Cancer Services Operational Policy (Patient Access) Version number 2.1

Cancer Services Operational Policy (Patient Access) V2.1 Cancer Services Operational Policy (Patient Access) Version number 2.1 Lead executive Name / title of author: Chief Operating Officer Karen Blackburn, Lead Manager Cancer Services Date reviewed: Target audience: Policy Summary: September 2015 Date ratified: 19/10/2015 Cancer Services Team Directorate Management Teams; Waiting List Teams Out Patient teams Clinical Teams; Performance and Information Team Cancer Analysts Ratifying Committee: Cancer Board This document sets out how UHSM will manage the pathway of patients who are waiting for an out-patient appointment, diagnostic investigation, in-patient or daycase admission on a cancer pathway including data entry and validation. Equality Impact Statement: University Hospital of South Manchester NHS Foundation Trust ( UHSM ) strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of health care, UHSM aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This document has therefore had an initial assessment, in accordance with the equality impact proforma incorporated in the Checklist for Review and Ratification of UHSM-wide Documents, to ensure fairness and consistency for all those covered by it regardless of their individuality. This initial impact assessment indicated that the potential discriminatory impact is nil (see Appendix C Training impact and plan summary: Outline plan for dissemination: Dissemination lead: name / title / ext n o Training on the cancer section of the Patient Access Policy and the Cancer Services Operational Policy is required by the Cancer Services core team and Performance and Information Team Cancer Analysts. This will be delivered via dedicated training sessions to be led by the Lead Manager Cancer Services. Out Patient and Waiting List staff will be trained by their local managers, to include both initial and refresher training Please see Appendix B Karen Blackburn, Lead Manager Cancer Services, extension number 2969 This version n o 2.1 Date published: 23/10/2015

University Hospital of South Manchester NHS Foundation Trust VERSION CONTROL SCHEDULE Version number Issue / Review Date Amendments from previous issue Date of Ratification by Committee V2.0 Addition: Section 5 Duties & Responsibilities:The Lead Manager Cancer Services will undertake on going review of the cancer services team staffing resources to ensure the team is fit for purpose Endoscopy booking team The endoscopy booking team have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the GP on referral straight to test, in order that patients can be tracked within the relevant national cancer time frame 19/10/2015 Amendment: 6.3.1 Out Patient Capacity escalation: The CPCs will query any outpatient appointment delays or 2WW target breaches with the outpatient call-centre clerical team in the first instance. The call-centre team will raise the capacity issue with the relevant Assistant Directorate Manager who should action any capacity issues. The CPCs will query any endoscopy straight to test 2ww target breaches with the endoscopy clerical team in the first instance. If not resolved the endoscopy clerical team will escalate to the Assistant Directorate Manager Medical Specialties. Amendment: Capacity issues diagnostic Section 6.3.2:The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the relevant Deputy Directors of Operations and finally via the weekly Patient Access board Amendment: 6.3.3Capacity issues treatment: The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the Deputy Directors of Operations and finally via the weekly Patient Access Board. Amendment: 6.3.4 Diagnostic Delays: 1

The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate firstly to the relevant departmental manager as identified by radiology and pathology and then via the weekly escalation report to the relevant Directorate Manager and Deputy Directors of Operations and finally via the weekly Patient Access Board. 6.3.5 Clinical or patient choice delays amendment: The CPCs will notify the Lead Manager Cancer Services/Deputy Manager Cancer Services of any patient-choice or clinical delays to the pathway and note the issue within the tracking comments section on SCR. 6.3.9 Step Downs Administrative SECTION DELETED 8.1 Peformance Monitoring addition: Root Cause Analysis forms will be completed by the relevant CPC for each breach of the 62 day target. This will be shared with commissioners and also with Directorate Management Teams who will be required to review and ensure action is undertaken to maintain and improve cancer performance and patient experience General: Throughout the document, Associate Director of Operations has been changed to Deputy Director of Operations, Director of Performance and Information has been changed to Chief Information officer. Escalation previously to Chief Information Officer and Chief Operating Officer has been changed to via the weekly Patient Access Board 2

