Patient Access Policy. Version 2.0

Transcription

1 Version 2.0 November 2013

2 Table of Contents 1. Introduction Purpose of this Policy/Procedure Scope Definitions / Glossary Ownership and Responsibilities Role of the Chief Operating Officer Role of the Waiting List Administrators Role of the Information Services Manager Role of the Associate Director of Commissioning & Performance and Access & Performance Manager Role of GPs and the Referral Management Service Role of Clinical Staff Standards and Practice Core Principles Overview of Trust Standards Waiting List Management Referral to Treatment (RTT) Outpatients Diagnostic Tests and Procedures Elective Procedures (Principles) Cancer Patients Inclusions and Exclusions Dissemination and Implementation Monitoring Compliance and Effectiveness Updating and Review Equality and Diversity Equality Impact Assessment...26 Appendix 1. Outpatient Outcome Form...27 Appendix 2. Add to Waiting List Form...28 Appendix 3. Theatre Escalation Process...29 Appendix 4. Consultant to Consultant Form...30 Appendix 5. Inter-provider Transfer Form...31 Appendix 6. Good Practice Guide for the Management of Planned Lists...32 Appendix 7. Governance Information...34 Appendix 8. Initial Equality Impact Assessment Screening Form...36 Page 2 of 37

3 1. Introduction 1.1. The aim of this policy is to ensure that patients waiting for treatment are managed in line with National Waiting List Guidance. This includes patients with a suspected cancer diagnosis The overall aim of the policy is to: Ensure patients are treated in a timely and effective manner To support the delivery of Referral to Treatment (RTT) targets To support the patient s rights to access health services under the NHS constitution. The NHS constitution can be found on the NHS choices website The guidance is derived from the refreshed RTT rules published by the Department of Health in May 2009 and the NHS Constitution (April 2010). The NHS Constitution gives patients legal rights to access services within maximum waiting times. Both the rights for NHS staff and for patients are set out in the Handbook to the NHS Constitution. The handbook states that patients can expect to start their consultant led treatment within a maximum of 18 weeks from referral for non-urgent conditions unless they choose to wait longer or it is clinically appropriate that they do so. For patients with suspected cancer the waiting time standard is a maximum two week wait to see a specialist from GP referral unless they choose, despite the urgency of the referral, to wait longer The Trust has established a process for patients who have not received a treatment date within 14 weeks to contact the Access Team The purpose of this document is both a statement of the policy for the management of patients on an RTT pathway and an operational guide for those staff who are involved in the management of patient pathways in conjunction with job specific handbooks and training. 2. Purpose of this Policy/Procedure 2.1. To provide a policy to ensure that patients waiting for an outpatient appointment, diagnostics, elective or planned admission are managed in line with national waiting list guidance and patient choice This is an organisation wide policy to ensure that patients are treated in a timely and effective manner and to support the delivery of referral to treatment targets and patients rights under the NHS constitution. 3. Scope The policy is aimed at all members of staff who administer waiting lists, staff that book outpatient appointments or arrange dates for patients elective inpatient treatment, clinicians, service leads and managers, Divisional General Managers and Divisional and Specialty Directors. 4. Definitions / Glossary RTT Referral to Treatment Time. Page 3 of 37

4 5. Ownership and Responsibilities 5.1. Role of the Chief Operating Officer The Chief Operating Officer is responsible for: Implementing the, waiting list management and ensuring compliance with the Policy. Ensuring that the waiting times targets are monitored and delivered. It is, however, the Service / General Managers (or equivalent) through the Divisional Managers who are responsible for achieving these targets Role of the Waiting List Administrators (including clinic staff, secretaries or booking clerks) The Waiting List Administrators are responsible: To the Service / General Managers with regard to compliance of all aspects of the Trust s. For the day-to-day management of their lists and are supported in this function by the Service / General Managers, Access Team and Divisional Managers who are responsible for achieving access targets Role of the Information Services Manager The Information Services Manager is responsible for: The maintenance of the RTT database Processing of the data and other reporting systems on which all waiting lists are held Providing regular data quality audits of standards of data collection and recording the submission of central returns produced by the Information Services Department Role of the Associate Director of Commissioning & Performance and Access & Performance Manager The Associate Director of Commissioning and Performance/Access and Performance Manager are responsible for: The reporting of information to the Executive Team Monitoring performance against locally or nationally agreed targets and ensuring this is fed into appropriate operational and performance forums. The Access and Performance Manager / Access Team is responsible for: Monitoring compliance with this policy Providing additional guidance, training and support to members of staff, Timely and accurate performance Monitoring information to divisional and executive teams Role of GPs and the Referral Management Service The GPs and the referral management service (RMS) is responsible for: Page 4 of 37

