the patient a quicker appointment at a range of alternative providers if the patient makes such a request. Page - 12 - of 41

5.2.4 As a general principle, the Trust expects before a referral is made for treatment that the patient is both clinically fit for assessment and possible treatment of their condition and is ready to start their pathway within two weeks of the initial referral. The Trust will work with GPs and other primary care services to ensure patients understand this before beginning an elective pathway. 5.2.5 As part of the RTT pathway the national rules make reference to clock starts and stops along a non-admitted (outpatient) or admitted (elective/inpatient) pathway. An admitted pathway means the patient requires admission to hospital, as either a day case or an inpatient, to receive their first definitive treatment. A non-admitted pathway means the patient does not require admission to hospital to receive their first definitive treatment i.e. treatment is given or prescribed in outpatients. 5.3 Referral to Treatment Rules and Definitions 5.3.1 This section covers the general principles that govern progressing patients through pathways. All patients will be managed according to their clinical urgency and within the operating standard. RTT Pathway Clock starts 5.3.2 A clock starts when a GP or other healthcare professional refers a patient to the Trust for any elective service to be assessed and, if appropriate, treated before responsibility is transferred back. This includes the following: Any referral to a consultant led service. Any referral to an interface service (e.g. MSK or Referral Management Centre service). 5.3.3 For paper referrals the clock start is the date the Trust receives the referral which should be date stamped on receipt. For Choose & Book referrals the clock starts on the date the patient calls to make an appointment and gives their unique booking reference number. 5.3.4 If following completion of a referral to treatment period, a patient requires treatment for a substantially new or different condition then a new clock starts. This is a clinical decision made in consultation with the patient. RTT Pathway Clock Pauses 5.3.5 Once the decision to admit has been made, the patient s clock may be paused to take account of the patient s availability, where they are unable to accept an appointment for admission two reasonable offers within three weeks. In these circumstances their clock will be paused for no longer than 8 weeks. If the patient is unable to be treated within this longer period they will normally be referred back to their GP. The Trust will ensure patients are kept informed. The Trust cannot pause patient pathways for clinical reasons. If a patient is clinically unfit to be treated, they will be referred back to their GP for management in primary care. RTT Pathway Clock stops 5.3.6 The clock stops when the patient receives the first treatment for the condition for which they have been referred. A patient s first definitive treatment is an intervention intended to manage a patient s disease, condition or injury and avoid further intervention. This may occur following a consultation, receipt of results from a diagnostic test or following surgery. Any subsequent treatment will not be subject to the operating standards. Page - 13 - of 41

5.3.7 There may also be clock stops for non-treatment. The following are examples where patient s clocks will be stopped for non-treatment reasons: Patient is returned to primary care for treatment (this includes primary care based therapy). Clinical decision to start a period of active monitoring. Patient declines treatment. Clinical decision not to treat. Patient DNAs their appointment and is discharged. Other Pathway Clock Events 5.3.8 Activity within an 18 week RTT period which does not stop the clock (ongoing activity in the pathway/ request to other service): This might be a follow up appointment, or request for a diagnostic test/image or adding a patient to a waiting list for admission. RTT Pathway Active Monitoring 5.3.9 The concept of Active Monitoring (watchful waiting) stops the clock and caters for periods of care without (new) clinical intervention e.g. three monthly routine checkups for diabetic patients. This is where it is clinically appropriate to monitor the patient in secondary care without clinical intervention or further diagnostic procedures, or where a patient wishes to continue to be reviewed as an outpatient, or have an open appointment, without progressing to more invasive treatment. 5.3.10 If after a period of active monitoring, the patient or the Care Professional decides treatment is now appropriate, a new pathway and a new clock starts. There is then a new patient pathway in which the patient must receive their first definitive treatment within a maximum of 18 weeks. 5.3.11 Transfer to another healthcare provider (Transfer to another Health Care Provider expected back/ not expected back): If a patient is referred from one provider to another as part of their RTT period, the patient pathway and the clock should keep ticking. The originating provider should ensure the patient's initial RTT clock start date forms part of the onward referral information. 5.3.12 The Trust will use the agreed Minimum data set to communicate the relevant information about the patient s treatment status as set out in section 5.3.27. When receiving Inter Provider Transfers, the relevant information must be entered on to the Trust s PAS systems. This is to ensure the Trust has an accurate record of the patient s pathway status. Consultant to consultant referral for a condition unrelated to the original referring condition 5.3.13 The Commissioners policy on Consultant to Consultant referrals for unrelated conditions is that this must be sent back to the GP to refer the patient to the appropriate service. Where a consultant to consultant referral is part of an agreed pathway this is allowable under the policy. A new RTT pathway would start for the unrelated condition once the GP referral is received. DNA and Cancellations see section 5.5.3 for non-admitted process and section 5.7.43 for admitted process Page - 14 - of 41

