ADO’s, clinical directors, SOM’s, SM’s, members of the admin · Approval Body: Chair of the Document Review Group Version Number: 6.3 Reference Number: PP (18) 138 Version Issue

Title: Corporate Access Policy

Author: Head Of Access

Issue date Sept 2019 Next review: August 2020 Ref: PP(19)138 Page 1 of 105

Trust Policy and Procedure Document Ref. No: PP(19)138 Corporate Access Policy

For use in: Trust Wide

For use by: All Staff

For use for: Managing Waiting Lists and Handling Referrals

Document owner: Hannah Knights, head of elective access

Other Contributors ADO’s, clinical directors, SOM’s, SM’s, members of the admin

teams.

Status: Approved




Document Control: Document Author: Interim Head of Access

Document Owner: Operational Directorate

Electronic File Name: WSH Access Policy_15062018 v6.3 final

Document Type: Corporate Policy (applicable to Acute & Hospital Based Services)

Stakeholder Consultation: Operational Directorate; Communications and Patient Groups; Commissioners

Approval Level: Scrutiny Committee

Approval Body: Chair of the Document Review Group

Version Number:

6.3 Reference Number: PP (18) 138

Version Issue Date: September 2019 Effective Date: September 2019

Review Frequency: 6 months to incorporate Community Services and Primary care comments (February 2020) Annually, and on issuances of revised guidance (September 2020)

Method of Dissemination: Intranet Hard Copy to Key Departments Print as Booklet

For Use By: All Staff, GPs, Patient Friendly Version by Patients

N.B. USER ADVISORY - IT IS RECOMMENDED TO ACCESS THIS FILE ELECTRONICALLY AS IT CONTAINS EMBEDDED DOCUMENTS IN THE APPENDICES WHICH WILL NOT NECESSARILY BE INCLUDED IN A PRINTED DOCUMENT. Version History: Version Date Author Reason

V4.0 July 2017 Alex Baldwin To originate document

V4.1 October 2017 Interim Head of Access Updated SoPs and consistent with National Guidance

V4.2 November 2017 Interim Head of Access Appendices added issue for comment

V4.2.1 November 2017 Interim Head of Access For Consultation

V5.0 December 2017 Interim Head of Access FINAL DRAFT FOR CONSULTATION AND COMMENT

V6.0 Jan 2018 Interim Head of Access Final Version for Approval

V6.1 Feb 2018 Interim Head of Access Incorp Community Paeds Services.

V6.2 June 2018 Interim Head of Access Incorp SOP’s and references to Paper Switch off




Contents

1.0 Introduction ................................................................................................................................ 6

1.1 Principles ............................................................................................................................. 6

1.2 Purpose ............................................................................................................................... 7

1.3 Overarching roles and responsibilities ................................................................................ 7

1.4 Competency and compliance .............................................................................................. 8

1.4.1 Competency .................................................................................................................... 8

1.4.2 Compliance...................................................................................................................... 8

1.5 General elective access principles ...................................................................................... 9

1.5.1 Individual patient rights .................................................................................................. 9

1.6 Patient Eligibility ................................................................................................................. 9

2.0 Individual Policy Specific Roles and Responsibilities ................................................................ 12

3.0 Service standards ...................................................................................................................... 16

3.1 General Principles RTT and Cancer Standards .................................................................. 16

3.2 Clinical Pathways ............................................................................................................... 17

4.0 Internal Minimal standards supporting delivery of the Access Standards ............................... 18

4.1 REFERRAL TO TREATMENT TIMES (RTT) ........................................................................... 18

4.2 Patients waiting over 52 weeks ........................................................................................ 20

5.0 TOOLS and TECHNIQUES ........................................................................................................... 20

6.0 OPERATIONAL MANAGEMENT ................................................................................................. 25

6.1 Pathway milestones .......................................................................................................... 25

6.2 Monitoring ........................................................................................................................ 25

6.3 Governance ....................................................................................................................... 25

6.4 Reasonableness ................................................................................................................. 25

6.5 Chronological booking ...................................................................................................... 26

6.6 Communication ................................................................................................................. 26

7.0 National referral to treatment and diagnostic standards ......................................................... 27

7.1 Clinical pathways ................................................................................................................... 27

7.2 Referrals, Outpatient Booking and Management Process ................................................... 27

8.0 National Codes .......................................................................................................................... 32

9.0 Overview of national referral to treatment rules ..................................................................... 33

9.1 Clock starts ............................................................................................................................ 33




9.2 Exclusions .............................................................................................................................. 33

9.3 New clock starts for the same condition .............................................................................. 34

9.4 Planned patients ................................................................................................................... 34

9.5 Clock stops for first definitive treatment .............................................................................. 34

9.6 Clock stops for non-treatment .......................................................................................... 35

9.7 Active monitoring .............................................................................................................. 35

9.8 Patient initiated delays ......................................................................................................... 35

9.8.1 Non-attendance of appointments/did not attend (DNAs) ........................................... 35

9.9 Cancelling, declining or delaying appointment and admission offers .............................. 36

9.12 Receipt of referral letters ...................................................................................................... 41

9.11 Referral types .................................................................................................................... 42

10. Outpatients Booking ................................................................................................................. 43

10.1 Booking new outpatient appointments ................................................................................ 43

10.2 Clinic attendance and outcomes (new and follow up clinics) ............................................... 44

10.3 Booking follow up appointments .......................................................................................... 45

10.4 Patient Initiated Actions (PIAs) ............................................................................................. 46

10.5 Hospital Initiated Actions (HIAs) ........................................................................................... 47

11.0 Diagnostics ................................................................................................................................ 47

12.0 Pre-operative assessment (POA) .............................................................................................. 52

13.0 ACCESS TO THERAPY SERVICES ................................................................................................. 53

14.0 Admitted pathways ................................................................................................................... 55

14.4 Scheduling patients to come in for admission .................................................................. 56

14.5 Patients declaring periods of unavailability while on the inpatient / day care waiting list

57

15.0 Cancer pathways ....................................................................................................................... 59

APPENDIX 001 ....................................................................................................................................... 61

Outpatient general principles ........................................................................................................... 61

Appendix 002 ........................................................................................................................................ 63

Outpatient appointment letters ....................................................................................................... 63

Appendix 003 ........................................................................................................................................ 64

Inpatient and Day case Principles ..................................................................................................... 64

APPENDIX 003A ..................................................................................................................................... 66




Inpatient/Day case TCI appointment Letters and Patient Information ............................................ 66

APPENDIX 004 ....................................................................................................................................... 67

ACCESS ESCALATION TREE ................................................................................................................ 67

DRAFT ACCESS POLICY FOR WHEELCHAIR SERVICE .......................................................................... 68

Appendix 006 ........................................................................................................................................ 74

Harm Review Policy for excess waiting times ................................................................................... 74

APPENDIX 007 ....................................................................................................................................... 79

Glossary and Acronyms ..................................................................................................................... 79

APPENDIX 008 ....................................................................................................................................... 87

Terms of Reference – Elective Aceess Meeting ................................................................................ 87

.......................................................................................................................................................... 87

APPENDIX 009 ....................................................................................................................................... 90

PTL GOOD PRACTICE GUIDE .............................................................................................................. 90

Appendix 010 ........................................................................................................................................ 96

Driving 18 Weeks Referral to Treatment Period Status FLOWCHART .............................................. 96

Appendix 011 ........................................................................................................................................ 97

Escalation tree for patients on a Suspected and/or confirmed Cancer Pathway ............................. 97

Appendix 012 ........................................................................................................................................ 98

Cancer Operational Policy ................................................................................................................. 98

Appendix 012A ...................................................................................................................................... 98

Cancer Waiting Times V9.0 National Standards ............................................................................... 98

Appendix 013 ........................................................................................................................................ 98

Endoscopy Access Policy ................................................................................................................... 98

Appendix 013A ...................................................................................................................................... 99

Endoscopy Access Policy ................................................................................................................... 99

Appendix 014 ........................................................................................................................................ 99

Radiology Department Operational Policy ....................................................................................... 99

Appendix 015 ...................................................................................................................................... 100

Equality Impact Assessment ........................................................................................................... 100




1.0 Introduction

1.1 Principles

West Suffolk NHS Foundation Trust is committed to delivering high quality and timely elective care

to patients.

This policy:

sets out the rules and principles under which the trust manages elective access to outpatient

appointments, diagnostics and elective treatment

gives staff clear direction on the application of the NHS Constitution in relation to elective

waiting times

demonstrates how elective access rules should be applied consistently, fairly and equitably.

The Trust’s Access Policy has been developed in consultation with staff, clinical commissioning

groups (CCG’s), general practitioner, clinical leads and other stakeholder’s. It will be reviewed

annually or earlier should there be changes to national elective access rules or locally agreed

principles. This policy does not however apply in totality to Community based services, which will be

covered under a separate policy.

The access policy should be read in full by all applicable staff once they have successfully completed

local induction, e-care or by other relevant systems (SystmOne NHSP etc) and other relevant RTT

training applicable to their role.

The policy should not be read in isolation as a training tool in and of itself. It should be included in all

local induction and training for roles which directly support the RTT and Cancer Standards delivery

(e.g. Service Managers, admissions staff, and appointments staff)

This Policy is underpinned by an extensive suite of standard operating procedures (SOP’s). All clinical

and non-clinical staff must ensure they comply with both the principles set out within this policy and

the specific instructions of the SOP’s.

No staff member should use the Patient Administration System (PAS) until they have received

training to the system and role in which they are employed; and/or until they have been assessed as

competent.

Staff operating within this Policy must recognise and understand the limitations of their knowledge

and seek support by escalating to their supervisor or line manager;

The Trust is committed to promoting and providing services which meet the needs of individuals and

does not discriminate against any employee, patient or visitor.




1.2 Purpose The purpose of this policy is to ensure all patients requiring access to outpatient appointments,

diagnostics or elective treatment are managed equitably and consistently, in line with national

waiting time standards and the NHS Constitution.

Full details of patient rights under the NHS Constitution can be located on the NHS website searching

under “NHS Constitution”. Patients‟ right to choice continues to be at the heart of what we do at the

Trust and patients may view the patient choice framework 2014-2015 at

https://www.gov.uk/government/publications/nhs-choice-framework

This policy:

is designed to ensure the management of elective patient access to services is transparent,

fair, equitable and managed according to clinical priorities

sets out the principles and rules for managing patients through their elective care pathways

applies to all clinical and administrative staff and services relating to elective patient access

at the Trust.

Does not apply in totality to Community based services.

The purpose of this policy is to outline the Trust and Commissioner requirements and standards for

managing patient access to secondary care services from referral to treatment on routine, diagnostic

and cancer pathways. This policy was developed and co-signed by WSH commissioners.

The policy covers the processes for booking, notice requirements, patient choice and waiting list

management for all stages of routine and cancer pathways.

This policy is intended to support a maximum wait of 18 weeks from referral to first definitive

treatment and all other key waiting times access standards relating to cancer and diagnostics. This

also includes all the stages that lead up to treatment, including outpatient consultations, diagnostic

tests and procedures.

The access and referral guidelines will enable all patients referred to the Trust to be treated

efficiently, equitably and in line with National Access Standards and Cancer Waiting Times guidance.

The best interests of patients are foremost of the Trust’s guidelines and patients are managed

according to clinical priority and in line with the NHS Constitution.

This policy MUST be read in conjunction with the National guidance on RTT waiting times, the Cancer

Waiting times guidance v.9.0 and any other guidelines and best practice guidance. Compliance with

this policy and national RTT, Diagnostics and Cancer guidance will be routinely monitored through

Access Board Meetings and non-compliance raised with the relevant operational leads to resolve.

This policy is to ensure that all key individuals, namely, Trust staff, local Clinical Commissioning

Groups (CCGs), and General Practitioners (GPs) have a clear, shared and agreed understanding of

their mutual roles and responsibilities in the successful clinical management of patients booked for

elective treatment.

1.3 Overarching roles and responsibilities Responsibility for ensuring this policy is fully implemented lies with the Trust Board, however

responsibility for achieving elective access standards sits with all staff.

https://www.gov.uk/government/publications/nhs-choice-framework




For example:

Associate Directors of Operations (ADOs) or equivalent roles are accountable for

implementing, monitoring and ensuring compliance with the policy within their divisions

The Chief Information Officer is responsible for the timely production of patient tracking lists

(PTLs) which support the divisions in managing waiting lists and RTT standards

Waiting list administrators, including clinic staff, secretaries and booking clerks are

responsible to ADOs, or equivalent roles, for compliance with all aspects of the trusts

elective access policy.

Waiting list administrators for outpatients, diagnostic and elective surgery are responsible

for the day-to-day management of their lists and are supported in this function by the ADOs

who are responsible for achieving access standards

ADOs and/or equivalent service leads are responsible for ensuring data is accurate and

services are compliant with the policy.

Operational managers are responsible for ensuring the NHS e-referral directory of service

(DOS) is accurate and up-to-date.

The business intelligence team is responsible for producing and maintaining regular reports

the enable divisions to accurately manage elective pathways, and ensure compliance with

this policy

General practitioners (GP’s) and other referrers play a pivotal role in ensuring patients are

fully informed during their consultation of the likely waiting time for a new outpatient

consultation and for the need to be ready, willing and able to attend when contacted.

The CCG are responsible for ensuring there are robust communication links for feedback to

GP’s and other referrers.

GP’s and other referrers should ensure quality referrals are submitted to the Trust first time.

1.4 Competency and compliance

1.4.1 Competency

As part of their induction programme, all new starters with undertake mandatory contextual

elective care training applicable to their role.

All existing staff will undergo mandatory contextual elective care training on an annual basis

All staff will undertake competency tests that are clearly documented to provide evidence

that they have the required level of knowledge and ability.

This policy, along with the supporting suite of SOP’s will form the basis of the contextual

training programmes.

1.4.2 Compliance

Functional teams, specialties and staff will be performance managed against key

performance indicators applicable to their role. Role specific KPI’s are based on the

principles set out in this policy and specific aspects of the trusts standard operating

procedures.




In the event of non-compliance, resolution should be sought by the team, specialty or

individual’s line manager. Staff should then be dealt with in accordance with the trusts

disciplinary or capability policy.

1.5 General elective access principles The NHS has set maximum waiting time standards for elective access to healthcare. In England,

waiting-time standards for elective care (including cancer) come under two headings:

• the individual patient rights (as in the NHS Constitution).

• the standards by which individual providers and commissioners are held accountable by

NHS Improvement and NHS England.

1.5.1 Individual patient rights

The NHS Constitution clearly sets out a series of pledges and rights stating what patients, the

public and staff can expect from the NHS. A patient has the right to the following:

• choice of Hospital and consultant, or other Service Provider.

• to begin their treatment for routine conditions following a referral into a

consultant-led service, within a maximum waiting time of 18 weeks to treatment

• consideration should also be given to non-acute based assessments, or

management of long term and/or complex conditions by non-hospital based service

providers

• to be seen by a cancer specialist within a maximum of two weeks from a GP referral

for urgent referrals where cancer is suspected. If this is not possible, the NHS has to

take all reasonable steps to offer a range of alternatives.

• The right to be seen within the maximum waiting times does not apply:

• if the patient or carer chooses to wait longer

• if delaying the start of the treatment is in the best clinical interests of the patient

(note that in both of these scenarios the patient’s RTT clock continues to tick)

• if it is clinically appropriate for the patient’s condition to be actively monitored in

secondary care without clinical intervention or diagnostic procedures at that stage.

All patients are to be treated fairly and equitably regardless of race, sex, religion or sexual

orientation.

1.6 Patient Eligibility The Trust has an obligation to identify patients who are not eligible for free NHS treatment and

specifically to assess liability for charges in accordance with Department of Health guidance /rules.

1.6.1 UK and EU Citizens

The Trust will check every patient’s eligibility for treatment. Therefore, at the first point of

entry, patients will be asked questions that will help the Trust assess ‘ordinarily resident

status’. Some visitors from abroad, who are not ordinarily resident, may receive free

healthcare, including those who:

• have paid the immigration health surcharge

• have come to work or study in the UK

• have been granted or made an application for asylum.




Citizens of the European Union (EU) who hold a European Health Insurance Card (EHIC) are

also entitled to free healthcare, although the Trust may recover the cost of treatment from

the country of origin.

1.6.2 Non-UK or EU Citizens

All staff have a responsibility to identify patients who are overseas visitors and to refer them

to the Overseas Visitor’s Office for clarification of status regarding entitlement to NHS

treatment before their first appointment is booked or date to come in (TCI) agreed.

1.6.3 Patients moving between NHS and private care

Patients can choose to move between NHS and private status at any point during their

treatment without prejudice. Where it has been agreed, for example, that a surgical

procedure is necessary the patient can be added directly to the elective waiting list if

clinically appropriate. The RTT clock starts at the point the GP or original referrer’s letter

arrives in the hospital and the patient will be treated in clinical priority then date order.

The RTT pathways of patients who notify the trust of their decision to seek private care will

be closed with a clock stop applied on the date of this being disclosed by the patient.

1.6.4 Exclusions

A referral to most consultant-led services starts an RTT clock but the following services and

types of patients are normally excluded from RTT:

• obstetrics and midwifery

• planned patients

• referrals to a non-consultant led service

• referrals for patients from non-English commissioners

• genitourinary medicine (GUM) services

• emergency pathway non-elective follow-up clinic activity.

1.6.5 Commissioner-approved procedures

Patients referred for specific treatments where there is limited evidence of clinical

effectiveness, or which might be considered cosmetic can only be accepted with the prior

approval of the relevant CCG.

For West Suffolk CCG further details can be obtained at :

https://www.westsuffolkccg.nhs.uk/your-health/operations-not-routinely-funded/ and

https://www.westsuffolkccg.nhs.uk/clinical-area/clinical-thresholds-lpps/

1.6.6 Military veterans

In line with the Armed Forces Covenant, published in 2015, all veterans and war pensioners

should receive priority access to NHS care for any conditions related to their service, subject

to the clinical needs of all patients. Military veterans should not need first to have applied

and become eligible for a war pension before receiving priority treatment.

GPs will notify the trust of the patient’s condition and its relation to military service when

they refer the patient, so the trust can ensure it meets the current guidance for priority

service over other patients with the same level of clinical need. In line with clinical policy,

https://www.westsuffolkccg.nhs.uk/your-health/operations-not-routinely-funded/





patients with more urgent clinical needs will continue to receive priority

https://www.england.nhs.uk/commissioning/armed-forces/armed-forces-coven/

1.6.7 Prisoners

All elective standards and rules are applicable to prisoners. Delays to treatment incurred as a

result of difficulties in prison staff being able to escort patients to appointments or for

treatment do not affect the recorded waiting time for the patient.

The Trust will work with staff in the prison services to minimise delays through clear and

regular communication channels and by offering a choice of appointment or admission date

in line with reasonableness criteria.