5 Ensuring patients are made aware during their consultation, or appointment booking, of the likely waiting times for a new outpatient consultation The need to be contactable and available when referred. NHS Kernow is responsible for ensuring robust communication links are in place to feed-back information to GPs Role of Clinical Staff All clinical staff are responsible for ensuring they comply with their responsibilities as outlined in this policy. 6. Standards and Practice 6.1. Core Principles 6.2. The Trust s is designed to: Support the delivery of high quality, compassionate clinical care Ensure fair and equitable access to hospital services that promote privacy and dignity Support the development and implementation of local waiting list rules Address the management of waiting lists and reasonableness Staff should familiarise themselves with the following statement taken from the Human Rights Act At the heart of human rights is the belief that everybody should be treated equally and with dignity no matter what their circumstances The Human rights act can be found on the Equality and human rights website This document complies with the Royal Cornwall Hospitals NHS Trust Equality and Diversity statement Overview of Trust Standards 6.7. The Trust aims to provide first definitive treatment for all patients within a maximum pathway of 18 weeks. This is in line with national standards as follows:- 90% of patients on an admitted care pathway 95% for a non-admitted pathway 92% of incomplete pathways 93% of patients with suspected cancer should be seen within 14 calendar days 99% of patients waiting for a diagnostic appointment will be seen within 6 weeks The only exception to this should be patients who choose to wait longer than the standard (as above), and patients who may have to wait longer for specialist consultants visiting the trust from out of Cornwall on an infrequent basis. The trust will also monitor maximum waiting times to ensure that patients who exceed their 18 week target date continue to be treated in chronological order (as capacity and case-mix restrictions allow) The Trust is committed to keeping the quality and safety of patient care as its priority and this policy should be read in conjunction with the following policies: Child Protection and Safeguarding Policy and Procedures Equality and Diversity Policy Did not Attend and Cancellation of Appointments Policy for Children and Young People up to the age of 18 years Page 5 of 37

6 NHS Kernow consultant to consultant referral policy Procedure for Safeguarding Vulnerable Adults This policy has been split into: Trust Principles and Standards Referral to Treatment Outpatients Diagnostics Elective In-Patients/ Day Case Procedures Cancer Patients References Appendices Waiting List Management It is imperative that all members of staff that govern the management of patients who are on our waiting lists understand RTT principles and definitions. This is primarily to ensure that no patient is unnecessarily disadvantaged. It is the responsibility of every member of staff to ensure that these rules are applied equitably All patients will be held on the appropriate electronic waiting list, e.g., Patient Administration System (PAS), CRIS or an assessment service within choose and book whilst they are waiting for an appointment of any kind or where appropriate returned to their referring GP for onward clinical management Good practice in waiting list management includes validating the list at regular intervals. It is the responsibility of the person adding a patient to an elective waiting list to ensure that the pathway is accurately recorded at the time of listing Patients should only be added or remain on a waiting list if they are fit for and in a position to accept dates for treatment/consultation within reasonable timeframes, as defined within this policy. The Trust will give priority to clinically urgent patients and treat everyone else in turn. War pensioners and service personnel injured in conflict must receive priority treatment if the condition is directly attributable to injuries sustained in conflict Patients added to the NHS waiting list following a private consultation will be added to the list from the date the patient confirms they are transferring to the NHS. Patients must take their place according to clinical priority and booked as a new outpatient appointment. A change of status form must be completed and forwarded to the Paying Patient Office All patients should receive reasonable notice of their appointment which must be timely, informative, clear and concise Reasonableness is defined as:- outpatient and elective care a minimum of three weeks notice consideration of specific location if requested by patient a choice of two dates Page 6 of 37

7 verbal agreement of the patient of short notice appointments diagnostic test a minimum of one week s notice a choice of 2 dates verbal agreement of short notice appointments The implementation of this Policy will be supported by training All medical staff are responsible, through their Divisional Director to the Medical Director, for ensuring they comply with their responsibilities as outlined in this Policy Clinical and non-clinical staff must not carry out any action that might contradict this policy It is the responsibility of any member of staff uncertain of the appropriate course of action to seek advice from their line manager in the first instance The management of patients on waiting lists will be equitable and transparent. All patients will be treated equally regardless of age, ethnic origin, gender or sexual orientation, in line with Trust policy The management of patients on waiting lists will be equitable and transparent. All patients will be treated equally regardless of age, ethnic origin, gender or sexual orientation, in line with Trust policy Referral to Treatment (RTT) RTT treats the patient s journey from referral to first definitive treatment as one joined up waiting time based on clock starts and clock stops GPs should ensure that patients are ready, willing and able to attend their appointment within RTT timeframes when being referred. Commissioning organisations are responsible for ensuring robust communication links are in place to feed-back information to GPs Although some referrals/patient pathways are not specifically included within the RTT targets, the principal of sustained improvement for all patients will be implemented across the Trust. Examples of non-rtt pathways include: Nurse led clinics Other non-consultant led clinics Patients waiting for planned or surveillance appointments/procedures Emergency admissions from ED Start of the 18 Week Pathway An 18 week clock starts when the Trust receives a referral from any health care professional or service permitted by NHS Kernow A medical or surgical 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. Page 7 of 37

