Elective Patient Access, Booking and
Choice of Date Policy
Document No
Version No
PC - 00002
2.0
Approved by
Date Approved
Policy Governance Group
20/0716
Ratified by
Date Ratified
Executive Committee
20/09/16
Date implemented ( made live for use)
Next Review Date
18/01/17
20/09/19
Status
LIVE
Target
All employees directly employed by the Trust, whether permanent, part-time or
Audiencetemporary (including fixed-term contract). It applies equally to all others working
who does the
for the Trust, including private-sector, voluntary-sector, bank, agency, locum, and
document
secondees.
apply to and
who should
All employees involved in the administration of patient activities and healthcare
be using it.
professionals involved in the delivery of that healthcare need to understand and
ensure that their practices are consistent with the content of this policy; and that
systems are in place to support effective schedule management.
For simplicity, they are referred to as ‘employees’ throughout this policy
Accountable Director
Chief Operating Officer
Author/originator – Any Comments on this document
Deputy Divisional Director, Planned
should be addressed to the author
Care
Division and Department
Planned Care
Implementation Lead
Divisional Director – Planned Care
Divisional Director – Diagnostics &
Outpatients
If developed in partnership with another agency
Commissioner’s
ratification details of the relevant agency
Equality Impact
Great Western Hospitals NHS Foundation Trust strives to ensure equality of opportunity for all service
users, local people and the workforce. As an employer and a provider of health care, the Trust aims to
ensure that none are placed at a disadvantage as a result of its policies and procedures. This document
has therefore been equality impact assessed in line with current legislation to ensure fairness and
consistency for all those covered by it regardless of their individuality. This means all our services are
accessible, appropriate and sensitive to the needs of the individual.
Special Cases
The RTT standards in this policy do not apply to non-consultant led services. However, the principles in
the policy and guidance around managing referrals and appointments should be adopted for patients
under Allied Health Professional Service. A separate policy based on the Allied Health Professional
Referral to Treatment Revised Guide 2011 will be published separately for these services
The following activity is excluded from the 18 week Referral to Treatment (RTT) standard:






Emergency admissions.
Obstetric patients.
Patients referred into a non-consultant led service (e.g. Dietetics) that is provided in an acute
hospital setting. These are managed under the Referral to Management (RTM) standard.
Elective patients undergoing planned procedures (removal of metalwork, procedures related to
age/growth, check cystoscopies etc.).
Patients receiving on-going care for a condition whose first definitive treatment for that
condition has already occurred.
Patients whose 18 week clock has stopped for active monitoring and has not yet restarted,
even though they may still be followed up by their Consultant.
Document Title: Elective Patient Access, Booking and Choice of Date Policy
Contents
1
Document Details .............................................................................................................. 5
1.1
Introduction and Purpose of the Document ....................................................................... 5
1.2
Glossary/Definitions .......................................................................................................... 5
2
Main Policy Content Details .............................................................................................. 7
2.1
Overview of Trust and National Standards ........................................................................ 7
2.1.1
Internal Operating Standards for non-urgent 18 week Pathways ....................................... 8
2.2
18 week ‘Clock’ Terminology............................................................................................. 9
2.2.1
Clock Starts ...................................................................................................................... 9
2.2.2
Clock Stops ..................................................................................................................... 10
2.2.3
Criteria for Discharging Patients in Line with Access Rules ............................................. 10
2.2.4
Clock Nullification ............................................................................................................ 11
2.2.5
Reasonable Offer ............................................................................................................ 11
2.3
Patients where Cancer is Suspected............................................................................... 11
2.3.1
Did Not Attends (DNAs) – For Cancer Patients ............................................................... 12
2.3.2
Patient Cancellations – For Cancer Patients ................................................................... 12
2.3.3
Inappropriate Referrals ................................................................................................... 12
2.4
Patients who are confirmed to Have a Cancer Diagnosis ................................................ 12
2.5
Locally Agreed Commissioner Requirements .................................................................. 12
2.6
Trust Values .................................................................................................................... 13
2.7
Application of and Compliance with this Policy ................................................................ 13
2.7.1
Escalation ....................................................................................................................... 13
2.8
Performance Monitoring and Reporting Structures .......................................................... 13
2.9
Statutory Reporting ......................................................................................................... 13
2.10
Recording the Status of Patients ..................................................................................... 14
2.11
Validating the Status of Patients...................................................................................... 14
2.12
Communication ............................................................................................................... 14
2.12.1
Communication with Trust Patients ................................................................................. 14
2.12.2
Communication with Referring Organisations or Individuals ............................................ 14
2.13
Patients moving between NHS and Private Care and Treatment .................................... 15
2.14
Access to Health Services for Armed Forces Community................................................ 15
2.15
Overseas Visitors ............................................................................................................ 15
3
Referral Management ..................................................................................................... 15
3.1
Urgent and Routine New Patient Referrals ...................................................................... 15
3.1.1
Referrals ......................................................................................................................... 15
3.1.2
e-Referrals ...................................................................................................................... 16
3.1.3
Overview of e-Referral Standards ................................................................................... 16
3.1.4
E-Referral Process .......................................................................................................... 16
3.1.5
Paper Referrals ............................................................................................................... 17
3.1.6
Referrals via Referral Management Centre or Interface Service ..................................... 17
3.1.7
Consultant to Consultant Referrals.................................................................................. 17
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
3.2
Clinic Templates ............................................................................................................. 17
4
Outpatient Booking Management .................................................................................... 18
4.1
Booking Rules ................................................................................................................. 18
4.2
Reasonable Offer of New and Follow Up Appointments and Admissions ........................ 18
4.3
Upgrading and Downgrading of Referrals ....................................................................... 19
4.4
Patient Initiated Cancellations and Delays ...................................................................... 19
4.5
Hospital Initiated Cancellations ....................................................................................... 19
4.6
Did Not Attend (DNA) Patients – Outpatient Clinics and Diagnostic Tests....................... 20
4.7
New Appointments .......................................................................................................... 20
4.8
Follow-Up Appointments ................................................................................................. 21
4.9
The Clinic Outcome Form ............................................................................................... 21
4.10
The Clinic Outcome Form for Virtual Clinics / Ad-hoc reviews / Telephone Appointments21
5
Inpatient Elective/Daycases Booking Management ......................................................... 21
5.1
Principles on Access to Elective Inpatient Care............................................................... 21
5.2
Waiting List (Booking) Form ............................................................................................ 22
5.3
Adding Patients to the Inpatient Waiting List ................................................................... 22
5.4
Prior Approval ................................................................................................................. 22
5.5
Inter- Provider Transfers ................................................................................................. 22
5.6
Determining Priority......................................................................................................... 23
5.7
Planned Patient Waiting Lists.......................................................................................... 23
5.8
Bilateral Procedures ........................................................................................................ 23
5.9
Pre-Op Assessment ........................................................................................................ 24
5.10
Did Not Attend (DNA) - Booked Pre-Op Appointments .................................................... 24
5.11
Did Not Attend (DNA) – Inpatients & Day Cases ............................................................. 24
5.12
Patient Initiated Delays ................................................................................................... 24
5.13
Cancellations .................................................................................................................. 25
5.13.1
Patient Cancellations ...................................................................................................... 25
5.13.2
Hospital Cancellations..................................................................................................... 25
6
Diagnostic Tests ............................................................................................................. 25
6.1
Requesting and Booking Diagnostic Test Appointments ................................................. 26
6.2
Diagnostic Results Reporting .......................................................................................... 27
6.3
Managing Patient and Hospital Cancellations ................................................................. 27
6.4
Patients due to have Planned Diagnostic Procedures ..................................................... 27
7
Duties and Responsibilities of Individuals and Groups .................................................... 28
7.1
Chief Executive ............................................................................................................... 28
7.2
Trust Board ..................................................................................................................... 28
7.3
Divisional Directors ......................................................................................................... 28
7.4
Ward Managers, Matrons and Managers for Non Clinical Services ................................. 28
7.5
Document Author and Document Implementation Lead .................................................. 28
7.6
Target Audience – As indicated on the Cover Page of this Document ............................. 28
7.7
Referrer........................................................................................................................... 28
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
7.8
Administrative Employees in all Clinical Divisions ........................................................... 29
7.9
Operational Management Teams .................................................................................... 29
7.10
All Clinical Employees ..................................................................................................... 29
8
Monitoring Compliance and Effectiveness of Implementation .......................................... 29
9
Review Date, Arrangements and Other Document Details .............................................. 29
9.1
Review Date ................................................................................................................... 29
9.2
Regulatory Position ......................................................................................................... 30
9.3
References, Further Reading and Links to Other Policies ............................................... 30
9.4
Consultation Process ...................................................................................................... 31
Appendix A – Equality Impact Assessment ....................................................................................... 32
Appendix B – Quality Impact Assessment Tool ................................................................................. 33
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1
Document Details
1.1
Introduction and Purpose of the Document
The aim of this policy is to ensure that patients accessing an outpatient appointment, diagnostic
appointment, elective or planned admission at the Great Western Hospitals NHS Foundation Trust
(hereby after referred to as the Trust) are managed in line with national access and choice guidance
(Ref 1 and 3). This includes patients with a suspected cancer diagnosis.
The overall aim of the policy is to ensure patients are treated in a timely, equitable and effective
manner and to:



Ensure that patients accessing an outpatient appointment, diagnostic appointment, elective in
patient, day case admission or planned admission are managed in line with national waiting
list guidance and access requirements appropriate for their referral route.
Ensure patients are treated in a timely and effective manner with fair and equitable access to
hospital services.
Support proactive management of waiting lists and ensure clear guidance on booking rules to
ensure compliance with condition-specific waiting time requirements.
The policy is based on nationally mandated guidance and local interpretation of these rules, to
provide both clarity and consistency for all patients and employees.
1.2
Glossary/Definitions
The following terms and acronyms are used within the document:
2WW
ASI
BCC
CA
CCG
CQC
DNA
DoH
DOS
DTA
DTT
EPEX
e-Referral
FDT
GP
GWH
INNF
IP&C
KPI
MATS
MDT
Medway
NHS
NHS
OPD
Two Week Wait
Appointment Slot Issue - When patients or professional users of Choose and Book
are unable to book an appointment. The most common reason for this is a lack of
appointment slots being made available to Choose and Book
Basal Cell Carcinoma
Cancer Access Service
Clinical Commissioning Group
Care Quality Commission
Did Not Attend
Department of Health
Directory of Services
Decision To Admit
Decision To Treat
Community Electronic Patient Record
e-referral – An online tool which patients (and their GPs) may use to determine
where they would like to be seen, at what time, within the acute hospital setting.
General Practitioner
Great Western Hospital
Intervention Not Normally Funded for non-commissioned procedures
Infection Prevention and Control
Key Performance Indicator
Musculo-skeletal Assessment and Treatment Service
Multi-disciplinary Team
Electronic Patient Record
National Health Service
National Health Service
Outpatient Department
Document Title: Elective Patient Access, Booking and Choice of Date Policy
PTL
PWL
RACPC
RCPATH
RMS
ROTT
RTT
SOP
TATs
TCI
UBRN
Patient Tracking List. Used to record the current 18 week waiting status of patients
referred to but not yet discharged from the Great Western Hospital
Planned Waiting List to track patient having planned procedures
Rapid Access Chest Pain Clinic
Royal College of Pathologists
Referral Management Service
Removal other than Treatment from waiting lists
Referral to Treatment. The point of referral (usually from the general practitioner) to
GWH, measured in weeks and days from the point of receipt of referral
Standard Operating Procedures
Turn around times
To come in. Refers to an expected date of elective day case or in patient
admission
unique booking reference number
Prior Approval - are the procedures that commissioners have either prohibited or restricted, and
funding request / authorisation processes apply. In some health economies they are called
“Procedures of Limited Clinical Value” or “Planned Procedures within Threshold.”
MDS – Minimum Data Set. A specific set of information required to be provided at the point of referral
or transfer.
Virtual Clinic –a clinic where a patient case is reviewed without the patient being physically present
(i.e. not a face to face consultation).
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
2
Main Policy Content Details
2.1
Overview of Trust and National Standards
The Operating Framework for the NHS in England 2012-13 (Ref 2) identified a series of performance
measures relating to elective access, including cancer. These are included as part of the Monitor
Framework (Ref 5), and are applicable to the Trust’s provision of its services in 2016-17.
The operational standards are as follows:
18 weeks pathway
92% of patients on an incomplete pathway
(admitted and non-admitted pathways) should
have been waiting no longer than 18 weeks.
Diagnostics
Less than 1% of patients are expected to wait
longer than six weeks for a diagnostic test.
Cancer waiting times - Two week wait (2WW) I.
93% of patients to be seen within two
standard:
weeks of receipt of an urgent General
Practitioner (GP) referral for suspected
cancer
II.
93% of patients to be seen within two
weeks of receipt of a GP referral with
breast symptoms (where cancer is not
suspected)
Cancer waiting times - 62 day standards I.
85% of patients to receive their first
Referral to Treatment (RTT):
definitive treatment for cancer within 62
days of receipt of an urgent GP referral for
suspected cancer
II.
90% of patients to receive their first
definitive treatment for cancer within 62
days of receipt of referral from an NHS
Cancer Screening Service (breast, bowel
and cervical)
III.
Maximum wait of 62 days for patients to
receive their first definitive treatment for
cancer where their consultant has
upgraded their referral to urgent – no
national performance measure is set for
this but an assumed measure is 85%.
Cancer waiting times
31 day standards Decision to Treat
(Decision to Treat to Treatment)
I.
II.
III.
IV.
96% of patients to receive their first definitive
treatment for cancer within 31 days of the
decision to treat.
94% of patients to receive subsequent
treatment for cancer within 31 days of the
decision to treat/earliest clinically appropriate
date to start a second or subsequent
treatment where that treatment is surgery.
98% of patients to receive subsequent
treatment for cancer within 31 days of the
decision to treat/earliest clinically appropriate
date to start a second or subsequent
treatment where that treatment is an anticancer drug regime.
94% of patients to receive subsequent
treatment for cancer within 31 days of the
decision to treat/earliest clinically appropriate
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
V.
date to start a second or subsequent
treatment where that treatment is a course of
radiotherapy.
Maximum wait of 31 days from receipt of
urgent (GP) referral to first treatment for
children’s cancer, testicular cancer and
acute leukaemia.
Patients excluded from monitoring under the cancer standards
Any patient:
 With a non-invasive cancer:
o Situ (with the exception of breast which is included);
o Basal cell carcinoma (BCC);
 Who dies prior to treatment commencing;
 Receiving diagnostic services and treatment privately. However:
o Where a patient chooses to be seen initially by a specialist privately but is then referred
for treatment under the NHS, the patient should be included under the existing and/ or
expanded 31-day standard;
o Where a patient is first seen under the two-week standard, then chooses to have
diagnostic tests privately before returning to the NHS for cancer treatment, only the
two-week standard and 31-day standard apply. The patient is excluded from the 62day standard as the diagnostic phase of the period has been carried out by the private
sector.
2.1.1 Internal Operating Standards for non-urgent 18 week Pathways
The phases of the patient pathway are outlined below:





Initial referral in to the Trust from GP or another provider – or from within the Trust, to a
Consultant led service or interface service.
First outpatient (OP) or straight to test appointment.
Diagnostic test phase – elective and planned.
Subsequent outpatient appointment phase.
Admission for surgery – elective and planned.
GP
Referral
received by
Trust
OP
First outpatient
/straight to
test
appointment
Diagnostic
test(s)
OP
Subsequent outpatient
appointment decision
to treat/admit
FDT
First
definitive
treatment
e.g.
surgery
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
The Trust must deliver non-urgent pathways within the time periods outlined in section 2.1. In
addition, the Trust will work towards reducing the waiting time for a first outpatient appointment as
follows:


Maximum five weeks for specialties with admitted pathways (i.e. those that may end in an
admission to hospital (either inpatient or day case) for treatment).
Maximum eight weeks for specialties with non-admitted pathways (i.e. where treatment
does not require admission to hospital) for treatment
The following activities are excluded from the 18 week RTT standard:






2.2
Emergency admissions.
Obstetric patients (unless referred for a condition other than pregnancy).
Patients undergoing a planned series of procedures (e.g. check cystoscopy, surveillance
colonoscopy) where it is clinically necessary and appropriate to wait for a defined period of
time.
Patients receiving ongoing care for a condition where the first definitive treatment for that
condition has already occurred.
Patients whose 18 week clock has stopped for active monitoring, and who have not yet had a
pathway started after this event, even though they may still be followed up by their consultant.
Patients referred in to a non consultant-led service.
18 week ‘Clock’ Terminology
The following section refers to booking rules and processes, along with the impact on patient waiting
times. To aid interpretation of these, the following national definitions around waiting times should be
used for all routine, urgent and cancer referrals. Full guidance is available in the Department of
Health (DH) publication Referral to treatment consultant-led waiting times Rules Suite (April 2014)
(Ref 1).
2.2.1 Clock Starts
A) A waiting time clock starts when the Trust receives a referral or the URBN is converted from
an e-Referral from any care professional or service permitted by an English NHS
commissioner to make such referrals, in to:


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;
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.
B) A waiting time clock also starts upon a self-referral by a patient to the above services, where
these pathways have been agreed locally by commissioners and providers and once the
referral is ratified by a care professional permitted to do so.
C) Upon completion of a consultant-led referral to treatment period, a new waiting time clock only
starts:
 When a patient becomes fit and ready for the second of a consultant-led bilateral
procedure;
 Upon the decision to start a substantively new or different treatment that does not already
form part of that patient’s agreed care plan;
 Upon a patient being re-referred into a consultant-led; interface; or referral management or
assessment service as a new referral;
 When a decision to treat is made following a period of active monitoring;
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Document Title: Elective Patient Access, Booking and Choice of Date Policy

When a patient rebooks their appointment following a first appointment does not attend
(DNAs) that nullified their earlier clock.
GP requests for Advice and Guidance will not start a RTT clock.
2.2.2 Clock Stops
A patient’s RTT clock will be stopped for a number of reasons which are outlined below.
a) First definitive treatment starts. This could be:
 Treatment provided by an interface service run by the Trust;
 Treatment provided by a consultant-led service;
 Therapy or healthcare science intervention, if this is what the clinician decides is the
best way to manage the patient’s disease, condition or injury and avoid further
interventions (e.g. community physiotherapy)
b) Decision not to treat.
c) Decision to embark on a period of active monitoring (also known as watchful waiting) i.e.
where it is judged to be clinically appropriate to start a period of active monitoring in secondary
care without clinical intervention or diagnostic procedures at that stage. Active monitoring can
be triggered by the clinician or the patient, for an extended period of consideration. A new 18
week clock would start when a new/further decision to treat is made following a period of
active monitoring. A new 18 week clock will start the next time the patient attends, and does
not have to necessarily be when a decision to treat is made.
d) Decision to add a patient to a transplant list.
e) Decision to return the patient to primary care for non-medical/surgical consultant-led treatment
in primary care.
f)
The patient declines treatment when offered it.
g) A patient DNAs any appointment or admission date, declines two reasonable offers and is
subsequently discharged back to the care of their GP, following review of the patient’s notes,
referral or history, as appropriate, by the clinician and provided that the criteria in section 2.2.3
is met.
2.2.3
Criteria for Discharging Patients in Line with Access Rules
Where a patient DNAs an appointment or admission, or declines two reasonable offers of a clinic
appointment or admission date, this will trigger a clinical discussion as to the appropriateness of the
patient remaining on the waiting list. The patient will be discharged following review of the patient’s
notes, referral or history, as appropriate, by the clinician and provided that
 The provider can demonstrate that a reasonable appointment was clearly communicated to
the patient or agreed with the patient if offered at shorter notice;
 Discharging the patient is not contrary to their best clinical interests;
 Discharging the patient is carried out according to local, publicly available/published, policies
on DNAs,
 These local policies are clearly defined and specifically protect the clinical interests of
vulnerable patients (e.g. children) and are agreed with clinicians, commissioners, patients and
other relevant stakeholders.
Patients who fall into the categories below will be reviewed by a clinician and a decision made with
regard to whether to discharge back to the GP or offer another appointment.
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Document Title: Elective Patient Access, Booking and Choice of Date Policy