1.6.8 Private Patients

In order to ensure that the Trust is able to recover income due from the treatment of private

patients the Private Patients Office must be informed of all private patient activity within the

Trust. The 18 Week RTT standard does NOT apply to such patients. These patients will NOT

be monitored via the PTL.

The only exception will be where additional capacity has been outsourced to the private

sector e.g. BMI These patients are NOT considered to be ‘private’ but remain NHS patients.

The Trust reserves the right to access an independent provider for patient treatment to

meet the 18 week standard. It will be known if the Trust has decided to do this. This

category of patient MUST have all eCare records maintained and will be monitored via the

PTL.

Patients can choose to move between NHS and private status at any point during their

treatment without prejudice. Where it has been agreed, for example, that a surgical

procedure is necessary the patient can be added directly to the elective waiting list if

clinically appropriate. The RTT clock starts at the point the GP or original referrer’s letter

arrives in the hospital and the patient will be treated in clinical priority then date order.

https://www.england.nhs.uk/commissioning/armed-forces/armed-forces-coven/




2.0 Individual Policy Specific Roles and Responsibilities

All staff of the Trust are bound by its policies and procedures. The Access Policy and

associated SOPs are no exception. It is the responsibility of the:

2.1 CHIEF EXECUTIVE

The Chief Executive has overall statutory responsibility for the patient safety, governance

and performance management as related to the delivery against the access standards and is

accountable to the Trust Board for their delivery.

2.2 MEDICAL DIRECTOR

Responsible for the clinical decision making required to implement this policy and to ensure

patients are not disadvantaged as a result of application of the rules in this policy. To

provide leadership to clinical colleagues in assessing and evaluating ‘harm’ to patients;

providing advice on the implications of not adhering to the operational standards as they

affect patients. Identifying capacity in Job Plans to allow Lead clinicians to have time

available for RTT functions. This also applies to Professional and/or clinical leads of services.

2.3 DIRECTOR of HR (Or equivalent role)

Responsible for ensuring the organisation can access training, education, skills and

knowledge pertinent to their role. To support staff to record their achievements,

competencies and training records annually; and to ensure the Trust training strategy is

supporting RTT knowledge and experience.

2.4 EXECUTIVE DIRECTORS

Each Executive Director is responsible for ensuring that annual Trust objective setting and

review is timely and effective within their sphere of responsibility. They play a key role in the

ensuring targets for key performance indicators within their remit are agreed,

communicated and delivered and that issues escalated to them in relation to that delivery

are effectively managed.

2.5 CHIEF OPERATING OFFICER via the nominated Deputy:

Is the individual responsible for the operational management and delivery of this policy:

overseeing executive responsibility for the application of the policy and overall delivery of

access standards by ensuring:

Robust systems are in place for the performance management and

improvement of national, local and internal targets around RTT, Diagnostics and

Cancer;

Production of the monthly Integrated Performance Report highlighting to the

Board areas not meeting RTT, Diagnostics or Cancer requirements (and actions

to address) by exception;

Plans to address areas of RTT, Diagnostics and Cancer requiring improvement

are developed and implemented;

That appropriate support is in place for teams facing significant RTT, Diagnostics

and Cancer issues that may take some time to resolve / address.




2.6 HEAD OF ELECTIVE ACCESS

Is the person responsible for oversight and advice in respect of all aspects of patient access,

the Trust’s policy and its development, review and implementation. The post holder will

ensure the most up to date knowledge and guidance is disseminated and incorporated into

the Trusts policies and procedures and all associated training and education. Furthermore,

the post holder

Is the individual responsible for overseeing Senior Manager responsible for

implementation of this policy.

Is the individual responsible for the accurate application of this policy within the

outpatients department.

Responsible for alerting staff to the presence of the policy on the intranet as well as

ensuring hard copies are available in all booking areas.

Responsible for adherence to the policy and ensuring it is up to date and

operationally implemented.

2.7 DIVISIONAL ASSOCIATE DIRECTORS OF OPERATIONS, EQUVALENT ROLES and their

nominated Deputies

responsible for delivery of services to the standards of this policy within the areas of

their general responsibility

ensuring all members of their team (clinical and managerial) are cognoscente of

their roles and responsibilities in the delivery of the operational standard

creating solutions to manage demand and/or capacity to ensure the operational

standards are delivered in accordance with the Trust responsibilities.

2.8 ADMISSIONS MANAGER

Is the individual responsible for the accurate application of this policy within the

admissions department, Telephone Appointments Centre and other associated

services

Responsible to ensuring the departmental staff are sufficiently trained and assessed

as competent in the operational delivery of the Policy and its SOPs.

Responsible to ensure that all IP, OP and DC events are recorded accurately on the

Trust PAS

Responsible for the maintenance of their knowledge base and skill set in the delivery

of the Policy and is associated and supporting SOPs

2.9 ALL ADMINISTRATIVE STAFF

Responsible for the accurate and timely administration of a patient pathway

according to the definitions and rules set out within this policy.

Responsible for ensuring they are trained to the fullest extent according to their

role; that they keep their knowledge and training up to date.

They escalate issues and exceptions to their supervisor/line manager when the SOPs

are unable to resolve the query.

Responsible for ensuring they recognise their role limitations and do not attempt to

circumvent or guess actions.




2.10 CONSULTANTS

Responsible for the clinical decision making required to implement this policy and to

ensure patients are not disadvantaged as a result of application of the rules herein.

Responsible for ensuring they are engaged in the clinical review and decision making

processes associated with RTT;

Responsible for notification of leave in accordance with the current Leave Policy

Responsible for ensuring their knowledge and skill in recording activity on the

clinical systems is done comprehensively, accurately and timely.

Responsible for early escalation of issues (clinical and administrative) so as NOT to

adversely impact the patient care or operational standards for 18 weeks.

2.11 SPECIALTY MANAGERS/SERVICE MANAGERS / SENIOR OPERATIONS MANAGERS

Responsible for the correct application of this policy within their specialty

departments and to ensure patients have access to hospital services in line with the

rules herein.

Responsible for the operationalization of their services to support the clinician,

patient, diagnostics services in achieving the operational standard.

Responsible for keeping their system knowledge and skills up to date with the latest

guidance, rules and objectives pertaining to the delivery of the operational standard

Responsible for early escalation to more senior staff when achievement of the

operational standards is compromised.

2.12 GENERAL MEDICAL PRACTITIONERS/GENERAL DENTAL PRACTITIONERS AND OTHER

REFERRERS

The Trust relies on GPs and other referrers, supported by local commissioners, to referrals

are appropriate, accurate and contain the MDS. Responsible for ensuring patients are fit and

available for treatment and care and patients understand their responsibilities, potential

pathway steps and timescales when being referred. This will help ensure patients are:

Referred under appropriate clinical guidelines;

Offered a choice of provider, as outlined in national guidance;

Aware of the speed at which their pathway may be progressed;

Able to accept timely appointments throughout their treatment.

They should also:

Inform the patient that failure to attend a first appointment may result in the

referral being returned. Any exceptions should be highlighted upon referral.

Ensure that referrals are in line with the CCG’s PoLCV policies and where required

approval has been obtained. https://www.westsuffolkccg.nhs.uk/clinical-

area/clinical-thresholds-lpps/

Ensure that suspected cancer patients are given appropriate information about why

they are being referred and the importance of being seen quickly so that they accept

and keep early appointments

It is a responsibility of GPs that the patients being referred are informed, ready, willing and

able to attend their appointments and have their surgery or treatment.






2.13 PATIENTS

Patients should be clinically fit for assessment, ready, willing and able to attend throughout

their pathway if the Trust is to deliver a successful 18 week patient pathway, in line with

patients‟ constitutional rights. This includes:

Attending their appointment or ensuring that they contact the service to cancel it,

giving as much notice as possible;

Managing their own health where possible;

In the context of children - this would be the parent or carer who would support this

and also be involved with management of treatment pathway (unless the young

person has capacity)

Involvement in the management of their treatment pathway;

Ensuring they inform their health care provider of any changes in personal

circumstances, particularly contact details and registered GP;

Being available and attending reasonably offered and accepted appointments

(avoidance of DNAs)

2.14 PATIENT PATHWAY COORDINATORS

To track patients along their pathways and alerting senior managers when there are issues

relating to the completion of their pathways within 18 weeks.

2.15 CANCER MANAGER and TEAM

Support the weekly Cancer performance management process by providing support and

challenge to all Cancer MDTs and their sites. Undertakes first line performance management

actions, escalating to the Cancer Manager, the relevant Senior Operational Manager or

other relevant member of the Senior Management team, where required in line with the

Performance/ Operational Delivery Escalation process and ensuring accurate and timely

National reporting. Work with the sector on improving the flow of patients between external

providers, (ITTs)

2.16 TRUST INFORMATION TEAM

The Information team provides the accurate and timely data and any analysis /interpretation

of performance data for performance review and follow up purposes and delivering National

reporting to the required timetable.

The team must be able to support the Operational team with accurate, timely and complete

data. To support with training and advice in the accurate recording of data and events on

the relevant PAS system. They should review data quality issues from the Access meeting

and ensure they are investigated and responded to.

2.17 HEAD OF PERFORMANCE

The Head of Performance will be responsible for the accurate reporting of performance on a

monthly basis. The post holder will identify areas of compliance and non-compliance and

recommend areas for audit and additional scrutiny. The post holder will be kept informed of

all risks, issues and associated remedial actions.




2.18 ALL STAFF

In order to maintain the highest standards of data quality and patient confidentiality, all staff

are responsible for ensuring that any data created, edited, used or recorded on the Trust’s

PAS system, within their area of responsibility, is accurate and recorded in accordance with

this policy and other Trust policies relating to the collection, storage and use of data.

3.0 Service standards

3.1 General Principles RTT and Cancer Standards

The following national operational standards apply to patients:

• 92% of patients on an incomplete non-emergency pathway (yet to start treatment),

waiting no more than 18 weeks.

• 8% of incomplete pathways who do not achieve this standard may have very complex

diagnostic or treatment pathways or choose to wait longer than 18 weeks (127 days).

• All patients will be seen in chronological order within 18 weeks; and no patient will wait

longer than 40 weeks.

• No patient will wait longer than 6 weeks for a diagnostic test or image.

• 93% of all urgent GP (GMP, GDP or Optometrist) referral for suspected cancer to first

outpatient attendance will be seen within 14 days of receipt of referral

• 93% of patients referred with breast symptoms (where cancer not suspected) to first

hospital assessment will be seen within 14 days of receipt of referral

• 85% of urgent GP (GMP, GDP or optometrist) referral for suspected cancer to first

treatment (62 day classic)

• All patients referred by GMP,GDP or Optometrist as suspected cancer or breast

symptomatic who are subsequently diagnosed with cancer will commence treatment

within 62 days of receipt of referral

• 90% of patients referred from screening programmes (bowel, breast, cervical) as

suspected cancer who are subsequently diagnosed with cancer will commence

treatment within 62 days of receipt of referral

• All patients that are upgraded by Consultants as suspected cancer will commence

treatment within 62 days of the date of upgrade (no operational standard)

• 96% of patients diagnosed as a new cancer will receive treatment within 31 days of

decision to treat (DTT) irrespective of treatment.

• All patients that are having a subsequent treatment for cancer will receive treatment

within 31days of the DTT/ECAD for surgery (94%), drug treatment (98%) and

radiotherapy (94%).

• No Patient should wait in excess of 52 weeks

• Patients waiting 52 weeks or more on any pathway will be subject to a clinical review to

assess harm and recorded on DATIX. See Appendix 007

• Patients should always be managed in chronological order on identified and recorded

urgency. Urgent patient are seen in date order sooner than routine patients.




Key business processes that support access to care have clearly defined service standards,

monitored by the trust. Compliance with each service standard supports effective and

efficient service provision, and the achievement of referral to treatment standards.

3.2 Clinical Pathways

Patients are administered and monitored via Pathways. These are usually known by the

terms:

3.2.1 Non-Admitted Pathway

The non-admitted stages of the patients’ pathway comprise both outpatient and the

diagnostic phase (shaded in red below). It starts from the clock start date (i.e. the

date the referral is received or UBRN converted) and ends when either a clock stop

happens in outpatients, or when a decision to admit is made and the patient

transfers onto an admitted pathway.

3.2.2 Diagnostic Pathway

This is where a patient is attending the hospital or community service for procedures

such as Non-Obstetric Ultrasound, MRI, CT, USS, Endoscopy Procedure, Fluoroscopy,

audiology or other investigation to determine diagnosis or plan treatment.

3.2.3 Admitted Pathways

The Admitted stages of the patients’ pathway comprise a patient attending the

hospital for definitive treatment in a day-case or inpatient setting. This is most

common for patients on a ‘surgical’ pathway;

3.2.4 Non-Elective Pathway

The Patient attends in an unplanned manner, either via the emergency Department,

or as an attendance to Ambulatory Care facilities. RTT rules do not usually apply

unless the admission or treatment is something already known to the hospital such

as exacerbation of symptoms and emergency treatment. This activity might stop an

RTT clock.




4.0 Internal Minimal standards supporting delivery of the Access Standards Key internal operational standards for implementation include the following:

• Referral receipt and registration (within 48 hours)

• Referral vetting and triage (within 48 hours of registration)

• Addition of urgent outpatient referrals to waiting list (within 48 hours of registration)

• Addition of routine outpatient referrals to waiting list (within 48 hours of registration)

• Urgent patient contacted by the trust after addition to waiting list (within 48 hours)

• Routine patient contacted by the trust after addition to waiting list (within 2 weeks)

• Urgent diagnostic reporting (within 24 hours)

• Routine diagnostic reporting (within 48 hours).

• Weekly Review of all patients reported on the Trust’s RTT PTL led by the Head of Access

• Weekly Review of all patients on a Cancer Pathway in accordance with the Cancer

Operational Policy

• Local review within clinical divisions on a weekly basis in preparation for the Weekly

Access Meeting

See Appendix 009

4.1 REFERRAL TO TREATMENT TIMES (RTT)

The maximum length of time that a patient may wait from referral (i.e. clock start date) to

medical or surgical consultant led care, until treatment commences, is 18 weeks unless the

patient chooses to wait longer. The exceptions to this are suspected cancer patients and

“diagnostic only‟ patients. The 18 week RTT pathway is based on a clock start when a

referral is received and a clock stop when the patient begins first definitive treatment, a

clinical decision is made that treatment is not required or a patient chooses to decline

treatment.

The policy states where there are timescales in which certain activities and tasks should be

performed in order to ensure the 18 week maximum RTT pathway is achieved.

Overall, the Trust aims to receive, accept and provide a first outpatient appointment for all

referrals within agreed polling range for each specialty and provide any diagnostic phase of

the pathway within 6 weeks and an admitted phase within 6 weeks, in line with good

practice. There are likely to be slightly rules for Community based paediatric services.

Reference should be made to that specific policy which site outside the National 18 week

RTT programme

4.1.1 Clock Start for 18 weeks

An 18 week clock starts when a GP, Dentist or other health care professional refers a

patient to the Trust for any elective service for the patient to be assessed and, if

appropriate, treated before responsibility is transferred back to the referrer.

All GP referrals must come through the NHS e-Referral Service (ERS) and the clock

will start on the date when the Trust receives the referral or, or when the patient

books their appointment and the Unique Booking Reference (UBRN) is converted.




4.1.2 Clock Re-start for 18 weeks

Upon completion of a consultant-led referral to treatment period, a new waiting

time clock starts upon the decision to start a substantively new or different

treatment that does not already form part of that patient’s agreed care plan. An RTT

clock will re-start when a “due date‟ for a patient on a planned list is passed by 6

weeks or more.

4.1.3 Clock Stops for 18 weeks

The 18 week RTT clock stop will occur when first definitive treatment for the

condition for which they have been referred or a decision is made not to treat. This

is defined as an intervention intended to manage a patient’s disease, condition or

injury and avoid further intervention. First definitive treatment is a matter for

clinical judgment in consultation with others as appropriate including the patient.

A clock stop may occur for non-treatment such as a patient choosing to decline

treatment or a clinical decision is made and communicated to the patient that

treatment is not required

4.1.4 Clock Pauses for 18 weeks

On 1st October 2015, the NHS Commissioning Board and CCGs (Responsibilities and

Standing Rules) (Amendment) (No.2) Regulations 2015 came into effect, removing

the provision for a patient pause.

4.1.5 Clock Continues for 18 weeks

From the clock start, the clock continues to tick until either the first definitive

treatment is given, or another event occurs which can stop the clock. The clock

continues through events such as diagnostic tests, subsequent outpatient

appointments prior to treatment and when a patient is added to the waiting list for

a procedure.

The clock continues when the patient is transferred to another health care provider

(e.g. another hospital) (See Inter provider transfers)

4.1.6 Active Monitoring for 18 weeks Pathway patients (RTT)

Active monitoring can be an appropriate clinical intervention on a RTT pathway. It

can be initiated in two ways:

Initiated by the patient:

During consultation with a patient, the patient may decide that they wish to

wait to see if their condition deteriorates or improves prior to making a

decision whether to have surgery. If this occurs the patient would be placed

into active monitoring until their next appointment

Initiated by a care professional:

During a consultation a patient may be asked to take action e.g. cease

smoking, lose weight as the clinician may want to see if the condition

improves or declines before considering an intervention. These decisions

would place the patient into a period of active monitoring.




The Trust will stop a patient’s 18 week clock if a decision is made to actively monitor

the patient’s condition and not to treat at this stage.

Active monitoring should not be used for thinking time. It is in itself an

intervention. It does NOT pause a clock as this is NOT allowed.

A new 18 week clock starts if and when a decision to treat is made.

4.2 Patients waiting over 52 weeks

There is a zero tolerance of any patient waiting more than 52 weeks. Any patients approaching 26 weeks must be escalated to the Senior Operations Manager and if necessary to the Head of Elective Access if a treatment plan cannot be agreed with the relevant consultant. Such patients will be managed via the PTL.

ALL patients waiting over 40 weeks must be reported to the Associate Director of Operations and Head of Access and discussed at the weekly Access meeting as failure to treat patients within 52 weeks can have clinical safety and financial consequences.

No Patient over 40 weeks will be without a clear and time dated management plan.

In the event that a patient waits over 52 weeks this MUST be reported through the Trust’s internal incident reporting process.

All 52+ week Breaches will be reported via the incident management system DATIX. This will trigger an investigation which MUST include a clinical harm assessment by the clinician responsible for the care of the patient. The outcome will be reported on the DATIX system and appropriate action taken.

Consideration MUST be given to DUTY OF CANDOUR requirements and reference made to the Trust Clinical Risk procedures.

There is a ZERO Tolerance for 52+ week waits other than very exceptional circumstances which have been agreed with the Chief Operating Officer and Medical Director.

