REFERRAL TO HOSPITAL ACCESS POLICY INCLUDING DID NOT ATTEND (DNA) AND COULD NOT ATTEND (CNA)

Transcription

1 REFERRAL TO HOSPITAL ACCESS POLICY INCLUDING DID NOT ATTEND (DNA) AND COULD NOT ATTEND (CNA) Last Review Date September 2014 Approving Bodies NHS Doncaster Clinical Commissioning Group Doncaster & Bassetlaw Hospitals NHS Foundation Trust Date of Approval September 2014 Date of Implementation September 2014 Next Review Date September 2017 Review Responsibility NHS Doncaster Clinical Commissioning Group Doncaster & Bassetlaw Hospitals NHS Foundation Trust Version Version 8 Page 1 of 36

2 REVISIONS/AMENDMENTS SINCE LAST VERSION Date of Review October 2013 to August 2014 Amendment Details Policy changed to reflect the transition from Doncaster Primary Care Trust to NHS Doncaster Clinical Commissioning Group (CCG) as statutory body. Updated to reflect latest Planning Guidance, NHS Mandate and Constitution. Heading numbers, paragraph numbers and layout of policy changed to reflect the standard Policy on Procedural Documents approved by NHS Doncaster CCG governing body on 2 April Clarified: Length of time allowed for treatment delays. DNA and CNA s. Timescales for prior approval requests. The section on Follow up waiting lists. Definition of vulnerable patients. Timescales for reviewing referrals. Page 2 of 36

3 CONTENTS PAGE Section A Policy 5 1. Policy Statement, Aims & Objectives 5 2. Legislation & Guidance 6 3. Scope 6 4. Accountabilities & Responsibilities 7 5. Dissemination, Training & Review 10 Section B Procedure Week Clock Rules 1.1 Clock Starts 1.2 Clock Pauses 1.3 Clock Stops 1.4 Consultant to Consultant Referrals 1.5 Did Not Attend (DNA) 1.6 Can Not Attend (CNA) 2. Referral, Diagnostic and Admission Procedures 2.1 Outpatient referrals Reasonableness of appointments Open referrals Named consultant-led teams Managing electronic referrals Clinic cancellation or reduction Patients found to be unfit for treatment at outpatient appointment 2.2 Diagnostic referrals Reasonableness of diagnostic appointments 2.3 Adding patients to an inpatient waiting list Patients not fit for surgery Selecting patient for admission Confirmation to the patient Reasonableness of dates for admission Patients who choose to delay admission Cancellations on day of surgery Patient exclusions for 18 week waits Tertiary Referrals and Inter-Provider Transfers (IPT) 20 Page 3 of 36

4 4. Cancer Referrals 21 Two Week Wait 31 Day Standard (Decision to Treat to 1 st Definitive Treatment) 31 Day Standard (Subsequent Treatment) 62 Day Standard (Referral to 1 st Definitive Treatment) Tertiary Referrals optimum time to referral Managing Patients on the 18 Week Pathway Patients Transferring Between NHS and Private Care New Developments Affecting Waiting List Management Quality Assurance Education and Training Security and Confidentiality References Appendices A Definitions 25 B C D E F G National 18 Week Referral to Treatment (RTT) Guidance Guidance for decision making when a child does not attend a hospital appointment Access to Health Services for Military Veterans Priority Treatment Protocol for Urgent Referrals into Children s Clinical Service Unit Consultant to Consultant Referral Pathway Patient DNA Pathway Page 4 of 36

5 SECTION A POLICY 1. Policy Statement, Aims & Objectives 1.1 This policy highlights the key principles that govern effective and reliable referral and admission management throughout Doncaster s local health community. The policy is in place to ensure patients attending for elective care receive timely, equitable treatment in line with national access standards and the NHS Constitution. 1.2 The aims and objectives of this policy are to ensure: The processes of referral, diagnostic and admission management are transparent to the public and external organisations, including procedures for the management of: Consultant to consultant referrals DNA s CNA s Patients receive treatment in line with agreed access targets according to their clinical priority, with routine patients and those with the same clinical priority treated in chronological order. The time patients spend on the waiting list is minimised to improve the quality of patient experience. The number of cancelled operations for non-clinical reasons is reduced. Patients maximise their right to patient choice in the care and treatment they need. Patients are fit, ready and willing to access services within a maximum of 18 weeks. The exception being patient choice and overriding urgent patient pathways. The number of patients with a booked outpatient or in-patient/day case attendance is increased, thereby minimising Did Not Attends (DNA), cancellations and improving patient experience. All referrals, additions and removals from the waiting list will be made in accordance with national Referral to Treatment policy. The provider shall ensure that patients meet all waiting time parameters for follow up/review appointments and will provide in-trust based intelligence early indication of any waiting time difficulties to meet Department of Health and commissioner specifications. Clear lines of responsibility and accountability are outlined in respect of accuracy and reliability of waiting list and diagnostic information. Clarity around consultant to consultant referrals (including referrals initiated by junior medical staff and nurse specialists) Consultants will only refer directly to other consultants in urgent cases (e.g. two week wait conditions or other urgent Page 5 of 36

6 conditions), or for conditions related to the original reason for the referral ( related conditions ). Military 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, in line with current guidance. (See Appendix D). 2. Legislation & Guidance 2.1. The following legislation and guidance has been taken into consideration in the development of this policy: Health and Social Care Information Centre (SCIC) National Data Set for Referral to Treatment Consultant-Led Waiting Times Measurement NHS Constitution (2013) Department of Health Everyone counts: Planning Guidance as applicable The Mandate A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015 (2012) Department of Health Referral to treatment consultant-led waiting times - Rules Suite (2014) Department of Health Operational guidance to the NHS: Extending Patient Choice of Provider (2011) Department of Health Standard NHS Contract as applicable Maximum Waiting Times Guidance for Commissioners (2013) NHS England Commissioning Policy: Defining the boundaries between NHS and Private Healthcare Reference: NHSCB/CP/12 (2013) NHS Commissioning Board PAT/PS10 v5 Doncaster and Bassetlaw Hospitals NHS Foundation Trust Safeguarding and Promoting the Welfare of Children PAT/PS8 V3 Doncaster and Bassetlaw Hospitals NHS Foundation Trust Safeguarding Adults Policy 2.2 This policy should also be used in conjunction with the policy for management of overseas visitors, policy on procedures of low clinical value (prior approval), cancer access policy, military veteran guidance and the outpatient guide. 3. Scope 3.1. This Policy reflects the overall expectations of the provider and commissioner on the management of referrals and admissions into and within the organisation, and defines the principles on which the policy is based. A separate Referral to Treatment Access Procedure Manual reflects the processes by which the policy expectations are activated. Page 6 of 36

