Patient Access Policy for Elective Treatment This document is uncontrolled once printed. Please check on the Trust s Intranet site for the most up-to-date version. Policy number: LNWHT/CQR/030/2017 Name of ratifying Committee: [Executive/Board Committee] Executive Team Meeting and Clinical Quality and Risk Committee Date ratified: 18 October and 4 th October 2017 Issue date: 20 October 2017 Review date: 19 October 2018 Responsible Executive Director: Chief Operating Officer, Lee Martin Name of author(s): Chris Robbins - General Manager Outpatient Services, Chris Robbins Deputy Chief Operating Officer, Anthony Fitzgerald Name of approving Clinical Quality and Risk Committee Group/Committee and date of 4 th October 2017 approval: This policy has considered the Trust s HEART values: Equality Impact Assessment outcome: Target audience: Associated documents/policies: Honesty Equality Accountability Respect Teamwork Completed see appendix Trust-Wide All Staff Members both Clinical and Non-Clinical that are involved in Elective Patient Care External Audience: Patients, GPs and CCG Staff Cancer Access Policy Data Quality Standards Accessible Information Standards Page 1 of 65
Relevant legislation: Were comments sought from the Counter Fraud Service with regard to fraud and bribery? Complaints Procedure Information Governance Policy Mental Capacity Act Safeguarding Adults At Risk Safeguarding Children s policy Department of Health Referral to treatment consultant-led waiting times. Rules Suite, October 2015 Not applicable Version control Version number: 2.1 Type of change/new policy: Updated previous Policy Brief description of change: Page 2 of 65
TABLE OF CONTENTS 1 PURPOSE OF THE POLICY 6 2 REFERRAL GUIDELINES 7 3 REFERRAL METHODS 10 4 OUTPATIENT PROCESSES 15 5 CANCER PATIENTS 23 6 DIAGNOSTICS 25 7 INPATIENTS 27 8 18 WEEK RULES 38 9 DELIVERY OF POLICY & SUPPORT 41 10 REFERENCES AND RESOURCES 43 APPENDIX 1 DEFINITIONS/ABBREVIATIONS APPENDIX 2 RTT OUTCOME CODES AND DEFINITIONS APPENDIX 3 ACTIVITY THAT IS NOT PART OF A RTT PERIOD APPENDIX 4 NORTH WEST LONDON ACUTE HOSPITAL PROVIDERS INTERNALLY GENERATED DEMAND POLICY APPENDIX 5A DEFAULTED & CANCELLED APPOINTMENTS FOR CHILDREN (0-18 YEARS) SAFEGUARDING GUIDANCE, PART I APPENDIX 5B DEFAULTED & CANCELLED APPOINTMENTS FOR CHILDREN (0-18 YEARS) SAFEGUARDING GUIDANCE, PART II APPENDIX 6 EQUALITY IMPACT ASSESSMENT Page 3 of 65
FLOW CHART DUTIES AND RESPONSIBILITIES If involved in managing patients pathways: Chief Operating Officer Implementation of Elective Access Policy, ensuring delivery and monitoring of waiting time standards and waiting list management Elective Access Manager Monitoring performance against locally or nationally agreed targets Working with Clinical Boards to ensure sustainability Associate Director of Information Providing accurate and timely information to support delivery Ensuring regular data quality audits of standards of data collection, data quality measures and reports Submission of central returns produced by the Information Team Validation Team Working through the Elective Access Manager. Working with divisions to ensure a standardised approach to validation and ensuring data quality Clinical Staff Through their relevant Divisional Clinical Director to the Clinical Board Medical Director: Compliance with their responsibilities as set out in the Elective Access Policy General/Service Managers Through Divisional Managers: ensuring data is accurate and Elective Access Policy is complied with achieving access targets supporting waiting list administrators Waiting List Administrators Whether clinic staff, secretaries, pathway coordinators, validators or booking clerks responsible to Service/General Managers for: compliance with all aspects of the Elective Access Policy day-to-day management of their lists, ensuring that information is accurately inputted on patient administration systems at source All Staff If involved in managing patients pathways: must not carry out any action about which they feel uncertain or that might contradict this policy always check with their line manager, local RTT admin lead, or the central elective access training and validation team GPs Ensuring patients are made aware during their consultation of the likely waiting times for a new outpatient consultation and of the need to be contactable and available when referred. Page 4 of 65
Key Points This policy applies to all members of staff employed by London North West Healthcare NHS Trust which includes; Northwick Park Hospital, St Marks Hospital, Central Middlesex Hospital and Ealing Hospital as well as Ealing, Brent and Harrow Community Services. Referrers have a major role to play in ensuring that patients who are referred are ready, willing and able to have treatment. Patients will have access to this policy and they will be made aware of their role in ensuring that the Trust is able to deliver the standards set out in this Policy. They are expected to attend their appointments, and to notify the Trust of any unavailability or changes to their personal circumstances. It is the responsibility of the Divisional General Managers, and ultimately the Chief Operating Officer at London North West Healthcare NHS Trust to ensure that all clinical, managerial and administrative members of staff adhere to this policy. Page 5 of 65
1 PURPOSE OF THE POLICY Statement of Intent 1.1 This policy explains the principles used by London North West Healthcare NHS Trust (LNWH) when managing patients on an elective (planned) care pathway. It will ensure they receive transparent, safe and equitable access to our services managed according to clinical priority. 1.2 The policy outlines the Trust and Commissioner requirements and operating standards for managing patient access to services for patients from referral to treatment, and discharge to primary care. 1.3 The policy covers the processes for booking, notice requirements, patient choice and waiting list management for all stages of a referral to treatment pathway. This policy should be read in conjunction with the Cancer Operational Policy. 1.4 This policy applies to all administration and clinical prioritisation processes relating to patient access managed by London North West Healthcare, including outpatient, inpatient, day case, therapies and diagnostic 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 progressing a patient through their treatment pathway. 1.6 The Chief Operating Officer is accountable for delivery of operational standards. The Divisional General Managers and General Managers have the overall responsibility for implementing and ensuring adherence the policy within their area. 1.7 This policy has been agreed by London North West Healthcare NHS Trust in consultation with its clinical commissioning groups. This policy will be reviewed and updated on an annual basis or earlier if national patient access targets are changed. Any changes will be ratified by the Trust executive committee. 1.8 As a general principle, the Trust expects that before a referral is made for treatment that the patient is both clinically fit for assessment and possible treatment of their condition, and ready to start their pathway within two weeks of the initial referral. The Trust will work with Commissioners, GPs and other primary care services to ensure that patients understand this before starting an elective pathway. Page 6 of 65
NHS Constitution 1.9 The NHS Constitution sets out the following right for patients: You have the right to access services within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of alternative providers if this is not possible. The waiting times are described in the Handbook to the NHS Constitution. 1.10 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. 2 REFERRAL GUIDELINES General Guidance 2.1 Before patients are referred, GPs/GDPs and other referrers must ensure that patients are fit, willing, and available to attend for any necessary outpatient appointments and/or treatment and that they fully understand the implications of any surgery or other treatment which may be necessary. 2.2 Any referrals that do not entail all relevant information such as the list in point 2.5 as well as clinical information will be rejected and sent back to the referrer Locally Agreed Referrers (Commissioners) 2.3 All referrals should be made via ERS where applicable in line with the national CQUIN target. Referrals should be addressed to a specialty rather than a named consultant. Aside from patients needing to be seen by a sub-specialty, all referrals will be pooled. 2.4 LNWH is a tertiary center for a number of services therefore some referrals will be consultant specific. 2.5 When a referral has been triaged and deemed inappropriate, this will be returned to the referrer clearly explaining the reason why so they can then have further discussion with the patient. Referral Form Content All referrals should contain the following administrative information. Please note that those marked with an asterisk are mandatory if this information is missing it will be returned to the referrer: NHS Number* Surname* Forename* Date of birth* Address* Page 7 of 65
Postcode* Daytime telephone number* Mobile number, if available* GP/GDP name / Referrer name* Designation / Contact phone number / Destination and address (printed) GP Surgery patient is under* Ethnicity* Interpreter if required* Transport if required (Adult Services) * Socially available to be treated within 18 weeks* Relevant PPwT form attached* The referral should also cover the following appropriate clinical information: Primary diagnosis and relevant medical history Relevant clinical findings Relevant test results to date Whether seen by a specialist about this already GP/GDP/Clinical treatment given and whether tolerated or not. Is it an urgent or routine appointment being sought Drug or other allergies Smoker or not (Adult) List of current medications GP/GDP/Clinical diagnosis (provisional, differential or definitive) Page 8 of 65
Qualify the diagnosis by indicating whether this is to be: confirmed: the diagnosis is strongly clinically suspected; excluded: the diagnosis is not strongly clinically suspected but needs to be excluded; and follow-up: the diagnosis is known and this investigation is to follow up progress Specific clinical question and diagnostic examination required. o o o o Whether asking for further investigations Whether asking for further treatment Whether asking or management plan Whether asking for access to surgery Any specific questions Relevant social history Further referral limitation GP/GDP/Clinical expectation from this referral Obstacles to diagnosis or treatment Page 9 of 65
