Quick Reference Sheet for Elective Access Policy: EDM006 V5.1

Quick Reference Sheet for Elective Access Policy: EDM006 V5.1 Sets out how Trust staff manage patients referred for elective assessment and treatment including: o o o o Outpatient appointments Elective inpatient treatment Elective day case treatment Diagnostic tests Supports timely and equitable access to Trust services for all patients including vulnerable patients who may find it difficult to access services Offers a transparent and fair process that is in the best interest of the patient Clinical need always takes priority Ensures the Trust meets or exceeds the National Waiting Times Standards Clearly defines responsibilities at each stage of the process for effectively managing waiting lists, scheduling and booking across the Trust Describes in detail how the Referral to Treatment (RTT) 18 weeks pathway is managed including: o o o o o o o o Booking Referrals/requests Determining priority Managing waiting lists Cancellations and DNAs Letters to patients Admitting patients Diagnostics Sets out guidance in relation to people who may not ordinarily be entitled to access free NHS services Links to the requirements of relevant legislation and Trust policies Page 1 of 51

Reference Number: EDM006 Version Number: 5.1 Elective Access Policy What is this document for? Who needs to know? Related PAT Documents: Related Legislation/ Obligations: Accountable Executive: Document Author(s): Developed with: The purpose of this policy is to clearly define the Trust and Commissioner s responsibilities to all patients referred to Pennine Acute Hospitals NHS Trust for elective access and treatment All Trust staff who are involved in elective inpatient, day case and outpatient activity, including diagnostic and therapy appointments at the Trust, and the Trust s commissioners who are responsible for referring patients, managing referrals, adding to and maintaining waiting lists. Acute Services Policy for the Management of Case notes (EDM008) Child Protection Policy (NCWC001) Data Quality Assurance Strategy (EDI017) Data Quality Assurance Policy (EDI016) Holiday Leave Policy (EDH030) Information Governance Policy (EDI001) Policy for patients receiving private care in PAT Facilities (EDM013) Policy for the Protection of Vulnerable Adults (NCWC011) Record Keeping Policy (EDN004) Safeguarding Strategy (EDN010) Safeguarding Training Policy (EDN036) TDA Accountability Framework 2014/15 Referral to Treatment Consultant led Waiting Times Rules Suite October 2015 and others on P49 Jude Adams Interim Operations Director Jo Keogh Associate Director Elective Access NHS Interim Management And Support from the Intensive Support Team; Booking and Scheduling Department, PAHT; Associate Director Elective Access; Divisional Directors and Teams Information Team Caldicott and Information Governance Committee Ratified by: Damien Finn, Director of Finance Page 2 of 51

Date Ratified: 22 September 2016 Replaces: Elective Access Policy EDM006 version 5 How is this different from the previous document? What dissemination & training arrangements have been made? Review arrangements: The Policy reflects the transition of the National Choose and Book system to the E-referral system. The Policy has been amended to reflect the Department of Health publication Referral to Treatment Consultant Led Waiting Times October 2015 specifically that from 1 October 2015 there is no provision to pause or suspend an RTT waiting time and diagnostic clock under any circumstances This Policy will be available via the Document Management System The Policy will be reviewed annually Safety Arrangements: The Trust is required to undertake an annual internal audit and a 3 yearly external audit Addendum Addition to section entitled Patients Unable To Start, Continue with their Pathway or DNA 15 March 2017 Priority Level: 2 Impact Level: Trustwide Keywords: Elective Access, treatment, waiting times, 18 weeks, patient choice, RTT Page 3 of 51

Contents Page 1. What is this policy for? 5 2. Why do I need to know? 5 3. What is the policy 5 3.1 NHS constitution 5 3.2 National and Local Operating Standards 7 4. What do I need to do? 36 5. List of Abbreviations and Terms used 40 6. References 44 7. Appendices 46 Appendix 1 - Equality Impact Assessment 47 Appendix 2 - Cancer and Rapid Access Chest Pain Wait Times 48 Appendix 3 - Guidance for the Follow Up of Vulnerable Children 49 and Vulnerable Adults Page 4 of 51