7 3.2 This Policy is intended to be of interest to and used by all individuals within the partnership organisations, who are responsible for referring patients, managing referrals, adding to, and maintaining waiting lists for the purpose of organising patient access to hospital treatment and is not intended to be exclusive to medical waiting list management. Whilst doctor and consultant may have been used throughout, this is for the purpose of simplicity. 4. Accountabilities & Responsibilities 4.1 Good practice determines that a clear distinction is drawn between the roles of staff responsible for meeting targets, and those responsible for reporting on performance (Audit Commission, 2003). Having in place up to date policies and procedures, reliable, valid data collection systems and appropriate training for key staff is essential to the accuracy of referrals and waiting list information and management. 4.2 Whilst responsibility for achieving targets lies with the Operational Boards, accuracy of the referral and waiting list information is the responsibility of all staff that have access to and responsibility for the upkeep of systems that hold referral and waiting list information, during the course of their work. 4.3 Provider Accountabilities & Responsibilities Overall accountability for ensuring that there are systems and processes to guarantee effective and reliable referral and admission management throughout Doncaster s local health community, lies with the Chief Executive responsibility is also delegated to the following individuals: Chief Operating Officer Has delegated responsibility for ensuring: the Policy is adopted by the organisation following formal governance process compliance with the Policy and national requirements clinical staff are aware of and comply with all elements of the Policy practical implementation and monitoring by the Clinical Services Units (CSU) General Managers patients are provided with information of their right to be treated within the waiting time standards and details of who to contact if they feel these standards have been breached A robust waiting list module of the Patient Administration System (PAS) will be used to administer all inpatient and day case waiting lists; the outpatient module is used to administer all outpatient referrals. For diagnostic investigations, and some other services, this may be on local bespoke systems. In addition, the provider will use a weekly Patient Tracking List (PTL) to track patients through the 18 week RTT pathway and 31/62 day cancer pathways. Page 7 of 36

8 General Managers of all Clinical Services Units It is the responsibility of all General Managers to ensure: the Policy principles and definitions are applied to all aspects of individual speciality pathways, and referrals and waits managed and measured accordingly robust education and training processes for all members of staff (including all employees, whether full/part time, agency, bank or volunteers) to understand the 18 Week principles and definitions that the allocation and availability of slots between two week wait, urgent and routine appointments is robust enough to meet all targets, and that enough electronic capacity is available on the system to avoid appointment slot issues clinical staff understand their obligation to identify prior approval referrals outlined at 4.3 below, and follow the agreed process That centralised booking teams and speciality outpatient coordinators are aware of their responsibility for clinic management on a daily basis. Clinicians will be able to amend the make-up of their clinics by working with these groups to refine their Directory of Services in order to ensure that capacity is available to meet contracted demand Directory of Services are reviewed as appropriate and kept up to date For referrals for conditions not related to the original referral the patient will be returned to their GP. The GP should be informed by letter with a clinical opinion on options for further management of the patient s condition. The Trust will ensure that all of its clinical staff are aware of and comply with this. At the point where a consultant, or nurse specialist, makes the decision to refer an existing patient onto another consultant within the trust or to another service provider, the patients registered GP must receive notification and details of the nature of the referral within 5 working days of the referral. 4.4 Commissioner Accountabilities & Responsibilities Overall accountability for ensuring that there are systems and processes to guarantee effective and reliable referral and admission management throughout Doncaster s local health community, lies with the Chief Operating Officer. Responsibility is also delegated to the following individuals: Page 8 of 36

9 Chief of Strategy and Delivery Has delegated responsibility for ensuring: the Policy is adopted by the organisation following formal governance process administrative, clinical staff within the CCG and its stakeholders are aware of and comply with all elements of the Policy patients are provided with information of their right to be treated within the waiting time standards and details of who to contact if they feel these standards have been breached The CCG will work with Primary Care clinicians to ensure they are aware of their responsibility to inform the patient if they are on a cancer pathway and to ensure the patient understands why they are being referred. Head of Performance Head of Contracting Heads of Strategy & Delivery It is the responsibility of all CCG leads to ensure: All members of staff (including all employees, whether full/part time, agency, bank or volunteers) understand the 18 Week principles and definitions. communication and education for administrative, clinical staff within the CCG and its stakeholders to understand and comply with all elements of the Policy the Policy principles and definitions are applied to all aspects of individual speciality pathways, and referrals and waits managed and measured accordingly. 4.5 Prior Approval Schedule There are a number of interventions/procedures for which CCGs have published specific policy statements, setting out restrictions to access, based on evidence of clinical effectiveness or relative priority funding. Page 9 of 36