Document Control Summary of consultation process Control arrangements Draft policy circulated to Cancer Board members, Cancer Information Analyst, Deputy Manager Cancer Services, Cancer Tracking Coordinator, Directorate Managers (including Out Patients) Elective Access Manager, MDT Lead Clinicians and Chief Operating Officer, Chief Information Officer, Deputy Directors of Operation for comment. Publication on the trust intranet for a 3 week period of consultant and comment This policy will be subject to review by the Lead Manager for Cancer Services every 2 years, or, more frequently if external bodies eg NHS England issue updates on current Cancer Waiting Times Guidance in the meantime. [Reviews shall generally be undertaken every 2-3 years or more frequently to take account of organisational learning] Associated documentation and references Cancer Waiting Times Guidance v 8.1 Date July 2015 UHSM Patient Access Policy (2015) Policy for the Upgrade ( Step Up ) & Downgrade ( Step Down ) of Patients to and from the Fast Track, 62 day Cancer Pathway July 2015 References COSD - Cancer Outcomes and Services Dataset CPC Cancer Pathway Coordinator CaRP Communication and Referral Proforma CWT Cancer Waiting Times DoH Department of Health GP General Practioner GDP General Dental Practitioner SCR Somerset Cancer Register Database TCI To Come In (Admission) PAS Patient Administration System PPI Patient Pathway identifier MDT Multi-Disciplinary Team PCA Patient Choice Adjustment PTL Primary Target List (chronological list of patients being tracked against national standards) 2WW GP Two week wait referrals Cellular pathology: diagnosis by microscopic examination of tissue sections (histopathology) or cytological preparations (cytopathology) 3

DOCUMENT COMPLIANCE MONITORING ARRANGEMENTS Minimum requirement to be monitored Compliance with national and local cancer waiting time targets Process for monitoring e.g. audit Responsible individual / group/ committee Frequency of monitoring Individual responsible for preparation / approval of compliance report and action plan Individual / group / committee that is responsible for review of results / approval of action plan Individual / group / committee that is responsible for monitoring of action plan Review of patient pathways and achievement of waiting times targets at weekly PTL meetings Bi-annual audit of application of policy guidance via PAS, ensuring relevant information has been entered on to PAS and resulting adjustments have been applied to patient pathways on SCR. This will be undertaken via random selection of patients from a live PTL. Lead Manager Cancer Services Weekly via PTL Biannually via PAS and SCR Lead Manager Cancer Services Cancer Board Cancer Board 4

CONTENTS 1 Introduction and Purpose 6 2. Policy Statement 6 3. Relevant Access Standards 6 4. Scope 7 5. Duties and responsibilities 7 6. Access Policy Standards 9 7. Escalation outside the Team 14 8. Quality and Performance Monitoring 15 9. Training/ Communication Plan 16 10. Relevant Performance Reports 17 Appendices A Flowchart for dealing with repeated patient non-compliance 18 B Plan for Dissemination 19 C Equality Impact Assessment 20 Page 5