1. What is this Policy for? 1.1 This policy is to ensure that everyone (patients and staff) understand how to book eligible elective patients to ensure their treatment occurs within the agreed standards. 2. Why do I need to know? 2.1 You need to know so that all eligible patients are treated in accordance with the rules therefore meeting the patients right to be seen within 18 weeks. 3. What is the policy 3.1 The NHS Constitution clearly states that: You have the right to access certain services commissioned by NHS bodies within maximum waiting times or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible. Patients have the right to: start their consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions be seen by a cancer specialist within a maximum of two weeks from GP referral for urgent referrals where cancer is suspected. Patients are required to contact either the provider to which they have been referred or their local clinical commissioning group before alternatives can be investigated. Military Veterans The term military veteran refers to people who are receiving state benefits for wartime injuries. Such patients should receive priority access to NHS care for any conditions which are related to their service, subject to the clinical needs of all patients. The referral should state if this applies so the Trust can ensure it meets the current guidance for priority service over other patients with the same level of clinical need. Patients with more urgent clinical needs will continue to receive clinical priority. Disabilities / Special Needs The Trust is committed to providing, where ever possible, a booking system to support the requirements of individuals with disabilities. We will continually work towards ensuring that individuals with disabilities are not disadvantaged by this policy. Religious / Ethnicity The Trust is committed to providing, wherever possible, a flexible booking system to support the ethnic/ religious requirements of service users. We will continually work towards ensuring that individuals are not disadvantaged by this policy due to their ethnic/religious requirements. Patient Exclusions Page 5 of 51

The right does not apply to: Patients who are not on an 18 RTT week pathway Patients who are registered with a GP in Northern Ireland, Scotland or Wales. This policy only applies to England and the right applies to patients referred to a service commissioned by an English Clinical Commissioning Group or NHS England Patients who do not attend an agreed first appointment, or rearranged appointment, without giving prior notice if the date of the original appointment offered was reasonable Patients who refuse treatment. The reasons for the refusal of treatment by the patient, or someone acting lawfully on their behalf, should be recorded Patients for whom it is not clinically appropriate to start treatment within 18 weeks. Examples include pregnant women Patients who do not require treatment following clinical assessment Patients who are referred back to primary care services to receive treatment Patients who require active monitoring following assessment Patients who are placed on a national transplant waiting list following assessment Prisoners and people detained under the Mental Health Act are not excluded from the right Services Excluded The following services are excluded from the patients rights: Maternity Services Transplant Services Any healthcare services that are not consultant-led Page 6 of 51

Overseas Visitors The Trust has a legal obligation to identify patients who are not eligible for free National Health Service (NHS) treatment. 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. All NHS Trusts have a legal obligation to: Ensure 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 The Trust will check every patient s eligibility for treatment. An NHS card or number does not give automatic entitlement to free NHS treatment. Queries regarding patients eligibility should be directed to the Overseas Visitors Team. Patients Requiring Commissioner Approval No referral for an excluded procedure as detailed within the Greater Manchester (GM) Effective Use of Resources (EUR) Policies will 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 re refer once approval has been agreed. 3.2 National and Local Operating Standards There are several pathways that have national and / or local standards applied to them: Non-Admitted RTT Pathway This means the patient does not require admission to hospital to receive their first definitive treatment i.e. treatment is given, prescribed in outpatients or no treatment is required. Patients admitted for diagnostic procedures remain on a non-admitted pathway until such time a decision to admit for treatment is made. At this point they transfer to an admitted pathway. Admitted RTT Pathway This means the patient requires admission to hospital, as either a day case or an inpatient, to receive their first definitive treatment. Incompletes All patients who have been referred into Pennine Acute Hospitals NHS Trust and have not yet had a treatment or a decision not to treat (a clock stop). National Operating Standards Page 7 of 51

Within the Referral to Treatment time (18 weeks/rtt) National Operating Standards the following apply: Referral to treatment time (18 weeks / RTT) 92% of Incomplete pathways should be waiting no more than 18 weeks from receipt of their referral No patient will wait longer than 6 weeks for a diagnostic test or image Any patient who is on a planned, follow up or surveillance pathway will be put on a waiting list and given an indication of when they need to be seen again. If a patient cannot be accommodated for their planned procedure within the indicated timeframe the patient will revert back to an 18 week RTT pathway which includes the 6 week diagnostic standard Where patients have had their to come in (TCI) date cancelled on the actual day of their admission, for non-clinical reasons, a new operation / procedure date will be agreed with the patient; this operation date must be within 28 days of the on the day cancellation Local Operating Standards In addition, a number of local operating standards apply: A minimum of 8 weeks notice is required for any planned clinic or theatre session cancellation or change Clinic or theatre cancellations, or changes, at less than eight weeks notice will only be approved in an emergency or in exceptional circumstances Referrals to be registered on the PAS system within 24 hours of receipt Referrals to be clinically prioritised within three working days of receipt; where this does not occur referrals will be automatically accepted by the Booking and Scheduling Team Patients will always be given reasonable notice of their appointment. Reasonable notice is defined as: An offer of two dates with a minimum of three weeks notice for outpatient appointments and elective admissions An offer of two dates with a minimum of two weeks notice for diagnostics and preoperative assessment appointments Where a patient agrees and accepts an appointment at less than the given period of notice then this will be recorded on PAS and the appointment will be considered reasonable Referrals received by the Trust are considered as referrals to Pennine Acute NHS Trust o Patients who decline two reasonable offers of appointments or procedure dates with a suitable clinician at a suitable site will be returned back to their GP. However the Trust must demonstrate that they have appropriately communicated to the patient the potential consequence of declining two reasonable offers. For example, a patient who is offered two reasonable offers at North Manchester General Hospital (NMGH) who Page 8 of 51