10 4.5.2 Procedures not commissioned by the CCG should not be carried out by providers and will not be paid for unless prior approval (via an Individual Funding Request (IFR)) has been agreed by the CCG/and/or the West and South Yorkshire and Bassetlaw Commissioning Support Unit (WSYBCSU). The WSYBCSU should respond to all prior approval requests within 5 working days (for routine procedures) and one working day for urgent procedures Any GP referring for a specific exclusion procedure is responsible for obtaining prior approval for funding before referring the patient to secondary care. The Prior Approval letter should be sent/attached with the referral letter. If the provider receives a referral for an exclusion procedure that doesn t include evidence of prior approval, this should be returned to the referring GP. The commissioner will not pay for the procedure if it is carried out without prior approval If a GP refers a patient for an opinion and following the outpatient appointment the consultant decides that a restricted procedure is required then it is the responsibility of the consultant to obtain prior funding approval. If the procedure is carried out without this approval then the commissioner will pay for the outpatient attendance, but will not pay for the procedure. 5. Dissemination, Training & Review 5.1. Dissemination The effective implementation of this document will support openness and transparency. NHS Doncaster CCG along with Doncaster and Bassetlaw Hospitals NHS FT will: Ensure all staff and stakeholders have access to a copy of this procedural document via the organisation s website. Communicate to staff any relevant action to be taken in respect of complaints issues. Ensure that relevant training programmes raise and sustain awareness of the importance of effective complaints management This policy will form part of the NHS standard contract documentation Training All staff will be offered relevant training commensurate with their duties and responsibilities. Staff requiring support should speak to their line manager in the first instance Review As part of its development, this document and its impact on staff, patients and the public has been reviewed in line with NHS Doncaster CCG s Equality Duties. The purpose of the assessment is to identify and if possible remove any disproportionate adverse impact on employees, patients and the public on the grounds of the protected characteristics under the Equality Act This Policy will be reviewed 3-yearly, and in accordance with the following on an as and when required basis: Page 10 of 36

11 Legislatives changes Good practice guidelines Case Law Significant incidents reported New vulnerabilities identified Changes to organisational infrastructure Changes in practice Updates in NHS guidance Procedural document management will be performance monitored to ensure that procedural documents are in-date and relevant to the core business of both organisations. The results will be published in the regular Governance Reports. Page 11 of 36

12 SECTION B PROCEDURE Weeks Clock Rules The national 18 week rules can be found at Appendix B, with the following section detailing the local application of these rules. The 18-week pathway does not replace existing shorter waiting time guarantees, for example cancer and heart disease waits. 1.1 Clock Starts A waiting time clock starts when any referring healthcare professional refers to: a) a consultant led service, with the intention that the patient will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional or general practitioner; b) an interface, 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 A waiting time clock also starts upon a self-referral by a patient to the above services, where these pathways have been agreed locally by commissioners and providers and once the referral is ratified by a care professional permitted to do so The waiting period starts: 1.2 Clock Pauses a) at the point of conversion of the Unique Booking Reference Number in Choose and Book (CAB), or b) when the provider receives a manual referral letter A clock may be paused only where a decision to admit for treatment 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 for treatment. 1.3 Clock Stops A clock stops for treatment when: a) First definitive treatment starts. This could be: i) Treatment provided by an interface service; ii) Treatment provided by a consultant-led service; iii) Therapy or healthcare science intervention provided in secondary care or at an interface service, if this is what the consultant-led or interface Page 12 of 36

13 service decides is the best way to manage the patient s disease, condition or injury and avoid further interventions; b) A clinical decision is made and has been communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay, to add a patient to a transplant list Clock stops for non-treatment a waiting time clock stops when it is communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay that: a) It is clinically appropriate to return the patient to primary care for any nonconsultant-led treatment in primary care; b) A clinical decision is made to start a period of active monitoring; c) A patient declines treatment having been offered it; d) A clinical decision is made not to treat; e) A patient DNAs (does not attend) their first appointment following the initial referral that started their waiting time clock, provided that the provider can demonstrate that the appointment was clearly communicated to the patient; f) A patient DNAs any other appointment and is subsequently discharged back to the care of their GP, provided that: i) The provider can demonstrate that the appointment was clearly communicated to the patient; ii) Discharging the patient is not contrary to their best clinical interests; iii) Discharging the patient is carried out according to local, publicly available/published, policies on DNAs; iv) These local policies are clearly defined and specifically protect the clinical interests of vulnerable patients (e.g. children) and are agreed with clinicians, commissioners, patients and other relevant stakeholders. 1.4 Consultant to Consultant Referrals (flow chart at Appendix F) Consultants will only refer directly to other consultants in urgent cases (e.g. two week wait conditions or other urgent conditions), or for conditions related to the original reason for the referral ( related conditions ) For referrals for conditions not related to the original referral the patient will be returned to their GP. The GP should be informed by letter with a clinical opinion on options for further management of the patient s condition. The Trust will ensure that all of its clinical staff are aware of and comply with this At the point where a consultant, or nurse specialist, makes the decision to refer an existing patient onto another consultant within the trust or to another service provider, the patients registered GP must receive notification and Page 13 of 36

14 details of the nature of the referral within 5 working days of the referral. Consultant to Consultant referrals for related conditions will be included within the 18 week pathway, with the wait continuing from the original referral Consultant to consultant referrals for a different condition will start a new patient pathway with a new 18 week pathway clock. The original referral wait will continue concurrently until the patient is discharged or treated by the original consultant. 1.5 Did Not Attend (DNA) Following a DNA the patient will be sent a letter informing them of the DNA d appointment, and providing them with a contact number within the service so that the patient can ask for the appointment to be rearranged (if they still feel they need it). The letter will be copied to the referring GP. However, only one re-appointment will be given in these circumstances. If following this second offer of an appointment (of which the patient agrees) but the patient subsequently fails to attend, they will be removed from the waiting list, discharged and the GP and patient informed of their removal The exception to this will be where, in the clinical judgement of the consultant: The patient needs to be offered another appointment on the grounds of clinical need. The patient could be considered to be vulnerable due to age such as children (see Appendix C), or A person aged 18 yrs or over who is or may be in need of community care services by reason of mental or other disability, age or illness and is or maybe unable to take care of him or herself, or able to protect him or herself against significant harm or exploitation (DoH 2000 No Secrets). Additionally, there are on occasions, patients who are unable to access care independently, i.e. prisoners due to incarceration or patients who reside in care homes. This policy also includes these groups of patients when referring to vulnerable adults. Where the patient is unable to access care independently that the Trust will need to contact/liaise with the relevant authority. 1.6 Can Not Attend (CNA) Patients who wish to change their appointment after the date of the clock start should be given an alternative date agreeable to the patient at the time of cancellation. If a patient changes their appointment more than twice their case notes should be reviewed by medical staff to ensure that there is no clinical risk involved in not seeing the patient (e.g. patient considered to be vulnerable due to age, reliance on carers, mental capacity etc). Patients who are deemed not to be at risk should be removed from the waiting list and discharged back to their GP and their 18 week clock stopped. Patients who are deemed to be at clinical risk due to the nature of their condition should be offered another appointment. Page 14 of 36