8 6.32. An interface, referral management or assessment service, which may result in an onward referral to a medical or surgical consultant led service before responsibility is transferred back to the referring health professional or general practitioner. In Cornwall most elective referrals are managed are managed by Kernow RMS End of the 18 Week Pathway First definitive treatment ends the 18 week pathway; first definitive treatment is described as the start of treatment that is intended to manage a person s disease, condition or injury, without the need for further intervention week pathway stops include: Treatment as an inpatient or day case Treatment/discharge within the outpatient setting, i.e. surgery is not required or patient receives a therapeutic outpatient procedure. First Line Treatment for example medical management of pain where pain management is defined as the definitive treatment. Decision not to treat in secondary and return of patient to primary care. Active Monitoring - defined as a situation where a diagnosis has been reached but a period of active monitoring of the patient is deemed clinically appropriate. At this stage the 18 week clock is stopped. If a patient subsequently requires further treatment after this monitoring period, a new 18 week pathway would begin. Open appointment maximum of a 6 month period of monitoring in which the patient can initiate a further appointment. At this stage the 18 week clock is stopped. A new 18 week clock starts if the patient initiates a further appointment. Patient declines treatment - if the clinician decides treatment is appropriate but the patient declines treatment. The date the patient declines treatment should be used as the end date for the patient wait. Patient is listed for a planned procedure; a planned admission is one where the date of admission is determined by the needs of the treatment, rather than by the availability of resources. If the treatment requires a set delay before initiation, then it could be considered as planned. However if it could be started immediately given sufficient resources, then it should be classified as either waiting list or booked, depending on whether the patient is given a date at the time of the decision to admit Upon completion of an 18 week pathway, a new 18 week clock starts: When a patient becomes fit and ready for the second of a consultant led bilateral procedure, the patient should be listed from the date they are fit and are able to accept a date for surgery. Upon the decision to start a substantively new or different treatment that does not already form part of that patient s agreed care plan. When a decision to treat is made following a period of active monitoring. On the date the patient is contacted to re-book an appointment following DNA of the first new outpatient appointment (If it is deemed there is good reason for patient pathway to be re-instated after the DNA). Children s services are the exception to this rule, clocks continue following DNA Pausing the 18 Week Pathway Page 8 of 37

9 6.38. The RTT clock can only be paused for patients awaiting treatment on an elective inpatient or day case waiting list. The RTT pathway can be paused for social reasons providing reasonable offers of admission have been made and recorded. The RTT pathway cannot be paused for medical reasons. The Trust local policy is that the RTT clock can be paused for a minimum of 21 days and a maximum of 56 days (eight weeks) Pathway ID (PID) In order to submit data to the Department of Health, all events on a patient pathway must be linked using the PID. This includes emergency admissions and non RTT appointments This allows the patient to be tracked along their pathway and allows the Trust to measure the whole patient journey. All outpatient appointments, diagnostics and inpatient events must be linked to the pathway ID specific to the condition being treated, not just those for patients on an active 18 weeks pathway PIDs are created automatically for appointments made using Choose and Book but have to be created manually for appointments booked outside of the Choose and Book system This applies equally to follow-up as well as new patients Outcome form Specialty specific outcome forms are used to record: RTT starts RTT stops Outpatient procedures High cost drugs Appointment outcome MDT appointment Adjustments to the length of an RTT pathway in an outpatient setting are dependent on the Clinician responsible for the patient accurately recording the RTT code PAS must be updated with the above at the time of the clinic Inter Provider Transfers (IPT) When a patient transfers between providers in order to maintain the RTT clock, an IPT form needs to accompany the referral. This is for both patients transferring into and out of the Organisation The IPT form is available on clinical care and attached in Appendix The form needs to be completed by the referring clinician and have the RTT information recorded to ensure the receiving provider is able to maintain the patient s RTT clock status accurately For patients transferring into RCHT from another provider (this includes Bodmin Treatment Centre, the Duchy, Probus etc), an IPT is required from the referring clinician Page 9 of 37