declines because they prefer Rochdale will be returned to their GP if there is no clinical reason why their appointment or procedure should not take place at NMGH. Not to do so would not support the chronological booking of patients o Patients will be offered appointments in chronological order irrespective of referring CCG Patients requiring addition to waiting list must be listed within 48 hours of decision to treat and be fit, willing and able to attend All offers of dates to patients for outpatient, diagnostic, pre-operative assessment and inpatient episodes will be recorded in PAS at the time the offers are made. This includes earlier reasonable offer dates (ERODs) Booking staff will always attempt to identify a date appropriate to a patient s clinical priority and convenient to the patient. If an appointment or admission is less than three weeks, two attempts will be made to contact the patient by phone Where patient cancellations are initiated by the Trust, we should re-book an alternative appointment with the patient and this appointment should take place within two weeks where possible A patient s first outpatient appointment will be arranged and communicated to the patient within four weeks from receipt of referral where possible Patients should not be penalised where exceptional circumstances prevent them from attending an appointment, e.g. extreme weather conditions where public transport has stopped running. Staff should exercise discretion in such situations, seeking guidance from their line manager if required. However, certain circumstances may still arise whereby returning the patient back to the care of their GP would clinically be in their best interest and the safest course of action. These instances will be managed on an individual basis in discussion with relevant parties. Tolerances There are reasons why not everyone can or should be treated within the operating standards, below are the three reasons; patients fitting these criteria s need to be auditable. Patients for whom it is not clinically appropriate to be treated in 18 weeks (Complex Clinical Reasons) Patients who choose to wait longer for one or more elements of their care (Choice) Patients who choose not to or do not attend appointments (Co-operation) These patients are taken into account in the tolerance set as part of the delivery standard therefore any reported breach should fall into 8% of incomplete patients Page 9 of 51

Understanding 18 Week Referral to Treatment (RTT) It is the responsibility of all members of staff to understand the 18 week principles and definitions. They must be applied to all aspects of the patients pathway. Definitions For the purposes of this policy, a set of definitions are set out in Section Five - Definitions. RTT (18 weeks) Rules Overview and Key Principles The concept of waiting lists for the different stages of treatment (outpatients, diagnostics and inpatients) has been replaced by the Referral to Treatment (RTT) pathway as the key access target for the NHS. RTT measures the patient s journey from referral to first definitive treatment as one single waiting time. Moreover, from 1 January 2009 the National Cancer Targets are also assessed in accordance with the RTT rules. There are a number of key principles: Patients should only be referred for consultant led services if they are fit, ready and willing to access services within a maximum of 18 weeks. The exception being overriding urgent pathways or if the patient chooses to wait longer Patients must receive information at each step of their pathway advising them of their responsibilities regarding following medical guidance and notification periods Where possible and clinically appropriate, surgical lists should be pooled. In these specialties, the patient will be informed by the clinical team at their outpatient appointment that they may be operated on by another surgeon Systems should ensure accurate and up to date information is collected about diagnostic, outpatient and Inpatient services and recorded on the appropriate system in a timely manner, and in line with national information standards All patients added to the waiting list should be given a priority of either Urgent or Routine by the referring clinician Patient Target Lists (PTLs) and the nine protected characteristics as defined within the Equality Act 2000 will be used to support equity for non-clinically urgent patients and delivery of the Access standards Systems should ensure effective two-way communication with patients and their GP Systems should ensure robust communication between Managers, Administrative Staff and Clinicians Where the current capacity available in a service is not adequate to meet the volume of patients referred or in a follow up, planned or surveillance status within the pre-agreed timescales, the Directorate Manager together with Divisional Directors will take action to ensure all patients are treated in accordance with their agreed treatment plan Systems for arranging appointments / admissions for patients will: Offer choice of dates Page 10 of 51

