Patient Access Policy

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1 Patient Access Policy SPONSOR: Jon Findlay - Chief Operations Officer AUTHOR: Scott West Associate Director of Contracts and Performance APPROVED BY: Referrals Management Group RATIFIED BY: Procedural Document Group TARGET AUDIENCE: All staff involved with patient appointments POLICY NUMBER: CM31 STRATEGY CATEGORY: Corporate Management (CM) This document is available in large print and alternative formats. Should you or someone you know require this in an alternative format please contact us on Ext or nicky.frost@southend.nhs.uk Cover Page

2 Patient Access Policy / CM31 / v6.0 Date Mar 2003 Aug 2005 Jun 2006 Oct 2011 Oct 2013 ISSUE AND REVISION RECORD: Version Details No 2 Detail changes 3 Detail changes 4 Detail changes 5 Full review inclusive of 18 week target 6 Full review inclusive of new guidance, NHS structures & Trust s CM-52 format. Review date Mar 2004 Aug 2006 Jun 2008 Oct 2013 Oct 2016 Page 2 of 54

3 Table of Contents 1 Introduction Purpose Definitions Duties National Operational Standards Outpatient Management Inpatient Management Inter-provider Transfer Monitoring compliance Associated documentation Equality Impact Assessment References Procedure Card 1 Outpatient Procedure Card 2.1 Outpatients Procedure Card Outpatients Procedure Card 3 Outpatients Procedure Card 3.1 Outpatients Procedure Card 4 Outpatients Procedure Card 5 Outpatients Procedure Card 6 Outpatients Procedure Card 7 Outpatients Procedure Card 8 Outpatients Procedure Card 9 Inpatients/Day Case Procedure Card 10 Inpatients/Day Cases Procedure Card 11 Inpatients/Day Cases Page 3 of 54

4 Procedure Card 12 Inpatient/Day Cases Procedure Card 13 Inpatient/Day Cases Procedure Card 14 Inpatients/Day Cases Procedure Card 15 Inpatient/Day Cases Procedure Card 16 Inpatients/Day Cases Procedure Card 17 Inpatients/Day Cases Procedure Card 18 Inpatients/Day Cases Procedure Card 19 Inpatients Procedure Card 20 Inpatients/Day Cases Procedure Card 21 Inpatients/Day Cases Procedure Card 22 Inpatients/Day Cases Procedure Card 23 Inpatients/Day Cases Page 4 of 54

5 1 Introduction This policy outlines the Trust s approach to the management of patients requiring an outpatient appointment or elective admission, ensuring that patients are seen: According to their clinical urgency (including 2 week wait target patients) in order of date received (i.e. on a first come first served basis) In the shortest time appropriate for their clinical need This policy applies to all members of staff dealing with patient appointments and takes account of the latest guidance from the Department of Health (DoH). 2 Purpose The policy aims to achieve the following across the Trust and Primary Care clinical pathways: Ensure that patients receive treatment according to their clinical priority, with patients of the same clinical priority treated in chronological order. Support the reduction in waiting times in line with the DH guidance, and the achievement of the Trust s locally agreed stages of treatment targets, alongside national access targets. Maintain the 100% target for patients with a booked appointment or TCI, thereby reducing DNA s, cancellations, and improving the patient experience. Provide a practical and easy to follow guide for those responsible for managing the day-to-day administration and clinical management of the patient pathway. Although the document cannot predict every eventuality, common sense will be required for cases that fall outside the policy. Ensure that all the information relating to the number of patients waiting, seen and treated is accurate and recorded on PAS. However, decisions made outside the policy will need to be justified and documented. Page 5 of 54

6 3 Definitions A&E ABUD BUD C2C CAC CCG DoH DNA FDT GDP GP GPSI MDT MIU NHS OPD PAS PTL RTT SHC SOT TCI UBRN WiC 2ww Accident and Emergency Associate Business Unit Director Business Unit Director Consultant to Consultant Clinical Assurance Committee Clinical Commissioning Group Department of Health Did not attend First Definitive Treatment General Dental Practitioner General Practitioner General Practitioner with Special Interest Multidisciplinary Team Minor Injuries Unit National Health Service Out Patients Department Patient Administration System. Patient Tracking List Referral to Treatment Sexual Health Clinic Stage of Treatment To come in Unique Booking Reference Number Walk in Centre Two Week Wait 4 Duties 4.1 Duties of Committees within the Trust Clinical Assurance Committee (CAC) is responsible for providing assurance and support on patient access to the Trust Board. It will monitor through the receipt of regular audit reports; that national and statutory requirements for access to services are being met. Referrals Management Group is responsible for the review and update of this policy, ensuring national and statutory requirements are fully reflected. In addition, it will facilitate the embedding of patient access requirements within Trust processes. 4.2 Duties of Individuals within the Trust Chief Executive as the Trust s Accountable Officer, has overall responsibility for ensuring the Trust provides appropriate and timely access to services for its patients. Page 6 of 54