3 REFERRAL METHODS 3.1 All referrals received by London North West Healthcare NHS Trust must be datestamped on the day they are received within the organisation and registered on PAS within one working day. 3.2 The date the referral is received will be the clock start day for the 18 week pathway for that specific referral, therefore, it is vital that referral letters are triaged or appointments booked directly within one working day to ensure that patients are treated within 18 weeks. E-Referral Service 3.3 It is the aim of the Trust to continuously promote the use of the NHS Digital E-Referral Service (ERS) for all applicable l GP referrals) in line with the National ERS CQUIN that states 100% of all applicable referrals must be made via ERS by October 2018. 3.4 GP s must attach a referral letter within five days of the appointment being entered onto ERS. If this does not occur within this time frame, these patients will be returned to the GP for re-referral. 3.5 It is the responsibility of the service operational management team to ensure their Directory of Services (DOS) within ERS is up to date and reflects the nature of their clinics. This gives the best chance of the patient being booked into the correct clinic at the first visit and reduces the rejection rate. It is the expectation that the operational management team will review their DOS on a quarterly basis, or more often should the need arise. 3.6 Where an E- referral has failed, appointment bookings may be made via The Appointment Line (TAL). These patients are given their unique booking reference number (UBRN), and asked to call TAL. The national contact center will then try to book the appointment on behalf of the patient. If this is not possible due to lack of capacity the UBRN is emailed to the Trust for local management to resolve. General Practitioner (GP)/General Dental Practitioner (GDP) referrals 3.7 The GP/GDP refers a patient into secondary care by one of the following methods: Electronic Referral Service Referral letter, addressed to a specialty, requesting they review a patient for a condition that they feel cannot be treated within the Primary Care setting. Consultant to Consultant referrals 3.8 In line with the GP Forward View, Clinicians can refer on a patient for the condition that they were originally referred for (with the exception of suspected cancer). This will be to redirect the patient to a consultant colleague or for routine activity such as diagnostics. A patient identified as having a new, non-urgent condition which is Page 10 of 65
unrelated to the original condition, needs to request a new referral for this new condition from their GP. 3.9 Direct consultant to consultant referral should automatically proceed only in the following cases: Page 11 of 65
Life threatening or under the 2 Week Rule ; i.e. malignancy or ischaemic heart disease. Symptoms which are part of a recognised care pathway for the primary medical condition. 3.10 If the criteria above have been met, the consultant referral starts a new, second clock (pathway) for the newly identified condition. The clock which was started by the original referral for initial condition continues to tick. Consultant to Consultant referrals 3.11 In line with the GP Forward View, Clinicians may refer on a patient for the condition that they were originally referred for (with the exception of suspected cancer). This will be to redirect the patient to a consultant colleague or for routine activity such as diagnostics. A patient identified as having a new, non-urgent condition which is unrelated to the original condition, needs to request a new referral for this new condition from their GP. 3.12 Consultants will only refer to colleagues those patients who require specialist advice and consultation for the condition that the patient was originally referred and they are not able to provide. 3.13 The 18 week clock will continue to tick from the date the original referral was received by the Trust. In urgent cases where the patient must be transferred to the care of the appropriate service, it is the responsibility of the referring clinician to inform the patient s GP that the patient has been referred to another team. Transferring Care to another provider 3.14 Where patients are transferred between providers, including primary care intermediate services, the standard minimum data set (MDS) must accompany the referral. 3.15 The principle need for using the MDS form is to ensure all service providers involved in a patient s pathway have adequate information about clock starts and other associated information to enable the patient s management to be conducted within appropriate time frames. 3.16 It is the responsibility of the referring organisation to ensure that the MDS, TCI and PPwT are fully completed when referring onto a new organisation for patients on a RTT pathway. 3.17 If a patient is referred from one provider to another during their RTT period (e.g. a pathway that includes a referral to a tertiary center), then this patient should be reported on the RTT return by the provider Trust who holds current clinical responsibility for the patient (i.e. at the time when the data snapshot is taken). Page 12 of 65
3.18 It is important that the correct start date is captured for patients who are received as inter-provider transfer, for example, if a patient s original referral from GP/GDP was received by an interface service on 2 January. After carrying out initial assessment, the interface service decided to refer patient on to an acute Trust for treatment. The acute Trust receives referral on 28 January. The acute Trust should record the RTT start date for this patient as 2 January, not 28 January. 3.19 Consultant (or consultant-led service) referrals can also start the clock, specifically: Separate conditions or complications developed with pregnancy, or if a new-born baby is suspected of having a condition requiring medical or surgical consultant-led treatment. New conditions are identified as a result of a genetic test 3.20 In cases where a decision to treat is made (at follow-up outpatients) for a patient whose programme of long-term care needs to be medical or surgical consultant-led 3.21 If further treatment is required after active monitoring (watchful waiting) then a new patient pathway and clock start would begin Private Patients Who Transfer To NHS Care 3.22 For patients who are seen privately but then transfer to the NHS on a RTT pathway, an 18 week clock would start at the point at which clinical responsibility for the care transfers to the NHS i.e. the date when the NHS Trust accepts the referral received from GP/GDP (in line with all NHS referrals into the Trust). 3.23 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. No patient should be referred direct to the private service. 3.24 Patients who are referred via their GPs from a private service can be added direct to the NHS waiting list on the referral received date. They do not need an NHS appointment prior to addition. Patients transferring from the NHS to Private 3.25 NHS Patients already on NHS Waiting Lists opting to have a private procedure must be removed from the NHS Waiting List. This will stop the clock for the patient s elective access pathway on the date the patient informed the Trust of their decision. Access to Health Services for the Armed Forces Community 3.26 In line with the NHS Constitution and the armed forces covenant those in the armed forces, reservists, their families and veterans are not disadvantaged in accessing health services in the area they reside. guidance from the Department of Health all veterans and war pensioners should receive priority access to NHS care for any Page 13 of 65
conditions which are related to their service subject to the clinical needs of all patients. 3.27 Veterans receive their healthcare from the NHS and are encouraged to identify themselves to their GP as member of the Armed Forces Community. GPs should notify the Trust of the patient s condition and its relation to military service when they refer the patient, so the Trust can ensure it meets the current guidance for priority service over other patients with the same level of clinical need. In line with clinical policy patients with more urgent clinical needs will continue to receive clinical priority. 3.28 Family members of serving armed forces personnel should retain their relative position on any NHS waiting list, if moved around the UK due to the Service person being posted. 3.29 Families of serving personnel moving around the country, any time taken on an NHS treatment waiting list will be taken to account in their new location and they should retain their relative position on any NHS waiting list. Elective Referrals from A&E to Consultants 3.30 For example, patient attends A&E and Consultant suspects patient has a cataract and refers for ophthalmology appointment. This referral will generate a new 18 week clock start. Overseas Visitors Guidance for Trust staff 3.31 The Trust has a legal obligation to identify patients who are not eligible for free NHS treatment. The National Health Service provides healthcare for people who live in the United Kingdom. People who do not normally live in this country are not automatically entitled to use the NHS free of charge regardless of their nationality or whether they hold a British Passport or have lived and paid National Insurance contributions and taxes in this country in the past. 3.32 All NHS Trusts have legal obligation to: Ensure that patients who are not ordinarily resident in the UK are identified. Assess liability for charges in accordance with Department of Health Overseas Visitors Regulations. Charge those liable to pay in accordance with Department of Health Overseas Visitors Regulations. 3.33 The following steps need to be followed in order to assess a patient entitlement to free NHS hospital care (Appendix 10a/b); patients that do not come under NHS rules do not have an 18week RTT clock against them: Page 14 of 65
A Pre-Attendance form needs to be completed for all new episode/s (i.e. first) of care for a patient. Ensure all required details within the form have been completed by the patient. If not, request patient to complete it in full. Screen new patients who have not confirmed their GP detail/nhs number to you and ensure the Pre-Attendance Form is fully completed by the patient Forward these forms to the Overseas Visitors Office Any patient who in some way has revealed to you of any absence from the UK in the previous 12 months to taking treatment, of interest to the Overseas Visitors Office are those who have been absent from UK for more than 6 months in the previous 12 months 4 OUTPATIENT PROCESSES Allocating Referrals 4.1 All referrals should be addressed to a specialty rather than a named consultant. Named referrals will be pooled in the first instance for triaging. They will be allocated to the named consultant if the clinician carrying out the triage considers it clinically appropriate. All other referrals will be allocated to the consultant with the relevant expertise, and the shortest waiting time. This will also be offered to patients where there are lengthy delays to see the named consultant. Clinical Triage 4.2 Referral Management staff will electronically log all referrals for clinical triage. Best practice is whereby triaging of referral letters by a clinician is done on a daily basis, this is to ensure that appropriate referrals remain on the system and that patients are then booked into the correct clinic within the correct timescales (as part of their 18 week RTT) Referrals must be triaged by the specialty within 2 working days of receipt, 48hr turnaround for all referral letters within all specialties. 4.3 Examinations for booking prior to attendance may be identified as part of referral triage, and these will be arranged directly with the patient after triage. As part of clinical triage, Services should confirm: Vetting category for the referral (either urgent or routine only) Ensure all referrals are vetted within 2 working days of receipt Ensure vetting is undertaken on a daily basis, and encourage pooled vetting (particularly during staff leave) Page 15 of 65