Minimise the risk of cancellation Reduce the risk of Did Not Attends (DNAs) No patient will be inequitably affected by this policy or the practices it promotes on the basis of their race, gender, age, disability, sexual orientation or religion Consultant to Consultant referrals outside of originating speciality should only occur for Life or Limb threatening conditions Validation, Tracking and Measurement The Trust complies with the statutory reporting requirements for elective access: Monthly returns DM01 Diagnostics Waiting Times and Activity; RTT Complete and Incomplete Activity; RTT Audiology; Monthly Activity Return; Cancer Waiting Times Returns Quarterly Returns Quarterly Activity Return; Cancer Waiting Times Returns; Quarterly Diagnostic Census The Patient Tracker Lists (PTLs) which support the delivery and accurate reporting of all access targets must also be validated at key intervals or time points to ensure that the status of each individual patient is recorded correctly. RTT Tracking Team The RTT tracking team on a weekly basis will be expected to: 1) Review all patients over 25 weeks in all specialties 2) Review all patients over 18 weeks to ensure a clinical management plan is in place to commence treatment (evidence of next step in the pathway entered onto the PTL) 3) Review all patients between 12 17 weeks to ensure the patients will be seen and potentially treated before week 18 (126 days) 4) Validate patients who have had a clock stop event over 18 weeks The RTT Trackers would be expected to liaise with the Patient Pathway Coordinator and the Booking and Scheduling Team to bring patients forward and schedule appointments. They will liaise with the Clinical Administration Service and Directorate Teams to ascertain patient status and progress patients along their pathway. The RTT Trackers will highlight patients to the relevant Patient Pathway Coordinator and Directorate Management Teams on the timescales agreed in the escalation process. Booking and Scheduling Team The Booking and Scheduling Team on a daily basis will be expected to: 1) Add patients to the waiting list on as the proformas are received. The date on the waiting list will be the decision to treat date 2) Validate the RTT start date (liaising with the tracking team) and ensure the waiting list episode is linked to the correct pathway The Booking and Scheduling Team on a weekly basis will be expected to: Page 11 of 51

1) Review patients in the 10-14 week group booked with a future appointment beyond their breach date to inform the directorate teams at the PTL meeting. This will require proactive management from the directorate management teams 2) Review all patients on the PTL with 4 weeks to breach without a TCI to inform the Directorate Teams at the PTL meeting 3) Review all patients over 18 weeks to ensure a TCI date has been arranged. Any patients without a TCI to be discussed at the weekly PTL meeting Directorate Management Teams The Directorate Management Teams are expected to: Review capacity requirements for their services in response to demand Review the outputs of RTT tracking and respond to patients escalated as requiring management intervention Liaise with the Patient Pathway Coordinator on the provision of capacity to see patients before RTT breach date and those patients who cannot be accommodated as over bookings Provide updates on escalated patients at weekly patient level PTL meetings and performance meeting as appropriate Standards of Tracking The following standards for tracking should be following as a minimum when validating each cohort of patients. Tracking Live PTL Patients: Review the pathway from start to confirm the start and pathway events are recorded correctly Identify if a clock stop event has occurred if so ensure the Patient Administration System and RTT model are updated If the patient is still waiting identify the next steps in the pathway o o o o o If the patient is due an appointment check this is before the breach date if not before breach attempt to bring forward with the Booking and Scheduling Team (ensuring any diagnostic results will be/are available for the appointment). If the patient cannot be brought forward record on tracking notes and escalate to Patient Pathway Coordinator/ Directorate Manager as appropriate If the patient is awaiting an appointment liaise with the Booking and Scheduling Team if not able to book before breach escalate to the Patient Pathway Coordinator/ Directorate Manager If the patient is awaiting results of a diagnostic test liaise with Medical Personal Assistant for a clinical review and next step. If no outcome from clinical review request identify on tracking notes and escalate to Directorate Manager as appropriate If the patient should have been added to a diagnostic or admitted waiting list and hasn t, highlight to the Booking and Scheduling team leader If the pathway or management plan is not clear, liaise with clinical and directorate team, or obtain the medical records for further review Validation of RTT Pathways Identified with a clock stop : Page 12 of 51

Review the identified clock stop event and confirm the patient has received first definitive treatment or a clock stop for non-treatment has occurred Review the pathway to identify its accuracy including if a clock stop has occurred at an earlier point and/or the clock start is accurate If the clock stop is confirmed as inaccurate and the patient pathway remains open, the minimum standards for tracking live patients should be followed The RTT pathway should be accurately reflected on PAS and the RTT model with necessary changes made Sources of Referral That Start the 18 Week RTT Pathway A clock starts when a referral from a GP, dentist or other healthcare professional is sent to the Trust for the patient to be assessed at a Consultant Led Service and, if appropriate, treated before responsibility is transferred back to the referrer. For patients referred using the E-Referral system, the clock starts on the date that the provider receives notice of the referral (UBRN conversion date). This includes: A consultant led service regardless of setting An interface service or referral management or assessment service, which may result in an onward referral to a consultant led service before responsibility is transferred back to the referring health professional or general practitioner Self-referrals to these services (where agreed by commissioners and providers) The Point at Which the 18 Week Clock Starts For paper referrals the clock start is the date the Trust receives the referral. For E-Referrals the clock starts on the date the patient calls to make an appointment and gives their unique booking reference number (UBRN). If following completion of a referral to treatment period, a patient requires treatment for a substantially new or different condition then a new clock starts. This is a clinical decision made in consultation with the patient A new decision to treat is made for a patient currently receiving on going care at the hospital For example, a patient has been prescribed medication that is intended to treat their condition and is followed up in an outpatient setting. When the patient attends for a routine review the condition has changed and an intervention is required. A new care period starts when the decision to admit is made A referral is made by a Consultant either within the hospital or from another provider to a consultant led service for a new course of treatment For example, a patient has been managed conservatively in a medical specialty but their condition deteriorates and elective surgical intervention is required. A new 18 week pathway starts when the referral to the surgical specialty is made When a patient becomes fit and ready for a second stage of a bilateral procedure. A new 18 week pathway care period starts when the patient is fit to be treated and the waiting list is activated Page 13 of 51