1. Introduction and Purpose This document sets out University Hospital of South Manchester NHS Foundation Trust s (UHSM) Operational Policy for the Cancer Services Team. It details how UHSM will approach the management of patients against national cancer waiting time targets. It has been developed using current guidance from the Department of Health, including Cancer Waiting Times (CWT) guidance, and other sources of best-practice. The overall purpose of the document is to establish a consistent approach to the management of cancer waiting times across the organisation and robust validation of the same. 2. Policy Statement To ensure all staff involved in cancer waiting times management are aware of and follow the processes outlined in this document in order to provide equitable access for patients through effective cancer tracking, to enable the Trust to achieve the required access standards, taking into account national rules and guidelines. The key principles of this policy are: improve the patient experience as they move through the clinical pathways, minimising unnecessary delays where possible; ensure patients receive treatment according to clinical priority in the first instance, followed by actual waiting time; escalate bottlenecks in cancer-waiting-time pathways at an early stage to directorate management teams; provide timely, consistent and accurate data-recording for patients on cancer waiting-time pathways. 3. Relevant Access Standards a) Maximum 2 weeks from: i) receipt of urgent GP/GDP referral for suspected cancer to first outpatient attendance [Operational Standard of 93%]; ii) receipt of referral of any patient with breast symptoms (where cancer not suspected) to first hospital assessment [Operational Standard of 93%]. b) Maximum 31 days from: i) decision to treat to first definitive treatment [Operational Standard of 96%]; ii) decision to treat/earliest clinically appropriate date to start of second or subsequent treatment(s) for all cancer patients including those diagnosed with a recurrence where the subsequent treatment is: (1) surgery [Operational Standard of 94%] (2) drug treatment [Operational Standard of 98%] (3) radiotherapy [Operational Standard of 94%]. c) Maximum 62 days from: (i) receipt of urgent GP/GDP referral for suspected cancer to first treatment [Operational Standard of 85%]; (ii) receipt of urgent referral from NHS Cancer Screening Programmes (breast, cervical and bowel) for suspected cancer to first treatment [Operational Standard of 90%]; (iii) date of consultant upgrade of urgency of a referral to first treatment [No Operational Standard as yet]. 6

d) Maximum 31 days from receipt of urgent GP referral to first treatment for children s cancer, testicular cancer, and acute leukaemia [No separate Operational Standard Monitored within 62-day standard]. 4 Scope This document has been designed to be a reference guide for all staff involved with cancerpathway management and sets out the standards required. 5. Duties and Responsibilities Lead Manager Cancer Services The Lead Manager Cancer Services will ensure that all cancer services core team staff involved in cancer-pathway tracking are aware of this policy and the importance of following the procedures. Training will be provided to the cancer services core team on this policy together with the Trust s Access Policy. Training will also be provided to new members of the team at induction. The Lead Manager Cancer Services will undertake on going review of the cancer services team staffing resources to ensure the team is fit for purpose The Lead Manager Cancer Services is responsible for reviewing this policy. Deputy Cancer Services Manager, Project Support Manager and Cancer Tracking Coordinator The Deputy Cancer Services Manager and Cancer Tracking Coordinator will ensure that the processes outlined in this document are implemented and adhered to, without deviation by the cancer pathway coordinating team, on a day-to-day basis. The Deputy Cancer Services Manager will ensure that refresher training on this policy and the Trust s Access Policy is included within the cancer services core team annual training programme, in order to maintain skills and knowledge. Cancer Pathway Coordinators The Cancer Pathway Coordinators will ensure the accuracy of information for all patients managed against national cancer waiting time targets on the Somerset Cancer Registry Database, using information received from multi-disciplinary and Trust IT systems. All Cancer Pathway Coordinators have a responsibility to ensure that they comply with the guidance in this operational policy. Clinicians All clinicians must ensure that before adding a patient to the waiting list for a cancer treatment, the patient is fit, ready and able to come into hospital for their procedure. Clinicians must complete an upgrade form if they wish to upgrade patients to the national 62-day target or alternatively request the patient is upgraded via Sunquest ICE. Clinicians must sign a step down form, if they believe it is clinically appropriate to step the patient off a national cancer 62-day pathway, or alternatively request the patient is stepped down via Sunquest ICE. Directorate Management Teams 7

The directorate management teams have a responsibility to ensure that adequate capacity is available for all patients added to all waiting lists to enable the Trust to achieve the required local and national cancer standards. The Directorate management teams have a responsibility to ensure that their respective clinical teams have robust processes in place in order to enable cancer patients are added to the waiting list in a timely and consistent manner. Out-patient Call Centre Team The outpatient administrative clerks / receptionists have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the GP on referral, in order that patients can be tracked within the relevant national cancer standard time frame. Out Patient Clerks/Receptionists The outpatient administrative clerks / receptionists have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the clinical teams on the clinic-outcome proforma. Endoscopy booking team The endoscopy booking team have a responsibility to ensure that the data entered onto IPM / PAS accurately reflects the information provided by the GP on referral straight to test, in order that patients can be tracked within the relevant national cancer standard time frame Performance & Information Team The Performance & Information team has a responsibility to comply with all quality and performance monitoring duties described in section 8.2 of this document. Waiting List Teams Have a responsibility to ensure that patient data entered onto IPM/PAS is accurate and reflects the information provided by the clinician at listing. They also have responsibility to ensure that patients are dated within relevant waiting time standards and escalate to the relevant directorate manager where there are capacity issues. 8