15 1.6.2 The exception to this will be where, in the clinical judgement of the consultant: The patient needs to be offered another appointment on the grounds of clinical need. The patient could be considered to be vulnerable due to age such as children (see Appendix C), or A person aged 18 yrs or over who is or may be in need of community care services by reason of mental or other disability, age or illness and is or maybe unable to take care of him or herself, or able to protect him or herself against significant harm or exploitation (DoH 2000 No Secrets). Additionally, there are on occasions, patients who are unable to access care independently, i.e. prisoners due to incarceration or patients who reside in care homes. This policy also includes these groups of patients when referring to vulnerable adults. Where the patient is unable to access care independently that the Trust will need to contact/liaise with the relevant authority. 2. Referral, Diagnostic and Admission Procedures This section gives a summary of referral, diagnostic and admission management procedures based on changes introduced by the 18 week RTT. 2.1 Outpatient Referrals Methods currently employable to access services: Electronic referrals received through the CAB software Paper referrals Telephone bookings for services that are indirectly booking and a rebooking service for patients who wish to change appointment times (within agreed parameters) or who have been incorrectly referred or appointed and need to change their clinic or priority Where CAB is used, GPs should ensure that routine referral letters are attached within 3 days in order to facilitate the booking process. Providers will ensure that sufficient capacity is available on the system to enable electronic booking to take place Reasonableness of Appointments For patients not appointed through CAB, or those who are appointed into other services which do not have a CAB facility, the provider should offer appointments with one week s notice (though patients can still take a shorter appointment if they so wish) and two separate dates Open Referrals Page 15 of 36

16 Unless there is a clinical reason (e.g. prior treatment by that Consultant), patient choice or other particular reason, referrals should be addressed on a speciality or sub-speciality basis to minimise out-patient waits. This is to ensure that the delivery of the 18 week referral to treatment time is not compromised Named Consultant-led Teams The patient s right to choose a Named Consultant-led team in certain circumstances became mandatory on 1 April 2011, and all Directories of Service support this functionality. Patients may choose to be referred to a named consultant-led team or there may be genuine clinical reasons why a referrer may suggest to the patient that referral to a specific clinical team is preferable. These might include: referral to a consultant-led team known to have a particular specialist or subspecialist interest in the patient s condition referral back to a consultant-led team which had previously managed a patient as a follow-up to an advice and guidance (A&G) request, where it seems most appropriate and where the patient has chosen to see the clinician who has provided the A&G response Referrals to a named consultant-led team should only be made where the patients informed choice has been fully taken into account and where such a referral is clinically appropriate. Indiscriminate use of this facility will reduce available slots for that particular service Managing Electronic Referrals Reviewing referrals a maximum time limit of three working days to review referrals and change the priority set by the GP, if required. Rejected referrals referrals are not expected to be routinely rejected. The Directory of Services will be regularly updated and refined to ensure that information is accurate and current and reflects the service offered. In the event that a rejection is the only appropriate action, brief information will be provided to the GP explaining the reason why. Redirected referrals where appropriate, referrals received into the incorrect pathway will be directed by the outpatient coordinator into the correct clinic, and the GP practice will be advised of any redirections. Defer to Provider this functionality enables practices and patients to place a request onto a chosen provider worklist in the event that there are no appointment slots available. This facility can only be used where there are no slots, due to either lack of capacity or technical issues with CAB. Practice staff should therefore be aware of this when booking appointments. Once the appointment has been deferred onto the provider worklist, the practice is required to monitor progress. The patient will be advised that the provider has a certain number of days in which to book the patient, depending on the urgency of the appointment. The Provider must Page 16 of 36

17 contact the patient within these timescales and must wherever possible, book the appointment via CAB. Where no appointments are available the patient must still be contacted and reassured that they will be contacted as soon as an appointment becomes available. Only under exceptional circumstances, should the request be cancelled and booked manually, and certainly not without consultation with the patient Clinic Cancellation or Reduction The only acceptable reason for any clinic to be cancelled is due to the unplanned absence of medical staff (or nurse/therapist in nurse/therapist led clinics), for example, unplanned sickness absence. Clinics will not be cancelled for any other purpose unless exceptional circumstances arise. Clinics should not coincide with other known commitments. Clinic cancellation can only be authorised by the appropriate General Manager/Clinical Director. A minimum of six weeks notice of annual or study leave is required for clinic cancellation or reduction. In the event of cancellation of patients: The outpatient department staff will ensure patients are contacted as soon as possible by the appropriate method of contact e.g. short notice cancellations by telephone or 1 st class post. Patients will be offered the choice of two new appointments within the target timeframe, or should the patient wish to, may choose a date beyond that Patients Found to be Unfit for Treatment at Outpatient Appointment 2.2 Diagnostic Referrals Patients will have their clock stopped and be referred back to their GP. The GP will be informed of the reason they have been found unfit for treatment. If the patient becomes fit within 3 months, the GP will inform the consultant and the patient resumes in the outpatient clinic without a formal new referral with the start of a new clock. Beyond 3 months a new referral is required and a new clock will begin A Diagnostic test is defined as a test or procedure used to identify a person s disease or condition with the intention of enabling 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. For the purpose of RTT recording 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; Page 17 of 36

18 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 Reasonableness of Diagnostic Appointments It is good practice that all patients will book their diagnostic test on the same day of their outpatient appointment. The same rules for outpatient reasonable appointments apply. Wherever possible, the patient shall be able to choose their appointment date and time, within the limitations of the target window. For patients not appointed through CAB, the Trust should offer appointments with one week s notice (though patients can still take a shorter appointment if they so wish) and two separate dates. 2.3 Adding patients to an inpatient waiting list This is the final stage of the 18 week RTT episode, and on the date of admission the clock will stop for that episode unless either: a) the patient is cancelled, once admitted, for non-clinical reasons (in which case the clock continues to run), or b) the patient is cancelled for clinical reasons (in which case the clock is paused) The patient will have waited no longer than 18 weeks from the point of referral, unless the patient has chosen to do so, in which case this will be recorded on PAS and the clock will be paused for the extension due to the patient s exercise of choice The decision to add patients to the waiting list will be made by the consultant or under an arrangement agreed with the consultant and after discussion with the patient, and at that point the consultant will also discuss the rules around choice of delaying treatment Patients will only be added to the waiting list if there is an expectation of treating them, and when the patient has accepted the clinician s advice on elective treatment. The patient will be added to the waiting list within one working day of the decision to admit (DTA). Patients will not be added if: They are unfit for procedure They are not ready for the surgical phase of treatment There is no serious intention to treat them The procedure is not currently available or funded within the Trust Page 18 of 36