10 and must be forwarded by the receiving clinician to the appropriate clinical administration lead. Referrals from other providers will be rejected if they do not have an IPT form At the time of writing (October 2013), inter provider referrals can only be accepted from Ramsay Healthcare on the basis of their acceptance that any RTT breach which occurs will be attributable to Ramsay Healthcare, as agreed by NHS Kernow in July Outpatients Outpatient appointments, whenever possible, should be verbally agreed with the patient. Particular focus and attention will be paid to urgent/cancer referrals and all appointments made with less than three weeks notice. A date request received (DRR) must be recorded to capture the RTT clock start. For those referrals received by the RMS, this is the date the referral is received by the interface service and not the receipt into secondary care. Internal referrals from consultant to consultant for existing conditions do not start a new RTT pathway. The start date is from the original referral for that condition A text reminder service has been introduced for all outpatient appointments where patients have consented for its use. This service sends patients a reminder via their mobile telephone 6 days prior to their appointment Urgent and Routine New Patient Referrals (first appointment) It is the responsibility of the Trust to ensure capacity is available to meet the demand for appointments. It is then the responsibility of the patient to be available to accept an appointment within the locally agreed booking window. All appointments will be made with reasonable notice (section 1.7) The Trust will, where possible, provide services at community sites and will support patients in being able to access services at the place of their choosing where capacity and specialisation permits, which may mean they choose to wait longer to be seen closer to home A patient will be returned to their referring clinician if: They decline or cancel two reasonable offers of appointment (see section 1.7), or unavailable to accept an appointment within the whole of the outpatient booking window This applies to GP and to consultant to consultant referrals. The RTT clock will stop This is to ensure that the patient s condition can be appropriately managed. The patient will be informed of Trust policy and advised to return to their referring clinician when they are ready and available to be reinstated to the outpatient waiting list. A new RTT clock will then start Outpatient Booking Systems The Trust aims to receive all outpatient referrals electronically via the Referral Management Service (RMS). It accepts paper referrals (but expectation is that these should be in the minority) and referrals made using the Choose and Book system. The Page 10 of 37

11 Trust aims to ensure that 100% of consultant led new outpatient clinics have slots available in line with locally agreed booking windows The RTT clock starts (DRR) when:- The referral is received by the RMS The Trust date stamps paper referrals (except consultant to consultant where this is the date of the original referral for the same condition) The Trust receives a patients details on an ASI report A consultant to consultant referral is received for a different condition or for a substantively new treatment plan. These internal referrals for new conditions should be made in accordance with the NHS Kernow consultant to consultant policy All referrals should be reviewed by the clinician or nominated staff member within two consecutive working days. Where specialities have agreed not to vet, referrals will be automatically accepted. Where a referral is not vetted and then requires onward referral to a different speciality. the patient will be made a reasonable offer of appointment within RTT timeframes The RTT clock continues throughout this process Choose and Book is a national system which allows a referrer to find Trust services. It is the responsibility of the Trust to maintain an accurate directory of services (DOS) in line with local and national agreements and best practice Referrers are encouraged to follow DOS instructions to prevent delays in patient care or referrals being rejected. For Cornish residents, the RMS contact the patient once a referral has been received and negotiate an acceptable date. Referrals from the east of Cornwall will be via the Tamar Referral and Appointments Centre (TRAC) Slot unavailability (ASI) Patients unable to book appointments via Choose and Book through either Kernow RMS, TRAC as a patient or a GP Surgery will be added instantly and electronically to the ASI work list. It is the responsibility of the RCHT booking team to contact patients on the ASI work list and agree a reasonable appointment once capacity has been made available. These appointments will be made using the Choose and Book system Paper Referral Paper based referrals will be date stamped upon receipt, registered onto PAS, allocated a pathway ID and held on the appropriate waiting list until vetting instructions have been received. The DRR is the earliest date stamp. For some specialities, the referral will be booked straight into an appointment slot without the need for vetting. The Trust is moving to eliminate paper referrals in conjunction with NHS Kernow and a new local paperless policy is being developed by NHS Kernow and the Trust A single point of entry has been established for any paper referrals at the Outpatient Booking Centre, 1st floor Pendragon House, Treliske, Truro, TR1 3LJ Consultant to Consultant Referrals Page 11 of 37