Children up to the age of 16 years, in line with the Trust’s Child Protection and Safeguarding
Policy and Managing Child Missed Health Appointments Policy.
Two week rule suspected cancer referrals.
Urgent referrals (as above).
Other clinical exceptions as denoted by consultants/clinicians. This may include vulnerable
adults and/or children where discretion will be needed in how the service deals with DNAs
Patients who missed their appointment due to an inpatient stay.
The consultant responsible for the care of a child on the Child Protection Register must be informed if
the parent/guardian of the child DNAs any appointment or admission. The consultant should liaise
with the child’s GP to agree how to manage the child’s care. Copies of any communication with the
child’s GP/other referrer must be filed in the child’s clinical record
2.2.4
Clock Nullification
When a patient DNAs their first appointment following the initial referral that started their waiting time
clock, provided that the provider can demonstrate that a reasonable offer was clearly communicated
to the patient or agreed with the patient if offered at shorter notice, the clock is nullified.
2.2.5
Reasonable Offer
A ‘reasonable’ offer is a date that is at least three weeks from the time of the offer being made and a
choice of two dates. This does not preclude offering patients earlier dates, for example if a
cancellation slot becomes available, but patients will not be obliged to accept offers on a short notice
basis.
2.3
Patients where Cancer is Suspected
Patients referred by their GP (or service permitted by the commissioner to make such referrals) with
an urgent suspected cancer have the right to be seen within 14 calendar days of receipt of the
referral. GPs are encouraged to use a 2WW referral proforma for these referrals to be faxed through
to the Cancer Access Service (CAS) within the outpatient department (OPD) Booking Centre. When
normal referral letters are used, they should be clearly headed as “Urgent suspected cancer” or “two
week wait referral”. Any other form of words will not provide assurance that the patient is fast tracked.
The national cancer standards are outlined in section 2.1 of this document. Referrals for patients with
suspected cancer can also be made via the e-referral System.
The administrative rules for patients on a cancer pathway vary from those for patients on an 18 week
pathway and the CAS is responsible for co-ordinating the administration of patients through this
pathway.
If the patient goes ‘straight-to-test’ following a two-week wait (2WW) referral the receipt of the referral
is the clock start and the date of the test is the ‘date first seen’ under the two-week wait rule.
A 62-day pathway commences on receipt of a two-week wait (2ww) referral. If the patient goes on to
have a cancer diagnosis then treatment has to be delivered 62 days from receipt of the 2ww referral.
Upon upgrade of a routine referral (clock start) to delivery of treatment should be within 62 days
A 31-day pathway commences at the point of decision to treat and treatment should be delivered
within 31 days of this.
Where a patient wishes to transfer to an elective NHS pathway for treatment, following a private
consultation, a 31-day cancer pathway will commence once a decision to treat has been agreed, or at
receipt of referral if decision-to-treat date was in the private consultation period.
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
2.3.1 Did Not Attends (DNAs) – For Cancer Patients
Patients on a cancer pathway should not be referred back to their GP if they DNA their first
appointment, the Cancer Services team will attempt to make contact with the patient or their GP if the
patient does not contact the Trust following a DNA.
If the cancer pathway patient DNAs on multiple occasions (three or more) this will be discussed with
the clinician and the criteria for discharging patients in line with access rules in section 2.2.3 will be
followed.
The DNA guidance above does not apply to children. If a child DNAs an appointment, at any stage of
the cancer waiting times pathway, their clock should continue, and the GP should be informed.
2.3.2 Patient Cancellations – For Cancer Patients
Patients should not be referred back to their GP after a single appointment cancellation. Neither
should a patient be referred back to their GP after multiple (two or more) appointment cancellations
unless this has been agreed with the patient – as by cancelling an appointment a patient has shown a
willingness to engage with the service.
2.3.3 Inappropriate Referrals
If a consultant thinks that a two week wait referral is inappropriate they should contact the referring
GP to discuss the referral, and agree whether it should be downgraded. The number of ‘inappropriate’
referrals will be monitored by the Cancer Management Team who will feedback to Clinical
Commissioning Groups (CCGs) if patterns emerge from individual GPs / practices.
2.4
Patients who are confirmed to Have a Cancer Diagnosis
Where patients are confirmed to have a cancer diagnosis, such patients will receive the first definitive
treatment within 62 days of receipt of the GP’s referral and not more than 31 days after the decision to
treat (DTT). The DTT date refers to the date after the patient has been discussed at a MultiDisciplinary Team (MDT) when the treatment options are discussed and agreed between a specialist
clinician and the patient.
Patients who are not referred via the “two week wait” (2WW) rule but who are suspected or
diagnostically confirmed to have a diagnosis of cancer will receive their first definitive treatment within
31 days of the decision to treat (as defined above).
Urgent patients should not have their operation cancelled. Where any patient’s operation is cancelled
on the day for non-medical reasons, the Trust will always arrange to admit the patient within 28 days
of the cancellation. The cancer waiting times guarantee and required level of performance still also
applies.
2.5
Locally Agreed Commissioner Requirements
The Trust has no additional locally agreed contractual arrangements with local Clinical
Commissioning Groups (CCG) in addition to national access goals set by the Department of Health.
This section identifies the values, principles and governance that underpin the delivery of the Elective
Access, Booking & Choice of Date Policy.
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2.6
Trust Values
The Trust’s values are represented by the acronym STAR and four simple but powerful words:
Service - We will put our customers first.
Teamwork - We will work together.
Ambition -We will aspire to provide the best service.
Respect - We will act with integrity.
Each value has associated behaviours and skills to ensure that each employee provides the same
high quality care and level of customer service.
2.7
Application of and Compliance with this Policy
This policy applies to all clinical and administrative employees and services relating to elective patient
access managed by the Trust, including outpatient, inpatient, day case, therapies and diagnostic
services.
All employees involved in the management of patients’ access to the service are expected to follow
this policy. Each clinical service across all Divisions must follow this policy to deliver high quality,
consistent care to patients across the organisation as a whole.
Key performance indicators (KPIs) have been identified to monitor compliance with the policy, and
where performance is below the expected thresholds corrective action will be taken (e.g. further
training and support.)
2.7.1
Escalation
In accordance with the Trusts training needs analysis, employees involved in the implementation of
this policy, both clinical and administrative, must undertake appropriate training provided by the Trust.
It is the responsibility of all members of employees to understand the principles and definitions which
underpin delivery of all elective access performance measures; cancer, referral to treatment (18
weeks) and diagnostics. All employees involved in managing or administering patients’ pathways for
elective care must not carry out any action about which they feel uncertain, or that could contradict
this policy. They should escalate their concerns / uncertainties to their manager in the first instance.
2.8
Performance Monitoring and Reporting Structures
Performance of the RTT targets will be incorporated as appropriate in to a weekly Patient Tracking
List (PTL) meeting, the monthly Operational Resilience meeting (Trust level, where RTT reports from
a governance perspective) and monthly Divisional Performance Reviews. Reporting up to Executive
Committee and Board will be via a revised format of the existing Performance Report.
In the event that the Trust does not meet the monthly RTT or diagnostic targets as set in section 2,
the Informatics Team will inform the Divisional Director for Planned Care and a detailed breach report
with lessons learnt will be submitted.
2.9
Statutory Reporting
The Trust complies with the statutory reporting requirements for elective access and all external
reports must be signed off by the Divisional Directors of Planned Care and Diagnostics and
Outpatients before submission. The reports are outlined below:
Monthly returns – DM01 Diagnostics Waiting Times & Activity; RTT Complete and Incomplete
Activity; RTT Audiology; Monthly Activity Return; Cancer Waiting Times Returns.
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Quarterly returns – Quarterly Activity Return; Cancer Waiting Times Returns; Quarterly Diagnostic
Census.
The Trust also supplies returns to Commissioners as defined in the contracts.
2.10 Recording the Status of Patients
Alongside patient and referrer communications all employees (clinical and non clinical) must be aware
of their responsibility to accurately and contemporaneously record interactions with patients which
impact on their pathway status, whether that be an 18 week pathway, a cancer pathway or a
diagnostic pathway.
This includes the ‘cashing up’ (i.e. the recording of the outcomes of the clinic attendance) of activity
within 24 hours of that activity occurring (e.g. outpatient attendance, admission, discharge etc.) This
requires the completion of clinical outcome sheets for every patient-clinician interaction in every
outpatient clinic and for any clinical decision made out of an outpatient environment (i.e. virtual clinics,
telephone clinics, office-based reviews etc.).
2.11 Validating the Status of Patients
The Patient Tracker Lists (PTLs) which support the delivery of all access targets must also be
validated at key intervals or time points to ensure that the status of each individual patient is recorded
correctly.
Any patient with an open pathway which has been inactive for six months or more (note: annual
review patients are active) will be validated and discharged back to their GP. A letter will be sent to
the patient and copied to their GP.
The 18 week non-admitted PTL is to be validated on a weekly basis for patients who move into week
six of their pathway.
The 18 week admitted PTL is to be validated weekly with particular attention for those approaching 16
weeks.
The cancer PTL is reviewed weekly by the Cancer Data Manager, who will escalate issues as
required at the weekly PTL meeting.
The diagnostic PTL is to be validated weekly by a nominated manager from the Diagnostics and
Outpatients Division.
2.12
Communication
2.12.1 Communication with Trust Patients
The rules and principles within which the Trust will operate to deliver elective care to all patients;
whether they be urgent suspected cancer referrals, 18 week pathway patients or patients on planned
waiting lists; must be made clear and transparent to patients at each stage of their pathway within the
Trust.
All communications with patients, whether verbal or written, must be informative, clear and concise.
The patient’s GP will be copied in to all correspondence. Copies of all correspondence with the
patient must be kept in the patient’s clinical notes or be available electronically for auditing purposes.
2.12.2 Communication with Referring Organisations or Individuals
Similarly, all communications with referring organisations and individuals (e.g. the patient’s general
practitioner or consultant in another Trust) will make clear the rules and principles being applied at
each stage of the patient’s pathway or as their status may change (e.g. from active wait to planned
care.). Where clinical responsibility for a patient’s care is discharged back to that referrer (e.g. after
treatment is completed or where a patient has failed to attend a number of appointments or
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admissions), this must be made clear in any communication. Copies of all correspondence with the
referrer must be kept in the patient’s clinical notes or available electronically for auditing purposes.
2.13
Patients moving between NHS and Private Care and Treatment
Patients can choose to convert between NHS patient and private status patient at any point during
their treatment, without prejudice (assuming entitlement to NHS care is verified.) Where it has been
agreed, for example, that a surgical procedure is necessary in a private outpatient consultation, the
patient can be added directly to the elective NHS waiting list. The RTT clock starts at the point the
GP or original referrer’s letter arrived in the Trust seeking NHS care.
The elective access pathways of patients who notify the Trust of their decision to seek private care
will be closed as a pathway stop event on the date of this being disclosed by the patient, and if the
patient is on a waiting list they will be removed from the list and a letter sent advising their GP.
2.14
Access to Health Services for Armed Forces Community
In line with the Armed Forces Covenant from the Department of Health, those in the armed forces,
reservists, their families and veterans must not be disadvantaged in accessing health services in
the area they reside. If moved to a different part of the country due to the service person being
posted, they should retain their position on the relative waiting list and their RTT clock will continue.
In order to facilitate this, the process for completing and receiving an inter-provider transfer (section
5.5) must be followed.
All veterans and war pensioners should receive priority access to NHS care for any conditions
which are 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 should notify the Trust of the patient’s condition and its relation to military service
when they refer the patient so that the Trust can ensure that it meets the current guidance for
priority service over other patients with the same level of clinical need. In line with clinical policy
patients with more urgent clinical needs will continue to receive clinical priority.
2.15
Overseas Visitors
Patients who are identified as, or possibly are, overseas visitors will be registered on Medway (the
Trusts Electronic Patient record). The Department of Health Guidance on implementing the overseas
visitors charging regulations (Ref 8) should be followed. If employees are unclear about what they
should do they should contact the Overseas Visitors Officer (Finance Division).
3
Referral Management
This section of the policy details the principles under which the Trust will govern access and choice
within the outpatient and diagnostic settings. It is intended to provide an outline of core rules
established and an overview of procedures to be followed. It should be read in tandem with the
relevant Standard Operating Procedures.
3.1
Urgent and Routine New Patient Referrals
3.1.1 Referrals