7 Chief Operating Officer has strategic responsibility for the implementation of the patient access policy, monitoring of compliance and reporting performance to the Trust Board. Head of Performance and Patient Services is responsible for ensuring patient access procedural documents are appropriate, up to date and available when needed. Business Unit Directors (BUDs) are responsible for ensuring staff are aware of, and adhere to this policy. Service Managers are accountable for compliance to this policy within their service areas on a daily basis. All Staff Involved in the Administration of Patient Appointments are responsible for ensuring they are familiar with, and follow the Trust s policy and procedures relating to the patient access. 5 National Operational Standards As a general principle, the Trust expects before a referral is made for treatment that the patient is both clinically fit for assessment and possible treatment of their condition and is ready to start their pathway within two weeks of the initial referral. The Trust will work with CCG s, GPs and other primary care services to ensure patients understand this before beginning an elective pathway. The following national operating standards apply to all patients: 95% of non-admitted patients will receive their first definitive treatment within 18 weeks (127 days) of their referral. 90% of admitted patients will receive their first definitive treatment with 18 weeks (127 days) of the referral. No patient will wait longer than 6 weeks for a diagnostic test or image The following additional national standards apply to cancer patients: 93% of patients with suspected cancer who are referred urgently and patients with breast symptoms (where cancer is not suspected) must be seen within 14 days of the receipt of referral. 85% of patients referred through the urgent 14 day cancer referral route and subsequently diagnosed with cancer, will receive their first treatment within 62 days of the receipt of referral. 90% of patients referred from NHS Cancer Screening Programmes (breast, cervical and bowel) for suspected cancer will receive their first treatment within 62 days of the receipt of referral. Page 7 of 54

8 All patients referred through the urgent 14 day cancer referral route for children s cancer, testicular cancer, and acute leukaemia and subsequently diagnosed with cancer, will receive their first treatment within 31 days of the receipt of referral. Patients who are not referred through the urgent 14 day pathway but who have highly suspicious symptoms may be upgraded to a 62 day pathway at the request of a hospital specialist. 96% of patients diagnosed with any form of cancer will receive their first treatment within 31 days from the date the patient consented to treatment. All patients having a subsequent treatment following diagnosis of cancer, or recurrence, will receive their treatment within 31 days from the date the patient consented to treatment. Operational standards apply as below; o surgery [Operational Standard of 94%] o drug treatment [Operational Standard of 98%] o radiotherapy [Operational Standard of 94%] As a general principle, the Trust expects before a referral is made for treatment that the patient is both clinically fit for assessment and possible treatment of their condition and is ready to start their pathway within two weeks of the initial referral. The Trust will work with CCG s, GPs and other primary care services to ensure patients understand this before beginning an elective pathway. 5.1 Key principles The policy describes how the Trust will manage access to its services and ensure fair treatment to all patients. The successful management of RTT pathways is covered in this policy, as well as general principles for all patient access issues. It is vital that these principles are applied for the Trust to achieve the national objectives to reduce waiting times, improve patient care and patient choice. Everyone involved in patient access should have a clear understanding of his or her roles and responsibilities. The policy defines a number of good practice guidelines to assist staff with the effective management of patients requiring outpatient, diagnostic or in-patient/day case treatment. The advice given in this policy is, at all times, consistent with: the NHS Good Practice Guide and Guidelines for Good Administrative Practice, the NHS Data Manual, the Royal College of Surgeons and follows the RTT guidance. This policy will be applied consistently and fairly across the Trust. The Departmental Manager, Operational Manager, and Clinical Director for each directorate/ specialty have the overall responsibility for implementing the policy within their area. Page 8 of 54

9 Special exemptions exist for Military Veterans All Veterans should receive priority access to NHS secondary care for any conditions which are likely to be related to their service, subject to the clinical needs of all patients Persons in receipt of a War Pension will be given priority Hospital treatment for the condition for which they receive a war pension, except in the case of emergencies To ensure compliance with the policy the Trust will be audited routinely by the Audit Commission and/or District Audit. The Data Quality Team will also conduct regular reviews to ensure adherence to policy. 5.2 Pathway definitions Clock start definition: Any referral for a new condition starts the 18-week clock if it is expected that: o The patient will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional; and o Any treatment will or might be carried out by a consultant-led service, irrespective of setting. Referrals for a new condition to the following services do start 18-week clocks: o Consultant-led services irrespective of setting. o Cancer services (Please refer to policy CL15 Cancer Two Week Wait Policy) o Referral-management centres. o Practitioners with special interests if they are part of a referralmanagement arrangement as defined. Whose referrals can Start the Clock? Professions/services accepted by the Primary Care Trust/CCG s may commission 18-week pathways and start the clock, these include: o o o o o o o o o o o o General practitioners (GPs). General dental practitioners (GDPs). General practitioners (and other practitioners) with a special interest (GPSIs). Optometrists and Orthoptists. Accident & Emergency (A&E). Minor injuries units (MIU). Walk-in centres (WiC). Sexual Health Clinic (SHC) National screening programmes. Specialist nurses or allied health professionals with explicit CCG authorisation. Prison health services. Consultants (or consultant-led services) but specifically: Page 9 of 54