Decision not to treat / no treatment required 5.3.14 When the clinician determines that treatment is not required or a decision that no treatment is to occur; the patients clock is stopped. The patient can either be returned to the care of the GP or remain under the care of the Consultant as required. A decision not to treat / no treatment required may occur outside a clinical consultation, for example if a patient is discharged on the basis of a test result which is communicated to the patient and their GP by letter. This can occur at any stage of the patient s pathway and will stop the clock. Patient declines offered treatment 5.3.15 Patients may choose not to proceed with the treatment offered and therefore their clock is stopped. Patient dies before treatment 5.3.16 When a patient dies before they receive treatment and this is recorded on the Trust s PAS system, their RTT clock will be stopped. Patients transferring from the Private sector to the NHS 5.3.17 Patients can choose to convert between an NHS and Private status at any point during their treatment without prejudice. All patients wishing to transfer from the private service to the NHS must be returned to their GP to be offered choice and onwards referral to an NHS provider. This referral will start a new RTT pathway in the NHS. No patient should be referred direct to the Trust from the private service. Patients transferring from the NHS to private 5.3.18 NHS patients already on NHS waiting lists opting to have a private procedure must be removed from the NHS waiting list and their RTT pathway status updated. NHS Provider Commissioning Private Sector Service 5.3.19 There may be circumstances where the Trust chooses to commission services provided by the private sector to enable waiting time standards to be met. In this situation the RTT Pathway waiting time would continue with the Trust remaining accountable for the delivery of the RTT pathway standards. Interprovider Transfers (IPT s) 5.3.20 Patients may be referred into the Trust from another provider including CAS services, this is classed as an IPT and the referring Trust is mandated to accompany the referral letter with a minimum dataset containing the relevant 18 week information if applicable. Any patient transferred from another provider will be managed in line with their RTT waiting time. If the referral into the Trust is for a new condition this would result in the generation of a new RTT pathway and clock start at the receiving Trust. If the referral into the Trust is for a condition that the patient is already being seen for at the referring provider then the referring Hospital must provide the RTT clock position. 5.3.21 The minimum dataset must include patient: Name Page - 15 - of 41

Date of Birth NHS No Address Patient Pathway Identifier (PPI) Current 18 week position Current RTT start date Date decision to refer 5.3.22 Incomplete RTT data is not an acceptable reason for delaying the acceptance of an appropriate referral however this information must be obtained from the referring provider and the Trust PAS system updated. This is the minimum level of information the Trust should be sending for patients referred out of the organisation, Patients requiring commissioner approval 5.3.23 No referral for an excluded procedure should be accepted without an exceptional treatment approval form. If the referral does not have the relevant approval the referral should be rejected and returned to the GP for them to request exceptional treatment funding via the relevant CCG panel. 5.3.24 In some instances it will not be apparent until the Outpatient Consultation that the patient requires an excluded procedure, when it is identified at the Outpatient Consultation, the relevant clinician should request the GP to progress the exceptional treatment panel approval. Access to Health Services for Military Veterans 5.3.25 It is the GP s responsibility to inform the Trust that the patient being referred is a Military Veteran and that the condition they are being referred for is service related. Military veterans should be prioritised over other patients with the same level of clinical need if their condition is service related. An alert must be added to the Trust s PAS system and the patients case notes to identify the patient s status. 5.4 Capturing Patient s Treatments and Clinic Outcomes 5.4.1 Each step along the patient s pathway (outpatient appointment, diagnostic appointment, pre-assessment, admission, discharge, any decision by the patient or clinician to delay further treatment at any stage) must be recorded on Trust PAS system as either a clock start, on-going activity on an already ticking clock, a clock stop, or as activity which is not part of an RTT pathway. 5.4.2 Clinic outcome forms are used to obtain clinical information about the patient s treatment status. This information is then inputted on to Trust PAS systems. These forms must be completed by the clinician for all patients. They need to be accurately filled in with all necessary information. If these are not completed this may delay patient treatment. The lack of completion of the forms means the Trust may not know which patients are still awaiting treatment with validation staff reviewing medical records to determine what has happened to the patient. 5.4.3 An outcome code exists for each type of activity and this code must be recorded in the PAS within the referral to treatment history at each point during the pathway. It is the responsibility of the booking staff entering the codes on the PAS to ensure they are accurately entered on the system. If clarification of status i sreqruied this should Page - 16 - of 41