Referrals should be made to a service rather than a named clinician, wherever possible, and
be aligned with the Patient Choice national agenda.
Urgent suspected cancers should be referred using the appropriate referral proforma and
process.
Referrals must be registered and stored onto the Trust’s electronic system within one working
day of receipt of referral by the Trust.
Patient contact must be made within three to five working days of receipt of referral for
routine referrals, and within two working days for urgent suspected cancer referrals.
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

Clinical review must take place within four working days of receipt of routine referrals and
two working days of urgent suspected cancer referrals.
GP letters requesting Advice and Guidance do not start an RTT clock
3.1.2 e-Referrals
The NHS e-Referral service is a tool patients (and their GPs) may use to determine where they would
like to be seen, and at what time. Patients have the facility to schedule their appointment date and
time via the Internet, or use a dedicated e-Referral Appointment line.
The Trust will be measured against contractual e-Referral standards defined by the Clinical
Commissioning group (CCG). Services must ensure that all Consultant-led new patient clinics have
slots available for GPs/patients to book via the e-Referral service, in line with national targets.
3.1.3 Overview of e-Referral Standards
96% of patients should be able to book on their first attempt to do so (<4% patients experiencing an
appointment slot issue (ASI))
The Directory of Services (DOS) should be of high quality
Move towards all referrals being received via the e-referral service
3.1.4 E-Referral Process
The core principles of the e-Referral process are:

The responsibility for maintaining the directory of service and taking an overall Trust lead sits
with the Outpatient Services Administration Manager working in conjunction with the
responsible Divisions. Speciality managers will provide accurate information in order for the
directory of service to be maintained.