Scenario Where further treatment is required that was not already planned, what date should the new RTT clock start? Where further (substantively new or different) treatment may be required that was not already planned, a new RTT clock should start. This new RTT clock will often start when a decision to treat is made. However, where a patient is referred for diagnostics or specialist opinion with an expectation that this will be followed by treatment, it may be more appropriate to start the new clock from the point that the decision that diagnostics or specialist opinion is required is made. In common with other referrals, the clock should start on the date that the new referral is received. Where the patient will be remaining under the care of the same Consultant or under the care of a different consultant within the same provider, then the date of the decision to refer and the referral being received will be the same. However, where a patient is referred to a different provider for the new treatment, then the RTT clock will not start until the referral is received by the receiving provider. As patients will perceive their wait as starting from the time that the consultant told them they were going to refer, there should not be a significant delay between the date the decision to refer was made (and communicated to the patient) and the date that the referral is received in the receiving provider. Referrals Types That Do Not Start An RTT Pathway Allied Healthcare Professionals (e.g. Physiotherapy), Healthcare Science or Mental Health Services that are not medical or surgical consultant-led (including multi-disciplinary teams and community teams run by Mental Health Trusts) irrespective of setting Direct Access Diagnostics the GP refers the patient for diagnostics and on receiving the results then makes the decision whether or not to refer the patient on to secondary care. The onward referral would start an RTT pathway, the original diagnostic referral does not start an 18 week clock Primary Care Dental Services provided by dental students in hospital settings Private patients or patients under the care of a non-english commissioner Patients admitted as emergency admissions Fracture Clinics Obstetric patients Elective patients undergoing planned procedures (e.g. removal of metalwork, procedures related to age/growth, check cystoscopies etc.) Routine dialysis patients Scenario Are referrals to orthodontics services covered by RTT measurement? Page 14 of 51

A referral from primary care to an orthodontic consultant starts an RTT pathway. However, a large proportion of orthodontics work is carried out by non-consultants and referrals from primary care to such non-consultant services would not start an RTT clock. First definitive treatment is defined as "an intervention intended to manage a patient s disease, condition or injury and avoid further intervention." An example of first definitive treatment in orthodontics is the first fitting of a dental brace (sometimes referred to as "case start"). Treatment will often continue beyond the first definitive treatment and after the RTT clock has stopped. If a patient on an orthodontic pathway is not yet ready for treatment (e.g. child will require a dental brace but their teeth are not yet developed enough), then a period of active monitoring should commence and the RTT clock stops at the point that the clinical decision is made and communicated to the patient and their GP (or other original referrer) to commence active monitoring. Once the patient has reached the appropriate age/stage of development as identified in their care plan, a new RTT clock should start. What about orthodontic patients who require general anaesthesia. Are they covered by RTT measurement? Yes. Dental care provided under general anaesthesia in secondary care (even where the treatment is carried out by a primary care dentist) is covered by RTT. For these dental pathways, the decision to include them within the scope of RTT was taken on the basis that these patients are typically from vulnerable groups (mainly children but also some adults with learning disabilities etc.) and it would be appropriate for them to be included in RTT. The rationale is that there has to be a consultant involved in their care as by law, general anaesthesia must be carried out in a hospital setting under the care of a consultant anaesthetist. This approach has received support from dental colleagues within the NHS. Capacity Management General Principles The Pennine Health Community will ensure that there is a shared approach to capacity management. The Commissioners will ensure that patients are offered a full range of choices for providers of treatment. Where the current capacity available in a service is not adequate to meet the numbers of patients referred to it within the pre-agreed timescales, the Directorate Manager together with senior managers will take action to ensure all patients are treated in accordance to the RTT standard. Provider units must manage the available capacity and link these to clinical job plans. Directory of Service (DoS) Management A Directory of Service contains information that describes the service the provider offer, and allows referring clinicians to search for appropriate services to which they can refer patients through E-Referral. The Booking and Scheduling Department will manage the Trust s DoS on E-Referral. The DoS must be developed in conjunction with the relevant clinical leads of the service. Page 15 of 51