always be done in clinic where possible, directly with the clinician completing the form. Any concerns regards incomplete or incorrect use of codes should be flagged to the relevant Service Manager for action. 5.4.4 Patients may have more than one clock ticking simultaneously (patient pathway) if they have been referred to and are under the care of more than one clinician at any point in time. Each pathway must be measured and monitored separately. Page - 17 - of 41

5.5 Process for Non-Admitted Pathways Trust internal milestones GP OP D OP IP GP Visit 1 st Outpatient Appointmen Decision to treat Treatment (6) weeks (6) weeks (6) weeks 5.5.1 The Trust will aim to deliver patient care within the above internal operating standards and time periods. Outpatients Scheduling General Principles 5.5.2 The following principles should be followed for all outpatients services. The Trust s internal operating standards are to achieve a maximum wait of 6 weeks. We currently have different waiting times for first appointments in different specialities due to capacity, conversion rates and specialities that would receive first definitive treatment at first outpatient appointment. No patient shall wait longer than a maximum of 11 weeks for an outpatient appointment. Processes should be in place to provide patients appointments where there is currently no capacity within the service. This process should define the roles, responsibilities and communications between outpatient appointment areas and service management teams. All new referral by letter must be date stamped and scanned within 24 hours of receipt of the referral letter. Referrals should be prioritised by the consultant/clinical team within 48 hours of receipt. Patient should be offered reasonable notice of appointments for outpatient appointments (excluding diagnostic) both New and Follow-up, the Trust deems a reasonable offer for an Outpatient appointment is an offer of a date and time two Page - 18 - of 41

or more weeks from the date that the offer is made. For a diagnostic outpatient appointment a reasonable offer of appointment is at least three weeks of the date the appointment is being offered as per the national diagnostic guidance. Appointment letters must be sent to the patient within 24 hours of the appointment being booked. Patients are seen in the order of clinical priority and date on list. Patients should be given appointments in date order to ensure equity of access. Patients are kept fully informed and have a single point of contact at the Trust. Contact Numbers are: Lewisham Hospital Outpatient Call Centre: 020 8333 3216 Queen Elizabeth Hospital Appointments: 020 8836 5050 All patient referrals, appointments, waiting list entry should be recorded in a real time manner on Trust PAS systems. If the appointment is re-scheduled this should be recorded at the time the appointment is agreed or sent to the patient. For choose and book referrals the patient s pathway and clock starts on the date the booking is made. If no capacity is available in the required specialty the booking is made by the appointments team and original attempted booking date remains the clock start. There must be a new referral for a patient with an existing condition if the request for further consultation is after the discharge of the original referral. Staff must abide by the parameters of the clinic structure/template available; unless free slots occur thereby swapping new and follow-up slots accordingly to ensure full capacity is maintained. This must only be done in conjunction with the speciality service management and outpatient booking teams. The Trust will operate a waiting list system based on taking patients in turn except for emergencies and 2 week waits appointments for suspected cancer. Cancelled slots must not be given to the next routine referral that comes to hand. They should be used to bring forward the longest waiting patients. When making the appointment, the booking on Trust PAS systems must be linked to the appropriate referral, which has already been logged. Staff must ensure duplicate referrals are not created as this causes double counting of referrals and miscalculation of the patient s waiting time The patient will be sent a confirmation letter regarding their booked appointment. The letter must be clear and informative and should include a point of contact and telephone number to call if they have any queries. The letter should explain clearly the consequences should the patient cancel the appointment or fail to attend the clinic at the designated time. Page - 19 - of 41

