Patient Access. UCLH policy

Patient Access UCLH policy Version 3.2 Version Date June 2014 Version Approved By EB Policy Approval Sub-Group Publication Date July 2013 Author Kevin Nicholson Review By Date June 2016 Responsible Director Geoff Bellingan Medical Director - Surgery and Cancer Monitoring EB Performance Board Committee Target Audience All administrative/clerical staff involved in the administration of the patient pathway All medical and clinical staff seeing patients in outpatient setting and those with admission rights Related UCLH Child Safeguarding and Protection Policy Policies Safeguarding Adults Policy Private Patients Policy Treatment of Overseas Visitors Policy Diversity, Equality & Human Rights Policy Number of Pages and 13 pages including 1 Appendix Appendices Equalities Impact Low Assessment Policy Category Clinical Policy Number 043/CLN/T

Table of Contents Page Number 1.0 Summary 2 2.0 Introduction 2 3.0 Objectives 2 4.0 Scope 3 5.0 Duties 3 6.0 Details of the Policy 5 7.0 Monitoring Compliance with the Policy 9 8.0 Reference 10 Appendix 1: Glossary of Terms 12 UCLH - 2013 1

1.0 Summary 1.1. This Policy sets out the overall expectations of the University College London Hospitals NHS Foundation Trust (UCLH) and local commissioners on the management of referrals and admissions into and within the organisation. It sets out the responsibilities of UCLH staff and should be read in conjunction with the Patient Access User Manual. 2.0 Introduction 2.1.1 This policy details how patients will be managed administratively at all points of contact within UCLH and should be read in conjunction with the Patient Access User Manual. 2.1.2 The policy has been developed to ensure UCLH provides a consistent, equitable and fair approach to the management of patient referrals and admissions that meets the requirements of the NHS Operating Framework and the commitments made to patients in the NHS Constitution. 2.2 The NHS Constitution states that patients can expect to start their consultant led treatment within a maximum of 18 weeks of referral for a non-urgent condition. Patients with more urgent conditions, such as cancer or heart disease, will be seen and treated more quickly.. 2.3 UCLH will work to ensure fair and equal access to services for all patients, and ensure it meets its obligations towards people who have had, or have disabilities under the Equality Act (2010). This places a legal obligation on organisations to make reasonable adjustments to facilitate the care of people with disabilities. The decision as to what adjustments to make is not prescriptive, and must be agreed with the patient, their carer and the team caring for the person. By Law, if the adjustment is reasonable, then it should be made. Examples of reasonable adjustments can be found in the practice guideline: supporting people with learning disabilities. 3.0 Objectives 3.1 This policy sets out the way in which UCLH will manage patients who are waiting for treatment on admitted, non-admitted or diagnostic pathways. It covers the management of patients at all sites where UCLH operates, including outreach clinics. 3.2 Every process in the management of patients who are waiting for treatment must be clear and transparent to the patients and to partner organisations and must be open to inspection, monitoring and audit. 3.3 UCLH will give priority to clinically urgent patients and treat everyone else in turn. War pensioners and service personnel injured in conflict must receive UCLH - 2013 2

priority treatment if the condition is directly attributable to injuries sustained in conflict. 3.4 UCLH will work to meet and improve on the maximum waiting times set by the Department of Health for all groups of patients. 3.5 UCLH will aim to negotiate appointment and admission dates and times with patients. 3.6 UCLH will work to ensure fair and equal access to services for all patients in accordance with the Equalities Act (2010) 3.7 In accordance with training needs analysis, staff involved in the implementation of this policy, both clinical and clerical, will undertake training provided by UCLH and regular annual updates. Policy adherence will be part of the staff appraisal process.. 3.8 UCLH will ensure that management information on all waiting lists and activity is recorded on an appropriate UCLH system. This must be CareCast or other approved reporting systems authorised by the Director of Performance & Partnerships, e.g. Radiology Information System (RIS). All approved reporting systems form part of the UCLH electronic patient record (EPR). Stand-alone or paper based systems must not be used in isolation or without prior agreement with the ICT Director. 4.0 Scope 4.1 This policy sets out or advises on the overall expectations of UCLH and local Commissioners on the management of referrals and admissions into and within the organisation, and defines the principles on which the policy is based. 4.2 A separate Patient Access User Manual reflects the processes by which the Policy expectations are activated. 4.3 This policy and the Patient Access User Manual are intended to be of interest to and used by all those individuals within UCLH, who are responsible for referring patients, managing referrals, adding to, and maintaining waiting lists for the purpose of organising patient access to hospital treatment. The principals of the policy apply to both medical and administrative waiting list management. 5.0 Duties Whilst responsibility for achieving targets lies with the Clinical Board, all staff with access to and a duty to maintain, referral and waiting list information systems, are accountable for their accurate upkeep. UCLH - 2013 3