10 o Self referrals (subject to prior agreement with commissioners eg Sexual Health) For urgent non-related conditions, newly identified by the consultant, in which case this may cause a second clock to start (and a 31-day clock if cancer is the new condition) with any first clock still ticking. What defines the Clock Start date? o The clock-start date is the date on which the provider receives the patient s referral, or, in the case of clocks legitimately started by consultants, the date of the consultant s decision to start the clock. o For referrals made through Choose and Book, the clock starts on the date on which the patient converts their Unique Booking Reference Number (UBRN) to an appointment. o For non-choose and Book referrals (including those from GDPs, A&E, Walk-in Centres (WiCs) and others not currently connected to Choose and Book) the clock starts on the date on which the referral letter is received by the provider and initiates the start of the pathway. o When a patient is referred to another Consultant, for the same condition, either externally or internally, the Original Referral Date is the date the 18 week pathway commenced (for suspected cancer patients 62 day pathway). The same applies when the patient s pathway commences in primary care e.g. Orthopaedic triage or GPSI (GP with special interest). What does not Start the Clock? Referrals from primary care to the following services will not start the clock: o Therapy, healthcare science or mental health services that are not consultant led (including multi-disciplinary teams and community teams run by mental health trusts) irrespective of setting o Diagnostic services (i.e. direct to x-ray) if the referral is for the GP to make a decision about onward referral for treatment. o Primary dental services provided by dental students in hospital settings Clock Pauses The patient must be on an Elective Therapeutic Waiting List this excludes Diagnostic patients. Once the decision to admit has been made, the patient s clock may be paused for social reasons only to take account of the patient s availability, where they are unable to accept an appointment within the Trust s normal policy two reasonable offers with at least three weeks notice. In these circumstances their clock will be paused for up to 3 months. If the patient is unable to be treated within this longer period they will normally be referred back to the referrer. The Page 10 of 54

11 Trust will ensure patients are kept informed. The Trust will not pause patient pathways for clinical reasons. Cancer Patients Where a patient has requested thinking time prior to making a decision to proceed with a treatment option the clock will continue to tick. Regular contact should be made to ensure the patient is not lost in the system and is being given the support needed to make a decision about their treatment. The patient s clock will continue to tick during this period and must not be paused/adjusted, even if the patient requires longer to make a decision. Clock Stop definition The clock stops when a clinical decision is made that treatment is not required or when first definitive treatment begins. What Stops the Clock? The following clinical decisions stop the clock; these are to be taken from the date the decision is communicated to the patient and GP or original referrer if not the GP: o o o o o o Decision not to treat Patient declines treatment First definitive treatment Decision to embark on a period of active monitoring Decision to add a patient to a transplant list Decision to return the patient to primary care for non-medical/surgical consultant-led treatment First Definitive Treatment Definition First Definitive Treatment (FDT) is defined as an intervention intended to manage a patient s disease, condition, or injury and avoid further intervention. (Treatment will often continue beyond the First Definitive Treatment and after the clock has stopped). First Definitive Treatment can be: o Inpatient or day-case therapeutic treatment; the clock stops on the date of admission. o Diagnostic tests turned into therapeutic procedures during the investigation; for example, a colonoscopy which reveals a polyp that can be removed there and then. o The fitting of a medical device, with the clock stopping on the date on which definitive fitting or trial fitting begins, and with no undue delay in subsequent fitting sessions thereafter. Page 11 of 54

12 o Outpatient treatment (or consultant-led treatment irrespective of setting) if no subsequent inpatient or day-case admission is expected, with the clock stopping on the date of attendance. o First-line treatment less intensive treatments or medical management attempted with the intention of avoiding more invasive procedures or treatment, with a new clock starting if a decision is later taken to provide more aggressive treatment. o Therapy(e.g. physiotherapy, speech and language therapy, podiatry, counselling) or healthcare science interventions (e.g. hearing-aid fitting) if that is what the medical or surgical consultant-led service decides is the intervention intended to manage the patient s disease, condition or injury and avoid further intervention. o Prior Approval Patients - If it is determined that a patient requires a procedure that is an excluded procedure by the commissioners, the patient should be removed from the 18 week pathway and returned to the GP for approval to be sought. Once approved, the patient can be rereferred to the Trust with the approval documentation for the start of a new 18 week pathway. What does not Stop the Clock? The following examples do not stop the clock: o Administration of pain relief before a surgical procedure takes place, or other steps to manage a patient s condition in advance of definitive treatment o Consultant-to-consultant referrals for the same condition. o Referring to another Hospital for the same condition. Dealing with legitimate exceptions or delays There are important reasons why not every patient can, or should, be treated within these operating standards: o Patients for whom it is not clinically appropriate to be treated in 18 weeks (CLINICAL REASONS) o Patients who choose to wait longer for one or more elements of their care (CHOICE) o Patients who (choose not to) do not attend appointments (CO- OPERATION) These patients are taken into account in the tolerance set as part of the delivery standard: 5% non-admitted patients and 10% admitted patients 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. Clinical exceptions Page 12 of 54