The Outpatient Services Administration Manager will be responsible for validating whether all
clinics are open to e-Referral and exception report any non-complaint areas to Divisional
Director, Diagnostic and Outpatients.

Individual Divisions will make sure sufficient capacity exists in the e-Referral service to avoid
the occurrence of Appointment Slot Issues.

The date of referral to be recorded on the hospital’s patient administration system (is the date
on which a patient referred via e-Referral converts their unique booking reference number
(UBRN) irrespective of whether or not an appointment is made. This is the clock start.

Not all referrals booked via e-Referral will be appropriate and it may be necessary to change
or reject some appointments. This is the responsibility of the triaging clinician.

If the e-Referral appointment has been booked in the correct specialty, but in an incorrect
clinic, it is the responsibility of the receiving Clinician at triage to re-direct the appointment to
the appropriate clinic rather than rejecting back to the GP.

The patient must be informed if the appointment is to be re-booked and given the opportunity
to agree a convenient date within the agreed Trust timeframe. The 18 week clock keeps
ticking throughout this process.

If the Trust is attempting to rebook an e-Referral appointment, and is unable to contact the
patient after two attempts, an appointment is to be booked and confirmed in writing. The 18
week clock keeps ticking throughout this process.
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
If the patient or GP has been unsuccessful in directly booking via e-Referral, an Appointment
Slot Issue (ASI) will be generated. A regular ASI report will be generated by the Booking
Centre from the national e-Referral system and escalated to the appropriate speciality
manager.

Any patients on the ASI report will be given an appointment within four days of issue raised as
per national guidance, and specialities must respond to enable this to be delivered.

Any ASI not resolved within the above time frame will be escalated in line with the e-Referral
Management of Polling Range Guidance.
3.1.5
Paper Referrals
All referral letters should be sent to Medical Records for registration on Medway within 24 hours of
receipt, who will then send it for the relevant speciality for clinical triage to take place within 48 hours
of the date the referral was received. This will be monitored via routine audits, and where this
standard is not being achieved action will be required from the relevant speciality. For recording
purposes, and the start of the 18 week clock, the date of referral is the date received at the hospital,
(except for referrals mentioned in below) and all referrals should be clearly date stamped by each
department upon receipt.
3.1.6
Referrals via Referral Management Centre or Interface Service
For referrals which come via an interface service such as the Musculo-skeletal Assessment and
Treatment Service (MATS) or the Swindon Referral Support Centre (RSC), the RTT clock start is the
date those services received the referral from the GP, and the date of their date stamp should be
entered as the RTT clock start date if the patient is subsequently registered with the hospital
regarding an appointment with a consultant clinician.
3.1.7
Consultant to Consultant Referrals
Consultant to consultant referrals should not be made in routine cases (clinical exceptions apply) and
where a referral is for a different condition, the patient should be sent back to their GP to make a
decision to refer (or not.)
If the patient is referred internally for the same condition, then it is a continuation of the original clock
until first treatment is commenced. If the patient has been internally referred for a new problem, one
that is separate to the original referral, whether or not they are being seen by the original specialty, a
new 18 week clock will start when the receiving department date stamps the referral and a new
treatment pathway commences.
3.2 Clinic Templates
Clinic templates are crucial to ensuring that new and follow-up clinic capacity is managed and utilised
in the most efficient manner possible, and should be maintained robustly. The core principles are:

The speciality clinical lead and Head of Service will review their outpatient clinic templates at
least yearly in order to reflect the changing demands of the service.

Any changes to an existing template must be submitted to the relevant Outpatient Assistant
Manager, on a Clinic Template Change Request Form (available from the intranet).

Any changes to an existing template must be submitted to the relevant Outpatient Team
following the SOP for Clinic Changes or Cancellations, on a Clinic Template Change Request
Form (available from the intranet) or from the Outpatients Department.
Any template changes (including reductions and cancellations) require a minimum notice
period of six weeks. Services have two weeks to consider backfill options for alternative
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clinicians to run clinics at risk of cancellations. Requests for clinic changes or cancellations
made under six weeks from the clinic date should be escalated to the relevant Divisional
Director for approval with an explanation of why circumstances are exceptional.
4
Outpatient Booking Management
This section of the policy details the principles under which the Trust will govern access and choice of
date within the outpatient setting. It is intended to provide an outline of core rules established and an
overview of procedures to be followed.
4.1 Booking Rules
A number of basic booking rules apply to managing outpatient capacity (including diagnostic tests), to
ensure patients are able to be treated in a clinically appropriate way, and so that the Trust can provide
a sustainable service:
4.2

All patients will be offered appointment dates in chronological order, unless there is an
appropriate clinical decision that patients need to be treated more urgently to prevent
deterioration in their clinical condition.

No patient waiting for an outpatient appointment can have their RTT clock suspended or
paused for any reason.

Patients should wherever possible be offered a choice of appointment dates, in line with
national policy and good customer service principles.

Each clinical speciality should be aware of the target first to follow up appointment outpatient
ratios associated with their service and manage activity accordingly.

Each clinic will be set up with a template defining the number of available new and follow-up
slots, 2ww and e-referral slots.

Agreed limits of over bookings may be locally agreed with specialty clinicians and not
exceeded without clinical authorisation.

Cancer ‘2 week wait’ slots should not be used for any other type of appointment, until three
days prior to the clinic date. At this point, employees booking appointments may book into
available appointments of this type with the specific agreement of the outpatient supervisor.