Clinical Directors will be responsible for reviewing and signing off the DoS annually or when a service change occurs. Any new DoS entry must be agreed by the Clinical Director/Directorate Manager before publication on the E-referrals system and they must ensure that the entry contains a clear description of the service and the clinics provided. Clinics attached to the DoS should not be cancelled or reduced within eight weeks of the clinic date (except for unpredictable sickness or compassionate leave). If a clinic has been requested to be cancelled the Directorate Manager must be notified in order to assess impact on the lost capacity and patients before authorising said cancellation. It is not acceptable to reschedule a patient more than twice. Systems must be in place to ensure that patients are seen within the 18-week target. The rescheduled date for new patients, who have already been notified of their original clinic date, should be within two weeks of that original date and soon enough to achieve the 18 weeks guarantee where possible. If re-scheduling does occur this should still allow patients to be seen in chronological order, in line with their RTT start date. The efficient delivery of services is dependent upon robust planning. The Pennine Acute Hospitals NHS Trust has a Consultant Leave policy for Consultant medical staff which requires at least eight weeks notice of absence. Outpatient Clinic Booking Rules Clinic booking rules must, as part of the capacity planning process, be agreed with each Consultant for his/her clinical team and reviewed at least annually. PAS should accurately reflect the agreed clinic rules. Changes to clinic booking rules for consecutive clinic sessions must be agreed with the appropriate Directorate Manager in order to take account of the impact of the change on service delivery. Any clinic changes should be assessed against the Directory of Service and a plan to manage the impact should be agreed. Management of Outpatient Booking In order to improve patients experience and quality, Pennine Acute Hospitals NHS Trust will allow patients to negotiate their appointment date and time at their own convenience using the National E-Referral system and work towards partial booking though-out the patient journey The Trust will also work towards implementing a Texting Reminder Service to patients deemed clinically appropriate Direct Booking The National E-Referral system will be the primary referral and booking method. The waiting time clock start is at the point of conversion of the Unique Booking Reference Number (UBRN), i.e. date an appointment is booked. Page 16 of 51

Where a patient attempts to book an appointment and there is no appointment slot available, or a technical issue prevents booking, the request can be deferred to the PAHT. Then the waiting time clock start is at the point in which the referral details are deferred to the PAHT, i.e. when the patient s UBRN appears on the Appointment Slot Issue (ASI) work list Pennine Acute Hospitals NHS Trust Clinical Services will be published on the Directory of Services (DoS). Appointments will be made available far enough ahead, to support delivery of the 18 week RTT commitment. Referral Management Centres Manchester, Oldham and Heywood Middleton and Rochdale have Referral Management Centres (RMC). These are interface services that provide a level of clinical triage, assessment and treatment between traditional primary and secondary care. Bury CCG have commissioned an administrative only interface service. A referral management centre or assessment service is a specific type of interface service that does not provide treatment, but accepts GP (or other) referrals and provides advice on the most appropriate next steps for the place or treatment of the patient. Depending on the nature of the service they may, or may not, physically see or assess the patient. Referral Management Centres and assessment services should only be in place where they carry clinical support and abide by clear protocols that provide benefits to patients. They must not be devices either to delay treatment or to avoid having clinical discussions with GP practices about good referral practice. Referrals to the Referral Management Centres are covered by RTT and a referral starts an RTT clock. The clock starts on the date that the patient rings to make an appointment and the UBRN is activated. Therefore, the referral should be received by the provider no more than three days after the 18 week clock start date. The Trust therefore receives the majority of referrals electronically. Paper referrals from these Commissioners are returned to the relevant Referral Management Centre. However, paper referrals may continue to be received from other Commissioners and from General Dental Practitioners. Referral Letters Referral letters must be electronically attached to E-Referral by the referrer within three working days of the appointment request, where the appointment is more than 5 days in advance. Where the appointment is less than five days then the referral must be attached within 24 hours. Accept and Reject Referrals All referrals must be accepted or rejected by the receiving clinical team within three working days. Referrals outstanding after five days will be automatically accepted by the Booking and Scheduling Team. Clinical Teams will have a responsibility to review any patients booked into the wrong services whose referral was not accepted or rejected by the clinical team. Rejected Referrals Where a referral has been clearly referred into a clinically inappropriate service and no other suitable service is provided, the referral must be rejected on E-Referral with a clear definitive reason and possible alternative action to be taken by the referrer. Page 17 of 51