See APPENDIX 007

5.0 TOOLS and TECHNIQUES

5.1 PTL – Patient Tracking List in Hospital Based context

The PTL or Patient Tracking List will be the primary tool used to measure progress

and compliance with the RTT Standards.

The Trust Information Department is responsible for ensuring that this list is

compiled from the most up-to-date data held on the eCare PAS system.

Operational divisions and clinical services are responsible for ensuring the PTL is

monitored and updated twice weekly.




The Head of Patient Access is responsible for leading discussions and monitoring

remedial actions using the most up to date PTL which will inform the weekly Access

Meeting.

The Associate Director of Operations or equivalent role is responsible for the

delivery of remedial actions and compliance against the operational standard

The Validation Team are responsible for raising appropriate checks and challenges

regarding pathway activities

The SOPs associated with these transactions can be found here:

5.2 The Structure of the PTL

5.2.1 The PTL will provide:

Guidance for what data is required to assist Operational services in monitoring

progress and compliance with the RTT Operational standards is recorded here:

https://improvement.nhs.uk/resources/displaying-referral-to-treatment-data/

The Minimum Data Set will ensure that a filterable Excel Spreadsheet or similar

Business tool is provided twice weekly (Monday and Thursday). Other OPWL; 1st

OPWL and IPWL

• Pathway ID • MRN • Patient Name • TFC • Consultant • RTT Start Date • 18 Week Breach Date • Weeks Wait • RTT Description • Priority • Planned Procedure (sometime known as Surveillance) • Original DTA • eCare Booked Date • Opera Booked Date • Service commentary • Action • Previous Action • Validation Team Comment (Info)

The primary forum for monitoring compliance will be the Weekly Access Meeting where all clinical services will be reviewed and actions agreed. See APPENDIX 009

https://improvement.nhs.uk/resources/displaying-referral-to-treatment-data/




A checklist of a good PTL is attached at Appendix 010




5.3 Validation of the Patient Tracking List (PTL)

5.3.1 Key Principles:

All records on a PTL must be validated / sense checked for accuracy as follows:

Date on list and source of addition should marry up i.e. if the source of addition is 1 – Outpatients then the patient should have attended a clinic appointment on that date

Intended Management field must be accurate. The HCP will make the decision to treat as an inpatient or day case upon the decision to treat. This field should not be changed at a later date i.e. if a day case patient needs a bed overnight post the procedure taking place.

Accurate Method of Admission must be recorded for example there are different rules for EW and EP entries. All EP waiting list entries must show a target date.

All records should have an RTT code recorded

If the RTT code status is blank, this should be regarded as a Data Quality (DQ) issue for local resolution or escalation

All 3 codes on a PTL should be checked / validated; has a clock start been missed, should the patient be on a waiting list, are we booking in turn?

All 9 codes on PTL should be checked / validated; has a clock start been missed

Outpatient - Every waiting list entry should have an appointment type and category recorded to identify if the patient is waiting for a new of follow up appointment

Inpatient - All waiting list entries must have a procedure code, if no procedure code is added the record will show on the diagnostic PTL as a precautionary measure

The RTT code must be validated to ensure we are booking the patients in the correct order on the PTL’s.

Patients on a 20 code showing on the incomplete report must be progressed through their pathway. This may involve checking diagnostic tests have been booked, attended, or reported. A follow up appointment may need to be booked to discuss a diagnosis or care plan or a letter may need to be typed confirming the test is clear and no follow up required, the patient is being discharged from our care.

Delays with progressing patients through their pathway will impact the ability to treat within 18 weeks.

Administrative delays such as a typing back log can delay a clock stop being added in a timely manner, this could impact month end performance and 18 week submissions.

All administrative concerns which could impact 18 weeks must be escalated to Operational Managers as soon as possible so corrective measures can be taken.




Diagram 1 – The Ideal RTT Pathway




6.0 OPERATIONAL MANAGEMENT

6.1 Pathway milestones

Key milestones in a surgical pathway are highlighted in Figure 1.

6.2 Monitoring

Operational teams will regularly and continuously monitor levels of capacity for each

pathway milestone to ensure any shortfalls are addressed in advance. This will avoid poor

patient experience, resource intensive administrative workarounds and, ultimately, breaches

of the RTT standard.

6.3 Governance

The Trust’s elective governance structures are underpinned by the following series of

meetings.

Six weekly performance review meetings with NHS Improvement

Monthly system wide elective care board

Monthly performance review (Trust only)

Weekly access meeting (Trust only)

Weekly specialty based access meetings

6.4 Reasonableness

‘Reasonableness’ is a term applicable to all stages of the elective pathway. Reasonableness

refers to specific criteria which should be adhered to when offering routine appointments




and admission dates to patients to demonstrate that they have been given sufficient notice

and a choice of dates.

The Trust adopts national best practice which defines a reasonable offer as a choice of two

dates with at least three weeks’ notice.

6.4.1 Reasonable offer

A ‘reasonable’ offer is an outpatient appointment date that is at least three weeks from the time of the offer being made or two weeks for a diagnostic test Patients who have been deemed clinically urgent or have been referred from an emergency-type encounter may be booked outside of the definition. Should the patient cancel this type of appointment they will revert to the standard definition unless specifically instructed by a clinician otherwise.

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.

There is no definition of reasonableness regarding offers of admission or appointment within the cancer waiting time rules.

6.5 Chronological booking

Patients will be selected for booking appointments or admission dates according to clinical

priority. Patients of the same clinical priority will be appointed/treated in RTT chronological

order, i.e. the patients who have been waiting longest will be seen first. Patients will be

selected using the Trust’s patient tracking lists (PTLs) only. There is opportunity to consider

theatre list efficiency in the booking of some patients. But the principle is that this should be

a secondary consideration.

6.6 Communication

All communications with patients and anyone else involved in the patient’s care pathway

(e.g. general practitioner (GP) or a person acting on the patient’s behalf), whether verbal or

written, must be informative, clear and concise and recorded on the ‘message centre’ in

eCare Copies of all correspondence with the patient must be kept in the patient’s electronic

clinical record (eCare) for auditing purposes.

GPs or the relevant referrer must be kept informed of the patient’s progress in writing. When clinical

responsibility is being transferred back to the GP/referrer, e.g. when treatment is complete, this

must be made clear in any communication.




7.0 National referral to treatment and diagnostic standards

REFERRAL TO TREATMENT

INCOMPLETE 92% of patients on an incomplete pathway (i.e. still waiting

for treatment) to be waiting no more than 18 weeks (127

days)

DIAGNOSTICS – These should be managed by the same principles laid out in the policy.

Exceptions MUST be agreed and documented.

Applicable to diagnostic tests 99% of patients to undergo the relevant diagnostic

intervention within 5 weeks and 6 days (41 days) from the

date of decision to refer to appointment date. This is

known as DM01

In addition to the elective care standards above, there are separate cancer standards which must be

adhered to. The details associated with these standards are contained in the CANCER STANDARDS

section of this policy.

7.1 Clinical pathways The Trust aims to treat all elective patients within 18 weeks however the national elective

access standards are set at less than 100% to allow for the following scenarios:

7.1.1 Clinical exceptions: when it is in the patient’s best clinical interest to wait more than

18 weeks for their treatment.

7.1.2 Choice: when patients choose to extend their pathway beyond 18 weeks by

declining reasonable offers of appointments, rescheduling previously agreed appointment

dates/admission offers, or specifying a future date for appointment/admission.

7.1.3 Co-operation: when patients do not attend previously agreed appointment dates or

admission offers (DNA) and this prevents the trust from treating them within 18 weeks.

Please refer to the Cancer Operational Policy for detailed process information relating to

patient referred to the Trust on a 2 Week Wait Pathway with suspected cancer. Appendix

012 and 013

7.2 Referrals, Outpatient Booking and Management Process Referrals can come into the Trust in a variety of formats. This section deals with the most common

forms of referrals at this hospital. The overarching principles are noted here.

7.2.1 Minimum data set requirements

All referrals, however received MUST contain a minimum data set or the Trust will

be unable to appropriately register and acknowledge the referral on their systems.




All proforma-based referrals for specific services MUST also comply with the

minimum data set.

Full Name of Patient

Patient Date of Birth

Patient Gender

Patient full address including postcode

Patient contact telephone number (landline and mobile), in the case of children

and young people this will be the parent or carer's number however provision

is desirable.

Patient NHS Number

Referrer details (to include a telephone contact, e.mail address, GP or GDP

details and/or other relevant details)

The Trust encourages referrers to include any previous names, aliases and include

any relevant prior investigation reports and results. This will assist in the clinical

prioritisation of the referral and reduce the risk of unnecessary repeat testing.

Should the patient have any specific entitlements e.g. service personnel or war

veteran injured in conflict which will assist in the prioritisation of the patient.

In the case of children and young people, referrers should specify any known

risks/status such as Looked After Child, Child in Need or Child Protection Plan in

place,

7.2.2 NHS e-Referral Service (Formerly known as Choose and Book)

The GP may generate a referral which enables the patient to choose the hospital and

book an appointment convenient to them from the choice available.

ERS has been set up to poll, on a daily basis, a number of weeks in advance, which is

specified by each service (surgical and medical). The clock will start from the time

the patient converts their referral into an appointment or upon notification of an

appointment slot issue (ASI). The Trust should aim to contact patients if an ASI

occurs to inform them the Trust has received their request. If there has been no

contact within 28 days these patients will be reviewed and their GP notified. Should

the patient attempt to re-use the UBRN number after that time, they will be

instructed to call the Telephone Appointments Centre (TAC) or national line. The

Patient will be informed at that point to seek further advice from their GP.

The Appointments Centre (TAC) provides a telephone booking service for patients to

book, check, change or cancel their appointments via the NHS e-Referral Service. It

also supports choice discussion with the aid of the NHS Choices website and the

information held within the Directory of Services.

7.2.3 Paper Referrals for Hospital based services

Paper referrals should not be used to refer patients to the hospital. In the event of receipt of a paper referral it should be date stamped and forwarded to the appointments office on the date of receipt.




7.2.4 Electronic Referrals via e.mail

The process for the management and administration of these referrals is attached at

Appendix 003B. This type of referral is not to be used for Consultant led services.

7.2.5 Two Week Wait (2WW) referrals for suspected Cancer patients

This detail can be found in the Cancer Operational Policy. This can be found at

Appendix 013 (embedded document)

7.2.6 Direct Access Services

Where a GP refers a patient for diagnostic reasons with a view to making a

decision to refer or not based on the results, the patient will not have an 18

week clock started for the direct access diagnostic test. These tests are subject

to the six week diagnostic standard.

Please refer to Appendix 014 and 014A (embedded documents)

7.2.7 Straight to Test

A specific type of direct access diagnostic service whereby a patient will be

assessed and might, if appropriate, be treated by a medical or surgical consultant

led service before responsibility is transferred back to the referring health

professional. The clock starts on receipt of referral and stops when the patient is

referred back to Primary Care

7.2.8 Therapeutic Services

WSFT has a number of services to which this section can apply. However, unless

there are CONSULTANT led services they are not included in the RTT

performance standards.

Access policies and procedures are however based on the key principles and

objectives of this policy.

Performance against internally set objectives are excluded from national RTT

performance figures currently.

7.2.9 Rapid Access Services

7.2.9.1 Breast Symptomatic referrals

All patients with a new breast symptom must be seen in Outpatients within 14

days of receipt of the referral. A letter will be sent to the GP following the

appointment.

7.2.9.2 Rapid Access Chest Pain

All patients with new exertional chest pain must be seen in outpatients within 14

days of receipt of the GP referral. The results/outcome form is sent with a letter

to the GP after the patient’s consultation.




7.2.10 Private Patients

In order to ensure that WSFT is able to recover all income due from the treatment of

private patients, the private patient office must be informed of all private patient

activity within the Trust.

Consultants are responsible for ensuring that their private patients, whether

inpatient or outpatient are identified as such.

The 18 week target DOES NOT APPLY to such patients.

The Trust is required to cover what happens to patients that transfer to and

from the Private sector in terms of clock starts etc.

7.2.11 Inter-Hospital referrals and ITPs clinical directorates

This will include patients to be brought in from Private Sector for start of NHS

Treatment

Patients at other hospitals requiring transfer and admission to WSFT

Patients being sent for specific and specialist diagnostics to another Trust

Where an acute tertiary referral for the same condition is needed, the

consultant should make that referral and also copy the referral details to the

GP.

Where an elective tertiary referral is considered necessary for a different

condition, the consultant should refer the patient back to their GP for

forward referral.

A completed RTT Minimum Data Set (MDS) proforma must be sent with all

inter-provider transfers.

For Inter-provider transfers, the patient will remain on the original

provider’s waiting list until the patient has been accepted by the receiving

provider.

Patients transferred in to WSFT must be entered on the PAS database within

one working day of receipt.

7.2.12 Diagnostic services

WSFT has a number of services to which this section can apply. These services

are usually reported under the DM01 Operational standards. They will include

services such as X-ray, Non-Obstetric Ultrasound, Fluoroscopy, CT, MRI, PET and

Urodynamics. The operational policy for Radiology is attached at Appendix 15

(embedded document)

7.2.13 Choice of Consultant/Named referrals

The Trust will pool referrals unless the patient indicates a particular choice of

clinician, in order to achieve quicker availability, equitable workload and shorter

wait times.

Referrals should be made to a service rather than to a named clinician.

Referrals will be pooled with the exception of clinical need and patient choice.




7.2.14 Consultant to Consultant (C2C) Referrals

These are referrals generated within the Trust for patients seen by a Consultant,

who subsequently decides that a different specialty would best serve the patient for

the condition for which they were originally referred.

Unless definitive treatment has been given, the original clock will continue.

A patient who needs to be seen by another specialty for a different condition will be

referred back to the GP for a new referral to be generated and a new clock will start

on receipt of that referral. However, if the patient’s condition is clinically urgent, a

Consultant to Consultant referral will be made.




8.0 National Codes




9.0 Overview of national referral to treatment rules Figure 2 provides a visual representation of the chronology and key steps of a typical RTT

pathway.

9.1 Clock starts An RTT clock starts in the following scenarios

The RTT clock starts when any healthcare professional (or service permitted by an

English NHS commissioner to make such referrals) refers to a consultant-led service or

on the day the patient converts their unique booking reference (UBRN). The RTT clock

start date is the date the trust receives the referral. A referral is received into a

consultant-led service, regardless of setting, with the intention that the patient will be

assessed and if appropriate, treated before clinical responsibility is transferred back to

the referrer.

A referral is received into an interface or referral management assessment centre which

may result in an onward referral to a consultant-led service before clinical responsibility

is transferred back to the referrer.

A patient self-refers into a consultant-led service for pre-agreed services agreed by

providers and commissioners

9.2 Exclusions A referral to most consultant-led services starts an RTT clock but the following services and

types of patients are excluded from RTT:




• obstetrics and midwifery

• planned patients

• referrals to a non-consultant led service

• referrals for patients from non-English commissioners

• genitourinary medicine (GUM) services

• emergency pathway non-elective follow-up clinic activity.

9.3 New clock starts for the same condition

9.3.1 Following active monitoring

Some clinical pathways require patients to undergo regular monitoring or review diagnostics

as part of an agreed programme of care. These events would not in themselves indicate a

decision to treat or a new clock start. If a decision is made to treat after a period of active

monitoring/watchful waiting, a new RTT clock would start on the date of decision to treat

(DTT).

9.3.2 Following a decision to start a substantively new treatment plan

If a decision is made to start a substantively new or different treatment that does not

already form part of that patient’s agreed care plan this will start a new RTT pathway clock

and the patient shall receive their first definitive treatment within a maximum of 18 weeks

from that date.

9.3.3 For second side of a bilateral procedure

A new RTT clock should be started when a patient becomes fit and ready for the second side

of a consultant-led bilateral procedure.

9.3.4 For a rebooked new outpatient appointment

The RTT clock is stopped and nullified in all cases in the event of a first appointment DNA (as

long as the trust can demonstrate the appointment was booked in line with reasonableness

criteria). If the clinician indicates another first appointment should be offered, a new RTT

clock will be started on the day the new appointment is agreed with the patient.

Patients can choose to postpone or amend their appointment or treatment if they wish,

regardless of the resulting waiting time. Ideally this should be no longer than 16 weeks as

patients should be available to accept an appointment during this period. Patients may be

referred back to their GP if ‘reasonableness’ cannot be considered and a clinical review has

been undertaken and deemed this as appropriate action.

9.4 Planned patients A Planned Patient PTL is currently being developed. However, all patients added to the planned list

will be given a due date by when their planned procedure/test should take place. Where a patient

requiring a planned procedure goes beyond their due date, they will be transferred to an active

pathway and a new RTT clock started. The detailed process for management of planned patients is

described in the relevant standard operating procedure.

9.5 Clock stops for first definitive treatment An RTT clock stops when:




First definitive treatment starts. This could be:

Treatment provided by an ‘interface service’ OR

Treatment provided by a consultant-led service OR

Therapy or healthcare science intervention provided in secondary care or at an

interface service, if this is what the consultant-led or interface service decides is the

best way to manage the patient’s disease, condition or injury and avoid further

interventions OR

A clinical decision is made and has been communicated to the patient, and

subsequently their GP and/or other referring practitioner without undue delay, to

add a patient to a transplant list.

9.6 Clock stops for non-treatment

A waiting-time clock stops when it is communicated to the patient, and subsequently their

GP and/or other referring practitioner without undue delay that:

It is clinically appropriate to return the patient to primary care for any non-

consultant led treatment in a primary care setting

A clinical decision is made not to treat a patient

A patient did not attend (DNA) which results in the patient being discharged from

Consultant care

A decision is made to start a patient on Active monitoring

A patient declines treatment having been offered it

9.7 Active monitoring

Active monitoring is where a decision is made that the patient does not require any form of

treatment currently, but should be monitored in secondary care. When a decision to begin a

period of active monitoring is made and communicated with the patient, the RTT clock

stops.

Active monitoring may apply at any point in the patient’s pathway, but only exceptionally

after a decision to treat has been made.

It is not appropriate to stop a clock for a period of active monitoring if some form of

diagnostic or clinical intervention is required in a couple of days’ time, but it is appropriate if

a longer period of active monitoring is required before further action is needed.

Stopping a patient’s clock for a period of active monitoring requires careful consideration

case by case and needs to be consistent with the patient’s perception of their wait.

9.8 Patient initiated delays

9.8.1 Non-attendance of appointments/did not attend (DNAs)

Other than at first attendance, DNAs have no impact on reported waiting times. Every effort

should be made to minimise DNAs, and it is important that a clinician reviews every DNA on

an individual patient basis.




9.8.2 First appointment DNAs

The RTT clock is stopped and nullified in all cases (as long as the trust can demonstrate the

appointment was booked in line with reasonableness criteria). If the clinician indicates

another first appointment should be offered, a new RTT clock will be started on the day the

new appointment is agreed with the patient.