19 2.3.5 Patients who are not fit for surgery If following investigations it is found that the patient is not fit for their surgery, they will be referred back to their GP to be managed in primary care. This will end their 18 week clock. However, if the patient becomes fit for surgery within 3 months from the date the patient was returned to the GP, the GP practice will contact the appropriate pre-assessment service and the patient will be added directly back onto the waiting list via the pre-assessment clinic and will access the 18 week pathway at the point where a TCI date can be negotiated. A new 18 week clock will begin at this point, and patients will be offered a new operation date within seven weeks. Pre-assessment clinic staff will keep a record of those patients who have the option to return within 3 months. If the patient fails to reach a suitable level of fitness within the agreed timeframe, and surgery is still considered to be a requirement by the GP, a new referral will need to be generated, starting a new 18 week pathway beginning with a new first outpatient appointment, when the GP considers the patient is medically fit Selecting Patients for Admission Patients will be selected from the waiting list according to clinical priority, and then in accordance with the individuals 18 week pathway. All patients will have pre-assessment screening as part of their 18 week pathway where clinically appropriate. Wherever possible an admission date will be negotiated with the patient at the time the decision to admit is made Patient admissions should not be cancelled for non-clinical reasons Confirmation to the Patient Every patient will be sent written confirmation that he or she has been put on to the waiting list, and/or confirming the date of their admission, and requesting that they confirm attendance Reasonableness of dates for admission Reasonableness for admission is defined as 3 weeks notice (though patients can choose an earlier date if they so wish) and 2 separate offered dates Patients who choose to delay admission It is the expectation that patients will only be referred to the Trust if are able to undertake potential treatment within 18 weeks. However if a patient chooses to delay treatment longer than the reasonable offered appointments their 18 week clock may be paused. The clock is paused on the date of the first reasonable offer and restarted when the patient informs the Trust or GP they are available for admission. A patient will be allowed to remain on a pause for admission for a maximum of 3 months. Page 19 of 36

20 Trust administrative staff will keep a record of those patients who have decided to pause their clock. At 3 months into the pause, they will contact the patient to agree a new TCI. The clock will restart from the date the patient states they are available for treatment Once a reasonable date for admission has been agreed, patients who choose to delay treatment may be allowed to cancel booked TCI dates up to a maximum of 2 separate occasions If the patient does not want their treatment within the 3 month period, or cancels booked TCI dates on more than 3 occasions, the patient will be referred back to the GP and the clock will stop. A new referral can be made when the patient chooses to have their treatment. This will start a new 18 week pathway Cancellations on day of Surgery It is the expectation that no patient will be cancelled by the hospital on day of surgery. However in extreme circumstances when this is unavoidable patients must be booked a new date either within 28 days (as per the national standard) or before their 18 week breach date if this is shorter than 28 days, unless the patient chooses a later date, in which case the clock may be paused for the interval. 2.4 Patient exclusions for 18 week waits There are a group of patients for whom it is inappropriate to begin treatment within 18 weeks. These are described as: Clinical Exceptions where it is not clinically appropriate for treatment to begin within 18 weeks of referral, because the patient is either unfit for treatment or there is genuine clinical uncertainty about the diagnosis. These patients will fall under the operational tolerances already built into the national target. Other Exclusions such as overseas visitors, emergencies, or obstetrics for normal pregnancy, fall outside the scope of 18 week wait. Full guidance can be found at Referral to Treatment Consultant-led Waiting Times, Rules Suite: /Referal_to_treatment_Rules_Suite.pdf 3. Tertiary Referrals and Inter-Provider Transfers (IPT) 3.1 IPT is a critical mechanism to manage and monitor performance and performance sharing on the 18-week pathway and to allow equitable attribution of breaches of that pathway. When clinical responsibility for a patient is transferred, there is a danger that the administrative data on the patient does not pass to the new organisation and subsequent responsibility for breach sharing lacks clarity. 3.2 The IPT minimum data set is designed to support the transfer of administrative data from the referring provider to the receiving provider, thus allowing the receiving provider to report on the 18 week patient pathway. By sharing information via the minimum data set for inter provider transfers; all parties involved can be fully aware of the patient s pathway. All services that refer onwards into provider services must Page 20 of 36

21 use the IPT process. This includes such interface services such as Clinical Assessment and Treatment services (CATS) that may refer a patient into secondary care. 3.3 All IPT minimum data sets (IPTMDS) will be completed and sent to the receiving provider within 48 hours (DSCN 44/2007). It is the referring organisation s responsibility to ensure the IPTMDS is sent and that an NHS.net address is used as the secure service. A Performance Sharing report will be completed by the Provider where the 18-week clock stop event occurs. This will only be completed for breaches of the 18-week pathway. It is therefore essential that the IPT process is adhered to. 4. Cancer Referrals 4.1 Since 1 January 2009, all cancer pathways have been subject to monitoring on 18 week pathways, although still managed to guidance linked to specific cancer waiting time guidance. 4.2 It is the Clinician s (GP and/or Trust specialist) responsibility to inform the patient of the significance and risk being taken by a patient who chooses to delay their appointment for more than 14 days, and to counsel them accordingly. Booking of the two-week wait referral to appointment will be booked in the first instance by: Electronic referrals received through the CAB software where the patient has booked into a specific clinic slot and a GP referral template has been attached to the booking. This should be the standard form of referral fully completed in all instances where this mechanism is available. Where a service is not directly bookable or there is an issue with slot availability or other substantial reason the EBS via C&B cannot be used, referrals should be faxed to the appropriate OPC for the required service. 4.3 All potential cancer patients will be managed according to current national targets which are: Two Week Wait All patients who are referred by their GP with a suspected diagnosis of cancer must have their first hospital consultation (out-patient appointment or investigation) within 14 days of a converted UBRN or receipt of fax. If a patient cannot attend or did not attend for their appointment a follow-up must be negotiated directly with the patient within 14 days of the original UBRN conversion. If a patient DNA s for a second time the Trust will inform the referrer and discharge the patient back to the care of their GP day Standard (Decision to Treat to 1st Definitive Treatment) This standard is linked to every patient who has a newly diagnosed cancer and the decision to treat date is the date when the patient and consultant agree on the type of treatment. The first definitive treatment may commence in the Trust, Tertiary Centre or Community setting day Standard (Subsequent Treatment) This standard is linked to every patient who requires subsequent treatment as part of a newly diagnosed cancer pathway or for recurrent disease. N.B. Patients referred via national cancer screening programmes will have a clock Page 21 of 36