Where cancellations are initiated by the Trust, patients should be booked as close to their original appointment as possible and still within maximum wait thresholds. All patients will be given a specified time of appointment, no block bookings of appointment times will be administered to the clinics. Only nominated staff will book appointments into the clinics. The policy of this Trust is that 6 weeks notice of clinic cancellations must be given. The Clinical Director and Service General Manager must give authorisation for cancellations under 6 weeks as an exception. When a patient cancels their appointment and does not wish to have another, the Trust must write to the GP to inform them. The referral must then be discharged on PIMS. Each speciality manager must ensure the Choose & Book Directory of Services is up to date and a true reflection of its services. If referrals bypass the Outpatients Booking Team, then they should be date stamped and forwarded immediately to the Outpatient Booking team for processing. All referrals (both paper and electronic) must include full demographic details, including NHS number and telephone numbers (both day and evening, if possible) to reduce administrative time contacting the patient. DNA and Cancellations 5.5.3 As a Trust we will make every effort to book a mutually agreeable date and time for all Outpatient Appointments and that the booking has been clearly communicated to the patient. The onus is therefore on the patient to attend their appointment. 5.5.4 Where patients do not attend appointments and are discharged the patient and GP should be sent a letter confirming discharge from the Trust s services. Patients that are being discharged for not attending an appointment should be reviewed by the relevant clinical team to ensure the patient is not at clinical risk, they do not have suspected cancer are vulnerable adults or paediatric patients. These groups of patients should be offered a further appointments at the clinician s discretion. 5.5.5 Patient does not attend (DNAs) their first care activity following referral (Failure to attend 1 st care activity after referral): When a patient fails to attend the first activity (appointment or diagnostic test) in their pathway, their patient pathway and RTT clock is nullified and they are no longer counted in the overall returns. Trust policy is that they must be discharged back to their GP. Only if the Consultant requests that a patient is rebooked for clinical reasons should the patient be offered another appointment. In the event that they are rebooked, the patient must be contacted in person to agree the date for their new appointment. A new RTT pathway starts on the date of the rebooking of the new appointment. 5.5.6 Patient DNAs subsequent activity on pathway: As above the Trust policy is that when a patient DNAs an appointment, diagnostic test or image, pre-assessment appointment or TCI for elective admission, their clock will be stopped and they will be Page - 20 - of 41

returned to the care of the GP. Should the patient still wish to receive treatment, they can then be re-referred by their GP and a new clock would start on receipt of the rereferral at the Trust. Unlike with new appointments, if the Trust rebooks a DNA d follow up appointment, the 18 week clock continues to tick. 5.5.7 As above where patients do not attend appointments and are discharged the patient and GP should be sent a letter confirming discharge from the Trust s services. Patients that are being discharged for not attending an appointment should be reviewed by the relevant clinical team to ensure the patient is not at clinical risk, they do not have suspected cancer are vulnerable adults or paediatric patients. These groups of patients should be offered a further appointments at the clinician s discretion. 5.5.8 Only if the Consultant requests that a patient is rebooked should the patient be offered another appointment. As above, in the event that they are rebooked, the patient must be contacted in person to agree the date for their new appointment. 5.5.9 Patient cancellations: If a patient needs to rearrange their care, the Trust should make every effort to re-book this within target timeframes. The Trust policy is that when a patient cancels care activity for the second occasion on their pathway and requests a third appointment (e.g. patient cancels an outpatient appointment and then cancels a pre-op assessment appointment), then their clock will be stopped and they will be returned to the care of the GP. Should the patient wish to receive treatment, then they can be re-referred by their GP a new clock would start on receipt of the re-referral at the Trust. Template Changes 5.5.10 Templates should reflect the mix of referrals and the capacity required to deliver the Access targets. They identify the number of slots available for new and follow-up appointments and specify the time each clinic is scheduled to start and finish. The length of time allocated for each clinic varies from three to four hours. All requests for template and temporary clinic rule changes will only be accepted from the Service Management Team for the relevant specialty on the agreed email proforma: These changes should then be submitted to: Lewisham Site - LHOutpatientclinicprofiles@nhs.net Greenwich Site - SLH-TR.Qe-opdsystems@nhs.net 5.5.11 All requests for template changes must be made with at least 6 weeks notice to allow the Out-patient Services Staff to make the necessary time to make the changes and more importantly to avoid unnecessary disruption to patients. Annual and Study Leave 5.5.12 All requests for annual and study leave by consultant, career grade doctors and all other clinicians must be approved 6 weeks before leave is to be taken. At the time leave is requested the form Notification of Senior Medical and Dental Staff Leave must be completed and approved within the relevant specialty service management team. Page - 21 - of 41