12 6.76. Internal consultant to consultant referrals should not be made for conditions unrelated to the original referral. If a referral for a new condition is required, then this must be sent back to the GP for them to action The consultant to consultant form must be added to the internal referral letter. This form is attached at Appendix 4. The relevant booking office must be informed. If the consultant to consultant form is not included, the booking office will return and action once correct information is received. Responsibility for ensuring the correct information is included in the revised referral rests with the referring team If the booking office is unable to offer the patient a suitable date due to the patient s unavailability, then the referral letter and form will be returned to the medical secretary to re-refer the patient when they are ready If a patient has been referred for the same condition and has not received first definitive treatment, the RTT clock continues from the original referral date (DRR) A referral for a diagnostic test will start a new six week diagnostic pathway. The original RTT pathway clock will continue Where a referral starts a new clock, it does not automatically stop the RTT clock for the original referral Patients who have previously been seen at another provider (i.e. Duchy, Probus, Bodmin TC) are classed as inter-provider transfers and should be recorded appropriately and accompanied by an IPT form from the referring provider (see section 2.6) Straight to test GP referrals who require subsequent care should be referred back to the GP for onward referral, unless the patient meets the exception criteria detailed within the NHS Kernow consultant to consultant policy (i.e. urgent/cancer). In this case, the DRR is the date that the GP referred the patient for their straight to test diagnostic Changing Appointments It is recognised that in the following circumstances, appointments need to be changed. When rebooking appointments, the rules of reasonableness apply. Administrative processes must ensure that patients are easily able to contact the outpatient booking centre to change their appointments Redirections If an appointment has been booked in the correct speciality, but the patient would be best served by being transferred to a different clinic, it is the responsibility of the receiving clinician or nominated booking team to re-direct the appointment to the appropriate clinic rather than rejecting back to the GP. The patient must be informed if the appointment is to be re-booked and given the opportunity to agree a reasonable offer of appointment within the agreed Trust timeframe. The RTT clock continues throughout this process Rejection If an appointment has been booked in the wrong specialty, it is the responsibility of the receiving clinician or nominated booking team to reject the appointment. Patients will Page 12 of 37

13 not be rejected without an explanation in the comments box on Choose and Book. If the referrer takes longer than one week to re-refer the patient into an appropriate service, they should use a new UBRN It is the responsibility of the RMS to inform the patient if their referral has been rejected The RTT clock continues throughout this process unless a new UBRN has been generated Patient Cancellations When a patient changes any (new or follow up) outpatient appointment, one further reasonable offer of appointment must be made. The RTT clock continues. If the patient cancels the second appointment the patient must be returned to the care of the referrer (see section 3.1). The RTT clock will stop Hospital Cancellations A minimum of eight weeks notice, excluding exceptional circumstances, is required to cancel or reduce any outpatient session for reasons of: Annual leave Study leave On-call commitments Some specialty doctors only have to give six weeks notice of leave but this must be considered a minimum All short notice cancellations must be authorised in writing by the appropriate Divisional General Manager/Service Manager. The Outpatient booking team will not action any short notice cancellations without appropriate authorisation Appointments must be rebooked before or as close to the original appointment date as possible. The RTT clock will continue during this time Exceptional Circumstances There may be exceptional circumstances which prevent some patients from attending their outpatient appointment For instance: Isles of Scilly patients where weather conditions or mechanical breakdown prevent patients from travelling to the mainland. Severe weather conditions preventing travel around Cornwall Patients must give prior notice, however short, that they are unable to attend and re-negotiate their appointment date. The second cancellation and return to the GP does not apply in these circumstances Did Not Attend (DNA) Patients Outpatients Page 13 of 37

14 A DNA is defined strictly as a patient failing to give prior notice that they will not be attending their appointment. Care must be taken when booking appointments without patient consent, that reasonableness notice has been given. Patients will not be held accountable where reasonable notice has not been given. See separate rules for cancer Patients should be returned to the referrer unless the clinician responsible for the patient determines that a second appointment is clinically appropriate and is still required. If no further appointment is considered necessary or the patient is unwilling/unable to accept another appointment, a letter will be sent to the patient and referrer informing them that they have been referred back In the clinical interests of vulnerable adults, paediatric patients and safeguarding children, non-attendance will result in the offer of a further appointment, and the RTT clock will continue. Please see separate policy DNA for Children and Young People The RTT clock will be nullified (returned to zero) for patients who fail to attend their first appointment, unless the DNA has been caused by unreasonable notice. When a further appointment is booked following DNA, the RTT clock and maximum wait target will restart on the date that the new appointment is agreed and communicated with the patient and NOT the date of the appointment Patients who give prior notice of a change in appointment, however short, are not classed as DNA s and their clocks should not be stopped and should be recorded as a patient cancellation A second DNA will always result in the patient being referred back to the GP and both the GP and the patient will be informed of the decision Late attendances - Late clinics If a patient arrives late for their outpatient appointment, all reasonable attempts should be made to accommodate that patient on that day. If this is not possible and the clinic is still running then this should be treated as patient cancellation and re-booking. If the clinic has stopped running, then this should be recorded as a patient DNA Follow Up Appointments Follow-up appointments are appropriate when a patient s condition requires the continued intervention of specialist clinical expertise Follow-up appointments should be booked at an appropriate interval following the test in line with diagnostic waiting times. For test results on an active RTT pathway, follow up appointments must be booked in line with the RTT pathway. Any patient requiring a follow-up appointment within six weeks will be given an outpatient appointment at the time of their attendance. Patients requiring an appointment beyond six weeks will be added to the speciality s follow-up waiting List on PAS with a To Be Seen by date Where there are capacity issues, urgent follow-ups may be booked at the time of attendance up to a maximum of 12 weeks Diagnostic Tests and Procedures Page 14 of 37