Identify examinations that can be booked before booking the first appointment and ensure booking occurs on the day of receipt of the request 4.4 The Trust will monitor vetting of referrals (referral turnaround time and ensure appropriate follow up of referrals that are not vetted within the designated agreed service standard. Clinically Inappropriate Referrals 4.5 If the referral is clinically inappropriate, the consultant may not accept the referral. If this is the case, the reason for the decision will be communicated by correspondence from the consultant to the referrer and the patient within 10 working days of receipt by the Trust. The RTT pathway will be nullified in this instance. 4.6 The referral decision must be updated and discharged accordingly on PAS. 4.7 If a referral has been made and the special interest of the Consultant does not match the needs of the patient, the Consultant should cross-refer the patient to the appropriate colleague where such a service is provided by the Trust and the referral amended on PAS. Offer of Appointment 4.8 For outpatient appointments, the organisation will offer the patient a minimum of two separate dates with at least three weeks notice. 4.9 If the patient becomes unfit and unavailable for treatment after they have been referred to the Trust, the patient will be returned to the referrer requesting that the patient is re-referred when they are available to attend. 4.10 The booking targets for all patients are as follows: Routine 1 st appointment will be made within the appropriate timeframe for each service. Routine FU (post diagnostics will be made within the appropriate timeframe for each service. TCI confirmed with patient no later than week 14 (over 21 days from DTA) to allow for changes if needed and an offer of 2 ERODs. Exceptions patients referred under the Cancer 2 week wait rule by GPs/GDPs. If a consultant thinks the two week wait referral is inappropriate it should not be downgraded but this should be discussed with the GP and the GP asked to withdraw the two week wait referral status. Page 16 of 65
Short Notice Appointments 4.11 Occasionally, an outpatient appointment may be available in a shorter time frame. Where the patient accepts an appointment at short notice, it is considered a reasonable offer. In these circumstances the consequences of DNA/cancellations still apply (see below), provided that this has been made explicit (verbally) to the patient at the time of booking the appointment as well as in the text reminder. Appointment Cancellations 4.12 The cancellation of an appointment can be made by the patient, GP, consultant or hospital. 4.13 For all new referrals, where the patients cancels their appointment, a further appointment will be offered at the time of cancellation and these patients will not have their 18 week clock stopped; therefore it is imperative that the next appointment date is within no more than three weeks of the initial appointment. If an appointment cannot be arranged within this period, this should be escalated to the Service Manager. 4.14 Patients who cancel before the appointment time are recorded on PAS with details of the reason for the cancellation. An alternative appointment is offered. 4.15 If a patient cancels a routine appointment on two occasions they will be removed from the waiting list and returned to the referrer. If the patient is a vulnerable (paediatrics, cancer or adult) patient and their clinical situation requires urgent attention, they should be referred to the clinical team for review, in consideration of whether the patient should be offered a further date, in which case the clock continues to tick. 4.16 Any form of contact either prior to the time of the appointment / within the parameters of the clinic or before a clinic has been cashed up / finalised are defined as Late Cancellations and not DNA, therefore, should be treated as such and recorded with a continuing clock. 4.17 When patients cancel their appointments and do not wish to have another appointment, inform the patient to contact their GP with this information. The referral must then be discharged on PAS. 4.18 Patients wishing to cancel their appointment following validation will have their referral discharged and recorded on PAS as patient request and the referral placed in the patient s notes and a letter sent to the GP Patient Left - Not Seen / Refused to Wait 4.19 If a patient leaves either before the stated appointment time or within thirty minutes of the appointment start time, this should be recorded as Refused to wait and interpreted as Cancellation by Patient. Page 17 of 65
4.20 If the patient waits beyond the 30 minute window after the appointment time, and decides to leave before being seen, this should be recorded as Patient left / not seen and interpreted as Cancellation by Provider. 4.21 In both cases, a new appointment date and time should be agreed with the patients prior to them leaving the clinic where possible. Did Not Attend 4.22 Where a patient Does Not Attend (DNA) an appointment on their RTT pathway and have not at any point made contact with the organisation to advise that they will not be attending, the patient s record will be reviewed by their consultant. The patient will be discharged back to their GP provided that: The Trust can demonstrate that the appointment was clearly communicated to the patient Discharging the patient is not contrary to their best clinical interests, which may only be determined by a clinician Consideration has been given to protect the clinical interests of patients who are children, cancer patients or patients who are considered to be vulnerable. 4.23 If the above criteria are fulfilled, then the RTT clock stops on the date that the patient is discharged back to the care of their GP. This must be clearly communicated to the GP in writing. 4.24 (N.B. any form of contact either prior to the time of the appointment are defined as Late Cancellations and not DNA). A DNA is defined as where a patient fails to attend an appointment/admission without prior notice. Patients who re-arrange their appointments in advance (irrespective of how short the period of notice they give) should not be classed as a DNA. 4.25 The 18 week rules stipulate that the clock is nullified for a new first appointment DNA. Where the Trust can demonstrate the appointment was clearly communicated to the patient, the patient pathway may be nullified, and a new 18 week clock will start from the date contact is made with the patient to offer a further appointment (a Reset, post a code 33). Clinic Cancellation or Reduction process 4.26 Every effort will be made to backfill absent clinicians by the specialty. 4.27 A minimum of six weeks written notice of planned annual, study or professional leave must be given when a doctor or other professional requires a clinic to be cancelled or reduced. Page 18 of 65
4.28 Wherever possible patients that have been previously cancelled should not be cancelled a second time. 4.29 When clinics have to be unavoidably cancelled at short notice specialty will inform the relevant clinic staff. 4.30 On receipt of a request to cancel or reduce a clinic, specialty staff will prioritise the rebooking of the following patients: Urgent cancer referrals Long term follow up flagged cancer patients Urgent appointments Those with a time dependent appointment Those cancelled before Vulnerable adults 4.31 Outpatient booking staff will notify the doctor by providing clinic forecasts of the next available appointment dates for new and follow-up patients. It is the doctor s responsibility to indicate if any patients cancelled, should be seen before the next available appointment. 4.32 Every effort must be made not to breach the locally agreed waiting times standard for new patients. The 2 week target for urgent cancer referral (QMCW) and Rapid Access Chest Pain Clinics must not be breached. This may mean it is necessary to move the appointment to another site and time slot. Capacity Management 4.33 All clinical sessions should be fully booked when available. Responsibility for clinic utilisation for new patients is with the Access Centre and for treatment/review patients with departmental clinical staff. 4.34 Clinics agreed on an ad hoc basis will be booked by the outpatient booking staff following utilisation guidance from the specialty manager; a notice period of two weeks will be required. 4.35 Where Access Centre staff are unable to book patients within the specialty milestones for access, this will be escalated to the relevant Service Manager. Recording Clinic Outcome 4.36 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 in PAS as either a Page 19 of 65
clock start, ongoing activity of an already ticking clock, a clock stop, or as activity which is not part of the operating standards. 4.37 In some circumstances clinic outcome forms are used to obtain clinical information about the patient s treatment status. This information is then inputted on to the PAS system. These forms must be completed for all patients in any setting. Clinic Ward Diagnostics 4.38 They need to be accurately filled in with all necessary information. If not completed this may delay patient treatment. The lack of completion of the current form means that many staff spend many hours working out where a patient is on their pathway 4.39 A clinic outcome sheet must be attached to the front of the notes of all clinic patients within the 18 week pathway. It is the clinicians responsibility to complete the form and select by ticking the box on the form the correct outcome. It is the clinic receptionist s (where possible) responsibility to update the PAS systems accurately with the appointment outcome as the patient leaves the clinic. Where an outcome form as not been received for a patient, the clinic receptionist should confirm details with the relevant clinician. 4.40 The clinic prep staff will print the outcome sheets per clinic, using merge-mail, the RTT information will be presented both clock start and breach date to support the clinicians and admin staff to outcome correctly and in line with 18week targets. Template Changes 4.41 Templates should reflect the mix of referrals and the capacity required to deliver the Access targets and aim to deliver contracted levels of activity. 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 and the time allocated for each appointment slots varies by specialty. 4.42 All requests for template and temporary clinic rule changes will only be accepted in writing on the specified pro-forma with General Manager Sign off. Non-outpatient managed areas should also use this form. All requests for template changes must be made with a minimum of 6 weeks notice to allow Access Centre staff the necessary time to implement the change. Clinic change templates should be actioned within 3 days. Annual and Study Leave 4.43 All requests for annual and study leave by consultant and career grade doctors must be approved at least 6 weeks before leave is to be taken. At the time leave is Page 20 of 65