6. Access Policy Standards 6.1 General Principles All patients with suspected or diagnosed cancer will be managed in line with national cancer waiting time standards. All relevant patients will be added to the Somerset Cancer Registry Database (SCR) which will hold full and comprehensive records for each patient. Patient records will include MDT discussion and a full Cancer Outcomes and Services Dataset (COSD) and where relevant National Audit data. Patients will be tracked against the appropriate local and national standards and any bottlenecks or pathway breaches will be actioned and / or escalated as appropriate. Compliance/ breaches of target will be reported in line with national reporting guidance. Data quality checks will be undertaken. Cancer team members will receive comprehensive induction and refresher training to allow them to undertake their duties. 6.2 Operational Process 6.2.1 Adding patients to SCR Referral details for all patients referred to UHSM for treatment by their GP/GDP as a suspected cancer (all tumour groups) and all symptomatic breast referrals will automatically transfer from PAS to SCR as part of an overnight extract from the Trust s data warehouse. Organisations across Greater Manchester and Cheshire Cancer Network have agreed a communication and referral process, which requires that a Communication and Referral Proforma (CaRP) includes accurate demographic and pathway data with each referral between hospital trusts. The Cancer Tracking Coordinator and Cancer Services Central Office team will check the generic email account at regular intervals during each working day and will immediately add any CaRPed referrals received on to SCR, to include accurate demographic and patient pathway data. The Cancer Tracking Coordinator and Cancer Services Central Office team will add any faxed CaRPed referrals immediately upon receipt on to SCR, to include accurate demographic and patient pathway data (having reviewed to ensure patient is not already on an existing 62 day pathway). The Cancer Tracking Coordinator and Cancer Services Central Office team will add any faxed Upgrade referrals immediately upon receipt on to SCR, to include accurate demographic and patient-pathway data. The Cancer Services Central Office or Breast CPC will add any screening referrals to SCR immediately upon receipt, to include accurate demographic and patientpathway data. The Cancer Services Central Office team will add to SCR any upgrade referrals received via the generic cancer services email account from the ICE electronic upgrade system, to include accurate demographic and patient pathway data. The 9

referrals will be added immediately following a triage of tumour group and referral details from GP where those are required. The tumour specific Cancer Pathway Coordinator (CPC) will check any new additions to the elective waiting list daily to ensure all appropriate patients have been added to SCR, all records added to include accurate demographic and patient-pathway data. 6.2.3 Pathway Management The Cancer Tracking Coordinator will produce a full cancer PTL each Monday and distribute to CPCs, waiting-list team and directorate teams. Cancer Pathway coordinator duties Check the full PTL for their specialty daily to ensure patient pathways are expedited. Check agreed, timely next steps are in place for all patients, chase outcome of outpatient appointments, diagnostic tests and treatments and update information for all patients on SCR. Escalate as necessary (see section 6.3 for details). Meet with the relevant Booking & Scheduling Clerk from the waiting-list team on (at least) a weekly basis, to ensure patients are given a TCI date within the required timescale. Check the daily pathology report to identify incidental cancer diagnoses not known to SCR and update SCR for all relevant patients. Ensure real-time, accurate, comprehensive tracking comments exist on SCR, for each event/relevant patient within their specialty. NB each patient should have an SCR record which includes: Full demographic detail and PPI Standard recorded (31, 62, 2 nd /subsequent, screening & upgrade) Diagnosis where known (primary, recurrence, mets etc) ICD10 diagnosis code Tests and treatments booked in accordance with agreed pathway so as to avoid unnecessary breaches Cancer registration dataset completed in the relevant field on the diagnosis screen All relevant staging Complete COSD dataset National audit data where relevant Ensure the outcome from each patient discussed at the MDT meeting is entered onto SCR, preferably during the MDT meeting, but no later than 24 hours following the meeting. Ensure Step Down proformas are collected and actioned daily. Ensure Patient Choice Adjustment (PCA) forms are completed for all relevant patients (as indicated by DoH Cancer Waiting Times guidance and Trust s Access Policy) and signed by the relevant Directorate/Assistant Directorate Manager. 10