9.8.3 Subsequent (follow-up) appointment DNAs

The RTT clock continues if the clinician indicates that a further appointment should be

offered. If patients wait more than 18 weeks as a result of such delays, the 8% tolerance is in

place to account for this. The RTT clock stops if the clinician indicates that it is in the

patient’s best clinical interests to be discharged back to their GP/referrer.

See Appendix 016

9.9 Cancelling, declining or delaying appointment and admission offers

Patients can choose to postpone or amend their appointment or treatment if they wish,

regardless of the resulting waiting time. Such cancellations or delays have no impact on

reported RTT waiting times. However, clinicians will be informed of patient-initiated delays

to ensure that no harm is likely to result from the patient waiting longer for treatment

(clinicians may indicate in advance, for each specialty or pathway, how long it is clinically

safe for patients to delay their treatment before their case should be reviewed). Where

necessary, clinicians will review every patient’s case individually to determine whether:

the requested delay is clinically acceptable (clock continues)

the patient should be contacted to review their options – this may result in

agreement to the delay (clock continues) or to begin a period of active monitoring

(clock stops)

the patient’s best clinical interest would be served by discharging them to the care

of their GP (clock stops)

the requested delay is clinically acceptable but the clinician believes the delay will

have a consequential impact (where the treatment may fundamentally change

during the period of delay) on the patient’s treatment plan-active monitoring (clock

stops).

The general principle of acting in the patient’s best clinical interest at all times is paramount.

It is generally not in a patient’s best interest to be left on a waiting list for an extended

period, and so where long delays (i.e. of many months) are requested by patients a clinical

review should be carried out, and preferably the treating clinician should speak with the

patient to discuss and agree the best course of action. Patients should not be discharged to

their GP, or otherwise removed from the waiting list, unless it is for clinical reasons.

It is a responsibility of GPs that the patients being referred must be ready, willing and able to

have their surgery. Patients who do not want to be treated in the next 4 months (16 weeks)

should not be referred for routine treatment; there is a likelihood that the Trust will advise

the patients to return to their GP when they are ready to be referred.




It is good practice for the referring practitioner to have a conversation with the

patient to explain the importance of being available for hospital appointments,

diagnostics and treatments. This is AS important for routine referrals as patients

being referred on a 2 week suspected cancer pathway or other rapid access

services.

9.9.1 Cancellations by the patient:

Patient Initiated Cancellations / Delay (PIC/D): This is defined as an event for which

the Patient has given prior notice (ideally at least 24hrs) in advance of the scheduled

event. These events are often referred to as CNAs (Cannot Attends).

When a patient cancels an appointment for the first time, and the patient has not

yet received first definitive treatment, a further appointment will be offered in

accordance with their access target (to meet 18 weeks).

When a patient cannot agree a new appointment within a reasonable timeframe in

accordance with the principle of the patient being willing, ready and able, following

a clinical review, the GP may be asked to re-refer the patient when they are fully

available to engage with the management plan.

9.9.2 Rebooking a patient following a PIC

A patient must be given the option of two appointments (at least three weeks

ahead) and up to 4 weeks from the original date. This is deemed a ‘reasonable

offer’. The patient is to be advised that a third offer may not be made if not

considered clinically appropriate. If these appointments are declined the referral

will be reviewed by the consultant and unless there is a clinical need for the patient

to remain on the waiting list, they may be referred back to their GP. This applies to

follow ups as well as first OPD appointments.

Patients who have waited in excess of 40 weeks, should be given the option of two appointments (at least three weeks ahead) and up to 8 weeks from the original date. This is deemed a ‘reasonable offer’. The patient should be advised that a third offer may not be made. If these dates are declined the referral will be reviewed clinically and unless there is a clinical need for the patient to remain on the waiting list, they will be referred back to their GP. Where the patient has waited for over 40 weeks the offer will be made by telephone rather than by letter but the detail will be recorded on eCare.

It is considered good practice for GPs and Hospital -based services to have

conversations outlining concerns about patient engagement before taking such

action. Where possible this should be between the referring and accepting

clinicians; these actions must be documented.

In all the above situations, special consideration needs to be given to patients where there is a suspected cancer, children and vulnerable patients.




9.10 INPATIENTS

9.10.1 Did Not Attend (DNA) Patients who fail to attend an appointment, or an admission may do so for a variety of reasons. It is not always as a result of patient negligence so this should NOT be the automatic position to adopt. Every case is different, and the reasons for non-attendance are numerous.

Best Practice is clear that in most circumstances a patient negotiated appointment will be much less likely missed.

In order to reduce the number of unnecessary DNAs, the Trust will send out a text reminder for an increasing number of services where a mobile number is held in the Trust systems.

Patients who do not attend a clearly communicated first appointment or if a patient cancels two appointments for the same condition following a clinical review, may be returned to the care of the GP following a clinical review..

Urgent patients who do not attend will be contacted and a new TCI date agreed. If the patient DNAs a second time the consultant following a clinical review may discharge the patient, inform the GP and the patient will be removed from the waiting list.

Routine patients who do not attend their date for elective admission may be removed from the waiting list after clinical review and their GP will be informed.

Urgent patients should be contacted by phone to find out the reason for the DNA. A decision whether to offer a further clinic appointment date will be clinically evaluated on a case by case basis. Cases should be escalated to the Admissions Manager.

The following groups of patients will be offered a new appointment where the original clock will be nullified and a new clock started

Cancer and suspected cancer patients

Vulnerable adults

Paediatrics (see section 9.7below)

Clinically led decision re clinical condition

However, if the patient DNAs on a second occasion, the patient may be returned to the care of the GP, as agreed with the Consultant following a clinical review - and the RTT clock will stop.

To ensure fair and equitable treatment, the following is in place to support the above:

The patient has been made an offer with reasonable notice

It is simple and easy for patients to cancel or reschedule their appointments by either phone or email




It has been made clear to the patient through any verbal and all written communication about the appointment that the patient will be returned to the care of the GP if he or she DNAs

All and any cases where the patient, GP or other referrer believes that this was not a true DNA and that the patient should be reinstated, must be referred to the Telephone Appointments Centre (TAC) Manager for escalation.

In all the above situations, special consideration needs to be given to patients where there is a suspected cancer, children and vulnerable patients. 9.11 Cancellations by the Hospital

9.11.1 Hospital Initiated Cancellation (HIC)

9.11.2 Non-Clinical Reasons

Appropriate escalation MUST be undertaken in every event. Clear and unambiguous communication must be made with the patient and delivered as soon, and as sensitively as possible. The conversation MUST be documented ideally using the “message Centre” on eCare Distinguish between IP/DC and OP

A Senior Manager will take responsibility for the conversation and any follow-up

action or reassurance.

Following a “last minute cancellation” for non-clinical reasons (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. All breaches of this standard will be logged on DATIX and an

investigation triggered under the normal process. Clinical involvement in the

decision making process is important.

If a patient is cancelled by the hospital prior to their admission date due to lack of an

available bed, the patient will be rescheduled as soon as possible.

9.11.3 Clinical Reasons

There are a number of reasons why a patient may be cancelled on the day of

surgery. This should be minimised by an effective and appropriate pre-

admission assessment, and determined appropriate at the time of placing

the patient of the Waiting List by the consultant. At every stage event MUST

be recorded on the eCare system.

9.11.4 Patients who are unfit for surgery

If the patient is identified as unfit for the procedure, the nature and duration

of the clinical issue should be ascertained, recorded within OPERA and eCare

accurately and in a timely fashion. This information should also be used to

update the PTL




9.11.5 Short-term illnesses

If the clinical issue is short-term and has no impact on the original clinical

decision to undertake the procedure (e.g. cough, cold), the RTT clock

continues.

9.11.6 Longer term illnesses

If the clinical issue is more serious and the patient requires optimisation and

treatment for it, clinicians should indicate to administration staff:

if it is clinically appropriate for the patient to be removed from the

waiting list (This will be a clock stop event via the application of active

monitoring.)

if the patient should be optimised/treated within secondary care (active

monitoring clock stop) or if they should be discharged back to the care

of their GP (clock stop).

9.11.7 Pathway specific principles referral to treatment and diagnostic pathways

The non-admitted stages of the patient pathway (see Figure 3) comprise

both outpatients and the diagnostic stages, as highlighted by the section

with the green border around it in the diagram below.

It starts from the clock start date (i.e. the date the referral is received) and

ends when either a clock stop happens in outpatients (this could be the first,

second or a further appointment) or when a decision to admit is made and

the patient transfers to the admitted pathway.




9.12 Receipt of referral letters The NHS e-Referral Service (e-RS) is the only method of receiving referrals from GPs and

Referral Management Centres (RMCs). These referrals will be received in the TAC office.

Where clinically appropriate, referrals will be made to a service rather than a named

clinician. Services have agreed clinical criteria to support triage and vetting, and patients will

then be allocated to the most appropriate clinician, taking into account waiting times.

Referring to services is in the best interests of patients as pooling referrals promotes equity

of waiting times and allows greater flexibility in booking appointments.

It is good practice for the referring practitioner to have a conversation with the patient to explain the importance of being available for hospital appointments, diagnostics and treatments. This is as important for routine referrals as patients being referred on a 2 week suspected cancer pathway or other rapid access services.

9.10.1 Methods of receipt

All referrals must be reviewed and accepted or rejected by clinical teams within 72

hours ideally or 5 working days maximum limit. Where there is a delay in reviewing

e-referrals this will be escalated to the relevant clinical / management team and

actions agreed to address it. If an NHS e-Referral is received for a service not

provided by the trust, it will be rejected back to the referring GP advising that the

patient needs to be referred elsewhere. This will stop the patient’s RTT clock.




9.10.2 Paper-based referrals


REMEMBER THE CLOCK STARTS ON THE DATE THE REFERRAL IS RECEIVED IN THE TRUST OR WHEN

THE UBRN IS CONVERTED.

9.11 Referral types

9.11.1 Rapid access chest pain clinic (RACPC) referrals

RACPC patients must be seen by a specialist within 14 days of the trust receiving the

referral. To ensure this is achieved:

RACPC referrals should be made via e-RS only.

GPs should ensure that appropriate information regarding the RACPC

referral is provided to the patient.

9.11.2 Transient ischaemic attack (TIA) clinic referrals

Details awaited

9.11.3 Consultant to consultant referrals

Consultant to consultant referrals (C2Cs) are allowed in the following

circumstances:

referrals that are part of the continuation of investigation treatment

of the condition for which the patient was referred − this includes

referrals to pain management where surgical intervention is not

intended

urgent referrals for new condition

suspected cancer referral - this will be vetted and dated by the

receiving consultant and upgraded if deemed necessary. Once

upgraded the patient will be treated within 62 days of the date the

referral was received by consultant.

9.11.4 Clinical assessment and triage services (CATS) and referral management

centres (RMCs)

A referral to a CATS or an RMC starts an 18-week RTT clock from the day the

referral is received in the CAT/RMC. If the patient is referred on to the trust

having not received any treatment in the service, the trust inherits the 18-

week RTT wait for the patient.

A minimum dataset (MDS) form must be used to transfer 18-week

information about the patient to the trust.

9.11.5 Inter-provider transfers (IPT’s)

Incoming IPTs All IPT referrals will be received electronically via the trust’s

secure generic NHS net email account in the central booking office.




The trust expects an accompanying MDS pro-forma with the IPT, detailing

the patient’s current RTT status (the trust will inherit any RTT wait already

incurred at the referring trust if they have not yet been treated) and if the

patient has been referred for a new treatment plan for the same condition

(where a new RTT clock will start upon receipt at this trust). The patient’s

pathway identifier (PPID) should also be provided. If the IPT is for a

diagnostic test only, the referring trust retains responsibility for the RTT

pathway.

If any of the above information is missing, the referral should be recorded

on PAS and the information actively chased by the central booking office.

Reference should be made to the Cancer Operational Policy for specific

details.

9.11.6 Outgoing IPTs

The trust will ensure that outgoing IPTs are processed as quickly as possible

to avoid any unnecessary delays in the patient’s pathway.

An accompanying MDS pro forma will be sent with the IPT, detailing the

patient’s current RTT status (the receiving trust will inherit any RTT wait

already incurred if the patient has not yet been treated). If the patient has

been referred for a new treatment plan for the same condition, a new RTT

clock will start on receipt at the receiving trust. The patient’s patient

pathway identifier (PPID) will also be provided.

If the outgoing IPT is for a diagnostic test only, this trust retains

responsibility for the RTT pathway.

Referrals and the accompanying MDS will be emailed securely from the

specialty NHS net account to the generic central booking office NHS account.

The central booking office will verify (and correct if necessary) the correct

RTT status for the patient. If the patient has not yet been treated, the RTT

clock will be nullified at this trust. They will then forward to the receiving

trust within one working day of receipt into the generic email inbox

10. Outpatients Booking

10.1 Booking new outpatient appointments

10.1.1 E-referral service

Patients who have been referred via e-RS should be able to choose, book

and confirm their appointment before the trust receives and accepts the

referral.

If there are insufficient slots available for the selected service at the time of

attempting to book (or convert their Unique Booking Reference Number




UBRN), the patient will appear on the appointment slot issue (ASI) work list.

The RTT clock starts from the point at which the patient attempted to book.

Patients on the ASI list must be contacted as soon as possible (or no longer

than 10 working days) by the central booking office to agree an

appointment.

If a patient’s appointment has been incorrectly booked on the NHS e-

Referral system into the wrong service at the trust by the referrer, the

referral should be electronically re-directed in the e-Referral system to the

correct service. A confirmation letter of the appointment change will be sent

to the patient. The patient’s RTT clock will continue to tick from the original

date when they converted their UBRN.

10.1.2 Paper-based referrals


10.2 Clinic attendance and outcomes (new and follow up clinics)

10.2.1 Clinic Management / Administration

Every patient, new and follow-up, whether attended or not, will have an

attendance status and outcome recorded on eCare at the end of the clinic.

Clinics will be fully outcome or ‘cashed up’ within one working day of the

clinic taking place.

10.2.2 Use of the COF

Clinic outcomes (e.g. discharge, further appointment) and the patient’s

updated RTT status will be recorded by clinicians on the agreed clinic

outcome form (COF) and forwarded to reception staff immediately. The

clinic outcomes forms must be forwarded to the TAC within 24 hours of the

clinic date.

10.2.3 Clinician Responsibility

When they attend the clinic, patients may be on an open pathway (i.e.

waiting for treatment with an RTT clock running) or they may already have

had a clock stop due to receiving treatment or a decision not to treat being

agreed. It is possible for patients to be assigned any one of the following RTT

statuses at the end of their outpatient attendance, depending on the clinical

decisions made or treatment given/started during the consultation:

This is a term often referred to as Cashing Up. It is the way by which the

clinical decision is recorded and next steps administered on the PAS. It is

ALWAYS a clinician responsibility to make the decision on the next step; it

MAY be an administrative function to accurately add this to the PAS. This

MUST be completed within 24 hours of the clinic session ending.




This should be monitored and reported by the Information Team at the

performance meetings as a KPI.

All decisions must be made by the clinician reviewing that patient in cl inic; This must be clearly documented on the eCare syste m.. It is a clinical responsibility to ensure that the outcome is recorded accurately and in a timely manner

10.2.4 Patients on an open pathway

There are a number of national codes which must be used to accurately

record the outcome from that clinical encounter. The most appropriate code

should be picked; This may be validated and checked at any time.

• Clock stop for treatment

• Clock stop for non-treatment

• Clock continues if requiring diagnostics, therapies or being added to

the admitted waiting list. Patients already treated or with a decision

not to treat

• New clock starts if a decision is made regarding a new treatment

plan.

• New clock starts if the patient is fit and ready for the second side of

a bilateral procedure.

• No RTT clock if the patient is to be reviewed following first definitive

treatment.

• No RTT clock if the patient is to continue under active monitoring

Accurate and timely recording of these RTT statuses at the end of the clinic

are therefore critical to supporting the accurate reporting of RTT

performance.

If clinical staff are unsure what to choose or how to action please seek advice in

clinic from the clinic manager or trained member of the administration team who

can offer further support and guidance

10.3 Booking follow up appointments

10.3.1 Patients on an open pathway

Where possible, follow up appointments for such patients should be avoided; by

discussing likely treatment plans at first outpatient appointment, and/or use of

telephone/written communication where a face-to-face consultation is not clinically

required. Where unavoidable, such appointments must be booked to a timeframe

that permits treatment by week 18 (unless the patient choses a later date).

Where possible, follow-up appointments should be agreed with the patient prior to

leaving the clinic. The clinician should consider the most appropriate clinical

timeframe acceptable in the context of available capacity. Where this is not possible,

clear instructions should be given to overbook a clinic, or discuss with your service

manager what options are available.




The Service manager / Senior Operational Manager for the specialty have the

responsibility for managing the capacity available.

10.3.2 Capacity shortfall and escalations

Capacity shortfalls MUST be escalated in the event of a patient not being able to be

allocated an appointment within a clinically acceptable or pathway compliant

timeframe. This provides the best opportunity for patient choice to be

accommodated within the required timescale for achievement of the RTT standard.

Where insufficient capacity is available, the clinic receptionist will escalate in line

with local arrangements to obtain authorisation to overbook.

10.3.3 Patients not on an open pathway

Consideration should be given to the introduction of a formal Partial Booking or

Patient Focussed Booking process. This will therefore be subject to approval and

further revision. Patients who have already been treated or who are under active

monitoring and require a follow-up appointment are to be managed via the GOO

PTL. (NB This section will require an update as soon as a formal Diagnostic and

Planned PTL is established on eCare)

10.3.4 Did not attends (DNA)

All did not attend (DNAs) (new and follow-up) will be reviewed by the clinician in

clinic prior to ‘cashing up’ in order for a clinical decision to be made regarding next

steps. Paediatric and vulnerable patient DNAs should be managed with reference to

the Trust’s safeguarding policy.

Patients who DNA for a second time must be reviewed by the clinician in clinic. This

review may result in the patient being discharged from clinic. The GP will be

informed in writing and copy letter to the patient is also sent.

A letter should be generated automatically from the ‘system’ and sent to the GP and

the patient in the event of a DNA being recorded. This is a clinically safe process

initiative when the Consultant has completed the COF at the end of clinic. This is

NOT deemed to be an administrative decision.

10.4 Patient Initiated Actions (PIAs)

10.4.1 Appointment changes and cancellations initiated by the patient

If the patient gives ANY prior notice that they cannot attend their appointment

(even if this is on the day of clinic), this should be recorded as a CANCELLATION

(CNA) and not DNA.

If the patient requires a further appointment, this will be booked with the patient at

the time of the cancellation. If the patient is on an open RTT pathway, the clock

continues to tick. If there are insufficient appointment slots within the agreed

pathway milestones, the issue must be escalated to the relevant speciality

management team. Contact with patient should be made within two working days

to agree an alternative date.