5.5.13 Notification will only be accepted on sign off of the relevant leave notification form by the Service Management Team who are responsible for reviewing service capacity, requirements and arranging cover where possible during periods of absence on leave. 5.5.14 All leave requests should be copied to the site booking teams with appropriate clinic cancelations forms attached. Cancellation of Appointments 5.5.15 If a patient needs to rearrange their care, the Trust should make every effort to rebook this within target timeframes. The Trust policy is that when a patient cancels care activity for the second occasion on their pathway and requests a third appointment (e.g. patient cancels an outpatient appointment and then cancels a preop assessment appointment), then their clock will be stopped and they will be returned to the care of the GP. Should the patient wish to receive treatment, then they can be re-referred by their GP a new clock would start on receipt of the rereferral at the Trust. 5.5.16 Patients who cancel before the appointment time should be recorded on Trust PAS systems with details of the reason for the cancellation. An alternative appointment is offered. 5.5.17 When patients cancel their appointments and do not wish to have another appointment, the Trust will inform the GP with this information. The referral must then be discharged on the Trust PAS system. 5.6 Diagnostic Pathways Diagnostics 5.6.1 Many patients require diagnostics to determine the appropriate diagnosis and therefore subsequent treatment of a patient. Diagnostic tests can be in the form of a blood test or an endoscopy procedure 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. 5.6.2 Patient should be offered reasonable notice of appointments. For a diagnostic outpatient appointment a reasonable offer of appointment is at least 3 weeks of the date the appointment is being offered as per the national diagnostic guidance. 5.6.3 The DNA and cancellation rules for outpatients apply to diagnostic patients. Diagnostic patients cannot have their clock paused, and suspensions do not apply to diagnostic patients. 5.6.4 Diagnostic areas must have processes in place for capturing RTT events where diagnostic patients become a therapeutic procedure and for managing and reviewing planned waiting lists. GP requested diagnostics 5.6.5 Where a GP requests a diagnostic to determine whether onwards referral to secondary care or management in primary care is appropriate, then the patient s clock does not start on an RTT pathway. The patient must have the diagnostic procedure within 6 weeks of referral. If the GP subsequently refers the patient to Page - 22 - of 41

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. 5.7 Process for Admitted Pathways Overview of the Elective Waiting List 5.7.1 Patients on the Active Waiting List are waiting for elective admission for treatment and diagnostics and are currently fit and available to be called for admission. 5.7.2 Patients on the Planned Waiting list are waiting to be admitted as part of a planned sequence of treatment or investigation, e.g. check cystoscopy. OR where the procedure has to be performed at a set point linked to a clinical criteria, e.g. where a child needs to be four years old before a procedure can be performed. OR where the date of admission is determined by the needs of the treatment, e.g. a child needs to be 4 years old / certain size before a procedure can be performed. 5.7.3 These patients are not on an active waiting list, and are not included in national waiting time returns. It is the responsibility of Service Management Teams to ensure patients on the planned waiting list are treated at their clinically intended treatment date. Forming and Maintaining the Waiting List 5.7.4 The decision to add a patient to a waiting list must be made by a Consultant, or under an arrangement agreed with the Consultant. 5.7.5 Patients will only be added to the waiting list when they have accepted Consultant advice for elective treatment. 5.7.6 Patients who are added must be clinically ready for admission on the day the Decision to Admit is made i.e. if there were a bed available tomorrow in which to admit a patient, that patient would already be medically fit to come in. 5.7.7 Patients should not be added to the waiting list if they have not reached a suitable weight to undergo surgery. Patients should not be added to the waiting list if, in the opinion of the listing Consultant and/or anaesthetist, they are unfit for anaesthetic. 5.7.8 Patients should not be added to the waiting list when there is no serious intention to admit them, e.g. in the following case scenarios: When they are pregnant at the time that the decision to add to the list is made. When there are procedural restrictions such as clinically prohibited procedures (e.g. reversal of sterilisation) or when procedures are not funded at the present time or the procedure is not undertaken at the Trust. Patient Information when Joining a Waiting List 5.7.9 When the patient leaves clinic, the following information should be obtained by whoever books the patient out of clinic: Confirmation of the patient s address (including postcode), referring General Practitioner and the General Practice where the patient is registered, if different. Patient s telephone number (home, work, mobile) or another number through which they can be contacted. Page - 23 - of 41