Medical Directors 5.1 The Clinical Board Medical Directors are accountable for implementing the Patient Access Policy, monitoring waiting list management and ensuring compliance with the policy. 5.2 The Clinical Board Medical Directors are accountable for ensuring that the waiting times targets are monitored and delivered. 5.3 The Director of ICT is accountable for the maintenance of CareCast and other reporting systems on which all waiting lists are held. 5.4 The Director of Performance and Partnerships is accountable for the management of data once it has been entered onto CareCast and on other reporting systems on which all waiting lists are held. 5.5 The Head of Performance is responsible for the reporting of information to the Clinical Board Medical Directors monitoring performance against locally or nationally agreed targets and ensuring this is fed into appropriate operational and performance forums. 5.6 The Head of Information is responsible for providing regular data quality audits of standards of data collection and recording the submission of central returns produced by the Information Services Department. Clinical Staff 5.7 All clinical staff are responsible through their Divisional Clinical Director to the Clinical Board Medical Director for ensuring they comply with their responsibilities as outlined in this policy. General Managers 5.8 General Managers through Divisional Managers are responsible for ensuring the data is accurate and the policy is complied with. Waiting List Administrations 5.9 Waiting List Administrators, be they clinic staff, secretaries or booking clerks, are responsible to the Service/General Managers with regard to compliance of all aspects of the UCLH Patient Access Policy. 5.10 Waiting List Administrators are responsible for the day-to-day management of their lists and are supported in this function by the Service/General Managers and Divisional Managers who are responsible for achieving access targets. All Staff UCLH - 2013 4

5.10.1 Staff involved in managing patients pathways for elective care must not carry out any action about which they feel uncertain or that might contradict this policy. 5.11 Any staff not following this policy or its accompanying operating instructions will have this reported to their line manager and this may result in action under UCLH disciplinary policies. GPs & Clinical Commissioning Group (CCG) 5.12 GPs play a pivotal role in ensuring patients are made aware during their consultation of the likely waiting times for a new outpatient consultation and of the need to be contactable and available when referred. 5.13 The CCG is responsible for ensuring robust communication links are in place to feed back information to GPs. 6.0 Details of the Policy 6.1 Management of New and Follow-up Outpatient Appointments (User Manual section 9 and see appendix 1 for definitions) 6.1.1 Named Referrals Referrals should be made to a service rather than a named clinician. Where patients are referred to a named consultant they may be offered appointments with a different consultant; however, unless the change of consultant is due to ill health, retirement or is clinically inappropriate, a refusal of this offer does not affect the patient s breach date. 6.1.2 Outpatient Referrals Referrals must be registered and scanned onto UCLH systems on the same working day. Clinical review must take place within three working days of receipt of referral. Patient contact must be made within four working days of receipt of referral. Where patients cannot be contacted they will be discharged to their GP, with both patient and GP being informed in writing. 6.1.3 General Principles for Booking All patients must be seen in order of clinical priority and length of wait. Patients have an opportunity to negotiate their appointment time and date. No patient waiting for an outpatient appointment can be suspended or paused. No patient waiting for a diagnostic appointment or admission can be suspended or paused. UCLH - 2013 5

A decision to add to an outpatient, diagnostic or elective waiting list must be recorded on an approved information system within one working day. 6.1.4 Reasonable Offer A reasonable offer is a date that is at least three weeks from the time of the offer being made Patients who decline one reasonable offer must be offered one further reasonable date. If two reasonable offers are declined for either a new or follow-up outpatient consultation, the patient will be discharged to their GP. All appointments will be confirmed in writing. 6.1.5 Suspected Cancer & Rapid Access Chest Pain All patients with suspected cancer or new exertional chest pain must be seen in outpatients within 2 weeks of referral by their GP or GDP. 6.1.6 Overseas Visitors Patients who are identified as overseas visitors must be referred to the Overseas Patients Officer for clarification of status regarding entitlement to NHS treatment before registration takes place (See Treatment for Overseas Visitors Policy). 6.1.7 Clinic Cancellation or Reduction Patients should not be cancelled more than once. A minimum of six weeks notice of annual or study leave is required for clinic cancellation or reduction. Clinic cancellation with less than six weeks notice can only be authorised by the appropriate Divisional Manager or Divisional Clinical Director. 6.1.8 Cannot Attend (CNA) Patients are able to cancel their outpatient appointment before their agreed time & date without penalty. 6.1.9. Did Not Attend (DNA) Patients (with the exception of paediatrics and vulnerable adults) who do not attend their outpatient appointments will be discharged back to the GP 6.1.10. Open Appointments Open appointments are deemed to be clinically unsafe and should no longer be used within the Trust. 6.2 Management of Diagnostic Appointments and Admissions (Patient Access User Manual section 10) 6.2.1 Patients Referred on for Diagnostics UCLH - 2013 6