22 start at the point the screening programmes identify further investigation is required day Standard (Referral to 1st Definitive Treatment) This standard is linked only to patients who have a newly diagnosed cancer and have been booked by the 2 week wait process. The timeline for the standard starts on the day the UBRN is converted, and ends at the point where first definitive treatment commences either in this Trust, Tertiary centre, or Community setting Tertiary Referrals optimum time to referral All referrals into Tertiary Centres for either MDT opinion or definitive treatment planning will be referred over using the agreed processes linked to specific tumour groups. All shared care cancer breaches will be reviewed against potential reallocation using the North Trent Cancer Network Breach Reallocation Policy. 5. Managing Patients on the 18 Week Pathway 5.1 Waiting lists will be kept up to date using data from various sources. It is essential that data is entered on to the PAS within 2 working days of an action in order to maintain accuracy of data collection and waiting list management. Patients who no longer need their operations will be removed from the waiting list. 5.2 Amendments to, or overwriting of TCI dates on PAS are only acceptable if a date is entered in error and corrected on the same working day, if this timeframe is exceeded the TCI should be cancelled as an administrative error and a correct TCI allocated. 5.3 DBHFT may hold a follow up waiting list in appropriate circumstances: A follow up waiting list will be proactively managed and monitored, given the same status as an inpatient PTL It is acknowledged that it is not appropriate for all patients/clinics to be hold a follow up waiting list Care Group Clinical Director approval will be required to hold a follow up waiting list All patients on the follow up waiting list will be dated 6 weeks prior to their appointment due date As part of on-going monitoring DBHFT will formally review the follow up waiting list and report their findings both internally and to commissioners 5.4 It should be noted that for diagnostic investigations, and some other services, this may be on local bespoke systems. 6. Patients Transferring Between NHS and Private Care 6.1 As outlined in A Code of Conduct for Private Practice, Recommended Standards of Practice for NHS Consultants : Any patient referred for an NHS service following a private consultation or private treatment should join any NHS waiting list at the same point as if the consultation Page 22 of 36

23 or treatment were an NHS service. Their priority on the waiting list should be determined by the same criteria applied to other NHS patients. The patient should not be referred back to General Practice for a decision about onward referral unless the patient wishes to take this course of action. It is essential that the Trust ensures its clinicians fully understand and apply this condition and ensures consistency of this condition in its other operating protocols. Full guidance is available at: AndGuidance/DH_ New Developments Affecting Waiting List Management 7.1 The local health community (LHC) recognises that over time, a number of new ways of working are likely to be developed, in relation to managing the challenges of national access targets, and as new evidence-based practice emerges. Where any such developments may impact on waiting list accuracy, the National Data Standards and guidance on waiting list management will be adhered to, until systems and procedures have been validated by the Data Quality Lead for consistency with National Data definitions, and subsequently approved by the respective Boards or appropriate sub groups. 8. Quality Assurance 8.1 In order to establish that the Policy and Procedures are appropriately carried out, and reflect current standards, an audit of the processes will be undertaken periodically. This process will be led by the Data Quality Leads, in conjunction with the Internal Audit Office, and compliance will be assessed against national benchmarks. 8.2 Waiting lists will also be subject to rolling validation programmes according to current best practice. 9. Education and Training 9.1 All grades of staff that use PAS as part of their daily work requirements will undergo education and training in the use of PAS, and in the management of waiting list processes. It is the responsibility of the Trust to ensure that all staff required to access waiting list systems will attend, as minimum, mandatory induction training. 9.2 All staff required to access waiting list systems will attend mandatory induction training on basic processes and thereafter yearly updates in order to maintain current knowledge and skill in relation to waiting list administration and management. 9.3 New changes in processes will be managed by ad hoc training. 9.4 The 18 week rules suite at will be the definitive document for training purposes. Page 23 of 36

24 10. Security and Confidentiality 10.1 All staff engaged in the application of this policy are bound by the LHC IM&T Security and Confidentiality policies. 11. References 1. Audit Commission (2003) Waiting List Accuracy assessing the accuracy of waiting lists information in NHS hospitals in England. Audit Commission Publications: 2. Health and Social Care Information Centre (SCIC) National Data Set for Referral to Treatment Consultant-Led Waiting Times Measurement 3. NHS Constitution (2013) Department of Health 4. Everyone counts: Planning for Patients 2013/14 (2013) NHS England 5. Standard NHS Contract 6. Allied Health Professional (AHP) Referral to Treatment (RTT) guide (2010) Department of Health 7. The Mandate A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015 (2012) Department of Health 8. Referral to treatment consultant-led waiting times - Rules Suite (2014) Department of Health 9. Maximum Waiting Times Guidance for Commissioners (2013) NHS England 10. Operational guidance to the NHS: Extending Patient Choice of Provider (2011) Department of Health 11. Commissioning Policy: Defining the boundaries between NHS and Private Healthcare Reference: NHSCB/CP/12 (2013) NHS Commissioning Board Page 24 of 36