If the patient has never been seen and advises they do not wish to progress their

pathway, they will be removed from the relevant waiting list and a clock stop and

nullification applied. The patient will be informed that their consultant and GP will

be informed of this. This action provides a safeguard for clinical intervention.

If as a result of the patient cancelling, a delay is incurred which is equal to or greater

than a clinically unsafe period of delay (as indicated in advance by consultants for

each specialty), the patient’s pathway should be reviewed by their consultant. Upon

clinical review, the patient’s consultant should indicate one of the following:

• Clinically SAFE for the patient to delay; continuation of the pathway. The RTT

clock continues

• Clinically UNSAFE for the patient to delay; Clinician to contact the patient

directly, copying in the patient GP with a view to persuading the patient that any

delay is against clinical advice continuation of the pathway. The RTT clock

continues

• Clinically UNSAFE length of delay; in the patient’s best interest and/or clinical

interests to return the patient to their GP. This MUST be done by the clinician in

writing. The RTT clock stops on the day this is communicated to the Patient and

GP (date on letter)

• All the above MUST be completed and evidenced on eCare.

10.5 Hospital Initiated Actions (HIAs)

10.5.1 Appointment changes initiated by the hospital

Hospital-initiated changes to appointments will be avoided as far as possible as they

are poor practice and cause inconvenience to patients.

• Clinicians are actively encouraged to book annual leave and study leave as early

as possible. Clinicians must a minimum of provide 6 weeks’ notice of a clinic has

to be cancelled or reduced. (NB This section should reflect the most uptodate

Leave Policy requirements)

• Ref:

http://staff.wsha.local/CMSdocuments/TrustPolicies/PDFs/251-

300/PP(15)298ApprovalofSeniorMedicalStaffAnnualLeave.pdf

• Patients will be contacted immediately if the need for the cancellation is

identified, and offered an alternative date(s) that will allow patients on open

RTT pathways to be treated within 18 weeks. Equally, this will allow patients not

on open pathways to be reviewed as near to the clinically agreed timeframe as

possible.

11.0 Diagnostics

http://staff.wsha.local/CMSdocuments/TrustPolicies/PDFs/251-300/PP(15)298ApprovalofSeniorMedicalStaffAnnualLeave.pdf

http://staff.wsha.local/CMSdocuments/TrustPolicies/PDFs/251-300/PP(15)298ApprovalofSeniorMedicalStaffAnnualLeave.pdf




11.1 Summary

Figure 4 below outlines within the green border the diagnostic stage of the RTT

pathway which forms part of the non-admitted pathways. It starts at the point of a

decision to refer for a diagnostic test and ends on the results/report from the

diagnostic procedure being available to the requester.

11.1.1 Operational Standard – DM01

The Standard to be met is 99% of diagnostic tests must be completed within

6 weeks of the date the decision is made to request a test. This excludes

‘planned’ investigations such as surveillance activity; therapeutic events

where the sole intention was cure and Obstetric ultrasound scans and other

events not included in the list below. If the intention was at any stage

diagnostic these activities are included under the standard. An example of

this could be the removal of a polyp during endoscopy. This can also trigger

a RTT clock stop event.

It is important to note, however, that patients can also be referred for some

diagnostic investigations directly by their GP where they might not be on an

18-week RTT pathway. This will happen where the GP has requested the test

to inform future patient management decisions, i.e. has not made a referral

to a consultant-led service at this time.

The main purpose for monitoring compliance against this standard is that

evidence demonstrates that access to timely diagnostic investigations can

positively impact on the clinical outcome of a patient. Further details can be

obtained at

https://www.england.nhs.uk/statistics/wp-

content/uploads/sites/2/2013/08/DM01-guidance-v-5.32.pdf

11.1.2 Monitoring DM01

The DIAGNOSTIC clock is monitored locally and compliance is reported via

the DM01 standard. The DM01 is modality reported. Investigations

monitored within this standard are:

• Imaging - Magnetic Resonance Imaging • Imaging - Computed Tomography • Imaging - Non-obstetric ultrasound • Imaging - Barium Enema • Imaging - DEXA Scan

i. Physiological Measurement (Audiology) Audiology Assessments ii. Physiological Measurement (Cardiology) echocardiography

iii. Physiological Measurement (Cardiology) electrophysiology iv. Physiological Measurement (Neurophysiology) peripheral neurophysiology v. Physiological Measurement (Respiratory physiology) sleep studies

vi. Physiological Measurement (Urodynamics) pressures & flows vii. Endoscopy Colonoscopy

viii. Endoscopy Flexi sigmoidoscopy

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/08/DM01-guidance-v-5.32.pdf

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/08/DM01-guidance-v-5.32.pdf




ix. Endoscopy Cystoscopy x. Endoscopy Gastroscopy

11.2 Figure 4 ‘The Diagnostic stage’

11.2.1 Patients with a diagnostic and RTT clock

The diagnostics section of an RTT pathway is a major pathway milestone. A

large proportion of patients referred for a diagnostic test will also be on an

open RTT pathway. In these circumstances, the patient will have both types

of clock running concurrently:

The patients RTT clock will continue to run from the date of the original

referral by the GP

The patient’s DIAGNOSTIC clock (reported under DM01) will start at the

point of the decision to refer the patient for a diagnostic test. This can be at




any part of the RTT pathway but most commonly at the First Outpatient

appointment.

11.2.2 Straight to test

For patients who are referred for a diagnostic test where one of the possible

outcomes is review and if appropriate treatment within a consultant-led

service (without first being reviewed by their GP) an RTT clock will start on

receipt of the referral. These are called straight-to-test referrals.

11.2.3 Patients with a diagnostic clock only

Patients who are referred directly for a diagnostic test (but not consultant-

led treatment) by their GP, i.e. clinical responsibility remains with the GP,

will have a diagnostic clock running only. These are called direct access

referrals.

Patients may also have a diagnostic clock running only where they have had

an RTT clock stop for treatment or non-treatment and their consultant

refers them for a diagnostic test with the possibility that this may lead to a

new RTT treatment plan.

11.3 National diagnostic clock rules

Diagnostic clock start: the clock starts at the point of the decision to refer for

a diagnostic test by either the GP or the consultant.

Diagnostic clock stop: the clock stops at the point at which the patient

undergoes the test.

11.4 Booking diagnostic appointments

The appointment will be booked directly with the patient at the point that

the decision to refer for a test was made wherever possible (e.g. the patient

should be asked to contact the diagnostic department by phone or face to

face to make the booking before leaving the hospital).

If a patient declines, cancels or does not attend a diagnostic appointment,

the diagnostic clock start can be reset to the date the patient provides

notification of this. However:

The trust must be able to demonstrate that the patient’s original diagnostic

appointment fulfilled the reasonableness criteria for the clock start to be

reset.

Resetting the diagnostic clock start has no effect on the patient’s RTT clock.

This continues from the original clock start date




11.4.1 Diagnostic cancellations, declines and/or DNA’s for patients on open RTT

pathways

Where a patient has cancelled, declined and/or not attended their

diagnostic appointment and a clinical decision is made to return them to the

referring consultant, the RTT clock should continue to tick.

Only the referring consultant can make a clinical decision to stop the RTT

clock, if this is deemed to be in the patient’s best clinical interests, by

discharging the patient or agreeing a period of active monitoring.

11.4.2 Active diagnostic waiting list

All patients waiting for a diagnostic test should be captured on an active

diagnostic waiting list, regardless of whether they have an RTT clock

running, or have had a previous diagnostic test.

The only exceptions are planned patients (see below):

11.4.3 Planned diagnostic patients

Patients who require a diagnostic test to be carried out at a specific point in

time for clinical reasons are exempt from the diagnostic clock rules and will

be held on a planned waiting list with a clinically determined due date

identified. However, if the patient’s wait goes beyond the due date for the

test, they will be transferred to an active waiting list and a new diagnostic

clock and RTT clock will be started.

11.4.4 Therapeutic procedures

Where the patient is solely waiting for a therapeutic procedure, for example

in the radiology department, there is no six-week diagnostic standard.

However, for many patients there is also a diagnostic element to their

admission/appointment, and so these patients would still be required to

have their procedure within six weeks.

11.5 Responsibilities

The responsibility for adherence to this policy resides with the Head of

Imaging; Responsibility for reporting against DM01 standards resides with

the Head of Information.

REMEMBER a diagnostic pathway must be completed within 6 weeks of the

referral; it contributes to the delivery of the RTT Pathway so early access to

these tests is always recommended. Tests will need to ‘reported’ so any and

all delays adds time to a patient pathway.




12.0 Pre-operative assessment (POA)

12.1 Figure 5

12.2 Operational Management

All patients with a decision to admit (DTA) requiring a general anaesthetic

will attend a Pre-Operative Assessment (POA) clinic ideally the same day as

the decision to admit to assess their fitness for surgery wherever possible.

The vast majority of patients can be assessed by the Trust’s dedicated Pre-

Operative Assessment nurse specialists. (POA)

If appropriate, Patients should be made aware in advance that they may

need stay longer on the day of their appointment for attendance in POA.

For patients with complex health issues requiring a POA appointment with a

nurse consultant, the trust will agree this date with the patient before they

leave the clinic. The trust will agree an appointment no later than seven

working days from the decision to admit.

12.2.1 Patient Event Management

Patients who DNA their POA appointment will be contacted and a

further appointment agreed. If they DNA again, they will be

reviewed by the responsible consultant. The RTT clock continues to

tick throughout this process.

If the patient is identified as unfit for the procedure, the nature and

duration of the clinical issue should be ascertained. If the clinical




issue is short term and has no impact on the original clinical decision

to undertake the procedure (e.g. cough, cold, UTI), the RTT clock

continues.

However, if the clinical issue is more serious and the patient

requires optimisation and/treatment, clinicians should indicate to

administration staff if it is clinically appropriate for the patient to be

removed from the waiting list, and if so whether the patient should

be:

• optimised/treated within secondary care (Active monitoring

clock stop for existing pathway and potentially new clock start

for optimisation treatment)

• discharged back to the care of their GP (clock stop –

Discharged). When the patient becomes fit and ready to be

treated for the original condition, a new RTT clock would start

on the date this decision is made and communicated to the

patient and their GP.

13.0 ACCESS TO THERAPY SERVICES

13.1 Acute therapy services

Acute therapy services consist of physiotherapy, dietetics, orthotics and surgical appliances.

Referrals to these services can be:

• Directly from GPs where and RTT clock would NOT be applicable

• During an open RTT pathway where the intervention as FDT (First Definitive

Treatment) or interim treatment.

Depending on the particular pathway or patient, therapy interventions could constitute an

RTT clock stop. Equally the clock could continue to tick. It is critical that staff in these

services know if patients are on an open pathway and if the referral to them is intended as

first definitive treatment.

13.1.1 Physiotherapy

For patients on an orthopaedic pathway referred for physiotherapy as first definitive

treatment the RTT clock stops when the patient begins physiotherapy.

For patients on an orthopaedic pathway referred for physiotherapy as interim treatment (as

surgery will definitely be required), the RTT clock continues when the patient undergoes

physiotherapy.

13.1.2 Surgical appliances

Patients on an orthopaedic pathway referred for a surgical appliance with no other form of

treatment agreed. In this scenario, the fitting of the appliance constitutes first definitive

treatment and therefore the RTT clock stops when this occurs.




13.1.3 Dietetics

If patients are referred to the dietician and receive dietary advice with no other form of

treatment, this would constitute an RTT clock stop. Equally, patients could receive dietary

advice as an important step of a particular pathway (e.g. bariatric). In this pathway, the clock

could continue to tick.

13.2 Non-activity related RTT decisions

13.2.1 Figure 6 - Non-activity related RTT decisions

13.2.2 Reviewing Results and non ‘face-to-face’ events.

Where clinicians review test results in the office setting and make a clinical decision not to

treat, the RTT clock will be stopped on the day this is communicated in writing to the

patient.

Administration staff should update PAS with the clock stop. The date recorded will be the

day the decision not to treat is communicated in writing to the patient.




This type of activity may also be resultant from contact form the patient, their GP or clinician

in another organisation; however, it must be evidenced by clear correspondence or

evidence which must be recorded on eCare.

This activity is always a clinical decision

14.0 Admitted pathways The section within the green border on Figure 7 represents the admitted stage of the pathway. It

starts at the point of a decision to admit and ends upon admission for first definitive treatment.

14.1 Figure 7 – Diagram Admitted Patients

14.2 Adding patients to the active inpatient or day case waiting list

Ideally patients will be fit, ready and available before being added to the admitted waiting

list. However, they will be added to the admitted waiting list without delay following a

decision to admit, regardless of whether they have undergone preoperative assessment or

whether they have declared a period of unavailability at the point of the decision to admit.

The active inpatient or day case waiting lists/PTLs includes all patients who are awaiting

elective admission. The only exceptions are planned patients, who are awaiting admission at




a specific clinically defined time. These patients will be managed locally until such time as

Planned PTL is available.

In terms of the patient’s RTT clock, adding a patient to the inpatient or day case waiting will

either:

• continue the RTT clock from the original referral received date

• start a new RTT clock if the surgical procedure is a substantively new treatment plan

which did not form part of the original treatment package, providing that either another

definitive treatment or a period of active monitoring has already occurred. The RTT clock

will stop upon admission.

14.3 Patients requiring more than one procedure

If more than one procedure will be performed at one time by the same surgeon, the patient

should be added to the waiting list with extra procedures noted. If different surgeons will

work together to perform more than one procedure, the patient will be added to the waiting

list of the consultant surgeon for the priority procedure with additional procedures noted. If

a patient requires more than one procedure performed on separate occasions by different

(or the same) surgeon(s):

• The patient will be added to the active waiting list for the primary (1st) procedure.

• When the first procedure is complete and the patient is fit, ready and able to

undergo the second procedure, the patient will be added (as a new waiting list

entry) to the waiting list, and a new RTT clock will start.

14.4 Patients requiring thinking time

Treatment options can have life changing impacts on a patient and/or their relatives or

carers, and may wish to spend time thinking about the recommended treatment options

before confirming they would like to proceed. It would NOT be appropriate to stop their RTT

clock where this thinking time amounts to only a few days or weeks. Patients should be

asked to make contact within an agreed period with their decision. It may be appropriate for

the patient to be entered into active monitoring (and the RTT clock stopped) where they

state they do not anticipate making a decision for a matter of months.

• This decision can only be made by a clinician and on an individual patient basis with

their best clinical interests in mind.

• In this scenario, a follow-up appointment must be arranged around the time the

patient would be in a position to make a decision.

• A new RTT clock should start from the date of the decision to admit if the patient

decides to proceed with surgery.

14.4 Scheduling patients to come in for admission

Clinically urgent patients will be scheduled first, followed by routine patients. All patients

will be identified from the trust’s PTL, and subject to the clause above about clinical

priorities, will be scheduled for admission in chronological order of RTT wait.

If the patient does not make contact, the demographic details will be confirmed with the GP.

Three attempts will then be made to contact the patient, with one being in the evening. If




still unsuccessful, a second ‘invitation to call’ letter will be sent to the patient and a copy

sent to their GP.

Patients will be offered a choice of at least two admission dates with three weeks’ notice

within the agreed milestone for the specialty concerned. Admission dates can be offered

with less than three weeks’ notice and if the patient accepts, this can then be defined as

‘reasonable’.

If there is insufficient capacity to offer dates within the required milestone, this issue will be

escalated to the relevant service manager. Any admission offers declined by patients will be

recorded on PAS. This is important for two reasons:

• Full and accurate record-keeping is good clinical practice.

• The information can also be used at a later date to understand the reasons

for any delays in the patient’s treatment, e.g. hospital or patient initiated.

14.5 Patients declaring periods of unavailability while on the inpatient / day care waiting list

If patients contact the trust to communicate periods of unavailability for social reasons (e.g.

holidays, exams), this period should be recorded on PAS.

If the length of the period of unavailability is equal to or greater than a clinically unsafe

period of delay (as indicated in advance by consultants for each specialty), the patient’s

pathway will be reviewed by their consultant. Upon clinical review, the patient’s consultant

will indicate one of the following:

• Clinically safe for the patient to delay: continue progression of pathway. The RTT

clock continues.

• Clinically unsafe length of delay: clinician to contact the patient with a view to

persuading the patient not to delay. The RTT clock continues. In exceptional

circumstances if a patient decides to delay their treatment it may be appropriate to

place the patient under active monitoring (clock stop) if the clinician believes the

delay will have a consequential impact on the patient’s treatment plan.

• Clinically unsafe length of delay: in the patient’s best, clinical interests to return the

patient to their GP. The RTT clock stops on the day this is communicated to the

patient and their GP. The patient could also be actively monitored within the Trust.

If this period is likely to be in excess of 16 weeks (4 months) then consideration should be

given to return the referral to the referring clinician (if clinically acceptable to do so).

Good Practice also suggests that should the patient fall into this category at the time of

referral, careful consideration should be given by the GP to defer the referral until such time

the patient is available in clinically acceptable scenarios.

14.6 Patients who decline or cancel TCI offers

If patients decline TCI offers or contact the trust to cancel a previously agreed TCI, this will

be recorded on the eCare. The RTT clock continues to tick. If, as a result of the patient

declining or cancelling, a delay is incurred which is equal to or greater than a clinically unsafe

period of delay (as indicated in advance by consultants for each specialty), the patient’s




pathway will be reviewed by their consultant. Upon clinical review, the patient’s consultant

will indicate one of the following:

Clinically safe for the patient to delay: continue progression of pathway. The RTT clock

continues.

Clinically unsafe length of delay: clinician to contact the patient with a view to persuading

the patient not to delay. The RTT clock continues.

Clinically unsafe length of delay: in the patient’s best, clinical interests to return the patient

to their GP. The RTT clock stops on the day this is communicated to the patient and their GP.

The requested delay is clinically acceptable but the clinician believes the delay will have a

consequential impact (where the treatment may fundamentally change during the period of

delay) on the patient’s treatment plan-active monitoring.

14.7 Patients who do not attend admission

Patients who do not attend for admission will have their pathway reviewed by their

consultant. If the patient’s consultant decides that they should be offered a further

admission date, the RTT clock continues to tick. If the patient’s consultant decides that it is in

their best clinical interests to be discharged back to the GP, the RTT clock is stopped

For first appointments on an RTT pathway:

If the patient DNAs, their RTT clock can be stopped and nullified on the date of the

DNA'd appointment.

If the patient DNAs but the trust chooses to rebook the patient, then their original

RTT clock would be stopped and nullified on the date of the DNA'd appointment and

a new clock would start (at zero) on the date that the trust rebooks the patient.

For subsequent appointments on an RTT pathway:

If the patient DNAs and the trust returns the patient back to primary care (having

fulfilled the criteria described above), then their RTT clock would stop on the date of

the DNA'd appointment.