requested the form Notification of Senior Medical and Dental Staff Leave must be completed and approved within the Directorate in question. 4.44 Notification will only be accepted in writing on the appropriate leave form that clarifies the arrangements to cover duties during absence on leave 4.45 The original form is to be completed and forwarded to the Booking Team, who will then cancel the clinic as per instructions. The reason for the cancellation will be recorded and form part of the monthly cancellation clinic report. 4.46 Clinics that require cancellation as a result of annual /study leave with less than 6 weeks notice, will require written approval by the Clinical Director. The Divisional General Manager and the General Manager must be informed. 4.47 Where cancellations are initiated by the hospital, patients should be booked as close to their original appointment as possible, according to clinical priority, but within the specified access target. Patient Information 4.48 All patients will be provided an appropriate amount of information about their care and treatment. This will be provided verbally, electronically or via literature depending on what is preferred by the patient. Accessible Information Standard 4.49 The Trust strives to deliver the Accessible Information Standard which directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents, where those needs relate to a disability, impairment or sensory loss. 4.50 It is of particular relevance to individuals who are blind, deaf, deafblind and / or who have a learning disability, although it will support anyone with information or communication needs relating to a disability, impairment or sensory loss, for example people who have aphasia or a mental health condition which affects their ability to communicate. 4.51 The Standard applies to service providers across the NHS and adult social care system, and it specifically aims to improve the quality and safety of care received by individuals with information and communication needs, and their ability to be involved in autonomous decision-making about their health, care and wellbeing. 4.52 Commissioners of NHS care and publicly-funded adult social care must also have regard to this Standard, in as much as they must ensure that contracts, frameworks and performance-management arrangements with provider bodies enable and promote the Standard s requirements. Page 21 of 65
5 CANCER PATIENTS 5.1 London North West Healthcare NHS Trust is required to record Cancer Waiting Time Data nationally on a monthly basis. The cancer waiting time targets for all patients are as follows: 2 weeks from urgent GP referral for suspected cancer to first outpatient attendance. 2 weeks from symptomatic breast referral (cancer not suspected) to first outpatient attendance. 1 month (31 days) from decision to treat to first definitive treatment for cancer. 1 month (31 days) from decision to treat or earliest clinically appropriate date (ECAD) to subsequent treatment (surgery, drug or radiotherapy) for all cancer patients including those with a recurrence. 2 months (62 days) from urgent GP referral for suspected cancer to first definitive treatment for cancer (31 days for suspected children s cancers, testicular cancer, and acute leukaemia). 62 days from a consultant s decision to upgrade the urgency of a patient (e.g. following a non-urgent referral) to first treatment for cancer. Consultant upgrades whereby a consultant has made the decision to upgrade patient to a cancer pathway. Cancer Patient Cancellations 5.2 The patient can change their first outpatient appointment and there is no limit on the amount of times they can do this. By cancelling or changing their appointment a patient has shown a willingness to engage with the NHS. 5.3 Patients should not be returned to their GP after multiple appointment cancellations unless this has been agreed with the patient. (Based on the GFOCW guidance) 5.4 If a patient cancels their first out-patient appointment and then DNAs the rearranged appointment, the DNA trumps the cancellation and the clock can be reset to the date the patient re-books the appointment. Clinic Cancellations 5.5 The Trust will make every effort to ensure that they do not cancel and rearrange patients appointments. Where this is unavoidable the Trust will contact the patient and rearrange their outpatient appointment. Page 22 of 65
5.6 LNWH will provide as much notice of the change as possible to the patient and aim to rebook the patient a new appointment which is convenient to them and within a clinically appropriate timeframe for their treatment plan. 5.7 Every effort will be made to ensure patients are contacted by telephone and text when cancellations are being made for clinics within two weeks of the patient s appointment. 5.8 When a patient has hospital transport or an interpreter booked the member of staff who changes the appointment must notify hospital transport and Interpreting services of the change. Cancer DNAs 5.9 Patients referred under the cancer 'two-week wait' that are given an appointment but who DNA, must be contacted and offered another appointment within two weeks of the date contact is made with the patient. 5.10 If a patient DNA s their initial out-patient or diagnostic clinic that would have been recorded as a first date seen, then the clock can be re-set from the receipt of the referral (recorded as the cancer referral to treatment start date), to the date upon which the patient makes contact to rebook their appointment (not the date of the new appointment). This period is call the waiting time adjustment (first seen) and is effectively deleted from the waiting time. 5.11 On the second DNA the patient will be returned to their referring clinician. The patient will be informed by letter and the referrer informed by pro forma fax to GP/GDP practice. 5.12 If following discussion with the patient it is deemed to be appropriate to refer the patient back into the Trust, the patient s existing clock will recommence on receipt of that second referral. In cancer, once a patient is discharged back to their GP, a rereferral generates a new 62 day pathway and therefore the 18 week pathway should be aligned to this. Page 23 of 65
6 DIAGNOSTICS 6.1 Many patients require diagnostics to determine the appropriate diagnosis and therefore subsequent treatment of a patient. Diagnostics covers services such as Radiology, Dental, Audiology, histopathology and various diagnostic and therapeutic interventional procedures. 6.2 As diagnostic waiting times are part of the 18 week pathways, it is important that patients are offered two reasonable dates for their tests, that the diagnostic test is complete and results sent back to the referring clinician ASAP and absolutely no more than 6 weeks for routine patients and 2 weeks for Urgent/Cancer patients to ensure that the next step in pathway is within the target time frame. 6.3 Patients must wait no longer than six weeks (2 weeks for patients on a suspected cancer pathway), for a diagnostic test regardless if they are part of an 18 week pathways or have been referred directly for diagnostics, from outpatients. 6.4 The DNA and cancellation rules apply to diagnostic patients. Diagnostic patients cannot have their clock paused, and suspensions do not apply to diagnostic patients. Direct Access to Diagnostics 6.5 Where a GP requests a diagnostic to determine whether onwards referral to secondary care or management in primary care is appropriate, this is referred to as Direct Access diagnostics. Direct Access referrals into diagnostics do not start an 18week RTT clock, these come under the 6 week diagnostic target only. Referrals from a diagnostic unit such as endoscopy post test results to a consultant will start an 18week clock. 6.6 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. Straight to Test Pathways 6.7 A straight to test pathway, is where a patient will attend a diagnostic appointment as part of the RTT pathway. This is commonly undertaken after triage within the Trust, however for some agreed pathways, the GP may refer a patient for a diagnostic prior to an outpatient appointment with a consultant. In these circumstances the patient is on an RTT pathway and the clock starts on receipt of the referral. 6.8 The patient must have the diagnostic procedure within 6 weeks of referral. 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. Diagnostic Test DNAs Page 24 of 65
6.9 The same rules apply for diagnostics as for any other clinical appointment, including the same exclusions. Diagnostic DNA - Cancer 6.10 Diagnostic DNA where diagnostic clinic would have been the first recorded date seen 6.11 If a patient DNA s their initial out-patient or diagnostic clinic that would have been recorded as a first date seen, then the clock can be re-set from the receipt of the referral (recorded as the cancer referral to treatment start date), to the date upon which the patient makes contact to rebook their appointment (not the date of the new appointment). This period is call the waiting time adjustment (first seen) and is effectively deleted from the waiting time. Diagnostic DNA Post First Attendance 6.12 If the patient fails to attend a diagnostic appointment (following an initial outpatient appointment) on more than one occasion, a clinical decision will be made as to whether it is appropriate to return the patient to the GP. The decision should be made by the treating clinician. Page 25 of 65
7 INPATIENTS Decision to Admit 7.1 The Decision to Admit (DTA) a patient to a schedule for surgery must be made by a consultant or their deputy, or under an arrangement agreed with the consultant or their deputy. 7.2 At the time of the DTA the clinician must indicate on the appropriate document whether the patient is having a minor operation, day case or inpatient treatment. It is the clinician s responsibility to ensure that is entered onto the system correctly and completely. The information needs to be sent to the appropriate scheduler immediately. 7.3 The following information should be obtained: The correct clock start date i.e. the start of this pathway of care assuming no other treatment has been given already for the same condition. If treatment has been given the clock start date is the date that the DTA is made this must be indicated on the clinic outcome sheet. Whether the patient is clinically and socially fit and ready for admission (see below) Any special circumstances requiring longer than usual notice for admission i.e. carer s responsibilities, transport arrangements etc. Patient s telephone number (home and work; daytime and mobile telephone where available) or a number through which he or she can be contacted. Overview of the Inpatient & Day Case Waiting List 7.4 Patients on the Active Waiting List are waiting for elective admission for treatment and are currently available to be called for admission. 7.5 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. Contents of the To Come In (TCI) Letter 7.6 The To Come in Letter should contain the following details: Patient s full name Patient s hospital number Page 26 of 65