25 SECTION C APPENDICES DEFINITIONS APPENDIX A For the purposes of this policy, the following terms have the meanings given below: Term Active Waiting List Clinical Assessment and Treatment Service (CATS) Choose and Book (CAB) Can Not Attend (CNA) Date Referral Received (DRR) Day cases Decision to Admit date (DTA) Did Not Attend (DNA) First Definitive Treatment Indirectly Bookable Service (IBS): Inpatients Inter Provider Transfer Definition Patients awaiting elective admission for treatment and are currently available to be called for admission. A specialist interface service between Primary and Secondary Care. Designed to ensure patients are directed efficiently and effectively into the most appropriate care pathway. CATS are bound by both choice and 18-week clock rules. A method of electronically booking a patient into the hospital of their choice. Patients who, on receipt of reasonable offer(s) of admission, notify the hospital that they are unable to attend. The date on which a hospital receives a referral letter from a GP. The waiting time for outpatients should be calculated from this date. Patients who require admission to the hospital for treatment and will need the use of a bed but who are not intended to stay in hospital overnight. The date on which a consultant decides a patient needs to be admitted for an operation. This date should be recorded in the casenotes and used to calculate the total waiting time. Patients who have been informed of their date of admission or preassessment (inpatients/day cases) or appointment date (outpatients) and who without notifying the hospital did not attend for admission/ pre-assessment or outpatient appointment. An intervention intended to manage a patient s disease, condition or injury and avoid further intervention. What constitutes First Definitive Treatment is a matter for clinical judgement, in consultation with others as appropriate, including the patient. Some provider services are not directly bookable through Choose and Book so patients cannot book directly into clinics from a GP practice. Instead they contact the hospital by phone and choose an appointment date. This is defined as an Indirectly Bookable Service. Patients who require admission to hospital for treatment and are intended to remain in hospital for at least one night. Patients who require admission to hospital for treatment and are intended to re The inter-provider transfer is a system whereby minimum data set (MDS) information is transferred electronically (best practice) from one provider to another and helps to track patients as they move Page 25 of 36

26 (IPT) Outpatients Pause Patient Tracking List (PTL) Reasonable Offer Referral to Treatment (RTT) To Come In (TCI) date Watchful waiting between providers. Patients referred by a General Practitioner or another health care professional for clinical advice or treatment. When the patient who is offered a reasonable TCI, chooses to wait longer than the RTT target timescale, the pathway may be adjusted for a maximum period of four months and a new date negotiated with the patient within that adjustment period. The PTL is a list of patients (both inpatients and outpatients) whose waiting time is approaching the guarantee date, who should be offered an admission/appointment before the guarantee date is reached. For an offer of an appointment to a patient to be deemed reasonable, the patient must be offered the choice of dates within the timescales referred to for outpatients, diagnostics and inpatients. Instead of focusing upon a single stage of treatment (such as outpatients, diagnostic or inpatients) the 18 week pathway addresses the whole patient pathway from referral to the start of treatment. The offer of admission, or TCI date, is a formal offer in writing of a date of admission. A telephone offer of admission should not normally be recorded as a formal offer. Usually telephoned offers are confirmed by a formal written offer. An 18w clock may be stopped where it is clinically appropriate to start a period of monitoring in secondary care without clinical intervention or diagnostic procedures. A new 18 week clock would start when a decision to treat is made following a period of watchful waiting/active monitoring. Page 26 of 36

27 NATIONAL 18 WEEK REFERRAL TO TREATMENT (RTT) GUIDANCE 1. Clock Starts PAT PA 1 v A waiting time clock starts when any care professional or service permitted by an English NHS commissioner to make such referrals, refers to: a) a consultant led service, regardless of setting, with the intention that the patient will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional or general practitioner; b) an interface or referral management or assessment service, which may result in an onward referral to a consultant led service before responsibility is transferred back to the referring health professional or general practitioner A waiting time clock also starts upon a self-referral by a patient to the above services, where these pathways have been agreed locally by commissioners and providers and once the referral is ratified by a care professional permitted to do so Upon completion of a consultant-led referral to treatment period, a new waiting time clock only starts: a) when a patient becomes fit and ready for the second of a consultant-led bilateral procedure; b) upon the decision to start a substantively new or different treatment that does not already form part of that patient s agreed care plan; c) upon a patient being re-referred in to a consultant-led; interface; or referral management or assessment service as a new referral; d) when a decision to treat is made following a period of active monitoring; e) when a patient rebooks their appointment following a first appointment DNA that stopped and nullified their earlier clock The waiting period starts: a) at the point of conversion of the Unique Booking Reference Number in Choose and Book, or b) when the provider receives a manual referral letter Consultant to Consultant Referrals for a different condition will start a new patient pathway with a new 18 week pathway clock. The original referral wait will continue concurrently until the patient is discharged or treated by the original consultant Consultant to Consultant referrals for related conditions will be included within the 18 week pathway, with the wait continuing from the original referral. 2. Clock Pauses APPENDIX B 2.1 A clock may be paused only where a decision to admit for treatment 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 for treatment. Page 27 of 36

28 3. Clock Stops 3.1 A clock stops for treatment when: a) First definitive treatment starts. This could be: i) Treatment provided by an interface service; ii) Treatment provided by a consultant-led service; iii) Therapy or healthcare science intervention provided in secondary care or at an interface service, if this is what the consultant-led or interface service decides is the best way to manage the patient s disease, condition or injury and avoid further interventions; b) A clinical decision is made and has been communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay, to add a patient to a transplant list. 3.2 Clock stops for non-treatment A waiting time clock stops when it is communicated to the patient, and subsequently their GP and/or other referring practitioner without undue delay that: a) It is clinically appropriate to return the patient to primary care for any nonconsultant-led treatment in primary care; b) A clinical decision is made to start a period of active monitoring; c) A patient declines treatment having been offered it; d) A clinical decision is made not to treat; e) A patient DNAs (does not attend) their first appointment following the initial referral that started their waiting time clock, provided that the provider can demonstrate that the appointment was clearly communicated to the patient; f) A patient DNAs any other appointment and is subsequently discharged back to the care of their GP, provided that: i) The provider can demonstrate that the appointment was clearly communicated to the patient; ii) Discharging the patient is not contrary to their best clinical interests; iii) Discharging the patient is carried out according to local, publicly available/published, policies on DNAs; iv) These local policies are clearly defined and specifically protect the clinical interests of vulnerable patients (e.g. children) and are agreed with clinicians, commissioners, patients and other relevant stakeholders. The 18-week pathway does not replace existing shorter waiting time guarantees, for example cancer and heart disease waits. Page 28 of 36