Check the PAS record for patients who have DNA(d) their first appointment on the 62 day pathway, to ensure there is an auditable trail prior to adding the adjustment in days to SCR. Produce an updated cancer PTL for all standards (31, 62, 2 nd /subsequent, screening & upgrades) for the weekly PTL meeting. Complete the breach-analysis template for all pathway breaches. 6.2.4 Communications The Cancer Tracking Coordinator will maintain a shadow list of UHSM patients CaRPed to other trusts for diagnostics or treatments, ensuring tracking comments are updated on SCR and breaches notified to Lead /Deputy Manager Cancer Services. The Cancer Service Tracking Coordinator will ensure that a full update is provided, to each referring organisation, on a weekly basis, of their patients who are on live tracking on the UHSM PTL. The CPCs will ensure inter-provider CaRPs, generated from SCR,are sent for all patients within their specialty for all cancer standards (31, 62, 2 nd /subsequent, screening & upgrades) immediately, with the referral letter being sent within 24 hours. The CPCs will ensure inter-provider CaRP information is entered into SCR. The CPCs will maintain a CaRPs Out List for all patients who are transferred out of UHSM where the initial management plan is chemotherapy and /or XRT (radiotherapy) followed by Surgery or chemotherapy at UHSM. These patients should be monitored for their 2 nd / subsequent treatment at UHSM. 6.3 Escalation Procedure 6.3.1 Capacity Issues Out Patient Appointments The CPCs will query any outpatient appointment delays or 2WW target breaches with the outpatient call-centre clerical team in the first instance. The call-centre team will raise any capacity issue with the relevant Assistant Directorate Manager who should take necessary action to prevent a breach of target. The CPCs will query any endoscopy straight to test 2ww target breaches with the endoscopy clerical team in the first instance. If not resolved the endoscopy clerical team will escalate to the Assistant Directorate Manager Medical Specialties. 6.3.2 Capacity Issues Diagnostics The CPCs will discuss any diagnostic appointment delays or target breaches with the relevant departmental booking clerk. If the delay is not resolved within a maximum 48 hours the CPCs will raise the issue with the relevant Assistant Directorate Manager and, if still not resolved within a further 24 hours, with the Lead Manager Cancer Services/Deputy Manager Cancer Services. The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, 11

to the relevant Deputy Directors of Operations and finally via the weekly Patient Access Board. 6.3.3 Capacity Issues First Treatment The CPCs will discuss any booked definitive treatment appointment delays or target breaches with the relevant waiting list clerical team (for in-patient surgical treatments), waiting list clerical team, secretary, administrative team (for day case/out patient treatments eg chemotherapy) in the first instance. If the delay is not resolved within a maximum 48 hours the CPCs will raise the issue with the relevant Assistant Directorate Manager and, if still not resolved within a further 24 hours, with the Lead Manager Cancer Services/ Deputy Manager Cancer Services. The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the Deputy Directors of Operations and finally via the weekly Patient Access Board. 6.3.4 Delays to diagnostic reporting If histopathology diagnostic biopsies remain unreported after 5 working days from procurement (where the report is not requested via ICE/ requesting clinician does not write the date on the request card, this will be date of receipt of specimen within pathology laboratory), the CPCs will flag the outstanding reporting to the pathology cancer pathway coordinator. If radiology remains unreported after 2 working days, the CPCs will flag the outstanding reporting to the radiology cancer pathway coordinator. If tests remain unreported within a further 48 hours the CPCs will escalate to Lead Manager Cancer Services/ Deputy Manager Cancer Services. The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate firstly to the relevant departmental manager as identified by radiology and pathology and then via the weekly escalation report to the relevant Directorate Manager and Deputy Directors of Operations and finally via the weekly Patient Access Board. 6.3.5 Clinical or patient choice delays The CPCs will notify the Lead Manager Cancer Services/Deputy Manager Cancer Services of any patient-choice or clinical delays to the pathway and note the issue within the tracking comments section on SCR. 6.3.6 Step Downs (Clinical) For all suspected cancer patients with the exception of those referred to breast, where diagnostic results/clinical correspondence appears to indicate that the patient does not have a malignancy and this has been communicated to the patient, the CPC will complete a step-down proforma, attach all relevant diagnostics results and clinical correspondence and where available, the patient case notes. The step down will be passed to the relevant medical secretary to request clinician sign off. It is the responsibility of the clinician removing the patient from the pathway to complete the step-down proforma promptly. If the proforma is not signed within 48 hours, the CPC will escalate to the relevant Assistant Directorate Manager and, if still not resolved, with the Lead Manager Cancer Services/Deputy Manager Cancer Services. 12