13 A maximum of 18 weeks is the goal for every patient. In some cases, however, treatment in 18 weeks may prove not to be possible for clinical reasons. For instance: o o If a series of tests must be done in sequence Where the patient and consultant have agreed that the patient should receive a second opinion which despite best efforts adds a critical delay. There may also be patients for whom there is genuine clinical uncertainty about the diagnosis but where active monitoring (and clock stop) is inappropriate. However 18 weeks should remain the clear goal for every patient. Exclusion from RTT pathway Patients who are not part of an 18 week RTT Pathway include: o o o o o Emergency Admissions. Obstetric Patients. Elective Planned Patients (in sequence of treatment, where 1 st treatment is definitive treatment). Patients receiving on-going care where First Definitive Treatment has occurred, i.e. regular outpatient appointments or subsequent elective treatment. Patients on Active Monitoring. Active Monitoring The concept of Active Monitoring (watchful waiting) stops the clock and caters for periods of care without (new) clinical intervention e.g. three monthly routine check ups for diabetic patients. This is where it is clinically appropriate to monitor the patient in secondary care without clinical intervention or further diagnostic procedures, or where a patient wishes to continue to be reviewed as an outpatient, or have an open appointment, without progressing to more invasive treatment. Active monitoring (watchful waiting) can be initiated by either the patient or the clinician. If after a period of active monitoring, the patient or the Care Professional decides treatment is now appropriate a new clock starts. Cancer Patients Active monitoring/surveillance (in terms of cancer waits) can be used where a diagnosis has been reached but it is not appropriate to give any active treatment at that point in time but an active treatment is still intended. The patient is therefore monitored until a point in time when they are fit to receive or it is appropriate to give an active treatment. Page 13 of 54

14 Active monitoring will not be used while waiting for a diagnosis to be confirmed or staging to be completed; neither will it be used to allow for thinking time or to address capacity issues that mean the proposed active treatment would not be available in 31/62 days. Clinically initiated delays [or patient unfit for treatment] If a patient is not fit for surgery or diagnostic test, the Trust will ascertain the likely nature and duration. If the reason is that they have a condition that itself requires active treatment then the Trust and CCG have agreed that they will either be discharged back to the care of their GP or will be actively monitored for their original condition. Either action results in their pathway and clock being stopped. 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 will initiate a new clock start and pathway. Bilateral Procedures Patients who require bilateral procedures (on both sides) should initially be listed for the first procedure. The patient s pathway and clock starts for the first procedure when the referral is received by the first provider on the pathway or following a period of active monitoring. The clock for this first condition will stop when the patient is admitted for the procedure. When the patient is fit, ready and able to have a second procedure undertaken a new elective waiting list entry should be generated. A new pathway and clock will start when the patient is fit and ready for the second procedure and the clinician and patient agree the patient should be listed for the second procedure, this likely to be in an outpatient consultation where the decision to admit is made. The clock will stop for this second procedure when the patient is admitted. Examples of bilateral procedures can be joint replacements and cataract surgery. Planned Procedures By planned, this means an appointment/procedure or series of appointments/procedures as part of an agreed programme of care which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency. Examples as follows: o Patients 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 Page 14 of 54

15 o Patients where a decision to admit has been made but the surgery is best done at a specific age (e.g. cardiac surgery) o Patients awaiting admission for a further stage in a plan of treatments (e.g. maxillo-facial surgery requiring more than one admission, removal of metal work etc) but only where it is clinically not appropriate to proceed to offer the patient their next appointment yet. These patients should be added to the planned waiting list, having been given a date or approximate date at the time the sequencing was agreed with the patient as they are not waiting for treatment, only for a planned continuation of treatment; e.g. a series of pain relieving injections or epidurals. Patients should only be included on planned waiting lists if there are clinical reasons why the patient cannot have the procedure or treatment until a specified time. Once the patient is clinically ready for treatment to commence the clock should start. The normal rules would then apply to these patients however it must be clear that patients should experience no further delays. Planned patients are not waiting for initial treatment only for planned continuation of treatment. They are not classified as being on the waiting list for statistical purposes. 5.3 On-going Clocks A patient has an ongoing clock if they have had a clock start but have not yet had either their first definitive treatment or decision not to treat or been placed on active monitoring (watchful waiting). 5.4 DNA s Scenario 1 - DNA of a first appointment on an 18 week pathway this leads to clock nullification and return to primary care unless not clinically safe to do so. In which a new clock is started from the date the appointment is agreed with the patient. Scenario 2 - DNA at any other point is recorded as a clock stop and sent back to primary care. If the patient is reappointed then a new clock starts as in Scenario 1 above. The difference between the two is that in scenario1 the event is not reported while in scenario 2 it is. Exceptions Children - in line with legislation which deals with the protection and safeguarding issues around children another appointment may be arranged 2ww Where a patient first DNAs their initial outpatient appointment, the patient will automatically be offered a further appointment. Where a patient on a Page 15 of 54