If the patient DNAs but the trust chooses to rebook the patient, then their existing

RTT clock would continue to tick.

14.8 ‘On the day’ cancellations

Where a patient is cancelled on the day of admission or day of surgery for nonclinical

reasons, they will be rebooked within 28 days of the original admission date and the patient

must be given reasonable notice of the rearranged date.

It is important that this event is escalated to the clinician and the operational managers at the point

of ‘risk’ of cancellation as well as actual cancellation. If the patient is likely to be at ‘risk’ of harm as a

result then this MUST be recorded via the DATIX system, and consideration be given as to whether

the patient has been exposed to ‘harm’ should be made.

The patient may choose NOT to accept a date within 28 days. If it is not possible to offer the patient

a date within 28 days of the cancellation, the Trust will offer to fund the patient’s treatment at the

time and hospital of the patient’s choice where appropriate.




14.9 Planned waiting lists

Patients will only be added to an admitted planned waiting list where clinically they

need to undergo a procedure at a specific time. The due date for their planned

procedure will be included in the planned waiting list entry. Patients on planned

waiting lists will be scheduled for admission at the clinically appropriate time and

they should not have to wait a further period after this time has elapsed.

When patients on planned lists are clinically ready for their care to begin and reach

their due date for their planned procedure, they will either be admitted for the

procedure or be transferred to an active waiting list and a new RTT clock will start.

For some patients (e.g. surveillance endoscopies) a diagnostic clock would also start.

14.10 Monitoring and audit

It is the responsibility of the information team to support a programme of audits for

data completeness and data anomalies. There is a need for the Trust to support

external and internal audits of the PTL and associated access standards

requirements as agreed with governing bodies and commissioners.

In addition, a regular data quality programme will be established to review the

following:

comparative audit of data on the PTL and PAS

comparative audit of cases removed from the RTT 18 Week pathway

patients within four weeks of removal.

These will involve reviewing a random selection of healthcare records from each

clinical specialty and will be led by the Head of Elective Access .

Other routine, periodic and ad hoc requests may be made throughout the year.

15.0 Cancer pathways

This section describes how the trust manages waiting times for patients with suspected and

confirmed cancer, to ensure that such patients are diagnosed and treated as rapidly as possible and

within the national waiting times standards. This policy is consistent with the latest version of the

Department of Health’s Cancer Waiting Times Guide and includes national dataset requirements for

both waiting times and clinical datasets.

This policy sets out key principles and practices to be followed. There is a specific and detailed

CANCER OPERATIONAL POLICY which can be reviewed at Appendix 012.




END




APPENDIX 001

Outpatient general principles For booking and management of Outpatient appointments, all WSFT staff should adhere to the

Outpatient General Principles as shown below:

Patients must be seen in order of clinical priority and then 18 week chronological order

(longest waits first).

Patients must be booked from a patient tracking list (PTL).

Patients are kept fully informed and have a single point of contact at the Trust.

Contact with the patient must be documented in the “additional information” field on the

PAS system.

Staff must abide by the parameters of the clinic structure (template) available unless vacancies

occur; thereby, swapping new and follow-up slots accordingly to ensure full capacity is

maintained. This must only be done in conjunction with the outpatient booking team. The usual

rule is to convert two follow up slots into one new slot.

Cancelled slots must not be given to the next “routine” referral. They should be used for the

longest waiting patients.

Only nominated staff will book appointments into the clinics.

When booking an appointment, PAS must be linked to the correct referral.

All patients will be given a specified time for their appointment. No block booking

appointment times will be administered to the clinics.

The patient will be offered an appointment giving reasonable notice via the Earliest

Reasonable Offer methodology.

All appointment dates will be mutually agreed with the patient using the Elective Booked or Partially

Booked methodology. If this is not the case then ‘reasonableness’ and discretion must be allowable.

There is a recognised direct relationship to the level of choice offered when negotiating an

appointment with a patient and the risk of that appointment being cancelled at short notice, or

resulting in a DNA.

The patient will be sent a letter confirming the booked appointment. The letter must be

clear and informative and should include a point of contact and telephone number to call if

they have any queries. The letter should explain clearly the consequences should the patient

cancel the appointment or fail to attend the clinic at the designated time, and the

implications of making themselves unavailable for more than 28 days.

All cancelled appointments will be rebooked within 2 weeks of the cancelled appointment to

avoid delays in the 18 week pathway.

The referral workbench must be reviewed and monitored on a weekly basis and the

appropriate action taken i.e. chase accept/reject, add to a waiting list or discharge the

referral.

The Trust will work towards a single point of receipt for referrals and will strive to transport

all referrals electronically between departments




Staff will adhere to the Cancer Policy and the RTT Access policy as DNA and patient

cancellations guidance can be different for patients on a cancer pathway.

Clinic templates should be reviewed on a regular basis to ensure they are fit for purpose.

The RTT history must be updated at every stage of the outpatient booking process.




Appendix 002

Outpatient appointment letters

The appointment letter should contain the following details:-

Patient’s full name

Patient’s Hospital number & NHS number

Date letter sent to patient

Date and time of appointment

Where to report to on arrival

Who to contact to change, postpone or query the appointment date

Any other response required from the patient either by telephone (to a named individual) or

on an enclosed response slip (with a business reply envelope)

Details of what will happen if a patient cancels or DNAs the appointment

Details of what may happen if a patient makes themselves unavailable for more than 28

days after a reasonable offer of appointment is made.

Patient Choice paragraph (new appointments only) as below:

Patient Choice Paragraph:

Under the rights of the NHS Constitution for England and the NHS Patient Choice Framework,

patients have the right to start consultant-led treatment within a maximum of 18 weeks, unless a

patient chooses or it is clinically appropriate to wait longer. Clinical Commissioning Groups must

provide advice or assistance to patients who have waited or will wait longer than 18 weeks. Further

information can be found on the NHS Choices website.

The associated literature should also contain:

Arrangements for transport e.g. ¡f you will not be able to drive after the appointment / procedure¡¨.

If a patient requires transport, they must call the Transport Service who will assess the patient for

eligibility and make necessary arrangements. Patients must be advised to contact the Transport

department if the appointment is amended or cancelled.

If the transport service fails to send transport and the patient contacts the hospital to cancel an

appointment / TCI, this should be recorded on PAS as a patient cancellation.




Appendix 003

Inpatient and Day case Principles

For booking and management of Inpatient and Day case Admissions, all WSFT staff should adhere to

the Inpatient and Day Case General Principles as shown below:

Patients must be seen in order of clinical priority and then 18 week chronological order.

Patients must be booked from a patient tracking list (PTL).

Procedure dates will be mutually agreed with the patient where possible.

The patient will be offered procedure dates giving reasonable notice via the Earliest

Reasonable Offer methodology.

When a decision to admit is made within an outpatient setting, the appointment date is

input as the ‘Original Date on list’ and ‘Date this Provider’ on the PAS WL entry screen.

A patient who is not fit, ready and available to come in for treatment on the day the decision

to admit is made should not be added to the waiting list. A clinical decision will be made to

discharge the patient back to their GP, which will stop the RTT pathway and the referral

should be discharged. GP’s should re-refer when the patient is fit, ready and available to be

treated. When the patient is subsequently referred, a new RTT pathway will start.

It is good practice to establish if the patient can accept a short notice appointment / TCI and

the short notice box should be ticked to assist waiting list holders. If a patient accepts a date

booked outside the reasonable offer criteria it becomes a reasonable offer. If a patient

confirms short notice as a possibility, but upon making an offer is unable to accept short

notice the patient should not be penalised.

Patients should not be added to an elective waiting list if they have confirmed periods of

unavailability.

Waiting list users must ensure waiting list entries are entered onto PAS in real time and no

later than 4 working days from original decision to admit (ODTA); this is to ensure waiting

times are correctly calculated for purposes of effective planning.

All patients will be kept fully informed from the point of entry onto a waiting list to their

admission offer and have a known point of contact at the Trust.

A patient who requires an excluded procedure, i.e. a procedure specified in the Prior

Approval Policy and Individual Funding Policy, should not be added to the waiting list until

funding approval is confirmed and an approval reference obtained. Approval can be sought

by Trust clinical staff who can complete the necessary form and forward according to the

Prior Approval process.

The patient’s RTT pathway continues to tick whilst a Prior Approval and Individual Funding

Requests (IFR) is being processed.

If a patient is from a CCG other than Suffolk, and requires an excluded procedure, funding

approval may be required from their responsible CCG prior to being added to a waiting list.

Please contact the Prior Approval team, telephone listed on the Data Quality web page.

The RTT history must be updated at every stage of the booking process.

Staff will adhere to the Cancer Policy and the RTT Access policy as DNA and patient

cancellations guidance can be different for patients on a cancer pathway.




All cancelled TCI’s will be rebooked within 2 weeks of the cancelled TCI to avoid delays in the

18 week pathway or another reasonable offer must be made.

When a decision to admit has been made upon reading diagnostic results or at MDT, the

date on list must be recorded on the date the decision to treat was made not the date the

waiting list card/document is received within a department.

The Source of Addition will be 11 – Other, with full annotation in the additional information.

Enter all patient contact details within Additional Information on the waiting list entry screen

i.e. patient on hols from/to (to maintain a full audit trail).




APPENDIX 003A

Inpatient/Day case TCI appointment Letters and Patient Information

The ‘To Come In Letter’ should contain the following details:

Patient’s full name

Patient’s Hospital Number & NHS Number

Date letter sent to patient

Date and time of admission

The procedure Date

Instructions regarding medication

Eating/drinking instructions

Where to report on arrival

Who to contact to postpone, change or queries relating to the admission dates

Trust Policy on what happens if the patient cancels or DNAs

Details of what will happen if a patient cancels or DNAs the appointment

Details of what may happen if a patient makes themselves unavailable for more than 28

days after a reasonable offer of TCI is made.

Expected length of stay or date of discharge

Request to check if bed is available on the day of admission

Any other response required from the patient either by telephone (to a named individual) or

on an enclosed response slip (with a business reply envelope)

The associated literature should contain:

Arrangements for transport.

Details should a patient requires transport - they must call the Transport Service (0333 2404100) to

be assessed for eligibility and to make necessary arrangements. Patients must be advised to contact

the Transport service if the appointment is amended.

Who to contact to discuss the operation.

What the patient can expect if the admission has to be postponed.

How long it is likely to be before they can return to work or resume a normal lifestyle

Any special care needs which are normal to expect on discharge.

A procedure information Leaflet to be included here

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/08/wait-times-guid-

comms.pdf

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/08/wait-times-guid-comms.pdf

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/08/wait-times-guid-comms.pdf




APPENDIX 004

ACCESS ESCALATION TREE




APPENDIX 005

DRAFT ACCESS POLICY FOR WHEELCHAIR SERVICE 1. Purpose

1.1. To establish a clear, consistent approach to Service User access and provision of equipment for Service Users that are referred and accepted into the Wheelchair Service for Suffolk.

1.2. To describe how the service will manage the access to its Wheelchair Services for both Adults and Children and ensure that the pathway to treatment is fair for all and is compliant with all relevant legislation and policy.

1.3. The specific goals of the policy are:

1.3.1 To ensure that all Service Users receive treatment according to their clinical need with routine Service Users treated in chronological order, thereby minimising the time a Service User spends on the waiting list and thus improving the quality of their Service User experience;

1.3.2 To improve the Service User experience by reducing Did Not Attends (DNAs) and cancellations;

1.3.3 To support the reduction of waiting times, cancelled appointments and DNAs and the achievement of the relevant waiting time targets;

1.3.4 To provide an administrative framework for the management of waiting lists;

1.3.5 To ensure that all the information relating to the number of Service Users waiting, seen and treated is accurate and recorded in a timely manner.

2. Target Population 2.1 The target population covered by this document are the actual or potential Service Users and all wheelchair service staff. 3. Definitions Of Terms

Term Definition

Breach Service User episode, which runs over the maximum referral to first definitive treatment (Handover of Equipment) time of 18 weeks

Clock Start

When a new completed referral or re-referral is received by the service:

Clock Stop Clock Stop for Treatment • Supply of prescribed equipment to the Service User (this does not include any interim equipment) • Issue of wheelchair voucher/personal wheelchair budget OR Clock stops for Non-Treatment • Return to referrer (inappropriate/incomplete referral) • Assessment and adjustment of existing equipment on first contact, with no further clinical intervention required • Service User declines offered treatment




• Service User DNAs first appointment offered after clock starts (*evidence that Service User aware - logged telephone calls and/or letters), unless the Service User (either Adult or child) is identified as vulnerable, see section 9 Vulnerable Service users. • Service User deceased • Service User cancels multiple appointments (see Section 6.8) • Service User moves out of Suffolk area

Clock Pause

A pause is a period of time excluded from the Service Users wait. This period must have a defined start and stop date.

MDA Multi –Disciplinary Assessment, where more than one clinical professional from another field is required for the Service Users treatment.

Service User

Individual who may be referred into or receive treatment from Wheelchair Services

Re-Entry to Pathway

May occur for a number of reasons: Service User re-referred for new/different treatment -OR- Service User re-referred for another course of treatment

New Referral

Request to service to treat Service User registered with a Suffolk GP from a health professional

Re-Referral Request to service from any source to review/treat a Service User known to the Wheelchair service

Referrer Individual referring Service User into Wheelchair Service. • Referrals must adhere to individual service clinical guidelines for appropriateness of referral. • date referral letter or form stamped by service • date of phone call

Self -Referral

A known Service User accessing the service directly without referral from another source

DNA Did not attend

4. Clock Starts

4.1. An 18 week clock starts when the Wheelchair Service receives a complete referral.

4.2. Completed referral will be a dated date referral letter /referral form stamped by service or

date of phone call.

4.3. A complete referral is considered to be the receipt of a referral form with ALL fields

completed.

4.4. Any referral received that does not contain the necessary information will be returned to

the referrer.

4.5. A clock will not be started until all relevant information has been received.

5. Clock Stops for Treatment

5.1. The clock stops at the handover of complete equipment (this does not include any interim

equipment). Initial assessment alone will not constitute a clock stop. The clock will only stop

at assessment when a decision that no treatment is required is made and communicated to

the Service User.




5.1.1. In cases where a package of care is to be delivered (e.g. multi-disciplinary teams,

Service Users requiring several items of equipment) the stop will be at the

commencement of the first definitive element of that treatment.

5.2. The clock stops at the handover of the Personal Wheelchair Budget – Independent Option

(Formally Wheelchair Voucher).

6. Clock stops for Non-Treatment

6.1. Return to referrer (inappropriate referral); when no equipment is required the clock will be

stopped and the Service user will no longer remain within the caseload for the service.

6.2. Return to referrer as referral incomplete, this will be sent back and the clock will stop.

6.3. Assessment and adjustment of existing equipment; there are examples where no further

clinical intervention required and the adjustment of equipment will be sufficient. i.e. the

existing chair seat can be widened.

6.4. Service User declines offered treatment; Where it is deemed that the Service User will not

accept further advice or equipment no further action will be taken.

6.5. Inability to contact Service User by telephone, If the Service user is unable to be contacted

by telephone x2, a letter would then be sent asking the Service User to contact wheelchair

services if no response is received within 2 weeks the clock would be stopped and the

patient discharged and referred back to the original source.

6.6. Service User DNAs first appointment offered after clock starts (*evidence required that

Service User aware - logged telephone calls and/or letters), unless the Service User (either

Adult or child) is identified as vulnerable, see section 9 (Vulnerable Service Users).

6.7. Service User dies before equipment provided. Arrangements will be made to collect the

equipment and the Service user details will be removed from the caseload.

6.8. Service User cancels multiple appointments; in the event that the Service User cancels 2

consecutive appointments, the clock will be stopped and the Service User will be referred

back to the originating source stating the reasons why.

6.9. Service User moves out of Suffolk area. The new service will be responsible for the Service

User, any equipment already issued from the Wheelchair service will transfer with the

Service User but any started clocks will be stopped as a result of the move.

7. Clock Pauses

7.1. A pause is a period of time excluded from the Service Users wait. This period must have a

defined start and stop date, and be able to be reported on. Cancellation of an appointment

by the wheelchair service will not result in a clock pause or stop.

7.2. Criteria to pause a clock is as follows;

7.2.1. Service User clinically unwell or lacks Mental Capacity;

7.2.1.1. Clinically unwell would include a Service User who is still at home but not fit

for assessment, this may be due to an infectious disease for example. The clock

pause is when the service is made aware of the illness and the clock restarts

when the service is made aware that the patient is available.




7.2.1.2. A Service User lacking mental capacity as assessed by the health care

professional who first sees them will then require a multi-disciplinary assessment

(MDA) a clock pause will apply from the date of the appointment when the

health care professional first visited whilst this is arranged and the clock restarts

when the MDA is complete and shared with the service.

7.2.2. Admission to hospital; where a Service User is admitted to hospital and is not fit or it

is not appropriate for them to be visited in hospital. The clock pause is when the

service is made aware of the hospital admission and the clock restarts when the

service is made aware that the patient is available.

7.2.2.1. The clock will pause for the period of their admission. If after a period of 6

weeks they are still not available they will be referred back to their referring

source and their clock stopped.

7.2.3. Cancellation of appointment by the Service User; Service Users may cancel their

previously confirmed appointment and request a rebooking once, but in doing so will

pause rather than stop the clock. The clock pause is when the service is made aware of

the patient phones and cancels the appointment and the clock restarts at the date of

the newly agreed appointment.

7.2.3.1. A second appointment date and time will then be agreed with the Service

User. If the Service User then cancels this second appointment, they will be

referred back to their referring source and their clock stopped.

7.2.4. Did Not Attend (DNA); If a Service User fails to attend an appointment a second

appointment will be made, in the interim the clock will pause, if they fail to attend a

second time they will be referred back to their referring source and their clock

stopped. The clock pause is when the patient DNAs the appointment and the clock

restarts when the patient attends the replacement appointment.

7.2.5. Service User unavailable – family holidays and school holidays. Where a Service User is

offered an appointment but chooses to delay that appointment for their own reasons

they will be offered an appointment when they choose but in the interim the clock will

pause. The clock pauses from the date of the offered appointment until the patient

says that they are available.

7.2.6. Issues outside of wheelchair services control; examples include:

7.2.6.1. External specialist/s required for the appointment to proceed and

availability is limited.

7.2.6.2. Out of area placements, the wheelchair service in the new placement would

usually undertake the assessment and send the prescription back to Suffolk; in

these instances the clock would be paused as the Wheelchair service would not

have control over when a Service User could have their completed assessment

undertaken by the out of area service.

7.2.7. Repeated refusal of access; if a Service User refuses (more than 2 times) access to a

health professional visiting their home the clock will pause and another appointment

will be arranged. Should the Service User refuse access for a further appointment, the

Service User will be referred back to their referring source and their clock stopped.