The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the relevant Deputy Director of Operations and finally via the weekly Patient Access Board. NB for those areas with a high volume of weekly step downs a weekly step down report will be produced for all patients with outstanding step down requests. This will be attached to the PTL produced by the CPCs for the weekly PTL meetings. If the clinician signs the step down proforma the patient s record will be closed on SCR and no further tracking undertaken. The relevant member of the Central Office team /CPC inputting the step down is also responsible for updating the Somerset cancer tracking system and changing the status of the patient. This can be done in the patient diagnosis screen. The patient status must be changed to no new cancer diagnosis identified, the tumour status must be amended to non-cancer, and the date of non-cancer should be completed with the date on the stepdown proforma or clinic letter. The non-cancer details section should be completed with the reason for removing the patient eg stepdown proforma received, removed as per clinic letter etc. Should any patient initially stepped down from the 62 day pathway later be diagnosed with cancer, this will be treated as an incidental finding and their pathway will be tracked against the 31 day target ( Date of Decision to Treat to First Definitive Treatment ). Patient may also be placed on an Upgrade 62 day pathway. The date of clinical decision to remove the patient from cancer 62 day tracking marks the end of the 62 day pathway. If the clinician declines to sign the patient off the pathway due to clinical reasons, the patient will continue to be managed within national targets and tracked accordingly. A copy of the signed step down must be filed within the relevant file within the Cancer Services Central Office. 6.3.7 Step Down at receipt of referral Only GPs and GDPs are able to downgrade referrals from the HSC 2ww referral pathway, at the point of receipt. Where a consultant believes that a referral does not meet the criteria for HSC205, 2ww referral prior to first appointment, the consultant must discuss the referral with the referring GP/GDP and the GP/GDP must agree to down grade the referral. Consultant must inform the outpatient schedulers they have spoken to the GP/GDP. Without this confirmation the downgrade will not take place. 6.3.8 Step Downs (Breast Referrals) For breast patients, a number of conditions or treatment plans have been identified locally by the clinical team in the clinic letter as acceptable evidence that the patient has received a formal non malignant diagnosis and can be removed from the pathway. In these circumstances a step down proforma is unnecessary. These have been reviewed in October 2015 by the Lead Breast MDT Clinician. 13