The Trust adopts a zero tolerance approach to any patients waiting more than 52 weeks from
referral to treatment
Reasonable Offer of New and Follow Up Appointments and Admissions
A ‘reasonable’ offer is a date that is at least three weeks from the time of the offer being made and a
choice of two dates. This does not preclude offering patients earlier dates.
Patients who decline one reasonable offer must be offered at least one further reasonable date. If
two reasonable offers (i.e. with three weeks’ notice) are declined for either a new or follow-up
outpatient consultation, the criteria for discharging patients in line with access rules in section 2.2.3
will be followed.
All appointments will be confirmed in writing unless there is insufficient time to post a letter and the
patient has agreed the date on the telephone.
The consultant responsible for the care of a child on the Child Protection Register must be informed if
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the parent/guardian of the child rearranges any appointment or admission. The consultant should
liaise with the child’s GP to agree how to manage the child’s care. Copies of any communication with
the child’s GP/other referrer must be filed in the child’s clinical record
4.3 Upgrading and Downgrading of Referrals
Referrals can be upgraded where a clinician suspects the possibility of cancer.
Referrals cannot be downgraded without discussion and agreement by the receiving consultant with
the original referrer. Any joint decision to downgrade a referral must be documented in the health
records and the patient must be communicated with. The referral can only be downgraded before the
patient attends their first outpatient appointment.
4.4 Patient Initiated Cancellations and Delays




When the patient cancels any (new or follow-up) agreed outpatient or diagnostic appointment,
the next available appointment will be offered.
If slots are not available within the 18 week RTT pathway, this needs to be escalated to the
specialty Head of Service and reported at the weekly PTL meeting if unresolvable
All appointment letters must have all required information and advice on how to change an
appointment and the impact of a cancellation or DNA.
Any patient cancellations up to the time of the appointment are considered a cancellation not a
DNA. Where a patient cancels two or more appointments which were given with reasonable
notice, and wishes to re-arrange the appointment, the steps in section 2.2.3 will be followed.
Where patients make themselves unavailable for a period of 3 months or greater this should be
reviewed by the relevant clinician to determine if it is clinically appropriate to retain the patient on a
waiting list without clinical monitoring for this period of time. Where it is not deemed to be appropriate
to retain the patient, they will be discharged back into the care of their GP and re-referred when they
are ready and available to proceed.
4.5 Hospital Initiated Cancellations
The Trust recognises there are occasions where planned outpatient clinics need to be cancelled or
reduced; this outlines the formal clinic cancellation procedure which must be followed for such
requests to be processed.

A minimum of eight weeks’ notice is required from all clinicians to cancel or reduce any clinic
session. Such requests must be made using the correct template change documentation (see
section 3.2) via the Head of Service. The consultant cancelling the clinic must specify at this
point where any patients require rebooking based on clinical priority.

Appointments must be made as close to the original appointment as possible. This is
particularly important when patients need to re-attend for test results or to review medication.
In addition, no patient should be cancelled on more than two occasions because of Trust
actions. Administrative teams should highlight this to the clinician when cancelling a clinic, for
alternative actions to be found.

It is the responsibility of each speciality / Division to make adequate provision of clinic
capacity, so that patients cancelled by the Trust can be seen within the 18 week pathway.

Clinic cancellation with less than eight weeks’ notice can only be authorised by the Head of
Service or Clinical Lead on an exceptional basis and such should be notified to the Divisional
Director.

All clinic cancellations will be monitored via the relevant Head of Service to ensure that job
plan requirements are fulfilled (that is, 42 weeks funded programmed activity of an annual
basis).
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4.6 Did Not Attend (DNA) Patients – Outpatient Clinics and Diagnostic Tests
A Did Not Attend (DNA) refers to a patient who has failed to attend their appointment when
reasonable notice of the appointment was communicated to the patient or carer or was agreed with
the patient if offered at shorter notice. In this circumstance, the guidance in section 2.2.3will be
followed.
All follow up appointment patients, where the decision has been made to discharge, will be
discharged to their GP with a letter, which, if the patient is well known to the consultant, will include a
detailed management plan. If the patient is not well known, a risk assessment will be carried out and
appropriate action put in place.



Low risk, no further action is required other than a discharge letter.
Medium risk, a letter will be sent to the GP advising of both the discharge and the consultant’s
risk analysis.
High risk, a new appointment or re-referral is required.
The Trust must offer a further appointment following a DNA to any patient where it is clear that
administrative error has led to the patient not attending their appointment (or where it is not clear that
the date has been communicated to the patient).
Examples of administrative errors will be where:


Patient claims he/she did not receive appointment letter at all/ on time.
Patient was not given choice of appointment at time of booking.
If upon review the Clinician feels it would be detrimental to the patient’s health if an appointment is not
re-booked, then the patient must first be contacted to ascertain the reasons for DNA and ensure
compliance to attend a rescheduled appointment.
In the event that a patient is discharged, both patient and GP will be notified of this in writing to ensure
the referring GP is aware and can action further management of the patient if necessary. It will also
be made clear to the GP whether the DNA appointment is a first or follow up booking. For 18 week
pathways this will stop the 18 week clock.
The Trust will make every effort to reduce the amount of DNAs by:




Telephoning patients booked at less than two weeks in advance of the clinic date offering
choice of appointment time wherever possible.
Encouraging patients to update their contact details at every visit to ensure the Trust is always
able to contact them.
Send Text message reminders where appropriate at least one week prior to appointment.
Carry out quarterly DNA audit to understand the reasons and take remedial actions where
feasible.
4.7 New Appointments



The internal operating standards for a first outpatient appointment will move to a maximum
five weeks for services with admitted pathways (i.e. those that end in an admission to
hospital (either inpatient or day case) for treatment and a maximum of eight weeks for
services with non-admitted pathways (i.e. where treatment does not require admission to
hospital) for treatment.
All patients once registered on Medway (within 24 hours) and agreed to be appropriate
referrals following vetting (within 48 hours) will be contacted and agree a first appointment
within a maximum of five days of the date of the referral being received.
All urgently referred and urgent suspected cancer referrals patients are to be contacted and
agree a first appointment within 48 hours of the referral being received.
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4.8 Follow-Up Appointments
Follow-up appointments are appropriate when a patient’s condition requires continued intervention of
specialist clinical expertise whether or not treatment of that condition has occurred.
In situations where there is no evidence that a further specialist clinical intervention is required the
patient should be discharged to the care of their GP. This clinic outcome documentation must be
completed to reflect this decision, by the clinician seeing the patient.
To ensure time to process test results, follow-up appointments should be booked at an appropriate
interval following the test, in line with diagnostic waiting times and RTT target dates.
If results are negative, consideration should be given to the need for the subsequent outpatient
appointment. A suitable letter to the patient and GP may be sufficient as would a telephone
consultation. The patient must be discharged on Medway via a “virtual clinic” review. This will stop the
18 week clock. Every opportunity should be taken to follow up patients virtually to ensure timely
follow up, reduce New to Follow Up ratios and prevent unnecessary journeys to the hospital for
patients.
4.9 The Clinic Outcome Form
It is imperative that every patient seen or reviewed in an outpatient setting has a completed outcome
form. The responsibility for completion sits with the clinician. The responsibility for entry of the
outcome details from the form onto Medway sits with the outpatient administrators and other
designated employees. All parts of the clinical outcome form are to be completed at consultation and
are to be entered on to the Medway within 24 hours of attendance (and ideally before the patient
leaves clinic).
The clinic outcome form must be filled in correctly, indicating the clinic visit outcome and also updating the 18 week pathway status at every outpatient visit. These forms must then be returned to the
reception desk where the appropriate next actions will be taken as specified for that patient.
It is the responsibility of the reception employees via their management structure to ensure that all
clinic outcomes are recorded. A report on un-actioned clinics will be provided daily to all outpatient
supervisors via the data warehouse.
4.10
The Clinic Outcome Form for Virtual Clinics / Ad-hoc reviews / Telephone Appointments
Where the patient is part of a virtual clinic or an ad-hoc review or a telephone
appointment/assessment, the responsibility for completion of the outcome form sits with the clinician.
It is the responsibility of the relevant Outpatient Managers covering that speciality to ensure
appropriate procedures are in place to input the information onto Medway within 24 hours
5
Inpatient Elective/Daycases Booking Management
This section of the policy details the principles under which the Trust will govern access and choice of
date within the inpatient elective/day case setting. It is intended to provide an outline of core rules
established and an overview of procedures to be followed.
5.1
Principles on Access to Elective Inpatient Care