7.2.8. Unsafe home environment; where the Service User requires a home visit and a health

professional deems their home environment to be too unsafe to conduct that

assessment; the clock will pause from the date of that appointment and the clock

restarted at the date of an agreed clinic appointment.

7.2.8.1. The Service User will be offered a clinic appointment if appropriate and the

clock restarts at the date of an agreed clinic appointment. If this is inappropriate

or they fail or decline to attend they will be referred back to their referring

source and their clock stopped.

8. Reasonableness definition

8.1. Notice given for appointments;

8.1.1. Appointments that are made by telephone and agreed with the Service User should

usually be made with at least 14 calendar days in advance, where shorter

appointments are made this will always be with the agreement of the Service User.

8.1.2. Appointments that need to be made in writing will allow 14 calendar days for receipt

and response.

8.1.3. On occasions, following a patient cancellation for example, an appointment slot may

have become free at short notice (within 14 calendar days). If a waiting patient is then

contacted to check their availability for this appointment slot and the patient is not

available, this offer will not count as 1 of their 2 offers of a ‘reasonable’ appointment.

8.2. Number of attempts;

8.2.1. 2 x Telephone attempts will be made to contact the Service User, if these are both

unsuccessful a letter will be sent detailing an appointment date and time, requesting

that the Service User contacts the service should they wish to change it.

8.2.2. In the event of a DNA one subsequent appointment will be made.

8.2.3. In the event of a Service User cancelling their appointment one subsequent

appointment will be made.

8.3. Location;

8.3.1. Appointments will be made at the nearest or most convenient clinic base to the

Service Users home address.

8.3.2. Where the Service User is unable to attend clinic or it is clinically necessary a home

visit will be offered.

8.3.3. If the patient chooses to attend a different location of their choice but this results in a

delay (due to longer wait at that location) the clock will be paused from the date that

the patient decides to choose another location to the date of the agreed appointment

for the length of the time that it is added to the pathway as a result of this choice.

8.4. Time;

8.4.1. Every effort will be made to accommodate a Service Users wishes where they would

like an appointment at a specific time of day e.g. to fit in with carers

8.4.2. Appointment slots should be offered to Service Users at any time that the clinic has

availability. Unless 8.4.1 applies the Service User should accept these otherwise this

would count as a clock pause in reference with 7.2.6.




9. Vulnerable Service Users;

9.1. In the majority of vulnerable adult cases, there will not be a requirement to provide

additional appointments, and the same guidelines as outlined above will apply. When a

family or individual is known to be vulnerable, additional actions will be taken by health

care professionals to ensure they are able to attend the appointment offered and any DNAs

are actively followed up by the appropriate service.

9.2. New Appointments for Vulnerable Service users;

9.2.1. It is essential that all patients who are vulnerable, for whatever reason, have their

needs identified at the point of referral.

9.2.2. If the patient cannot be contacted, or following their second DNA, the case should

then be raised, as soon as practically possible, within the Service (Multidisciplinary

Team Meeting, Team Referral Meeting etc.) with consensus being reached on what

further timely action should be taken i.e. contract Social Services

10. References

10.1. Referral to treatment - NHS England https://www.england.nhs.uk/resources/rtt/

11. Links to other policies and guidance

11.1. Adult Safeguarding Policy and Procedure

https://www.england.nhs.uk/resources/rtt/




Appendix 006

Harm Review Policy for excess waiting times It is recognised that the Trust currently has routine elective patients who have waited in excess of 52 weeks for first definitive treatment. This process has therefore been written to manage what is considered to be an exceptional circumstance. This process does not represent the Trusts business as usual process for investigating and responding to any potential clinical harm incidents. This process does not apply to any patients identified as requiring clinically urgent or cancer treatment. This is a staged process which will review patients waiting in excess of 52 weeks. Further review of other cohorts of patients will be considered subject to the outcomes of this initial process. Any harm identified through this process will be managed through the Trusts normal incident investigation process. The assessment of harm will be based upon the following criteria:

Is there a likelihood that treatment will have been more extensive as a result of the

delay

Is there a likelihood that the delay has precluded the originally planned treatment

option

Is there a potential for the delay to have resulted in the patient having greater

functional loss than originally anticipated

Is there a potential for the patient to have had an extended length of stay as a result of the delay

If the initial review identifies categories of treatment where the answer to any of the above questions is positive or inconclusive, a more detailed review of the individual patients will

be undertaken to assess the presence and extent of any harm. In any cases where the above review identifies actual harm, a full investigation in accordance with Trust policy will be undertaken. Duty of Candour considerations will be made and recorded. Reference should be made to the attached matrix which is agreed and operational within the Trust. The review team will be asked to answer the following questions in relation to any services where 52 week breaches have occurred.

Are there on-going safety concerns about the waiting times within the service

Is an RCA required to understand issues outside of those already identified

Is there an appropriate action plan to address excessive waits in each service

Is there appropriate governance and oversight of the improvement plans




Definition of ‘Harm’ (Proposed)

NO Harm In the clinician’s opinion, the patient has suffered inconvenience only

LOW Harm In the clinicians opinion, the patient has suffered inconvenience e.g.

prolonged discomfort not leading to the need for significantly stronger

analgesia or causing psychological harm.

In the clinician’s opinion the patient has suffered inconvenience or

symptoms that, whilst not sufficient to warrant and ‘moderate’

conclusion, have sufficient impact to warrant a letter of apology and

explanation

Example 1 – a child has multiple episodes of tonsillitis requiring

antibiotics and resulting absences from school

Example 2 – an adult is awaiting a total knee replacement and during

the extended wait suffered continuing pain (without the need for

stronger analgesia) and interruption to activities of daily living because

of poor mobility

MODERATE Harm In the clinician’s opinion, the patient has suffered moderate physical or

psychological harm. For example, if there was a delay in treating a

locally invasive basal cell carcinoma such that a larger cosmetic

procedure was required. This would be moderate harm unless it also

causes significant psychological harm in which case it should be

classified as severe harm.

SEVERE Harm In the clinician’s opinion, the patient has suffered significantly on a

similar level to the triggering of a clinical S.I (Serious Incident)

Example 1 – a patient who required increasing doses of NSAID and

was admitted with a GI bleed requiring transfusion

Example 2 – Local progression of a primary malignancy such that the

patient is at increased risk of metastatic disease

Example 3 – a primary malignancy has progressed significantly

requiring a change of management or has metastasised.

Example 4 – A patient has suffered psychological harm requiring

psychiatric management




Level of Harm Assessment

Tools to aid in the assessment of the level of harm as a result of an incident

Table 1 : WSHFT Risk Matrix

Likelihood of harm Consequence/severity of harm

Negligible Minor Moderate Major Catastrophic

20-yearly Green Green Green Green Green

5-yearly Green Green Green Amber Amber

Annually Green Green Amber Amber Red

Quarterly Green Green Amber Red Red

Weekly Green Green Amber Red Red

Table 2: Consequence/Severity of Harm

Type of Incident


1. Impact on the safety of patients, staff or public (physical/psychological harm)

Minimal injury requiring no/minimal intervention or treatment. No time off work

Minor injury or illness, requiring minor intervention Requiring time off work for >3 days Increase in length of hospital stay by 1-3 days

Moderate injury requiring professional intervention Requiring time off work for 4-14 days Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident An event which impacts on a small number of patients

Major injury leading to long-term incapacity/disability Requiring time off work for >14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects

Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients

2. Quality/complaints/audit

Peripheral element of treatment or service suboptimal Informal complaint/inquiry

Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal

Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review)

Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints/ independent review Low performance rating

Totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ombudsman inquiry Gross failure to meet national




Type of Incident


standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved

Repeated failure to meet internal standards Major patient safety implications if findings are not acted on

Critical report

standards

3. Human resources/ organisational development/staffing/ competence

Short-term low staffing level that temporarily reduces service quality (< 1 day)

Low staffing level that reduces the service quality

Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory/key training

Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory/ key training

Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training /key training on an ongoing basis

4. Statutory duty/ inspections

No or minimal impact or breech of guidance/ statutory duty

Breech of statutory legislation Reduced performance rating if unresolved

Single breech in statutory duty Challenging external recommendations/ improvement notice

Enforcement action Multiple breeches in statutory duty Improvement notices Low performance rating Critical report

Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report

5. Adverse publicity/ reputation

Rumours

Potential for public concern

Local media coverage – short-term reduction in public confidence Elements of public expectation

Local media coverage – long-term reduction in public confidence

National media coverage with <3 days service well below reasonable public expectation

National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House)




Type of Incident


not being met Total loss of public confidence

6. Business objectives/ projects

Insignificant cost increase/ schedule slippage

<5 per cent over project budget Schedule slippage

5–10 per cent over project budget Schedule slippage

Non-compliance with national 10–25 per cent over project budget Schedule slippage Key objectives not met

Incident leading >25 per cent over project budget Schedule slippage Key objectives not met

7. Finance including claims

Small loss Risk of claim remote

Loss of 0.1–0.25 per cent of budget Claim less than £10,000

Loss of 0.25–0.5 per cent of budget Claim(s) between £10,000 and £100,000

Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget Claim(s) between £100,000 and £1 million Purchasers failing to pay on time

Non-delivery of key objective/ Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) >£1 million

8. Service/business interruption Environmental impact

Loss/interruption of >1 hour Minimal or no impact on the environment

Loss/interruption of >8 hours Minor impact on environment

Loss/interruption of >1 day Moderate impact on environment

Loss/interruption of >1 week Major impact on environment

Permanent loss of service or facility Catastrophic impact on environment

National Patient Safety Agency (2009)

Further information and Policy guidance should be obtained from the Trust Duty of Candour Policy

(PP(16)197 at http://staff.wsha.local/CMSdocuments/TrustPolicies/PDFs/151-

200/PP(16)197BeingOpen-TheDutyofCandour.pdf

http://staff.wsha.local/CMSdocuments/TrustPolicies/PDFs/151-200/PP(16)197BeingOpen-TheDutyofCandour.pdf

http://staff.wsha.local/CMSdocuments/TrustPolicies/PDFs/151-200/PP(16)197BeingOpen-TheDutyofCandour.pdf




APPENDIX 007

Glossary and Acronyms Listed below are some of the most common terms and abbreviations used in this document. This is

not exhaustive, and aims to act as a guide. Other terms and their definitions can be checked and

validated using the NHS Data Dictionary http://www.datadictionary.nhs.uk/

Active monitoring An RTT waiting time clock may be stopped where

it is clinically appropriate to start a period of

monitoring in secondary care without clinical

intervention or diagnostic procedure at that

stage. A new waiting time clock would start

when a decision to treat is made following a

period of active monitoring (previously known as

“watchful waiting”).

Admission The act of admitting a patient for a day case or

inpatient procedure.

Admitted pathway A patient on a pathway that is likely to end in a

clock stop within an admitted setting (day case

or inpatient).

Bilateral (procedure) A procedure that is performed on both sides of

the body, at matching anatomical sites. For

example, removal of cataracts from both eyes.

Cancellation If a patient declines an appointment after it has

been booked, giving any notice, this is termed a

patient cancellation.

Care professional A person who is a member of a profession

regulated by a body mentioned in section 25(3)

of the National Health Service Reform and

Health Care Professions Act 2002.

Choose and Book (now called NHS e-Referral

Service)

From June 2015 this has been replaced by the

national electronic referral service that gives

patients a choice of place, date and time for

their first consultant outpatient appointment in

a hospital or clinic.

Clinical decision A decision taken by a clinician or other qualified

care professional, in consultation with the

patient, and with reference to local access

policies and commissioning arrangements.

Clinical Triage The process by which clinical staff prioritise,

http://www.datadictionary.nhs.uk/




approve and agree referrals

Clock Start A waiting time clock starts when any care

professional or service permitted by an English

NHS Commissioner to make such referrals, refers

to:

a) A consultant-led service, regardless of setting,

with the intention that the patient will be

assessed and, if appropriate, treated before

responsibility is transferred back to the referring

health professional or general practitioner;

b) An interface or referral management or

assessment service, which may result in an

onward referral to a consultant-led service

before responsibility is transferred back to the

referring health professional or general

practitioner.

i.e. the start of an 18 week referral to treatment

pathway.

The commencement of a patient pathway which

is initiated by a health care professional referring

to a Consultant led service

Clock Stop The point at which a decision is made and

communicated to the patient that treatment has

commenced, a period of active monitoring has

commenced or decision not to treat has been

made on an 18 week referral to treatment

pathway

Clock Continues The clock continues to tick until either the first

definitive treatment is given, or another event

occurs which can stop the clock

Consultant A person contracted by a healthcare provider

who has been appointed by a consultant

appointment committee. He or she must be a

member of a Royal College or Faculty.

Consultant-led waiting times exclude nonmedical

scientists of equivalent standing (to a consultant)

within diagnostic departments

Consultant-led A consultant retains overall clinical responsibility

for the service, team or treatment. The

consultant will not necessarily be physically




present for each patients’ appointment, but

he/she takes overall clinical responsibility for

patient care.

Consultant to Consultant referral (C2C) The internal referral of a patient from one

Consultant to another within the same NHS

Trust. This can be between Consultants in the

same, or differing specialties

CT

CT-PET

Computerised Tomography (Radiation dose)

CT-Positron Emitting Tomography

(Radionucleotide use)

DNA – Did Not Attend Where a patient fails to attend an

appointment/admission without prior notice.

Decision to admit (DTA) Where a clinical decision is taken to admit the

patient for either a day case or inpatient

treatment.

Decision to treat Where a clinical decision is taken to treat the

patient. This could be treatment as an inpatient

or day case, but also includes treatment

performed in other settings e.g. as an Outpatient

Direct Access “Direct Access‟ diagnostics is any arrangement

where a GP can refer a patient directly to

secondary care for a diagnostic test/procedure

without having to attend a consultant OP

appointment first. The GP remains managing the

on-going care – no clock start/no active RTT

pathway commences.

First definitive treatment

An intervention intended to manage a patient’s

disease, condition or injury and avoid further

intervention. What constitutes first definitive

treatment is a matter for clinical judgment, in

consultation with others as appropriate,

including the patient.

A FDT on an 18 week referral to treatment

pathway is applied when the treatment

addresses the condition for which the patient

was originally referred to secondary care.

Fit (and available)

Patients must be fit i.e. medically fit enough to

undergo the intended treatment and available




for treatment within 18 weeks from referral.

GDP

General Dental Practitioner

GP

General Practitioner

GPwSI A General Practitioner with a Specialist Interest;

most commonly in an area such as

Dermatology/Gynaecology/Continence. Has

Royal College qualifications but supports the

Consultant-Led Services.

HIC Hospital Initiated Cancellation

Incomplete pathways

For as long as the clock is still running on an RTT

pathway, it is called “incomplete”. Patients may

have been seen in clinic by a hospital doctor, and

may have had diagnostic tests, but they have not

yet started definitive treatment (or been

discharged) and so they have an “incomplete”

pathway.

Month End Incomplete pathways: This is the key

indicator for national reporting on RTT every

month. This indicator reports the percentage of

patients on incomplete pathways within 18

weeks against the total number of patients on an

incomplete pathway as at the end of a calendar

month. This is a “snapshot‟ on the day of

reporting. The organisation’s performance is

measured against a target of 92%.

Interface service (non-consultant led interface service)

All arrangements that incorporate any

intermediary levels of clinical triage, assessment

and treatment between traditional primary and

secondary care. Consultant-led referral to

treatment relates to hospital/consultant-led

care. Therefore, the definition of the term

“interface service‟ for the purpose of consultant

led waiting times does not apply to similar

“interface‟ arrangements established to deliver

traditionally primary care or community

provided services, outside of their traditional

(practice or community based) setting.

Inter-provider Transfer/Inter-provider minimum data set (IPTMDS)

An NHS provider may transfer patients to other

providers where it is in the best clinical interests




of the patient to receive diagnostic tests or care

and treatment elsewhere. The Inter-Provider

Transfer Minimum Data Set (IPTMDS) supports

the requirement to transfer administrative data

to allow the monitoring of a patients progress

along an 18 Weeks pathway where care has

been transferred between providers.

LIMS Laboratory Information System

MDS

Minimum Data Set – Information which should

be contained in all referrals.

MDT Multi-Disciplinary Team

MRI Magnetic Resonance Imaging

Non-admitted pathway

A pathway that results in a clock stop for

treatment that does not require an admission or

for “non-treatment‟ i.e. patients in an

outpatient setting with no decision to admit

Non consultant-led

Where a consultant does not take overall clinical

responsibility for the patient

Non Treatment clock stop

A clock stop may be applied to a patient pathway

for reasons other than treatment. For example, a

patient declines treatment having been offered

it or a clinical decision is made not to treat;

NHS provider

An NHS Provider is an organisation that can

supply services under commissioning agreement,

e.g. GP/GDP, Referral Management Centre,

GPwSI, Hospital Trust, and Community Services

such as Specialist Palliative Care Teams.

A cancer or RTT clock can stop at any of these

NHS organisations if they provide definitive

Treatment.

Outsourcing

Outsourcing is an arrangement with a private or

NHS organisation to provide additional inpatient,

diagnostic or outpatient services which could

also be or usually have been provided in-house.

This typically happens when demand exceeds

the hospitals capacity.

PAS Patient Administration System (IT system). WSH




uses eCare as its PAS system. It contains a record

of patient events on each pathway.

PIC/D Patient Initiated Cancellation/Delay

PoLCV Procedures of Limited Clinical Value

PTL

Patient Tracking List – Lists of patients who are

under the care of the Trust used to track their

progress along their pathways at various stages

in their treatment and care. Not all patients

therefore will be on active RTT or cancer

reportable PTLs.

Reasonable offer (of appointment)

A reasonable offer is an offer of a time and date

that gives the patients a minimum of three or

more weeks from the time that the offer was

made for an outpatient or diagnostic

appointment, inpatient or day case procedure.

Referral Management or Assessment service (RMS)

Services that do not provide treatment, but

accept GP (or other) referrals and provide advice

on the most appropriate next steps for the place

or treatment of the patient. Depending on the

nature of the service they may, or may not,

physically see or assess the patient. This may

lead into a consultant led pathway in which case

the clock could start in the RMS.

Referral to treatment (RTT) period

The part of a patient’s care following initial

referral, which initiates a clock start, leading up

to the start of first definitive treatment or other

clock stop.

The maximum time any patient may wait for RTT

is 18 weeks

RIS

Radiology Information System

Straight to test

This is an internal pathway within the Trust

where a patient is sent straight to test post

receipt of referral and whereby a patient will be

assessed and might, if appropriate, be treated by

a medical or surgical consultant-led service

before responsibility is transferred back to the

referring health professional.

Substantively new or different treatment

The start of a new waiting time clock upon the

decision to start a substantively new or different




treatment that does not already form part of

that patient’s agreed care plan.