15 Diagnostic means a test or procedure used to identify a person s disease or condition and which allows a medical diagnosis to be made. Once a decision is made for a diagnostic test or procedure, it must be undertaken within six weeks. If a patient is listed for a diagnostic test with treatment, the six week rule still applies A diagnostic could be (list not exhaustive): An outpatient appointment e.g. 24 hour tape, DEXA scan, ECHO, nerve conduction study, EEG A day case admission e.g. hysteroscopy, endoscopy, cystoscopy An imaging appointment e.g. X-ray, CT, MRI or ultrasound Access to diagnostics via an outpatient referral can be either: As part of a secondary care pathway or As a direct access request from a GP/GDP Appointments will be given with reasonable notice (section 1.7) If a patient cancels a diagnostic test, one further reasonable offer must be made within two weeks of the original date. If the patient cancels the second date, the patient must be returned to the Clinician/GP responsible for the patient s care For re-booked appointments on a secondary care pathway the patient s RTT clock continues; however, the six week diagnostic target resets to zero on the date the patient rings to cancel and restarts on the date of the cancelled appointment If the hospital cancels an appointment, both the RTT clock and the maximum wait target continue Any patient who DNAs their appointment will be returned to the referrer to determine if a further appointment is required. Care must be taken when booking appointments without patient consent that reasonable notice has been given. Patients will not be held accountable for missing appointments where the Trust has booked without consent and the patient has not been given reasonable notice. When a further appointment is booked, the maximum wait target restarts on the date that the new appointment is agreed or communicated with the patient. However, the RTT pathway clock continues Where a patient is on an active RTT pathway, the RTT clock continues throughout the diagnostic phase. If first definitive treatment is given during a diagnostic test or procedure e.g. removal of a polyp during an endoscopy the RTT clock will stop It is the responsibility of the referring clinician to ensure that the patient s RTT pathway is updated following receipt of diagnostic test results. A clock can be stopped at this stage if no further treatment is necessary and the referrer and patient informed Where outpatient referrals are vetted by a clinician and another diagnostic is requested, the DRR is the same as the original outpatient appointment. The requestor for the diagnostic must be recorded as the vetting clinician not the referring GP Elective Procedures (Principles) The decision to admit a patient for an elective procedure must be made by a consultant or person authorised by the consultant. Page 15 of 37

16 There are two types of elective list: Waiting List - A list of patients who have been offered elective treatment. Planned List A list of patients who require treatment of part of an agreed programme of care Patients have a maximum of two weeks to consider surgery, before being added to the waiting list. During this time the RTT clock continues. If a patient requires longer to decide, the RTT clock will stop and a new 18 week clock starts on the date they contact the inpatient booking coordinator (IPBC) to go ahead Patients will be offered reasonable notice (section 1.7). Good practice would be to give as much notice as possible for patients who have to give notice to employers or for child or other caring arrangements. All patients reaching 14 weeks on an active RTT pathway should have received notice of their treatment date Patients who are not fit, ready and able to come in at the time of listing must not be added to the waiting list. Examples of such patients are (list is not exhaustive): Patients with high blood pressure Patients needing to lose weight Patients with cardiac or respiratory problems Patients requiring any diagnostic test before a definitive decision to admit can be made Patients who require time to consider before deciding to go ahead with surgery If a patient becomes unwell after listing they should be removed from the list unless the condition is thought to be easily manageable or self-limiting (two weeks duration). Patients removed from the list must be returned to their GP for onward clinical management. Occasionally it may be clinically more appropriate to remove the patient from the waiting list and place the patient under active monitoring to be reviewed in clinic. This will stop the RTT clock The Trust is moving towards a policy of generic waiting lists for specific conditions. This ensures patients are treated chronologically and enables shorter waits Bilateral Procedures Patients who require bilateral procedures (on both sides) should initially be listed for the first procedure. When the patient is fit, ready and able to have the second procedure undertaken, a new elective waiting list entry should be generated, starting a new 18 week clock. 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. These patients are outside the scope of RTT Examples as follows: Page 16 of 37