16 suspected cancer pathway DNAs their initial appointment for the second time, then they should be discharged and referred back to the GP/GDP. This is to ensure that the patient is not left unmonitored in the system. Rapid Access Clinics Rapid access patients will have a further appointment arranged 5.5 Cancellations If a patient cancels an appointment or TCI anywhere in an RTT pathway, another appointment will be made. If the patient cancels an appointment or TCI date for a second time at any point in the pathway (only 1 cancellation allowed in the whole pathway), the patient will be returned to the care of the referrer and the RTT clock will stop. If they are subsequently re-referred, this will start a new 18 week RTT pathway. If the Trust cancels an appointment or TCI anywhere on an RTT pathway, the clock continues to tick. For an Out-patient or Diagnostic appointment, the patient should be re-dated within the Trust s Stage of Treatment (SOT) targets (6 weeks for Diagnostics). Patients on a cancer pathway If after two patient cancellations, the patient requests a third or more, following discussion between the hospital clinician, GP/GDP and with the patient, a decision may be taken to discharge the patient back to the care of their GP/GDP if this is deemed to be in the best interests of the patient, and a dictated letter should follow. The Trust must obtain consent from the patient and document this on the PAS system before discharging the patient. Again, this is to ensure that the patient is not left unmonitored in the system. 6 Outpatient Management Referrals are received from general practitioners, general dental practitioners, other healthcare professionals and hospital consultants. 6.1 Referrals All correspondence relating to patients should include the NHS number as the primary identifier where available. Referral letters should either be addressed to a specific consultant or as open referrals to a specialty, where this is appropriate. Patients referred as open referrals to a specialty will be allocated to the Consultant (with that special interest if appropriate) having the shortest waiting time. If a referral is received: Page 16 of 54

17 o With insufficient information to enable the Consultant to determine the appropriateness of the referral and/or the patient s prioritisation, or o Where agreed protocols have not been followed The referral should be rejected. 2ww Target Referrals (Suspected Cancer) To meet required NHS standards, these referrals must be seen by a specialist within 14 days of receipt of the referral. To help ensure that we achieve this, referrals: o must be received at the Trust within 24 hours of the decision to refer, o must comply with the agreed referral protocol. GPs must ensure that a Choose and Book two week wait appointment is booked before the patient leaves the Surgery. The letter must be attached immediately to allow the Trust to process the referral in time. Non choose and book referrals should be faxed to the dedicated fax number ( ). The Trust will attempt to contact the patient on at least two occasions on different days and at different times to negotiate the appointment date and time. A patient will be tracked from the moment a suspected cancer referral is received and appointment made, right until end of treatment (which may include several subsequent treatments) or at the point of confirming that the disease is benign. This includes recording of all appropriate appointments and treatments that the patient undertakes along their cancer pathway (whether the patient started their cancer treatment at this Trust or elsewhere). If the Trust receives a referral for a patient for a service we do not provide as we are not commissioned to provide the service i.e. a referral sent to the wrong organisation, then it should be immediately forwarded to an appropriate provider, thereby ensuring there is no delay to the patient pathway. Choose and Book Referrals GPs must ensure that the referral letter is attached to the created UBRN within 3 days for a routine appointment, 2 days for an urgent appointment and within 24 hours for a 2 week wait appointment. If a referral has been made and the special interest of the Consultant does not match the needs of the patient, the referral will be redirected. The clock starts from the first referral. Non Choose and Book Referrals Page 17 of 54

18 Any referral not received via Choose and Book should be faxed to the rightfax server, so that an electronic version of all referral letters is available. All non choose and book referrals will be entered on to PAS (Patient Administration System) and forwarded to the respective Consultants/ respective Health Care Professional for grading. If a referral has been made and the special interest of the Consultant does not match the needs of the patient, the referral will be redirected. The clock starts from the first referral. Patients who do not respond to an invite letter within two weeks of the date of letter will be discharged from PAS (one week for diagnostics). Consultant to Consultant Referrals C2C agreed criteria: o Suspected/diagnosed cancer. o Part of 18-week pathway for example onward referral to another consultant for the same condition for patients to receive first definitive (18- week clock is still ticking). o As part of the management of a long-term care patient requiring onward referral to another consultant for specialist advice/ treatment, whose symptoms directly/indirectly relate to the long-term condition. o All children under the age of 16. C2C will not be approved: If a condition unrelated to the original referral has been identified, the patient should be referred back to the GP C2C Redirection: Where there are sub specialties within a department a consultant may wish to redirect a referral to a colleague (clock continues to tick) 6.2 Appointments Cancer Appointments The patient should be contacted by telephone, within 24 hours of referral receipt, and an appointment agreed within the two week target. Where time permits, confirmation must be sent in writing. If unable to contact the patient, an appointment should be made and sent to the patient by first class post. The patient should be given reasonable notice, usually 2 days of receipt of letter. Once an appointment has been made following receipt of a GP/GDP suspected cancer referral, the Trust will add the date and time of the appointment on the proforma or letter and this is then faxed back to the GP/GDP within 24 hours. Page 18 of 54