TAC

The Appointments Centre (TAC) provides a

telephone booking service for patients to book,

check, change or cancel their appointments via

the NHS e-Referral Service, e.mail or telephone.

It also supports choice discussion with the aid of

the NHS Choices website and the information

held within the Directory of Services.

TCI date

“To come in‟ – the date given to a patient to

undertake an operative procedure or treatment

Therapy or Healthcare science intervention

Where a consultant-led or interface service

decides that therapy (for example

physiotherapy, speech and language therapy,

podiatry, counselling) or healthcare science (e.g.

hearing aid fitting) is the best way to manage the

patient’s disease, condition or injury and avoid

further interventions. The clock would stop for

the original referral in this service.

The Trust (WSFT) West Suffolk NHS Foundation Trust, usually the

‘provider’ organisation

UBRN (Unique Booking Reference Number)

The reference number that a patient receives on

their appointment request letter when

generated by the referrer through the NHS e-

Referral Service. The UBRN is used in conjunction

with the patient password to make or change an

appointment.

USS NOUSS

Ultrasound Scan

Non-Obstetric Ultrasound Scan

Unfit for Treatment

A clinical decision is made that the patient is

unsuitable for surgery/treatment and they are

discharged back to primary care or a decision is

made not to treat e.g. on-going heart problems

that make anaesthesia unsafe. The RTT clock is

stopped

Unwell (for treatment)

The treatment is cancelled by the provider after

admission for clinical reasons (e.g. patient

deemed temporarily unfit for surgery due to

chest infection). The RTT clock should continue




to tick

Vulnerable Person

A vulnerable person could be an adult or child at

risk who is or may be in need of community care

services by reason of mental or other disability,

age or illness; and who is or may be unable to

take care of him or herself, or unable to protect

him or herself against significant harm or

exploitation. This definition is from the DOH

guidance “No Secrets DoH 2000‟.

References to National Guidance (Hyperlinks)

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04/Recording-and-

reporting-RTT-guidance-v24-2-PDF-703K.pdf

https://www.nhs.uk/nhsengland/appointment-booking/pages/nhs-waiting-times.aspx

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/464956/RTT_Rule

s_Suite_October_2015.pdf

http://media.dh.gov.uk/network/261/files/2012/06/RTT-FAQs-v10-Oct-2012.pdf

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04/Recording-and-reporting-RTT-guidance-v24-2-PDF-703K.pdf

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04/Recording-and-reporting-RTT-guidance-v24-2-PDF-703K.pdf

https://www.nhs.uk/nhsengland/appointment-booking/pages/nhs-waiting-times.aspx

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/464956/RTT_Rules_Suite_October_2015.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/464956/RTT_Rules_Suite_October_2015.pdf

http://media.dh.gov.uk/network/261/files/2012/06/RTT-FAQs-v10-Oct-2012.pdf




Final November 2017

Elective Access Meeting Terms of Reference

AUTHORITY

The Access Group resides within the governance and accountability structures of the

Operations Directorate. Its constitution and terms of reference are set out below:

PURPOSE

The aim of the group is to provide a forum for the monitoring of access standards associated

with those services within the Operational Directorate; to assess risks and issues associated

with delivery of services to patients on both admitted and non-admitted streams.

There is a constitutional requirement to ensure patients are treated within 18 weeks of

referral. This can only be achieved by careful, regular and detailed scrutiny of key tools such

as the PTL (Patient Tracking List)

To oversee the delivery of RTT performance trajectories for each specialty against

trajectory and compliance with the Trust Access Policy.

To monitor progress against the Remedial Action Plans and associated documents

as required by the Board.

To support operational teams in appropriate escalation, assurance and accountability

in the delivery of a compliant position.

To oversee the delivery of performance against the DM01 standards; to oversee

delivery of access to diagnostics across the organisation.

This Group will formally report into the Operations Directorate Performance Management

meetings and by exception, and contribute to the Service Group Performance Reviews. It

will:

Provide a detailed monitoring forum in respect of RTT

Undertake at least weekly a full review of the PTL with Service Managers

Provide a detailed monitoring forum in respect of Access Standards to diagnostics

Provide clear, accurate and timely information relating to risks and issues to the

achievement of the above

To allow dissemination of new and emerging themes, risks and projects as affect

diagnostic services

To provide reassurance on remedial actions and associated milestones agreed with

the Deputy Director of Operations and the wider Executive Teams

To monitor remedial and corrective actions.

To maintain, revise and consider plans affecting Demand and Capacity for each

specialty including regular review using the IST toolkits.

APPENDIX 008

Terms of Reference – Elective Aceess Meeting




MEMBERSHIP

The Access will be chaired by the Head of Access or agreed Senior Manager within the

Operational Directorate; in his/her absence a nominated deputy from the management team

will be identified:

Membership will include the following:

ADO’s or Senior Operational Managers

Chief Operating Officer / Deputy Chief Operating Officer

Head of Elective Access (Chair)

Service Managers

Patient Access Service Manager

Informatics Representative (on request)

It is NOT expected for each division to attend for the whole Meeting; however by exception

this may change and/or wider collegiate discussions may be required. This will be by prior

arrangement at least 1 week in advance where possible.

Membership and participation in either ‘Part’ is not exclusive but a suitably briefed

service representative must be available.

The manager with responsibility for Administration Staff or a briefed deputy will be in

attendance.

A representative from the Data Quality Informatics team should be in attendance

By the Chair’s invitation, there will be an open invitation to other associated parties

(e.g. Pharmacy, CCG and Clinical Physics) and any other operational or clinical lead

as required to disseminate information relevant to the overall spirit of the Group.

ATTENDANCE FROM EACH AREA IS MANDATORY. A SUITABLY BRIEFED AND EMPOWERED

INDIVIDUAL MUST BE AVAILABLE AT EACH MEETING.

QUORUM

There is no requirement to be quorate. However, all specialities will be required to attend

weekly. The meeting will take place unless stood down by Chair, in exceptional

circumstances

FREQUENCY

There will be a WEEKLY meeting. Currently this is scheduled from 1230 to 1430 on

THURSDAYS

The Meeting will last no longer than 2 hours. However core business associated with the

standing agenda will mean a target duration of 30 minutes. This will be reviewed quarterly.

In EXCEPTIONAL circumstances, this may be INCREASED to twice weekly or daily contact.




WORKING METHODS

A Standing Agenda will be followed. Additional items of information or business will

be discussed in AOB

Clinical Services will ensure their Access Report is completed and available for the

meeting.

An Issues Log will be kept and monitored; it is the responsibility of the action owner

to ensure these can be closed down at each meeting in accordance with the agreed

deadline. Evidence will be required to ensure formal sign off can be given.

There will be an emphasis on service level ownership of the current position, known

issues, risks, remedial and mitigating actions.

The Action Log will be circulated by email within 24 hours of the meeting. Actions will

be required to be completed by close of play on WEDNESDAY following the meeting

so that it is reflected in the ‘live’ PTL.

Members should bring their own paper copies to the meeting. Non-core members of

the team will be invited on an ad hoc basis by the Chair.

There will be a presented and submitted report by the service weekly.

There will be a monitored composite action log.

This meeting will be at the core of the business of the Operations Directorate and will occur

weekly.

Frequency may be altered in the event of Bank Holidays but assumption should remain the

meeting will go ahead unless informed.

Access Report Example.pdf

Access Agenda standing.docx

rolling action log.xlsx




APPENDIX 009

PTL GOOD PRACTICE GUIDE

PTL REVIEW MEETINGS: Adapted from the GOOD PRACTICE CHECKLIST: MAY 2014:

This document is intended to be used as a checklist when setting up and running weekly PTL meetings and identifies good practice for these meetings:

GOOD PRACTICE: REQUIREMENTS: WHY? CHECKED:

A regular, timetabled

meeting

Weekly Weekly review of the PTL is the minimum timeline to be

able to manage patients within an 18 week pathway

Access to the most recent

PTLs

Electronic versions of the most recent i.e. that week

admitted and non-admitted PTLs or hardcopies of both

cut by urgent and routine patients with each cut in

breach date order

This ensures that the longest waiting patients are

prioritised for appropriate actions to be taken and that

the information being used to drive OP bookings and

TCI dates is the most recent and therefore the most up

to date

Access to each Trust site

PTL as above

The PTLs for each of the Trust sites need to be

accessible in the format described above. For Imaging

this will also include Modality waiting lists (MR, CT, USS

and Plain)

Patients must be managed on each Trust site

PTL will be available to analyse by site and by modality.

Access to the planned

waiting list for each Trust

The planned waiting list needs to be available either

electronically or in hard copy for each Trust site in

Planned patients must not be disadvantaged by the

management and prioritisation of 18 week patients





site chronological order of procedure date

Chaired by senior member

of team

Meeting chaired by ADO or service manager Demonstrates the importance of managing patients

within an 6 week time band from date of request and

demonstrates clear lines of accountability

Attended by key members

of the specialty team

responsible for validating

the PTL and responsible for

booking/chasing next

events i.e. OPAs and TCIs

i) the members of staff responsible for validation and

changing patients’ status on CRS

ii) the OP and scheduling teams (if different to the

above)

i) Clarity over the roles of key people in the team

ii) Clear accountability and timelines for the actions

required to manage the PTLs and to proactively manage

patients along their (6) 18 week pathway

Admitted PTL review:

Urgent patients are to be

dated in strict order and

within 2 weeks of the date

of decision to send for test

Urgent patients must be given clinical priority for

treatment.

2 weeks to be achieved as the first requirement and

then 2 weeks after appointment if this timeline is within

6 weeks

Clinical urgency takes priority to avoid clinical harm

Contributions to the pathway completion duration must

be minimised to the shortest possible time to obtain a

result.

Routine patients are to be

dated in strict

The longest waiting patients must be dated. Longest waiting patients must have priority to avoid

potential clinical harm





chronological order

No validated patient over 6 weeks should be undated

on the PTL

Recovery plans must be reviewed if a modality is

subject to one. This should be reviewed for at least 4

weeks after returning to compliance

Once the speciality is in a BAU position the PTL should

be routinely reviewed and validated as follows:

All patients added to the admitted PTL

No routine patient is to be disadvantaged over other

routine patients on an earlier time band on the PTL

The speciality must not report 6 week breaches

The speciality must be compliant with the 6 week

performance measure

All patients are to be routinely and proactively

managed on their 6 week pathway

There are to be no patients

with past TCIs on the PTL

Patients with past TCI dates are to be checked that they

have been admitted and treated and then removed

from the PTL using the correct RTT outcome code

The PTL needs to be ordered and clean to enable the

right patients to be identified and treated

Cancelled patients

(cancelled by the Trust) are

to be reviewed and re-

dated

Cancelled patients must be re-booked within 7 days or

within 4 weeks whichever timeline is the sooner.

Diagnostics tests may require expediting so that the

referring special does not breach the 18 week standard.







No specialty can report 52 week breaches. performance measure

Patients who have

cancelled or who have

DNAd are to be reviewed

to agree next steps

Patients who cancel or DNA a TCI date must be

reviewed with a decision regarding next steps i.e.

discharge, re-booking, contacting the patient or GP etc.

Patients are to be managed according to the Trust

Access Policy



performance measure

Planned waiting list review:

All planned patients are to

be dated as indicated by

the responsible clinician

Planned patients are to be dated within 4 weeks of the

date indicated by their responsible clinician (Trust KPI)

No planned patient is to be disadvantaged over patients

on an elective waiting list

Planned patients must be treated in line with the date

indicated by their responsible clinician to avoid


Non-admitted PTL review:





Urgent patients are to be

offered a first appointment

in strict chronological

order and within 2 weeks

of the date of receipt of

referral

Urgent patients must be given clinical priority for

treatment.

Clinical urgency takes priority to avoid clinical harm

Routine patients are to be

offered a first OPA in strict

chronological order within

the booking gate agreed at

speciality level (e.g. 6

weeks for all surgical

specialties)

All patients are to be offered a first appointment within

the booking gate for the speciality


performance measure and this starts with the first OPA

Patients on non-admitted

pathways must be

routinely and proactively

managed

No validated patient over 8 weeks should be on the PTL

without an accelerated management plan i.e. diagnostic

tests and OPAs arranged and agreed with the patient

Once the speciality is in a BAU position the PTL should

be routinely reviewed and validated as follows:

All patients at 2 weeks

All patients at 3 weeks (to check for next

steps/follow up etc.)

Longest waiting patients must have priority to avoid


No routine patient is to be disadvantaged over other

routine patients on an earlier time band on the PTL


The modality must be compliant with the 6 week





All patients at 4 weeks (to check as above and

accelerate as a matter of priority)

performance measure

All patients are to be routinely and proactively

managed on their 6 week pathway

Cancelled patients

(cancelled by the Trust) are

to be reviewed and re-

dated

Cancelled patients must be re-booked within 2 weeks of

their cancelled appointment (first or follow up) or

within 6 weeks whichever timeline is the sooner



performance measure

Patients who have

cancelled or who have

DNAd are to be reviewed

to agree next steps

Patients who cancel or DNA a OPA or diagnostic test

must be reviewed with a decision regarding next steps

i.e. discharge, re-booking, contacting the patient or GP

etc.

Patients are to be managed according to the Trust

Access Policy



performance measure




Appendix 010

Driving 18 Weeks Referral to Treatment Period Status FLOWCHART

(Embedded Object)

rtt flow.pdf




Appendix 011

Escalation tree for patients on a Suspected and/or confirmed Cancer Pathway




Appendix 012

Cancer Operational Policy (Embedded pdf)

Cancer Ops Policy Final_Nov17.doc

Appendix 012A

Cancer Waiting Times V9.0 National Standards (Embedded pdf)

CWT Guide V9.0_1015.pdf

Appendix 013

Endoscopy Access Policy (Embedded pdf)




Appendix 013A

Endoscopy Access Policy (Embedded pdf)

Appendix 014

Radiology Department Operational Policy (Embedded pdf)




Appendix 015

Equality Impact Assessment Policy or function being assessed: Corporate Access Policy Department/Service: Operational Directorate Assessment completed by: Hannah Knights Date of assessment: 03/09/2019

1. Describe the aim, objective and purpose of this policy or function.

The aim of this policy is to ensure that the Trust records, monitors, performance manages and reports data relating to the RTT (18 Week access standard) and Cancer Waiting Times Service Standards (CWTSS):

Key staff are aware of their responsibilities.

Internal professional standards, and administrative process are undertaken in accordance with the principles laid out in National Standards and other supporting policies.

Trust administrative and clinical staff take responsibility for progressing patients along agreed clinical pathways in the timescale set out within this policy.

All data is robust and accurate and can be audited both internally or / or externally.

2i. Who is intended to benefit from the policy? Staff YES Patients YES Public YES Organisation YES

2ii How are they likely to benefit?

The aim of the policy is to reduce all unnecessary non clinical delays in pathways and to ensure that patients are treated in the most timely manner appropriate to their condition The Trust will ensure accurate, timely and relevant information is available and published to required standards. Patients will receive diagnostics and treatments in a timely manner, consistent with




the NHS Constitution

2iii What outcomes are wanted from this policy? Staff to be aware of issues which could potentially delay patient pathways and to take action as required. Staff are empowered to ensure they have access to accurate information and training to ensure patients are not adversely impacted by delays in treatment

For Questions 3-8 below, please specify whether the policy/function does or could have an impact in relation to each of the six equality strand headings:

3. Are there concerns that the policy does or could have a detrimental impact on people due to their race/ethnicity?

N If yes, what evidence do you have of this? Eg. Complaints/Feedback/Research/Data

4. Are there concerns that the policy does or could have a detrimental impact on people due to their gender?


5. Are there concerns that the policy does or could have a detrimental impact on people due to their disability?


6. Are there concerns that the policy does or could have a detrimental impact on people due to their sexual orientation and/or transgender?


7. Are there concerns that the policy does or could have a detrimental impact on people due to their age?


8. Are there concerns that the policy does or could have a detrimental impact on people due to their religious belief?


9. Could the impact identified in Q.3-8 above, amount to there being the potential for a disadvantage and/or detrimental impact in this policy?

N No impact

10. Can this detrimental impact on one or more of the N No detrimental impact identified – the policy is designed to improve care




above groups be justified on the grounds of promoting equality of opportunity for another group? Or for any other reason? Eg. providing specific training to a particular group.

for all patients in line with national RTT standards and Cancer Waiting Times standards.

11.

Specific Issues Identified

Please list the specific issues that have been identified as being discriminatory/promoting detrimental treatment Page/paragraph/section of policy that issue relates to

1. None

1. None

12. Proposals

How could the identified detrimental impact be minimised or eradicated?

Not applicable

If such changes were made, would this have repercussions/negative effects on other groups as detailed in Q. 3-8?

Not applicable

13. Given this Equality Impact Assessment, does the policy need to be reconsidered / redrafted?

No. The policy is designed to benefit all patients irrespective of background and not to discriminate.

14.

Policy/Practice Implementation

Upon consideration of the information gathered within the equality impact assessment, the Director/Head of Service agrees that the policy/practice should be adopted by the Trust. Please print: Name of Exec Director: Helen Beck Title: Chief Operating Officer Date: Name of Policy Author: Neil Hardy-Lofaro (RTT) & Sam Dhungana (Cancer Standards) Title: Interim Head of Access




Date: (A paper copy of the EIA which has been signed is available on request).

15. Proposed Date for Policy/Practice Review

01/07/2018 – 6 monthly review in light of LMC comments and testing in ‘live’ operational environment. Thereafter 01/07/2019 and Annually (full Review) And Ad Hoc Review when National Guidance or Operational Standards are updated And Section specific review as other policies are updated (e.g. Leave Policy)

16.

Explain how you plan to publish the result of the assessment? (Completed E.I.A’s must be published on the Equality pages of the Trust’s website).

On the equality pages of the Trust’s website

17. The Trust Values

In addition to the Equality and Diversity considerations detailed above, I can confirm that the four core Trust Values are embedded in all policies and procedures. They are that all staff intend to do their best by: Putting patients first, and they will:

Provide the best possible care in a safe clean and friendly environment,

Treat everybody with courtesy and respect,

Act appropriately with everyone.

Aiming to get it right, and they will:

Commit to their own personal development,

Understand theirs and others roles and responsibilities,

Contribute to the development of services

Recognising that everyone counts, and they will:

Value the contribution and skills of others,




Treat everyone fairly,

Support the development of colleagues.

Doing everything openly and honestly, and they will:

Be clear about what they are trying to achieve,

Share information appropriately and effectively,

Admit to and learn from mistakes. I confirm that this policy does not conflict with these values.

Appendix 016

West Suffolk NHS Foundation Trust DNA Process

DNA Workflow Final Version .pdf

DNA process - Reception staff.pdf




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Documents

ADO’s, clinical directors, SOM’s, SM’s, members of the admin · Approval Body: Chair of the Document Review Group Version Number: 6.3 Reference Number: PP (18) 138 Version Issue