17 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. six month check cystoscopy or endoscopy. Patients where a decision to admit has been made but the surgery is best done at a specific age (e.g. cardiac surgery). Patients awaiting admission for a further stage in a plan of treatments (e.g. maxillofacial surgery requiring more than one admission, removal of metal work [excluding patients listed for complications of metal work] etc.) but only where it is not clinically appropriate to proceed to offering the patient their next appointment yet. Patients undertaking a series of chemotherapy treatments. Cardiac patients who are waiting for cardioversion following the prescription of warfarin. The commencement of warfarin is first definitive treatment and hence will stop the RTT clock at this point. The patient will be listed for cardioversion on a planned list. Patients waiting on a gynaecology list who require Decapeptyl treatment prior to surgery should be placed on a planned list once the instruction to commence the drug therapy has been given. A date for surgery should be agreed with the patient at this point These patients should be added to the planned waiting list with an urgency of TB having been given a date, or approximate date, at the time the sequencing was agreed with the patient. The rules of reasonable notice apply as in section 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 Further guidance on the management of planned lists is provided in Appendix Adding to an Elective List (decision to admit) Once the decision to add a patient to an elective list has been made, an Add to Waiting List form must be completed by the listing clinician. This form must be completed at the time of the decision to admit which in most cases will be during the outpatient appointment (see Appendix 2). The Access Team need to approve the process for clinicians who choose not to use an add to waiting list form It is the responsibility of the IPBC to contact the patient and confirm they have been added to an elective list. At this time it is good practice for the IPBC to ensure mobile phone numbers and short notice availability are recorded onto the PAS. Best practice would be to fully book the patient (in line with clinical priority and 18 week dates), arranging pre-operative assessment and agreeing the admission date. Where partial booking is used, book pre-operative assessment with the patient and give an indication of when they can expect to be treated (as above) Pre-Operative Assessment (POA) POA ensures that the patient is fit for surgery and anaesthesia and establishes that the patient is fully informed and wishes to proceed with surgery. POA can be: Telephone assessment by nursing staff Face to face nurse led Page 17 of 37

18 Face to face consultant led Wherever possible the Trust ambition is for POA to occur following the appointment where the patient is listed. POA should be booked at least three weeks prior to TCI date. Where a patient requires urgent surgery, POA will be arranged as soon as practicable for both patient and service. In exceptional circumstances, patients will be assessed when they arrive at the hospital for their surgery If the patient is not to go ahead with surgery following POA, they will be removed from the waiting list. The patient and their GP must be informed of this decision and the reasons. The RTT clock will be stopped. In some circumstances the patient may be relisted when the Trust receives confirmation that the patient is fit and ready. It will then be at the discretion of the clinician as to whether the patient is directly listed or asked to attend a further POA appointment Patients who are determined fit for surgery after a six month period should be referred back to outpatient department by their GP. This is to ensure their Consultant agrees to continue with the previously agreed treatment plan. A new RTT clock will start Selecting Patients from the Inpatient / Daycase Waiting List Patients should be selected by clinical priority and in chronological order in terms of their RTT wait (as capacity and casemix restrictions allow), unless it is for reasons of: Patient safety Improved efficiency (effectively utilise a list) Essential for training responsibilities The Clinical Administration Leads retain responsibility for identifying patients approaching their RTT 18 week date and patients who have been cancelled and require a new date. This should be communicated to the consultant responsible for the list by the Inpatient Booking Co-ordinator Patients clock status is not affected if they choose to decline short notice offers (less than three weeks' notice) Clock Pause: (PIP Patient Initiated Pause) The Trust locally agreed timescale for a clock pause has been set at a maximum of 56 days (eight weeks) If a patient chooses to delay their pathway at the time of the offer for admission, a clock pause can be applied and an adjustment made to the RTT clock, allowing for the time between the earliest reasonable offer date (EROD) and when they make themselves available for treatment, if this meets our Trust criteria of maximum 56 days (eight weeks) The RTT clock cannot be paused if the patient has not received a reasonable offer of admission. If in these circumstances the patient contacts the IPBC to inform them of a period of unavailability the patient can either, be discharged back to the referrer, or remain on the active waiting list until a reasonable offer can be made. Page 18 of 37