The conditions triggering removal from the pathway are fibroadenoma, gynaecomastia, lipoma, sebaceous cyst, abscess, benign phylloides and Eczema. The treatment plans are: Discharge pending results (such as blood tests for gynaecomastia when we have benign cytology) Write to with results of 2 nd FNA (when the 1 st FNA is benign) MRI for implant rupture Reconstruction/Reduction/Augmentation/Symmerisation procedures Nipple Eversion By local agreement, other breast patients to be removed from the 62 day pathway include those: attending the lymphoedema clinic where a pathology report from a surgical specimen is benign where a patient has been given a FU of 4 weeks/1month or more and is not undergoing any sort of treatment/trial The clinic letter may therefore be used in place of a Step Down proforma as evidence of a patient being removed from the 62 day pathway. The Cancer Pathway Coordinator (CPC) responsible for the tumour site has responsibility for ensuring the Step Down proforma is filled out, signed and returned to the cancer office fax by liaising closely with the clinician. The Breast CPC is responsible for checking clinic letters. The CPC is also responsible for updating the Somerset cancer tracking system and changing the status of the patient. This can be done in the patient diagnosis screen. The patient status must be changed to No new cancer diagnosis identified, the tumour status must be amended to Noncancer, and the date of non-cancer should be completed with the date on the stepdown proforma or clinic letter. The non cancer details section should be completed with the reason for removing the patient eg stepdown proforma received, removed as per clinic letter etc. Should any patient initially stepped down from the 62 day pathway later be diagnosed with cancer, this will be treated as an incidental finding and their pathway will be tracked against the 31 day target ( Date of Decision to Treat to First Definitive Treatment ). Such patients can also be upgraded to a 62 day pathway. The date of clinical decision/ adherence to protocol described above, to remove the patient from cancer 62 day tracking, marks the end of the 62 day pathway. 7. Escalation outside the Team 7.1.1 Capacity Issues and diagnostic reporting The Lead Manager Cancer Services/ Deputy Manager Cancer Services will escalate the issue firstly to the Directorate Manager and then, via the weekly escalation report, to the relevant Deputy Director of Operations and finally via the weekly Patient Access Board. 14

In addition, the Lead Manager Cancer Services/Deputy Manager Cancer Services will advise the Elective Access Manager of any surgical diagnostic or treatment capacity issues to facilitate dialogue with the relevant directorate management team regarding capacity planning at the weekly Theatre Management Meeting. 7.1.2 Clinical or patient-choice delays The Lead Manager Cancer Services/Deputy Manager Cancer Services will note any relevant breaches and advise the Chief Operating Officer, Chief Information Officer, Head of Performance and the Senior Information analyst (Cancer) accordingly. The Senior Information Analyst (Cancer) will include breaches in both internal and external cancer waiting times for reporting purposes. 8. Quality & Performance Monitoring 8.1 Lead Manager Cancer Services/Deputy Manager Cancer Services The Lead Manager Cancer Services/Deputy Manager Cancer Services chairs weekly Cancer PTL meetings, attended by the relevant tumour specific CPC and directorate management representative. Every patient on the Cancer PTL will be reviewed at the meeting, to ensure compliance with national and local cancer targets. Any gaps in tracking comments, identified from the PTL, will be discussed with the CPC at this meeting. Root Cause Analysis forms will be completed by the relevant CPC for each breach of the 62 day target. This will be shared with commissioners and also with Directorate Management Teams, to include diagnostic services, who will be required to review and ensure action is undertaken to maintain and improve cancer performance and patient experience. Breach trends and resulting action to improve cancer performance will be discussed at the Patient Access Board. 8.2 Performance & Information Team The Performance & Information team has a responsibility to ensure that validation checks are carried out prior to upload to the national cancer waiting times database. These are in the form of identifying missing treatments, missing mandatory data items and breach validation. Any inaccuracies identified should be reported to the Lead Manager Cancer Services/Deputy Manager Cancer Services for resolution prior to upload. The Performance & Information team has a responsibility to ensure that UHSM reports all cancer waiting time treatments and breaches in line with national reporting deadlines. Any individual within the Performance & Information team with responsibility for a submission must notify their Line Manager and the Lead Manager Cancer Services/Deputy Manager Cancer Services of any issues relating to compliance with reporting deadlines. 8.3 Cancer Pathway Coordinator The CPCs have a responsibility to undertake a number of data-quality checks each week: check records on SCR for patients with a treatment start date where there is no ICD10 code (N.B. when entering the ICD10 code, a 4-digit code is required e.g. C509, C342 etc); 15