Patient s NHS number Date letter sent to patient Date and time of admission Procedure Date Instructions regarding medication Eating/drinking instructions Where to report on arrival Who to contact to confirm, postpone or queries relating to the admission dates The Trust Policy on what happens if the patient cancels or DNAs Expected length of stay or date of discharge Request to check if bed is available on the day of admission Any other response required from the patient either by telephone (to a named individual) or on an enclosed response slip (with a business reply envelope) 7.7 The associated literature should contain: Arrangements for transport Who to contact to discuss the operation What the patient can expect if the admission has to be postponed How long it is likely to be before they can return to work or resume normal lifestyle Any special care needs that are normal to expect on discharge Any other information about the planned treatment Medically and Socially Fit 7.8 Patients who are added to a schedule must be medically and socially fit and ready for admission on the day of the DTA i.e. if there was a bed available tomorrow in which to admit a patient they are fit, ready, and available to come in. This may necessitate either further clinical investigation within primary or secondary care. 7.9 Note that in the event that the investigations are undertaken in secondary care the 18 week pathway continues. Page 27 of 65
Clinically Initiated Delays [or Patient Unfit for Treatment] 7.10 A patient may be considered medically unfit for treatment following clinical assessment due to a previously undiagnosed or untreated condition. If a patient is not fit for surgery the Trust will ascertain the likely nature and duration. Medically not fit to undergo treatment is not a clinical exception. The clock continues where it is NOT in the patient s best interest to stop and restart the clock. This scenario would include: Transient conditions such as a cold, flu or urinary tract infection. It also covers the management of co-morbidities including: Cardiac or haematology opinion and treatment or BP issues that can be managed Other conditions e.g. MRSA Optimisation to enhance recovery as part of pre-operative assessment. The local milestones of all pathways must allow for these occurrences. Transitory Conditions 7.11 If the reason is transitory (such as a cold) then they will be offered a further prescreening date within three weeks. This will allow patients with minor acute clinical reasons for delay, such as a chest infection, time to recover and the clock will continue to run during this time. If a patient is not fit after that time they will be discharged and returned to their GP where this is clinically appropriate for the management of their ongoing chronic clinical condition. Re-referrals should then be made by the GP when the patient is fit for surgery, which would initiate a new clock start and pathway. Condition requiring active treatment 7.12 If the reason is that they have a condition that itself requires active treatment then the Trust and Commissioners have agreed that they will either be discharged back to the care of their GP or will be actively monitored within the Trust for their original condition. Either action results in their pathway and clock being stopped. 7.13 Where the second condition will take an indeterminate amount of time to resolve before the patient may be fit for surgery, the patient can be discharged back to GP if it is sensible and appropriate for the condition(s) to be managed in primary care which will stop the clock. Alternatively the patient s condition(s) can continue to be managed in the acute Trust, and a period of active monitoring is started (i.e. the clock is stopped). A new 18 week clock will start when the patient is ready to proceed to surgery. The patient will return to an appropriate part of their pathway, depending on the time delay and clinical condition but should not experience any further delays. Page 28 of 65
7.14 Patients awaiting admission who become medically unfit for surgery for a condition that cannot be managed by the service (or organisation), the patient should be removed from the waiting list, their clock stopped and post discussion with the patient, discharged back to their GP/GDP/Referrer until such time they are fit, ready and able to be treated for their original referral. A new clock will start at this time 7.15 In circumstances where it would be appropriate for the interim (getting fit for treatment) care to be managed by the provider, the existing clock should stop. A new clock will commence once the patient is fit, ready and able to be treated. The Trust will aim to fast-track these patients so that they do not need to wait 18weeks all over again to be treated. 7.16 A GP/GDP/Referrer may reinstate a patient on the schedule (waiting list) within 4 months of the discharge by writing to the relevant consultant who will review the request either from the letter or by seeing the patient in an outpatient clinic. 7.17 If more than four months have elapsed, the patient must be referred to the appropriate consultant via outpatients. In both these cases a new 18 week clock begins. 7.18 The aim of the Trust s policy in respect of delays in scheduling is to ensure that levels of efficiency are maintained, ensuring that patients who want and need treatment are treated quickly. A report is run once every two weeks and the number of unavailable patients is monitored. Each patient must have a clear plan for their admission within 18 weeks. 7.19 The exception is cancer patients: if a cancer patient is deemed medically unfit for treatment, the patient should not be discharged back to their GP. Instead, they would remain on the cancer pathway until they are fit for treatment. If the treating clinician assesses that the patient will never be fit for the intended treatment, then the clinician and the patient would need to discuss and agree on either (a) suitable alternative treatment or (b) the decision not to treat. In the case of (a) the 18 week pathway continues and in (b) the 18 week clock stops. Adding a Patient to a Waiting List 7.20 Patients are added to the Active Waiting List when they are waiting for elective admission for treatment and are currently available to be called for admission. Page 29 of 65
7.21 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. 7.22 When logging a patient on the waiting list module of PAS systems, waiting list Schedulers must ensure that: As of the 1 st October 2015 patient pauses are no longer permitted Patients are not already listed for the same condition The entry is recorded correctly as either active or planned Patients are not scheduled for surgery and suspended at the same time Full treatment text and an accurate procedure code is noted That the patient is not already scheduled for surgery for another procedure 7.23 Any communication with the patient or patient s parent/guardian should be recorded on PAS systems in the free text section of the system. Information about the patient Agreeing an Admission for Treatment / TCI Date with Patient 7.24 The following rules will be applied when agreeing a TCI (to come in) date with patient: Patients will be contacted by telephone to schedule their TCI date. Patients will be phoned on at least two separate occasions on different days and at different times of the day. If a patient is not able to be reached by telephone then a letter will be sent to the patient asking them to phone the relevant department within 14 days. If the patient does not make contact then they will be discharged unless there is a clinical reason not to do so. A letter will be sent to both the patient and the referrer confirming this. Patients should be offered two separate dates with at least three weeks notice for day case or inpatient admissions. These are called Earliest Reasonable Offer Dates (EROD s) and each date offered should be recorded on the patient administration system. If a patient is not willing to accept a date within 12 weeks of first being contacted to arrange a TCI then a clinical review of their case will be required/. The patient will be discharged back to their referrer unless a clinical reason is identified not to do so in which case the details will be added to the patient s waiting list entry. A letter will be sent to both the patient and the referrer confirming this. Page 30 of 65
A patient may choose to accept a TCI date offered with less than three weeks notice. If this TCI date is subsequently cancelled by the patient, it will be deemed as having been a reasonable offer as it was initially accepted by the patient. 7.25 All appointments will be confirmed in writing. The Admission Letter 7.26 The admission letter should contain the following core details: Patient s name NHS number Hospital Number Date letter sent to patient Date and time of admission Name of procedure Instructions regarding medication Eating/drinking instructions Details of necessary pre-assessment before admission Where to report on arrival Named contact for queries relating to admission Reference to instructions for admission and/or booklet Specific information about the planned treatment Who to contact to confirm, postpone or queries relating to the admission dates The Trust Policy on what happens if the patient cancels or DNAs Expected length of stay or date of discharge Request to check if bed is available on the day of admission Any other response required from the patient either by telephone (to a named individual) or on an enclosed response slip (with a business reply envelope) The Associated Literature Should Contain: Arrangements for transport Page 31 of 65