Referring clinicians are responsible for informing patients of the likely waiting time for diagnostic tests. Where treatment has not been given, subsequent appointments must be given within in the RTT breach date. 6.2.2 Diagnostic Referrals All Access policy rules apply equally to diagnostics appointments and admissions. 6.2.3 Arranging Diagnostic Appointments and Admissions For diagnostic appointments and admissions a reasonable offer is considered to be a date with at least two weeks notice. At least one attempt will be made to telephone the patient to make a reasonable offer, then the patient can be send an appointment / admission date, including a clear offer to the patient to call to negotiate a date. Should a patient be unable to accept a date within two weeks, one further date with at least two weeks notice will be offered. An RTT pause or suspension cannot be applied for any patient waiting for an outpatient or inpatient diagnostic procedure. 6.2.4 DNA Diagnostic Appointments Patients who DNA a first diagnostic appointment can have a second appointment booked within 2 weeks. A second DNA will result in a letter to the referrer, who will discharge the patient back to the GP with advice. 6.2.5 Results Reporting Reporting of results must be made available in time to allow progress through all likely stages of the RTT pathway. 6.3 Management of Elective Admissions (Patient Access User Manual section 11) 6.3.1 Adding Patients to an Inpatient Waiting List On the date of admission for treatment, the clock stops for that pathway period. The decision to add patients to the waiting list must be made by the consultant or designate (eg SpR). The patient must have accepted the clinician s advice on elective treatment prior to being added to the waiting list. Additions to the waiting list on CareCast must be within one working day of the decision to admit. Patients must not be added if: o They are unfit for procedure o Further investigations are required first o Not ready for the surgical phase of treatment UCLH - 2013 7

o o They need to lose weight There is no funding available for the intended treatment. 6.3.2 Use of Planned Waiting List Patients should only be included on planned waiting lists if there are clinical reasons why the patient cannot have the procedure or treatment until a specified time. 6.3.3 Age Restriction to Elective Admission No child under the age of 1 year may be listed for elective surgery. 6.3.4 Selecting Patients for Admission Clinically urgent patients will be prioritised according to need All routine elective patients must be managed chronologically in order of RTT waiting time. War pensioners and service personnel injured in conflict must receive priority treatment if the condition is directly attributable to injuries sustained in conflict 6.3.5 Contacting Patients to Arrange a Date for Elective Admission Patients will be contacted by telephone to arrange their admission date and this date confirmed in writing. Where patients cannot be contacted they will be discharged to their GP 6.3.6 Reasonable Offer A reasonable offer for an elective admission is a date with at least three weeks notice Where a patient declines a second reasonable offer a pause may be applied from the earliest reasonable offer date (EROD) to the date the patient is available. If unwilling to accept a date within 12 weeks, clinical advice must be sought as to: offering a longer pause discharging with / without an open appointment clinical review at a later stage with clinician / pre-operative assessment 6.3.7 Patients Medically Unfit for Treatment Patients medically unfit at the time of decision to admit should not be added to an elective list. For patients on an elective waiting list, if the patient is is identified as not fit for their surgery, they must be removed from elective waiting list. Patients cannot be suspended for medical reasons. 6.3.8 Did Not Attend (DNA) UCLH - 2013 8

Patients (with the exception of paediatrics and vulnerable adults) who do not attend their date for elective admission will be discharged back to the referrer Clinically urgent patients can be offered one further admission date 6.3.9 Cancellations on Day of Surgery Following a last minute cancellation (on the day of surgery, day of admission or following admission), patients have a right to be offered a new date for treatment that is both within 28 days of the cancellation and within their RTT breach date Where a patient cannot be re-booked within 28-days following a cancellation by UCLH, they will be offered the choice to have the procedure in the private sector funded by UCLH 6.4. Tertiary/Inter-Provider Referrals A completed Inter-provider Administrative Minimum Data Set (IPTAMDS) proforma must be sent with all inter-provider transfers. 7.0 Monitoring Compliance with the Policy 7.1 The Executive Board monitors Clinical Board performance against patient access targets on a monthly basis. 7.2 The Performance Board receives monthly reports on Clinical Board performance against patient access targets and identifies and monitors where action is required to address underperformance. 7.3 Referral to Treatment Steering Group oversees the development of reporting mechanisms to support monitoring and compliance against access targets. 7.4 The Access and Data Quality Group ensures that key access, efficiency and data quality targets are achieved. It receives weekly reports on a range of indicators at division and speciality level including:- Outpatient data quality (unconfirmed attenders) Diagnostics waits (breaches within 6 weeks) Inpatient data quality (expired TCIs, suspensions from waiting lists) Cancelled operations 18 week admitted and non-admitted pathways 7.5 The Access and Data Quality Group identifies issues of non-compliance against access and data quality targets and agrees and monitors actions to address this. 7.6 The Access and Data Quality Group escalates non-compliance against access targets to Clinical Board Medical Directors UCLH - 2013 9