when entering a diagnosis on SCR ensure tumour laterality is recorded; check records on SCR for patients with a treatment start date where there is no TCI (to come in) date; ensure the Lead Manager Cancer Services/Deputy Manager Cancer Services are aware of any breaches of national target, prior to entering the treatment details on SCR ensure breach comments are entered on SCR for all relevant patients; check the SCR checklist weekly to ensure that any data issues highlighted in RED are resolved; check the COSD (Cancer Outcomes and Services Dataset) checklist to ensure that any data issues highlighted in RED are resolved; when entering treatment records on SCR ensure that Clinical Trial details are entered (Yes / No / Unknown). 9. Training/ Communication Plan The Access Policy and Cancer Services Operational Policy will be communicated to all members of the cancer services core team via team meetings and dedicated training sessions and to new members of the team at induction The cancer pathway coordinating team will participate in an annual training programme and this will include refresher training on the Trust s Patient Access Policy and the Cancer Services Operational Policy A copy of the Patient Access Policy and the Cancer Services Operational Policy will be provided to all cancer pathway coordinators. 16

10. Relevant Performance Reports Report description Location Frequency Actions Responsibility for Monitoring Addition to Intranet Daily CPC to check the addition to Cancer Tracking Waiting List waiting lists daily and add Coordinator report relevant patients to SCR and / or ensure patients are treated within national/local cancer targets Cancer Services Pathology Reports ICE Daily Check for any outstanding pathology reporting (patients who are already on tracking) CPC Cancer Services Pathology Reports Radiology Reports Endoscopy Reports Cancer PTL ICE Daily Check for incidental cancer diagnosis and add any previously unknown cancer patients to SCR CPC ICE Daily Check for radiology reports CPC Unisoft Daily Check for scope reports CPC SCR/ Intranet Daily Reviewed patient pathways daily Cancer PTL Intranet Weekly Full PTL to be reviewed at weekly PTL meeting National Cancer Waiting Times Checklist SCR Weekly CPC to review on weekly basis to ensure complete records uploaded to CWT, compliant with national and local cancer targets CPC Lead/Deputy Manager Cancer Services Lead/Deputy Manager Cancer Services 17

DNA/Cancellations Diagnostic phase of pathway Appendix A DNA/cancels Re-book appointment Attends Pathway Continues DNA Cancels Consultant or delegate contacts pt by phone No refer back to managing clinician Clerk asks if patient wishes to be referred back to GP Pt agrees to be discharged No response within 48 hours pt sent letter Pt re-books Yes clerk to discharge and advise consultant team for clinical review of patient s decision Discharged to GP 1 week no response Pt discharged back to GP Contact GP by letter, in agreement with the managing clinician. Pt is now discharged back to your care for re-referral if required 18

Appendix B PLAN FOR DISSEMINATION: of Cancer Services Operational Policy (Patient Access) Title of document Cancer Services Operational Policy (Patient Access) Date finalised Dissemination Lead Karen Blackburn Previous document Yes Lead Manager already being used? Cancer Services If yes in what format and where Word document stored on the Trust intranet Policies page and also on the S Drive within cancer services Proposed action to retrieve out of date Policy Administrator to remove from intranet. Deputy Cancer Manager to remove from S Drive copies of the document Describe the plans for dissemination of the document to the specific people/groups in specified formats and if appropriate with relevant training Policy to be circulated to core cancer services team, directorate managers, waiting list team, out-patient team, MDT lead clinicians, Cancer Information Analyst. All cancer core team members to be given training on the contents of the policy and implementation, both induction and refresher training. Dissemination Record to be used once document is ratified Date put out on register/library of policy or procedural documents Date due to be reviewed 19

Appendix C EQUALITY IMPACT ASSESSMENT Cancer Services Operational Policy (Patient Access) Yes/No 1. Does the policy/guidance affect one No group less or more favourably than another on the basis of Race No Ethnic origins (including No gypsies and travellers) Nationality No Gender No Culture No Religion or belief No Sexual orientation including No lesbian, gay, bisexual and transgender people Age No Disability No 2. Is there any evidence that some No groups are affected differently? 3. If you have identified potential N/A discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance No likely to be negative? 5. If so can the impact be avoided N/A 6. What alternatives are there to N/A achieving the policy/guidance without the impact 7. Can we reduce the impact by taking N/A different action Comments 20