Who to contact to discuss the operation What the patient can expect if the admission has to be postponed How long it is likely to be before they can return to work or resume normal lifestyle Any special care needs that are normal to expect on discharge Any other information about the planned treatment Patients Who Cancel or Delay Their Admission 7.27 Clocks for admitted patients can no longer be paused. Patients may still request to delay their treatment and they must still be offered two (2) ERODs, with the first being at a minimum of 3weeks of DTA, however, as of Oct 2015 their clocks cannot be paused and their pathways will not be aggregated at time of treatment. 7.28 Patients who request to delay their treatment must have clinical review to ensure that there is no clinical risk to their condition by delaying their treatment. Ideally, the delay to treatment should not exceed a total of 6-months without a further treatment plan agreed with a clinical review of the patient s notes or the patient themselves in clinic to ensure that there hasn t been a change in their clinical condition. 7.29 Whilst the above rules still apply to all patients, in the case of vulnerable groups, such as vulnerable adults and children, clinicians will take into account their particular needs before discharging patients back to referrers, therefore, where there is nonattendance of children and where there is an identified medical condition that if left untreated or unmonitored could lead to the impairment of a child s normal growth and development then the patient s parent/guardian should be advised that nonattendance/failure to allow access could be perceived as a sign of neglect. Should non-compliance continue then a referral to Social Care & Health should be initiated within a further 48 hours. Patients Who Do Not Attend 7.30 Patients should be offered a reasonable date (choice of two dates) with a minimum of three weeks notice. 7.31 It is important that the patient has been given instructions of who to notify and how if they subsequently cannot come in for their operation/procedure and that the letter clearly states the consequences of not attending their appointment. 7.32 In the case of a DNA, the referral should be reviewed by the clinician with a view to discharge. The patient will be discharged back to their referrer if the following measures have been met: Page 32 of 65
The tci date was clearly communicated to the patient Discharging the patient is not contrary to their best clinical interests There is specific protection for the clinical interests of suspected cancer patients, children and patients who are considered vulnerable. Trust Cancellations 7.33 If the Trust cancels an operation/procedure after admission or on the day of admission for non-clinical reasons, the patient must be offered a new date which is within 28 days of their original date and within the 18 week pathway timescale. 7.34 Patients that are cancelled at any point in time prior to surgery will always be notified by telephone and offered a new date. A notification of cancellation letter will be sent to the patients GP/GDP and referrer (if not the GP/GDP). 7.35 The final authorization to cancel a patient s operation is the responsibility of the relevant Clinical Director and General Manager. 7.36 All reasons for cancellation will be added to PAS by the Scheduler. Pre-Operative Assessment before Admission 7.37 Where Pre-Operative Assessment is required: patients should be pre-operative assessed as soon as possible after the Decision to admit is made to ensure patient is fit for procedure. Pre-operative assessment can be completed up to 12 weeks in advance of the TCI. If a patient cancels or DNAs a pre-operative assessment the same rules apply as if attending for an outpatient or TCI. 7.38 Pre-operative assessment will be used in elective surgical cases to determine the patient s fitness for surgery at the proposed time. 7.39 A patient may be assessed by questionnaire/telephone or they may attend either on the day of the decision to admit or at a later date prior to surgery. If the patient is found to be unfit due to a transitory condition, (example, treatment for MRSA),.the patient and the GP/GDP/Referrer will be informed by the pre-assessment nurse/consultant anaesthetist/surgeon of the reason, however their 18 week clock will continue. It is imperative that treatment is given to them so they are able to have their surgery 7.40 If the patient is found to be unfit due to a condition which requires active treatment, (example angina or renal failure), the patient and the GP/GDP/Referrer will be informed by the pre-assessment nurse/consultant anaesthetist/surgeon of the reason, and their clock will stop, patient will be put on active monitoring until they are fit, able and ready for surgery, at that point the clock will re-start from the point it had stopped, e.g. stopped at week 15, a new clock will start and ideally their pathway will be shorter i.e. given a TCI within less than 18 weeks Page 33 of 65
7.41 Cancer patients who are unfit for surgery please follow one of the following steps: Suitable alternative treatment the 18 week pathway continues (code 20) or The decision actively monitor until fit. In the case of the 18 week clock stops (code 32) 7.42 If a patient does not attend their pre-operative assessment they will be discharged back to their GP/GDP/Referrer and their 18 week clock will be stopped, unless one of the exceptions mentioned above applies. 7.43 As a general principle, the Trust expects that before a referral is made for treatment that the patient is both clinically fit for assessment and possible treatment of their condition, and ready to start their pathway within two weeks of the initial referral. The Trust will work with Commissioners, GPs and other primary care services to ensure that patients understand this before starting an elective pathway. Patients Listed for More Than One Procedure 7.44 Patients will only be put on the waiting list for one procedure at a time. The 18 week clock will stop when the first definitive treatment begins (i.e. when the procedure is carried out). A second new clock starts once the patient is ready to proceed with the second procedure. 7.45 If the decision to treat involves two-part treatment i.e. right and left knee replacements etc. then the patient will, before being discharged from part one of their treatment, be offered either: A date for the second part, or An early outpatient appointment for review of their condition. 7.46 If the decision to treat involves two procedures as part of a single pathway of treatment i.e. Trauma and Orthopaedic insertion of metal work and planned removal the clock stops when the first treatment begins. The subsequent procedure is undertaken based on clinical need as part of the same pathway but the clock has already stopped. Planned Procedures 7.47 Patients on a planned waiting list are outside of 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. Page 34 of 65
7.48 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. 7.49 Patients on planned lists should be booked in for an appointment at the clinically appropriate time and they should not have to wait for a further period after this time has elapsed. 7.50 When patients on planned lists are clinically ready for their care to commence and reach the date for their planned appointment, they should either receive that appointment or be transferred to an active waiting list and an 18 week pathway clock should start (and be reported in the relevant waiting time return). Planned Procedures with a Threshold (PPwT) 7.51 A large number of procedures have been included on London North West Healthcare PPwT list. 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 Commissioner panel. 7.52 In some instances it will not be apparent until the outpatient consultation that the patient requires an excluded procedure, when it is identified prior approval must be sought for all patients who are on this list prior to treatment otherwise the Trust will not receive funding for the patient s treatment. 7.53 The Consultant responsible for the patient s care must ensure that the appropriate form is completed at the time of addition to the elective waiting list, including the relevant clinical information, which must be completed on a form with the criteria are outlined at: www.northwestlondon.nhs.uk/ifr, then an email with this form needs to be sent to PPwTNW.London@nhs.net only using an nhs.net email account. 7.54 It is the responsibility of the Specialty Manager, supported by the Outpatient Division to ensure that PPwT forms are completed for all appropriate patients on the elective waiting list in a timely manner. Individual Funding Requests (IFR) 7.55 If a patient requires an unfunded procedure but the patient or clinician feels that given the clinical urgency of their condition further consideration needs to be made to fund it, an IFR can be made to the respective CCG. This patient s procedure will not routinely be booked until the funding has been approved. The patient s waiting list entry will be amended to reflect this whilst a decision regarding approval is being made. Page 35 of 65
Inpatient and Day case Patient Tracking List 7.56 To assist administrative staff involved in the process of booking patients the Trust will produce an 18 week PTL (Patient Tracking List). Staff should date patients in order of clinical urgency, and chronologically (by length of RTT pathway and not time on the waiting list post decision to admit). It is essential to note that the order of patients for treatment may not be the order in which they were scheduled, i.e. a patient only very recently scheduled may be approaching the maximum 18 weeks target as they may have taken a while to be diagnosed and a decision to admit agreed. 7.57 A patient may have been scheduled for a longer period of time yet has a shorter overall length of pathway. It is essential that listing is in accordance with clinical priority or pathway length and not according to the time spent solely on the waiting list. 7.58 A patient may want to defer their treatment, however a pause cannot be applied and the patient s pathway continues to remain open. Patients Who Move House 7.59 If a patient moves out of the Trust catchment areas then there will be two options available: Patient chooses to continue and have procedure done with the Trust if a TCI date has been. Patient decides to leave the designated Trust and have their treatment closer to their new home address, especially in cases of prolonged recovery. In this scenario the Trust will have their clinical care transferred and a full minimum data set will be completed and sent to the new provider. 7.60 It is imperative that the referrer is aware of the change to a patient s address Transfers Between Providers 7.61 Patients may be transferred from one Trust to another, or may be transferred into the Trust from another Trust. The referring Trust is obliged to ensure they provide a minimum data set and referral letter within five working days of the decision to refer, so as to make achievement of 18 weeks reasonable and possible. The receiving Trust will become responsible for reporting any breach of the standard. 7.62 Hospital-initiated transfers to alternative providers after referral to the Trust must always involve the consent of the patient; their GP/GDP/Referrer and the Consultant must be informed of the transfer of any of their patients. The receiving organisation needs to be informed of the 18-week clock position. A mandatory minimum data set Page 36 of 65