19 This is to notify the GP/GDP that the appointment has been made but also so that they can assist with ensuring that their patient attends the urgent appointment. Where a patient is admitted as an emergency for the same condition as their 2WW referral (i.e. related to the suspected cancer) before they are seen they should no longer be recorded against a two week wait standard. The emergency admission is the referral into the system and effectively supersedes the original referral. However, such a patient could be upgraded onto the 62 day pathway if a consultant or authorised member of their team suspect cancer is the cause of the admission. Patients who are admitted as an emergency for a different condition, continue with their existing pathway. If a patient fails to accept an appointment within 14 days, the offer should be recorded on PAS and another appointment offered within 14 days of the rejected appointment. Patients will only be discharged where there are no means possible to contact the patient to negotiate their appointment over the telephone or send an appointment to the patient in the post. Before the patient is discharged, the Trust must contact their GP/referrer to ensure that no other contact details are available. Should the Consultant consider the two-week wait referral to be clinically inappropriate then this should be discussed with the GP/GDP and the GP/GDP asked to withdraw the two-week wait priority. If this request to withdraw the referral is authorised by the GP/GDP then the twoweek wait referral must be withdrawn by the GP/GDP and then re-submitted as an 18 week referral. If the request is not authorised by the GP/GDP then the patient will remain on the two-week pathway and the clock will continue to tick. A consultant upgrade may occur where a referral is received and the receiving consultant (or other designated member of the clinical team) considers that the patient should be monitored on a 62 day cancer pathway as it is likely that the symptoms point towards a diagnosis of cancer. This decision to upgrade must be made on or before the first time a patient is discussed at a Multidisciplinary team (MDT) meeting otherwise the referral will not be eligible for an upgrade. Once the decision to upgrade has been made the Trust will communicate this to the relevant GP/GDP at the earliest opportunity. Choose and Book Appointments An appointment will be booked by the GP or patient using the choose and book system. Non Choose and Book Appointments Page 19 of 54

20 Once the referral letter has been graded by the consultant, patients will be contacted by the relevant call centre to book the next available appointment according to their clinical priority. Appointment protocol for Prisoners Refer to Procedure Card 8 Overseas Visitors The Overseas Visitors Manager (OVM) at the Trust must be notified of ALL Overseas Visitors and Non Residents who present for UK NHS Treatment in order to decide whether they are covered by a health care agreement or have to meet the cost of their treatment. As part of the process of identifying a patient s entitlement to free health care a Confidential Patient Registration Form (Stage I) should be completed. Emergency ( blue light ) treatment will always be provided free of charge. However, following initial treatment in Accident and Emergency further in-patient treatment may well be chargeable consequently there remains a need to ensure completion of the Stage 1 form as soon as possible. An Overseas Visitor s right to receive NHS care free of charge must be verified noting that care classified as being required urgently may be given prior to the patient s chargeable status having been confirmed. An invoice for treatment may be issued after such treatment has been provided. Patients should be made aware that they may have to pay for treatment but staff should not cancel any treatment bookings without reference to the Overseas Visitors Manager (OVM) who will consider each case details individually involving an appropriate Consultant as necessary. The UK has reciprocal agreements with some countries that entitle the patient to necessary healthcare provision either free of charge or at a reduced cost, but this is limited to emergency and necessary treatment only and does not include pre planned treatment. Where there is no reciprocal agreement in place to cover the patient s treatment the patient will either be required to pay in full for the expected cost of their treatment or sign an undertaking to pay. The OVM will determine the appropriate course of action during a formal Stage II interview having regard to the National Health Service (Changes to Overseas Visitors) Regulations On completion of the interview process the OVM will amend PAS to reflect the patient s status. 1 See decision tree flow diagram for guidance contained at page 50 in the Department of Health s GUIDANCE ON IMPLEMENTING THE OVERSEAS VISITORS HOSPITAL CHARGING REGULATIONS At: df Page 20 of 54