29 APPENDIX C PAT PA 1 v.8 Pathway for decision making when a child* DNAs a hospital appointment Child DNAs appointment Consultant/ practitioner reviews the child s records on the date of the appointment. Known child protection concerns / worrying history / serious condition that needs urgent review. Consider the impact of nonattendance for the child. No child protection or social concerns. Consider the impact of nonattendance for the child. Liaise with Health Visitor/ School Nurse/ GP and referrer re status. Establish whether child is subject to a Child Protection plan or whether there are safeguarding children concerns. Inform Social Worker as appropriate when already known or subject to a Child Protection plan. Decide plan re further follow up and management and document decisions. If threshold met for child protection referral, follow Local Safeguarding Children Board Child Protection procedures. Document all discussions and confirm significant decisions in writing to other professionals involved. Needs ongoing medical supervision. Confirm accurate address Send further appointments according to local policy. Further DNA Within the same day, the Consultant or practitioner will review the records and information known. Medical needs not being met. Liaise with referrer to assess risk and plan next steps. Document conversations and confirm plan in writing. Include parents in correspondence unless to do so would likely increase the risk to the child. Problem has potentially resolved or GP can manage care. Follow -up not necessary. Ensure this is documented clearly. Discharge letter to referrer, GP and parent. Page 29 of 36

30 Pathway for decision making when a child CNAs on the Day of the appointment or where there is a Second CNA Booking Clerk is informed a child cannot attend a health appointment on the day of the appointment or of a second episode where a child s health appointment is rearranged because they cannot attend. The content of conversation should be documented and shared with nursing staff on the day of notification. Where a child fails to attend to attend an Initial Looked after Children (LAC) Assessment Booking Clerk gives records to nursing staff to review. Consider whether there is a medisec or PAS history and systemone re-community concerns. The records are given to the Consultant responsible for care on the same working day. Actions Liaise with HV/SN/GP and referrer re: status of the child. Establish if the child is subject to a Plan Inform Social Worker if the child is already know, has a Child Protection Plan, or is a LAC child. Decide plan re-further follow up and management of care and document all decisions. If the threshold is met for child protection referral, follow Local Safeguarding Children Board Child Protection procedures. Document all discussions within health records and confirm significant decisions in writing to other professionals involved. Consultant makes decisions for the action required and undertakes these within 24 hours. The Consultant considers; 1, if there has been multiple appointment changes. 2, if there are known Safeguarding Issues. 3, whether the child has failed to attend a LAC or Child in Care health assessment appointment. 4. whether this is a failure to engage with treatment plan. Children who do not attend arranged Looked after Children (LAC) Record appointments- and document inform all Social Worker. Consider whether there are new Safeguarding concerns that should be referred to Children s Social Care, Child Protection department (MASH or Referral and Assessment Services within Doncaster) Document all concerns and actions taken within Health records. Page 30 of 36

31 APPENDIX D ACCESS TO HEALTH SERVICES FOR MILITARY VETERANS PRIORITY TREATMENT This follows Guidance from the DoH in 2007 extending the priority treatment arrangements for veterans from 1 January Military veteran registers with GP and advises of existing conditions and agrees to recording of veteran status. Military veteran registers with GP and advises of existing conditions and does not agree to recording of veteran status Attends GP with condition likely to be related to service Attends GP with condition likely to be related to service GP decides secondary care referral is required GP decides secondary care referral is required CAB Choose correct category i.e. routine, urgent, 2ww Paper referral Indicate category i.e. routine, urgent, 2ww Referral to secondary care waits in queue as normal Referral letter Clearly state link to military service Secondary care clinician review referral and agree it is likely to be related to service Secondary care clinician review referral and does not agree it is likely to be related to service and GP is advised Priority appointment given over other patients with same category (i.e. urgent, routine) Patient waits turn Page 31 of 36

32 Actions: GPs are asked to record the patient s veteran status when referring to secondary care for diagnosis or treatment. (Where the patient agrees to have this status recorded). Where the patient is content for their military status to be included, GPs are asked to clearly state this when drafting referral letters, including, in their clinical opinion, that the condition may be related to military service. Where secondary care clinicians agree that a veteran s condition is likely to be service-related, they are asked to prioritise veterans over other patients with the same level of clinical need. It remains the case that veterans should not be given priority over other patients with more urgent clinical needs. Contacts: DoH.ArmedForcesnetworks@nhs.net etters/dh_ etters/dh_ Page 32 of 36

33 APPENDIX E Protocol for Urgent Referrals into Children s Clinical Service Unit Acute medical referrals bleep the SHO, SHO will contact Registrar as required None Acute to be seen within 2 weeks (no 2 week wait applicable in CCSU) o Notify Outpatient Co-ordinator by telephone, voic and send fax. o Advise if confirmation of call/fax is required Suspected Torsion of the Testes or Testicular pain is an exception refer to A&E as emergency All Child Protection issues contact the Consultant on-call Page 33 of 36

34 Consultant to Consultant Referral Pathway Acute & Community Paediatrics Patient seen by paediatric consultant Consultant identifies possible need for another opinion Urgent Routine. Another paediatrician Routine. Relating to another department, i.e. non paediatrics Consultant makes necessary referral Consultant writes to patients GP describing the problem GP refers on GP manages in a different way Page 34 of 36

35 APPENDIX F Consultant to consultant referral pathway Patient seen by consultant Consultant identifies possible need for other opinion Urgent/2ww Directly related to the original reason for referral Non urgent & unrelated to the original reason for referral (incl. following A&E att, during acute admission etc ) Consultant makes necessary referral Consultant writes to patients GP identifying why another opinion may be needed Consultant advises the patient to contact practise in 3 weeks if they have not heard anything GP refers on GP manages in a different way Page 35 of 36

36 APPENDIX G Page 36 of 36