(MDS) form must be completed by the consultant/secretary and transferred to the receiving provider. 7.63 When a patient is transferred for treatment in the middle of a pathway the 18 week clock will continue to tick (code 21), and it is the joint responsibility of all providers to ensure that the patient is managed within 18 weeks and that inter-trust referrals are made as early as possible in the pathway to enable the receiving Trust to ensure treatment within 18 weeks. The wait of the patient transfers to the receiving provider and they are responsible for reporting this including any breach of the standard. 7.64 There may be occasions when a patient is transferred for further treatment (post a clock stop, code 30), of a significantly different condition after the original clock has stopped this information will also need to be shared with the receiving provider, and a minimum data set must be provided. In this instance a new 18 week clock will start with the new provider, if it s this organisation receiving a new clock, please use code 12, to activate the new pathway 7.65 Clinicians may accept a referral to treat a patient referred to them by a clinician from another hospital for a condition where the 18 week pathway has already commenced. The clock will continue ticking from the date it commenced at the referring hospital. 7.66 When a patient is transferred for a diagnostic investigation then the 18 week clock continues ticking and the on-going management of the patient s pathway remains with the Trust, use code 20 and indicate on the MDS that the clock is still ticking and include the breach date to ensure patients are sent back within the relevant timeframe. Data Recording 7.67 It is imperative that waiting list data including additions, deletions and admissions is entered promptly and accurately and that the RTT status for each patient is validated. 8 18 WEEK RULES 8.1 As part of the referral to treatment pathway the national rules make reference to clock starts and stops. Clock Starts 8.2 A RTT clock starts when a GP, dentist or other healthcare professional or service permitted by an English NHS commissioner to make such referrals, refers to: 8.3 A consultant led service, regardless of setting, with the intention that the patients will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional or GP/GDP; Page 37 of 65
8.4 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 8.5 A RTT 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. 8.6 For paper referrals this is the date the Trust receives the referral. For e-referral referrals the clock starts on the date the patient calls to make an appointment and gives their unique booking reference number. 8.7 Where a referral goes initially to a Referral Management Service (RMS) the patient s clock starts on the date on which the RMS receives the referral and the receiving Trust must enter this accordingly when logging the patient s referral. 8.8 Upon completion of a consultant-led referral to treatment period, a new waiting time clock only starts: 8.9 When a patient becomes fit and ready for the second of a consultant-led bilateral procedure; 8.10 Upon the decision to start a substantively new or different treatment that does not already form part of that patient s agreed care plan; 8.11 Upon a patient being re-referred in to a consultant-led; interface; or referral management or assessment service as a new referral; 8.12 When a decision to treat is made following a period of active monitoring; 8.13 When a patient rebooks their appointment following a first appointment DNA that stopped and nullified their earlier clock. Clock Pauses 8.14 Clocks for admitted patients can no longer be paused. Patients may still request to delay their treatment and they must still be offered two (2) ERODs, with the first being at a minimum of 3 weeks of DTA, however, as of Oct 2015 their clocks cannot be paused and their pathways will not be aggregated at time of treatment. Clock Stops 8.15 A clock stops when: First definitive treatment starts (these are nationally & locally agreed) When it is communicated to the patient, and subsequently their referrer and/or without undue delay that: Page 38 of 65
It is clinically appropriate to return the patient to their referrer / primary care for any non-consultant-led treatment in primary care; A clinical decision is made to start a period of active monitoring; A patient declines treatment having been offered it; A clinical decision is made not to treat; 8.16 A patient DNAs (does not attend) their first appointment following the initial referral that started their waiting time clock. Patient will be discharged back to their GP provided that; The Trust can demonstrate that the appointment was clearly communicated to the patient; Discharging the patient is not contrary to their best clinical interests, which may only be determined by a clinician; Consideration has been given to protect the clinical interests of patients who are children, cancer patients or patients who are considered to be vulnerable. A patient DNAs any other appointment and is subsequently discharged back to the care of their referrer, provided that: The Trust can demonstrate that the appointment was clearly communicated to the patient; Discharging the patient is not contrary to their best clinical interests, which may only be determined by a clinician. Consideration has been given to protect the clinical interests of patients who are children, cancer patients or patients who are considered to be vulnerable. Patient dies before receiving treatment RTT Standards 8.17 Reporting monthly on Unify as well as to local CCGs, TDA and NHSE are the clock stops for admitted and non-admitted as well as current incompletes (PTL) and any (ideally none) 52 week breaches: Reported locally: 8.18 90 per cent (90%) of pathways where patients are admitted for treatment should be completed within 18 weeks. Page 39 of 65
8.19 95 per cent (95%) of pathways that do not end in an admission should be completed within 18 weeks. Reported Nationally: 8.20 92 per cent (92%) of incomplete pathways should be under 18 weeks. 8.21 There is a zero (0%) tolerance on any individual patient waiting over 52 weeks on a RTT pathway. Tolerances 8.22 There are important reasons why not everyone can or should be treated within the 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) 8.23 These patients are taken into account in the tolerance set as part of the delivery standard. 5% non-admitted patients and 10% admitted patients 8.24 Where a referral goes initially to a Referral Management Service (RMS) the patient s clock starts on the date on which the RMS receives the referral. 9 DELIVERY OF POLICY & SUPPORT Responsibilities and Accountabilities 9.1 The General and Service Managers will provide advice and support to all staff in the effective implementation of this policy and have accountability for effective implementation and adherence to this policy. 9.2 The General and Service Managers are responsible for ensuring their staff comply with the policy and are fully trained by receiving the appropriate annual training and to keep records of staff training. Responsibilities of Waiting list holders: To maintain an up to date and accurate waiting list To enter patients onto Waiting lists, or update a provisional waiting list entry to full entry, within 48 hours of a Decision to Admit being made and to inform the patient that they are on a waiting list. Page 40 of 65
To ensure when a decision to admit is made in a clinic, the clinic attendance date = Original Date on list. To enter all patient contact details within Additional Information on the Waiting list entry screen (to maintain a full audit trail). To ensure patients are given adequate notice and choice when being offered Admission dates. To ensure social pauses are entered according to policy. To enter full free text reasons for social pauses and cancellations onto PAS. To regularly validate waiting lists to ensure lists are complete and correct at all times. To ensure PAS is updated correctly and timely with any Patient Choice decisions. To ensure the patient s appropriate waiting time status is accurately & timely recorded on PAS. Adherence to Policy 9.3 The management team for each service is responsible for ensuring waiting list data is available to all clinical and administrative teams. 9.4 All aspects of elective care are reported through the Trust Elective Performance Meeting Structures. These include Operational reporting to the Trust Board, Executive Committee, Divisional performance reviews and weekly Elective Access Waiting List Group. Cancer performance is reported through this same structure above, including also Trust Cancer Board and through structures which report into the London Cancer Alliance 9.5 Where issues arise with any member of staff in complying with the policy, the issue will be resolved between the Data Quality Team and the individual concerned. Any failure to reach agreement will be referred to the appropriate management team. Failure to reach agreement at this stage will be referred to the appropriate Director with responsibility for operational standards. Training 9.6 All staff that are involved with RTT are required to be fully trained to an appropriate level for their role both in understanding RTT and how the Trust electronic systems impact upon the pathways. 9.7 Staff that will receive training as standard, incudes but is not limited to: General Managers and Service Managers Page 41 of 65
Outpatient booking coordinators Inpatient booking coordinators Validation staff Outpatient reception staff HCAs and ward clerks Clinicians 10 REFERENCES AND RESOURCES NHS England; Recording and reporting referral to treatment (RTT) waiting times for consultant-led elective care; October 2015 Statistics» Consultant-led Referral to Treatment Waiting Times Rules and Guidance Department of Health, Consultant-led Referral to Treatment Waiting Times Rules and Guidance October 2015; https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-guidance/ Referral to Treatment Waiting Times Clock Rules and FAQ updated in May 2016 https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-guidance/ Department of Health; The NHS Choice Framework: what choices are available to me in the NHS? April 2016 https://www.gov.uk/government/publications/the-nhs-choice-framework/the-nhs-choiceframework-what-choices-are-available-to-me-in-the-nhs NHS Constitution October 2015 https://www.gov.uk/government/publications/the-nhs-constitution-for-england The Operating Framework for the NHS in England 2012-13 http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguida nce/dh_131360 Inter Provider rules in line with National Guidelines: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@pe rf/documents/digitalasset/dh_132485.pdf NHS England; General Practice Forward View April 2016 https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf NHS England; Five Year Forward View https://www.england.nhs.uk/five-year-forward-view/ NHS England; Delivering Cancer Waiting Times: A Good Practice Guide https://www.england.nhs.uk/wp-content/uploads/2015/03/delivering-cancer-wait-times.pdf Page 42 of 65