Redirection Where a referral has been booked into a clinically inappropriate service, the referral must be redirected to a more appropriate service if that service is provided. Slot Availability The Trust is measured against contractual E-Referral standards defined by the CCGs. It is the responsibility of the Directorate Management Teams to ensure that there are sufficient slots available on E-Referral to enable >98% of patients have a reasonable choice of dates and times. Directorate Management Teams must utilise the Future Slot Utilisation report on E-Referral to monitor slot availability and forward plan for any identified capacity constraints to ensure that the Trust has less than 4% Appointment Slot Issues (ASIs). The Booking and Scheduling Team will alert the management teams when there is a risk to slot availability. Polling Range The maximum polling range for slot availability on E-Referral will be managed by the Directorate Managers supported by the Booking and Scheduling team. Non-Directly Booked Appointment Processes Paper Referrals For all patients where the booking has not been made through E-Referral and a paper referral has been received, the 18 week clock will start on the date the referral was received in the Trust. If the referral is from another provider, the clock start is the date contained within the minimum data set (MDS) provided with the referral. Referrals received from another provider will keep the clock start of the original referral where there is a continuation of the same treatment pathway. All 18 week information should be contained in the referral MDS. All paper referrals received from Manchester, Oldham, Bury and HMR Commissioners must be date stamped within 24 hours of receipt and returned to the relevant RMC. Referrals received directly by a service or Consultant should also be date stamped and forwarded to the relevant RMC immediately. Paper referrals should only be received by the Trust for those services not on E-Referral and should be scanned into the approved Trust system at the time of adding to PAS. Paper referrals will be processed in line with E-Referrals to ensure fair and equitable access. Internal Referrals from Consultant to Consultant If a patient is seen by a Consultant in clinic and a different condition is identified, unless the second condition is clinically urgent, the patient should be returned to the GP. The GP should then make a new referral for this condition. The clock will start for the second condition upon receipt of the referral. Where the referral is made by the Trust Consultant a new clock will start for this new condition from the date of receipt of the referral in the Referral Management Centre/when the date the decision is made to make the referral. Page 18 of 51

Referral Letter Content The content must be clear and concise stating the clinical priority and reason for referral. Referral letters should be addressed to a service / speciality to allow the service / speciality to direct to the most appropriate clinician and the shortest waiting time. Where it is explicit that a particular member of the team / speciality needs to see the patient, this must be written on the referral / request with the reason. However, in the interests of the patient, the Trust reserves the right to appoint a patient to a clinically appropriate clinician with the shortest waiting list. If a referral has been made to an individual who does not have the necessary skills for the patient, the professional prioritising the referral will re-route the referral to an appropriate colleague via the E-Referral system, prior to seeing the patient. It is essential that vulnerable patients are identified at the point of referral. This group of patients includes: patients with learning difficulties, psychiatric problems patients with physical disabilities or mobility problems All relevant information should be recorded on PAS; communication with this patient group will recognise their needs and, where appropriate, involve other agencies. Inappropriate Referrals If the referral is for a service not provided by the Trust, or where a Consultant deems that a patient has been inappropriately referred, then the referral will be returned to the original referrer with advice as to the most appropriate management for that patient. Paper referrals will be returned to the Booking and Scheduling Department to close the referral on PAS/CRIS and then returned to the referrer. Insufficient / Illegible Clinical Information If the referral does not provide sufficient / legible information for the health care professional to make a decision, the letter should be returned to the Referral Management Centre who will return the referral to the original referrer indicating further information is required before the referral can be progressed / returned to the original referrer to refer the patient. The clock will only start when the referral is received with the required information. Prioritisation All electronic referrals should be prioritised within three working days and paper referrals within five working days of receipt in to the hospital by the clinician or their authorised deputy. The clinician should clearly indicate on the referral letter the priority that has been allocated. The only exceptions to the above are if the referrer had completed an agreed referral protocol thus indicating a particular care pathway to be followed e.g. direct access clinics, two-week cancer referrals and where the receiving clinicians do not need to prioritise referrals. Referrals for Cancer and Rapid Access Chest Pain Services To meet the required NHS standards, all referrals from GP/GDP s that are marked urgent and suspicious of malignancy must be seen by a specialist within the target days from the referral being made to the Trust. Page 19 of 51