21 There are three categories of Overseas Visitors and Non Residents and all accepted referrals or waiting list entries should have the category recorded correctly. o All Fees (patient liable for costs) o Reciprocal Agreement (exempt from charges) o Exempt (other reasons) List of EEA countries where bilateral agreements apply: Austria France Liechtenstein Romania Belgium Germany Lithuania Slovakia Bulgaria Greece Luxembourg Slovenia Cyprus (not North) Hungary Malta Spain Czech Republic Iceland Netherlands Sweden Denmark Ireland Norway Estonia Italy Poland Finland Latvia Portugal Switzerland has a separate agreement with the EU A List of Non-European Countries with bilateral healthcare agreements can be obtained from the Overseas Patients Department. Patients who convert between NHS and Private Sector Refer to Procedure Card 20 Patients who do not attend an outpatient appointment (DNA) o New patients who DNA and have agreed their appointment with the Trust should be discharged from the Choose and Book and the PAS system. The clinician may wish to review the referral and contact the referrer as necessary. The patient may be re-referred at the referrers discretion. o Follow-up Patient DNA s - Patients who do not attend their follow-up appointment should be discharged back to the referrer. The Consultant or appropriate professional may review their case notes. The patient should not be offered another appointment unless there are exceptional / clinical circumstances. Cancer Appointments Where a patient first DNAs their initial outpatient appointment, the patient will automatically be offered a further appointment. Where a patient on a suspected cancer pathway DNAs their initial appointment for the second time, then they should be discharged and referred back to the GP/GDP. This is to ensure that the patient is not left unmonitored in the system. Page 21 of 54

22 Patients who are unable to agree an appointment when offered Patients should be offered a minimum of two appointment dates with a minimum of three weeks notice to the first date. NB Earlier appointments can be offered but would not be deemed reasonable if the patient declines. If the patient is unable to accept a date long term, they should be told that we are unable to make appointments beyond the Target time and they should contact their referrer to re-refer them when they are ready and available. All dates offered to the Patient should be recorded on PAS. Offer minimum of two appointment dates with minimum of three weeks notice to the first date. NB Earlier appointments can be offered but would not be deemed reasonable if the patient declines. Cancer Appointments Cancer waiting times are too short for the usual Trust definition of reasonable offer (3 weeks notice and choice of 2 dates) to apply. NICE guidance says that an offer was reasonable if there was a sufficient amount of notice and the provider took account of personal circumstances. Patients who fail to follow pre-clinic instructions resulting in cancellation Where patients have been given explicit instructions prior to attendance which are not followed and result in the patient being cancelled, this will be recorded on PAS as a Patient Cancellation. Only one other appointment will then be offered to the patient providing they haven t cancelled before. If the patient does not follow the instructions the second time, they will be referred to the Clinician and removed from PAS. Patients who cancel an appointment Patients who cancel their outpatient appointment should be given an alternative date at the time (where possible) and informed if they are unable to keep the appointment they will be discharged. If a patient attempts to change the second appointment, they should be discharged unless there are exceptional / clinical circumstances. The patient may be re-referred at the referrers discretion. Appointment request should be cancelled on Choose & Book. Cancer Appointments Patients who are subject to the 2 week cancer wait must be offered a further date, regardless of the number of patient cancellations, taking in to consideration the length of the patient pathway. 6.3 Clinic Management Page 22 of 54

23 Clinic cancellation or reduction It is accepted that clinics will be cancelled or reduced due to absence of clinical staff e.g. study leave, annual leave, audit, post take ward rounds etc. However, once given an appointment, if cancelled by the Trust, the patients waiting time continues from the receipt of the original referral date. To minimise the Trust cancellation of patients already booked, ideally, a minimum of 11 weeks notice and no less than 6 weeks, of planned annual leave or study leave should, in normal circumstances, be given when a consultant requires a clinic to be cancelled or reduced. Where patients have to be cancelled at short notice, clinicians need to indicate clearly which patients need to be given an urgent appointment at the next available clinic. Wherever possible, patients that have previously been cancelled should not be cancelled a second time. When clinics have to be unavoidably cancelled on the day, the clinic staff must inform the Departmental Manager. If the Departmental Manager is not available the cancellation must be escalated to the appropriate ABUD/BUD. Clinic outcomes Every outpatient attendance must be recorded on PAS and the 18 week clinic outcome sheet completed where appropriate. If a patient has been added to the waiting list, a TCI card must be completed by the clinician and sent to the appropriate booking clerk within 1 working day. The appropriate outcome must be registered against their appointment on PAS. Unknown should not be used and the clinic should not be reconciled until all outcomes are complete. Reconciliation should occur within 24 hours of the clinic taking place. An outcome can have an open appointment for up to 6 months at which point they should be referred to their GP if they require an appointment after that date. Patients may have more than one clock ticking simultaneously (patient pathway) if they have been referred to and are under the care of more than one clinician at any point in time. Each pathway must be measured and monitored separately and will have a unique pathway ID number in PAS. 7 Inpatient Management 7.1 Adding patients to Inpatient and Day Case Elective Waiting List The decision to add a patient to a waiting list must be made by a consultant or others with agreed authority. Before a patient is added to the waiting list, they should be clinically and socially ready to have the procedure at the time this decision is made. Page 23 of 54