11 Department of Health; Guidance on overseas visitors hospital charging regulations https://www.gov.uk/government/publications/guidance-on-overseas-visitors-hospitalcharging-regulations#history The Ministry of Defence; The armed forces covenant April 2013 https://www.gov.uk/government/publications/the-armed-forces-covenant Page 43 of 65
APPENDIX 1 DEFINITIONS/ABBREVIATIONS AHPs Allied Health Professionals, clinicians that are not consultants but on 18week RTT outcomes as of April 2013 have to be reported Breach Patient episode, which would run over the maximum referral to first definitive treatment time of 18 weeks. This excludes cancer and rapid access chest pain patients as these have separate shorter access targets Clock start/stop Refers to number of days/weeks in a patient pathway, which is usually a maximum of 18 weeks. Refer to http://www.18weeks.nhs.uk for full details of pathway measurement Day Case Patient who requires admission for treatment but who does not need to stay overnight DBS Part of the Electronic Referral Service GP s are able to use Directly Bookable Services to make appointment into secondary care clinics from their surgery Did Not Attend Patients who have agreed their appointment date and who, without notifying the provider did not attend (DNA) their admission /outpatient appointment DH Department of Health DTA Decision to Admit - the point at which the clinician and the patient as a Day Case or inpatient is required agree that treatment, ERS National Electronic Referral Service Inpatient Patient who requires admission to the hospital for treatment and who will stay at least one night Page 44 of 65
Inter-Provider Transfers A patient pathway managed between more than one organisation (for the same condition). A specific form and minimum data set (MDS) must be completed ISTC Independent Sector Treatment Centre MDS Minimum Data Set Specific information about a patient that must be completed and sent with the letter of referral when transferring a patients care between providers. It will usually be completed by a medical secretary. (Appendix 2 parts 1&2) Medically unfit A patient who has a condition that prevents them from continuing along their current 18-week pathway of care. Special arrangements must be made for these patients to address their medical condition either in primary or secondary care and to fast track them back into the service if appropriate when they are fit and able to restart a pathway of care. Note: a new clock will start for these patients. Outpatient Patient referred by a general practitioner, general practitioner with special interest (GPSI), general dental practitioner, consultant, optometrist, or other clinicians for clinical advice or treatment, which does not require an admission to the hospital PACS Picture Archiving and Communication System used for the distribution of computerized images. Partial Booking Patients who have been added to the waiting list acknowledged, and who are given the opportunity to agree a future date for their outpatient appointment or admission. PAS: ICS Patient Administration Systems used across different divisions within the Trust Patient Cancellation A patient who has previously accepted an outpatient time or date for operation and they subsequently notify that they wish to change or cancel their appointment. PTL Patient Tracking List A model for collection of prospective waiting times. The report details patients requiring treatment and the starting point of their pathway. The information team refreshes the list daily. All operational staff will refer to the list to ensure Page 45 of 65
that patients are treated within a maximum waiting time of 18 weeks to their first definitive treatment Reasonable Offer Refers to the notice given to a patient by the hospital for a forthcoming appointment or admission. For an offer to be reasonable two dates with at least 3weeks notice must be given to a patient undergoing surgery. For outpatients good practice guidance suggests notice of at least 10 days. RTT Referral to treatment the measurement of the length of an 18 week pathway Schedules (waiting list) List of patient awaiting elective admission, diagnostic or outpatient appointment and who is currently fit willing and able to be called in Secondary Care Services provided by medical specialists who generally do not have first contact with patients, delivered in either a hospital or community setting Self-deferral Patient who notifies the provider that they no longer wish to come in or attend an appointment Self-referral A patient who contacts the provider directly. They would have been undergoing care by a clinician within secondary care but have been either medically unfit or unavailable to come in for further treatment. Arrangements have been put in place by the provider for the patient to contact a named person directly once they are fit and ready to continue with their treatment. TCI To come in a date and time for a patient to come to a hospital for a day case or inpatient admission. Tertiary Centre A third party organisation that usually supplies specialist services, using technology to a regional area advanced UBRN Unique Booking Reference Number a number given to a patient to progress a referral via the Electronic Referral Service. The number is unique to a specific pathway for a patient and is used to identify a single patient clock or pathway. A patient may have more than one pathway simultaneously Page 46 of 65
APPENDIX 2 RTT OUTCOME CODES AND DEFINITIONS Clock Status National RTT Code Treatment Status Description Definition and Examples Clock Start 10 1st activity after referral in RTT Use for any referral from GP s or their practices or Dentists as the patient s referral is registered Use for when starting a pathway directly after registering the patient on PAS, ICS should automatically do this OR after a 1 st DNA (33) for vulnerable patients like cancer & paeds Use if adding a patient directly to a waiting list without any outpatient appointment Clock Start 11 (code 20 as ICS default) 1st Activity after either watchful wait ends (end of active monitoring) or review post treatment (codes 90/91) Use if a patient has been on active monitoring or has had previous related treatment and treatment is now needed. First activity at the start of a new RTT period Clock Start 12 Consultant referral for a new condition Clock still ticking 20 Subsequent activity along an 18 week pathway before 1st definitive treatment has been given Use when a Consultant referral for a new condition is added to the existing referral made Use for anything that happens along a pathway after the first activity, for example a diagnostic test or a subsequent outpatient appointment where 1st definitive treatment has not yet started Clock still ticking 20 Referral to another Consultant / Associate Specialist / Junior doctor for the same condition before 1st definitive treatment has been given Use for referrals to another Consultant / Associate Specialist / Junior doctor for the same condition if 1st definitive treatment has not yet been given Clock still ticking 20 Request for any type of imaging or/& diagnostics Requests for imaging or/& diagnostics do not stop the clock Clock still ticking 20 Requests for Audiology Requests for Audiology do not stop the clock Clock still ticking 20 Additions to a waiting list Request for addition to a day-case waiting list does not stop the clock Request for addition to an in-patient waiting list does not stop the clock Clock still ticking 20 Tertiary referral for Diagnostics Use when a patient is referred to another health care provider for the same condition and it is anticipated that they will be referred back for this condition. Subsequent activity during the RTT period is the responsibility of this organisation and therefore they need to be monitored Page 47 of 65
Clock Status National Treatment Status Description Definition and Examples RTT Code Clock Stops 21 Tertiary referral for Treatment Use when a patient is referred to another health care provider for the same condition and it is not anticipated that they will be referred back for this condition. Subsequent activity during the RTT period is the responsibility of the other provider Clock Stop 30 Start 1st Definitive Treatment Use when 1st definitive treatment is given, whether it is given in an outpatient or inpatient setting. 1st definitive treatment is the start of treatment that is intended to manage the Clock Stop 31 Start of watchful wait by patient Clock Stop 32 Start of watchful wait by clinician Clock Stop 33 Patient DNA s the 1st Activity after initial referral patient was not brought to the 1st activity after initial referral patient's disease, condition or injury. Use when a patient chooses to decline treatment for the time being to see how their condition develops. This may occur following an outpatient appointment or when a patient is on a waiting list. Use when a clinician decides to monitor the patient s condition over a period of time rather than offer treatment. This may occur following an outpatient appointment, a diagnostic procedure or if a patient s management plan changes once they have already been added to a waiting list. Use when a patient DNAs ( is not brought to New Paediatrics DNA Policy) their 1st appointment / episode of an 18 week pathway if they are an Urgent, vulnerable patients only (such as mentally ill or under 16 year olds) Clock Stop 34 Decision not to treat Use when a clinical decision not to treat has been made, such as a Routine DNA Clock Stop 35 Patient declines treatment Use if the patient / parent / carer declines treatment at any point along an 18 week pathway Clock Stop 36 Patient deceased Will be used if a patient died before treatment Page 48 of 65
APPENDIX 3 ACTIVITY THAT IS NOT PART OF A RTT PERIOD Clock Status National RTT Code Treatment Status Description Definition and Examples Not during a RTT period Not during a RTT period Not during a RTT period Clock stopped at another provider 90 After 1st definitive treatment Use this for any activity after 1st definitive treatment has started. Use this for any activity that follows an emergency admission. 91 During a period of watchful wait 92 Patient is currently undergoing investigations requested by their GP but has not yet been referred into a Consultant-led service Use when active monitoring is underway and continues with this episode of care (i.e. no decision to treat has been made). Use for referrals from GP s requesting diagnostic investigations only. Where it is envisaged that the patient will be returned to the care of their GP once the investigations have been undertaken. 98 Not applicable to RTT Use for emergency admissions Use for referrals to non-consultant-led conditions 99 Not yet known Page 49 of 65
APPENDIX 4 NORTH WEST LONDON ACUTE HOSPITAL PROVIDERS INTERNALLY GENERATED DEMAND POLICY Page 50 of 65
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