19 Did Not Attend (DNA) Inpatients In line with local Trust policy, patients who fail to attend for reasons unknown for their agreed operation date should be removed from the waiting list following discussion with the consultant and discharged back to their referrer. Patients must be informed clearly in all Trust correspondence of this policy. This will stop the RTT clock In the extreme circumstance that the clinician feels it would be detrimental to the patient s health if an appointment is not re-booked, then the patient must first be contacted to ascertain the reasons for DNA and ensure compliance to attend a rescheduled appointment. The rescheduled appointment must be made using the original referral date. The RTT clock continues in this instance The process for cancer patients is slightly different and this is covered in section Cancellations The Trust objective is to have all patients on the waiting list treated. It is inevitable; however, that for a variety of reasons some admission dates will be cancelled. Where a patient s operation is cancelled on the day for non-medical reasons, the Trust will arrange to admit the patient within 28 days or earlier if RTT date is prior. Rules of reasonableness continue to apply Patients who cancel their own elective admission date for reasons other than sickness/or extreme personal circumstances at less than 48 hours notice, after receiving reasonable notice of this date (at least three weeks), will be removed from the waiting list in liaison with the consultant and discharged back to their referrer for any further action in primary care or re-referral when ready, willing and able to proceed Patient Cancellations Patients who either call in to cancel an agreed date for surgery due to sickness or extreme personal circumstances, or are deferred on the day of surgery due to a short and measurable medical condition, i.e., cold, UTI which can be resolved within a two week period, will be cancelled and a new date agreed with patient at this time within a reasonable timescale. The RTT clock will keep ticking throughout this period If the patient is either not willing or unable to accept a new date, they must be discharged back to their GP until fit and ready to proceed and the Consultant will be informed. The RTT clock will stop on date of discharge The agreed rules regarding medically unfit patients re-referring back to the Trust then apply Hospital Cancellations Theatre cancellations follow an escalation policy which includes Theatre Manager, Anaesthetic and Theatre Matron and Divisional Managers Cancelled theatre sessions should be taken up by other consultant/speciality wherever possible to ensure maximum theatre utilisation and this will be the responsibility of the List Broker. Please see Escalation Process Appendix 3. Page 19 of 37

20 If an agreed admission date is cancelled by the hospital at any stage up to and including the day of admission, a new date should be agreed with the patient within two working days. This new date of admission should be within 28 days or the RTT breach date, whichever is sooner. Rules of reasonableness continue to apply. The RTT clock will continue to tick throughout until treatment is started Cancer Patients GP TWO WEEK WAIT REFERRAL (2WW) Patients will wait a maximum of two weeks from receipt of urgent GP 2WW referral to their first outpatient appointment with appropriate specialties this target is for all cancer types. All new referrals for breast, with the exception of referrals to the family history clinic and referrals for cosmetic breast surgery, will fall under this target. Where referrals for breast are received from another consultant, the patient will be seen within two weeks from the booking team receiving the consultant referral - (compliance target 93%). All referrals must be registered on the cancer database From GP 2WW REFFERAL to first treatment Patients will wait a maximum time of 62 days from receipt of urgent GP referral to first treatment date this target is for all cancer types (compliance target 85%) Patients will wait a maximum of 31 days from a decision to treat or fit to treat date to their first treatment this target is for all patients who come into the Trust via 2WW referral and any other referral route (e.g. ED, routine and follow-up appointments).- (compliance target 96%) The 31 day target also applies for recurrent cancers and subsequent cancer treatments, 31 day drug treatment (compliance target 98%), 31 day surgery treatment (compliance target 94%), 31 day radiotherapy treatment (compliance 94%) For Children s, Testicular and Acute Leukaemia Cancers - there is a maximum 31 day wait from receipt of urgent GP referral to the patient s first treatment (compliance target 96%) Consultant to Consultant 62 Day Upgrade - Maximum waiting time is 62 days, starting from where a consultant suspects a potential cancer diagnosis and completes a consultant to consultant 62 Day Upgrade form which is ed on the day to Cancer Services and ends on the day that the patient has their treatment The maximum waiting time of 62 days referral through the Screening Programs to first treatment. (Compliance target 90%) Inclusions and Exclusions Which patients are included within the cancer waiting time service standards? Cancer waiting times service standards are applicable to patients cared for under the NHS in England with ICD codes C00-C97 and D05 (all carcinoma in situ breast), excluding basal cell carcinoma. This includes those patients: being treated within a clinical trial; Page 20 of 37