24 7.2 Patients listed for more than one procedure On occasions a patient may be on more than one waiting list for different specialties. They may also be admitted as an emergency while on the waiting list. Where it is identified that the patient is on the waiting list for two procedures, the general service manager should be contacted, to gain priority status from the relevant consultant. Where it is identified that the patient on the waiting list has had the procedure at a prior admission, the waiting list administrator should remove the patient from the waiting list on PAS. 7.3 Patient choice Patients should, whenever possible, agree dates for admission, at the time when the decision to admit is made. These patients are added to the elective waiting list and included in all statistical returns and monitoring. Patients should be offered the choice of two dates with a minimum of three weeks notice (two weeks notice for diagnostics). If the patient can not agree either date, they should be removed from the waiting list and the clock stopped. All dates offered to be recorded on PAS. Cancer Appointments All offers of admitted treatment are considered reasonable if they are between the start and end of the relevant cancer pathway, but should account for the preparations and planning that patients (and carers) often need to take and the clinical priority of the patient. 7.4 Information about the patient Patient s demographics and all patient contact numbers must be checked, as detailed in Trust Policy IS-26 Policy for the Management of Data Quality. 7.5 Confirmation to the patient When a patient is added to the waiting list they will receive a confirmation letter and relevant information leaflet, if appropriate. 7.6 Selecting patients for admission Patients will be selected for an admission date via the 18 week pathway and PTL lists. When a patient is selected for admission they will be booked according to their clinical urgency, in order of date received (i.e. on a first come first served Page 24 of 54

25 basis) and In the shortest time appropriate for their clinical need which will include booking the patient on PAS and the Sapphire System. 7.7 Routine admissions All patients requiring inpatient or day case surgery must be pre-operatively assessed, using either a paper, telephone or clinic attendance system, depending on the nature of the surgery. Ideally, assessment should take place a minimum of 2-3 weeks prior to surgery however this can be up to 8 weeks. When each patient is pre-assessed, it is the responsibility of the Pre-assessment nurse to inform the Waiting List Administrator of any changes in the patient s circumstances. If it is discovered that the patient is not fit for surgery, the Waiting List Administrator must keep the patient record updated which may include removing the patient from the waiting list. Once an admission date has been agreed with the patient they will receive a TCI (to come in) letter which will outline: Date and time of admission Arrangements for transport Where to report on arrival Response required from the patient Named contact for queries relating to admission Reference to instructions for admission and/or booklet Request to check bed is available on the day of admission Reasons for checking bed availability Information about planned treatment Pre-operative instructions 7.8 Trust cancellations If the Trust cancels an operation/procedure after admission or on the day of admission for non-medical reasons the patient MUST be given a re-arranged date within the 28 days of their original date. This must be noted on the waiting list record to ensure that this patient is not cancelled again. If the patient cannot accept the first offered date, this must also be recorded on PAS and on the TCI card. If a date cannot be arranged within the 28 days, this must be escalated to the Departmental Manager. 7.9 Expediting patients for elective admission Patient admissions should only be expedited on the advice of the referring practitioner where they believe that the patient s condition has deteriorated to warrant them being admitted more quickly than planned with the agreement of the consultant. Alternatively, the patient could be seen in outpatients to evaluate their condition, confirm their level of priority and that they are both fit and available for admission. Page 25 of 54

26 7.10 Patient cancellations Patients who self-defer for a valid reason should be informed of the likely arrangements for their future admission. Wherever possible, they should be given a re-arranged date at the time of deferral. A patient can only cancel their admission if they have not previously cancelled anywhere in the pathway. If the second agreed TCI date is cancelled the patient should be removed from the waiting list. A letter must be sent to the patient and the referrer explaining the decision, and a copy attached to the TCI card Patients who do not respond to Invite Letter Patients who do not respond to an invite letter within two weeks of the date of letter (one week for diagnostics) will be removed from the waiting list; for patients who subsequently make contact are advised to return to the referrer Patients who Do Not Attend The patient has the responsibility to attend a reasonably offered admission date or to inform us when they are unable to. When they give no advance warning of not attending the admission date, they must be recorded as Did Not Attend (DNA). If the patient has agreed the admission date in advance and it has been offered under reasonable guidelines, the patient will be removed from the waiting list and returned to the care of their referrer. Patients who are on the waiting list who are subsequently unavailable to accept an appointment will be removed from the waiting list. A letter of confirmation will be sent to the patient, the General Practitioner and the referrer Pause (excludes diagnostics) A clock may be paused only where a decision to admit has been made, and the patient has declined at least two reasonable appointment offers for admission. The clock is paused for the duration of the time between the earliest reasonable offer and the date from which the patient makes themselves available again for admission. Clocks may only be paused for patient initiated delays at the admission for treatment stage of the waiting time pathway. Once a decision to admit has been made, patients should, of course, be offered the earliest available dates to come in, as appropriate. However, where patients decline these offers, then, for a clock to be paused, they must be offered at least reasonable dates for admission. Reasonable is defined as an offer of an appointment with at least three weeks notice (two weeks for diagnostics). If the patient also declines these offers, then their clock may be paused from the date of the earliest reasonable offer. In order to ensure that the patient s Page 26 of 54

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