All patients referred to the Rapid Access Chest Pain Service must be seen within the target days from the receipt of the referral. The appointment date must be agreed directly with the patient. The target waiting times for patients are set out in Appendix 2 Cancer and Rapid Access Chest Pain Waiting Times National Targets. Referrals made via this route will be audited as to their appropriateness and regular feedback given to referrers in order to ensure that urgent capacity is utilised only for genuine urgent referrals. Patients Unable To Start, Continue with their Pathway or DNA If a patient cannot accept or fails to attend one reasonable appointment offer without valid reason the patient should be discharged back to the care of their referrer. The Trust will need to be able to demonstrate that: The appointment was clearly communicated Discharging the patient is not contrary to their best clinical interests Discharging the patient is carried out according to local, publicly available policies on DNAs These local policies are locally agreed, clearly defined and protect the clinical interests of vulnerable patients. Prior to a decision being made to discharge a patient who has DNA d back to their GP the patient s clinical record must be reviewed. If at this point the decision is made not to offer a further appointment the Clinician must document that if the GP or patient makes contact within two weeks and are able to attend an appointment the Clinician will see the patient rather than requesting a re-referral from the GP. If a patient cancels their appointment / admission in advance, this has no effect on Referral to Treatment Time therefore the 18 week clock should continue to tick. Patient Cancellations Patients who telephone to cancel their appointment should be offered another reasonable appointment date at the time of their telephone calls. If a patient accepts and then cancels their appointment for a second time without valid reason they should be discharged and returned back to referrer. This will stop the 18 week clock. Patients who cancel their appointment for a second time must be referred back to their referrer provided: The provider can demonstrate that the appointment was clearly communicated to the patient with reasonable notice The clinical interests of vulnerable patients (e.g. children) are protected and are agreed with clinicians, commissioners, patients and other relevant stakeholders Page 20 of 51

The Patient Administration System must be updated with details of the cancelled appointment dates along with details of any contact made with patient and / or referrer. For children, the requirements of legislation and good practise will override this and the detailed policy is set out in Appendix 3. Patient DNA When a patient does not attend for an appointment without giving prior notice, this is classed as a Did Not Attend (DNA). The patient must then be referred back to their referrer provided: The provider can demonstrate that the appointment was clearly communicated to the patient Discharging the patient is not contrary to their best clinical interests The clinical interests of vulnerable patients (e.g. children) are protected and are agreed with clinicians, commissioners, patients and other relevant stakeholders If a patient DNAs the first appointment of the 18 week pathway and the patient had accepted the offer or it was a reasonable offer then the 18 week clock will be stopped. If a clinician requests that the appointment is re-booked then a new care period will commence from date of the re-booking of the next new appointment. Any follow up appointment DNA will not affect the RTT clock at any other point in the 18 week pathway, unless the patient is discharged. PAS should be updated on the day of the clinic but as a maximum within 48 hours of failure to attend the appointment. For Children, the requirements of legislation and good practise will override this and the detailed policy is set out in Appendix 3. Follow Up Appointments If a patient requires a follow up appointment within six weeks, then this should be arranged with the patient before they leave clinic. If the review is to take place beyond six weeks then the patient must be placed on a follow up appointment waiting list with the expected date of appointment clearly recorded. These should be arranged keeping within the guidelines set to minimise any risk of the provider cancelling the booking. At the point of making the follow-up appointment any special support requirements such as lip readers, interpreter and transport should also be booked. Hospital Transport Transport for all new appointments should be arranged via the patients GP. Transport should only be booked where a patient s medical condition or impairment warrants the use of patient transport services. A clinical practitioner capable of assessing the patient s Page 21 of 51

medical condition must determine the need for transport as well as the type of transport required. Management of Diagnostic Bookings Defining Diagnostic Tests A Diagnostic test is defined as a test or procedure used to identify a person s disease or condition and which allows a medical diagnosis to be made. A patient s wait for a diagnostic test/procedure begins when the request for the test or procedure is made. The wait ends when the patient receives the test/procedure. The maximum wait time for a diagnostic procedure is six weeks but needs to be managed within plan to provide treatment within 18 weeks. For the purpose of waiting time measurement this does not include waits for diagnostic tests/procedures where: The patient is waiting for a planned (or surveillance) diagnostic test/procedure, i.e. a procedure or series of procedures as part of a treatment plan which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency, e.g. 6 month check cystoscopy The patient is waiting for a procedure as part of a screening programme (e.g. routine repeat smear test etc) The patient is an expectant mother booked for confinement The patient is currently admitted to a hospital bed and is waiting for an emergency or unscheduled diagnostic/test procedure as part of their inpatient treatment Booking Diagnostic Tests It is good practice that patients book their diagnostic test at their outpatient attendance or have it undertaken before attending the outpatient appointment. Where appointments are not booked prior to attending or on the day the patient attended outpatient consultation, patients will be contacted either by post or telephone with details of their appointment. Patient DNAs When a patient fails to attend the first activity diagnostic test, the patient pathway and RTT clock are nullified (as long as they were given reasonable notice). The patient will be returned to the care of the GP or when the clinician believes it is clinically inappropriate to discharge back to the GP. These patients will be booked a further appointment within appropriate waiting times. A letter will be sent to the patient and GP informing them of the Trust s actions. Mandatory Data Required For Radiology Requests All requests for tests must have all mandatory fields completed. If they are not complete this will result in a delay for the patient s imaging and / or pathway treatment. Patients on the diagnostic waiting lists cannot be suspended. Page 22 of 51