7.7 An annual internal audit of 18 week process and patient sampling is presented to the Audit Committee. 8.0 References Camden Primary Care Trust Partnership Board Commissioning Committee - Service Access Criteria Camden Primary Care Trust Partnership Board Service Access Criteria Board Decision (restricted treatments and referral managed interventions) January 2007 Department of health Getting patients treated; the Waiting List Action Team handbook. August 1999. Department of Health NHS Constitution: January 2009 18-weeks rules suite How to Measure guide The 18-week rules suite - How to apply guide Department of Health, Handbook on the Management of Private Practice in Health Service Hospitals. 1989. Department of Health Policy document Tackling hospital waiting: the 18 Week patient pathway, an implementation framework (Gateway reference 6468). Department of Health The 18 week Rules Suite, A how to guide to applying national 18 week rules locally. 2008 Department of Health Your guide to the NHS [Replaces the Patient s Charter] 2001 Department of Health The NHS Plan July 2000 Information Standards Board for Health and Social Care DSC Notice 07/2008: Data Standards: Inter-Provider Transfer Administrative Minimum Data Set (IPTAMDS). Information Standards Board for Health and Social Care DSC Notice 44/2007: Data Standards: Inter-Provider Transfer Administrative Minimum Data Set (IPTAMDS). Information Standards Board for Health and Social Care DSC Notice 05/2008: Data Standards: 18 Week Rules Suite NHS Executive A step-by-step guide to improving outpatient services. Variations in NHS Outpatient Performance, Project Report ii July 2000 UCLH - 2013 10

10 High Impact Changes NHS Executive EL(97)42 Access to Secondary Care Services - 1997 NHS Executive NHS Waiting Times Good Practice Guide 1996 NHS Executive EL(95)57 Transfer of Patients to Shorter Waiting Lists NHS Information Authority DSC notice: 20/2001: NHS Plan Booking Systems June 2001 NHS Information Authority NHS Data Dictionary Version 3 May 2007 http://www.connectingforhealth.nhs.uk/datadictionary/ NHS Modernisation Agency Ready, Steady, Book: a guide to implementing booked admissions and appointments for patients 2001. Royal British Legion, Honour the Covenant; Policy Briefing Healthcare for Veterans. Royal College of Surgeons of England Guidelines for the Management of Surgical Waiting Lists 1991 UCLH - 2013 11

Glossary of Terms Appendix 1 Active Monitoring (Also known as watchful waiting ) 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 active monitoring. Active Waiting List Patients awaiting elective admission for treatment and are currently available to be called for admission. Can Not Attend (CNA) Patients who, on receipt of reasonable offer(s) of admission, notify the hospital that they are unable to attend. Choose and Book A method of electronically booking a patient into the hospital of their choice. Date Referral Received (DRR) The date on which a hospital receives a referral letter from a GP. The waiting time for outpatients should be calculated from this date. Day cases 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. Decision to Admit date (DTA) The date on which a consultant decides a patient needs to be admitted for an operation. This date should be recorded in the case-notes and used to calculate the total waiting time. Did Not Attend (DNA) 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 OP appointment. First Definitive Treatment An intervention intended to manage a patient s disease, condition or injury and avoid further invention. What constitutes First Definitive Treatment is a matter for clinical judgement, in consultation with others as appropriate, including the patient. Indirectly Bookable Services 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. Inpatients Patients who require admission to hospital for treatment and are intended to remain in hospital for at least one night. Open Appointments Open appointments clinically unsafe and are no longer used within this Trust. UCLH - 2013 12

Outpatients Patients referred by a General Practitioner or another health care professional for clinical advice or treatment. Pause If a patient declines two reasonable offers (three weeks notice) of a TCI date for elective admissions, then a pause maybe applied from the earliest reasonable offer date (EROD) to the date the patient makes themselves available. The pause adjusts the RTT breach date. A pause can be for a maximum period of twelve weeks - if longer is required clinical consent must be sought. Primary Targeting List or Patient Tracking List (PTL) 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. Reasonable Offer 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 in patients. Referral to Treatment (RTT) 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. TCI (To Come In) date 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. UCLH - 2013 13