The decision to add a patient to the waiting list must be made by a consultant.

For patients with a decision to admit for treatment, at least two dates must be offered, with at
least three weeks’ notice for the offer to be deemed “reasonable”.
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5.2

Where available, patients can be offered earlier dates, however patients will have the
opportunity to decline if the dates are inconvenient without any adverse effect on their waiting
times or 18 week clock.

The waiting list must only contain patients who are fit, ready, able and available to have their
procedure.

If at pre-assessment, a decision not to proceed with a procedure is made because the patient
has an underlying condition (such as high blood pressure), these patients should be returned
to their GP. This will stop the 18 week clock. The GP is to be advised that they have to make a
new referral back to the waiting list when the patient is deemed to be fit and ready for surgery.
This will start a new 18 week clock. Note: short term conditions such as the common cold
do not count, and patients should not be discharged to their GP.
Waiting List (Booking) Form
Once the decision to add a patient to the Waiting List has been made, the form must be completed,
dated and signed by the clinician in the outpatient clinic. This form must be completed at the time of
the decision to admit, which in most cases will be during the outpatient appointment. This form should
then be passed to the booking office within 24 hours, who will then contact the patients to agree a
date and book the TCI date on to Medway.
5.3
Adding Patients to the Inpatient Waiting List
Patients must be made aware of the likely waiting time if a date cannot be agreed at the time they are
added to the waiting list. They should be asked if they are available at short notice and this
information should be entered onto Medway with a contact telephone number.
The list will consist of “Active Patients”, “RTT and non-RTT” and “Planned Patients”. Where patients
are of equal clinical priority, preference should be given to those patients who are approaching their
18 week breach date.
A selection of patients to replace cancellations should be taken from those who have been preassessed and who require completion of their 18 week pathway within these timescales. The patient’s
clock status is not affected if they choose to decline short notice offers of dates.
5.4
Prior Approval
These are treatments for which there is limited evidence of clinical effectiveness which have been
identified by a commissioner as requiring prior approval, or only appropriate on a criteria based
assessment basis.
Any patients who do not meet the clinical criteria should be advised by the clinician at the time of their
consultation and referred back to the GP.
All patients who meet the relevant criteria must have a booking form completed and be added to the
waiting list, where necessary, approval should be sought following the relevant commissioner
protocol. The clock continues during this period.
If funding is declined, the patient will be notified and removed from the waiting list and discharged
back to their GP and the RTT clock stopped. If funding is agreed, the relevant booking officer will
proceed to provide an admission date.
5.5
Inter- Provider Transfers
The DH mandated the use of a minimum data set for inter-provider transfers from 1st January 2008.
The pathway data contained within this data is essential in order for receiving organisations to
accurately monitor and report patient waiting times.
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Referrals from other providers to GWH must include a completed Inter-Provider Minimum Data Set or
ensure that one is sent within 48 hours of referring a patient. Likewise, the Trust must ensure the
appropriate standard minimum data set (MDS) is sent to any provider the Trust refers to.
Principles for administering this system are: Where patients are transferred between providers,
including Primary Care Intermediate Services, the MDS must accompany the referral.

The principle need for using the MDS form is to ensure all service providers involved in a
patient’s pathway have adequate information about clock starts etc. to enable the patient’s
management to be conducted within appropriate time frames.

When a patient is transferred for treatment or diagnostic investigation in the middle of a
pathway, the 18 week clock will continue and it is the joint responsibility of involved providers
to ensure that the patient is managed within 18 weeks.

There will also be occasions when a patient is transferred for management after the original
clock has stopped – this information will also need to be shared with the onward provider,
hence an MDS form will still be required. In this instance a new clock will start with the new
provider.
5.6
Determining Priority
All patients who are added to the waiting list must be given a clinical priority of either urgent or
routine. Urgent is defined as:



Life, limb or sight threatening
Likely to cause harm to a pregnant woman or unborn baby
Where the delay to treatment would cause a significant deterioration in prognosis
A number of specialities within the Trust operate “shared patient care”, or “list pooling.” This enables
patients to be listed to the most appropriate clinician with the shortest possible wait times (unless a
particular clinician is expressly stated on clinical grounds or via patient choice). Within the NHS
Constitution, all patients should be offered choice.
5.7
Planned Patient Waiting Lists
Commissioners and providers need to plan and manage their services so that new and planned
patients are treated at the right time and in order of clinical priority. Patients requiring initial or followup appointments for clinical assessment, review, monitoring, procedures, or treatment must be given
a specific date and time, as required by best clinical evidence. Patients should only be added to a
planned list where clinically they need to wait for a period of time. This includes planned diagnostic
tests or treatments or a series of procedures carried out as part of a treatment plan – which are
required for clinical reasons to be carried out at a specific time or repeated at a specific frequency.
Patients on planned lists should be booked in for an appointment at the clinically appropriate time and
they should not have to wait a further period after this time has elapsed. For example, a patient due to
have a re-test in six months time should be booked in around six months later and they should not get
to six months, and then have to wait again for non-clinical reasons. This is not an acceptable use of a
planned list.
When patients on planned lists are clinically ready for their care to commence and reach the date for
their planned appointment, they should either receive that appointment or be transferred to an active
waiting list and a waiting time clock should start (and be reported in the relevant waiting time return.)
5.8
Bilateral Procedures
Where the patient is declared fit and able to proceed with the second procedure by the Clinician, a
new 18 week clock will start.
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5.9
Pre-Op Assessment
All patients undergoing elective surgery should have undergone a pre-assessment process as per
current Trust policy depending on their planned procedure and anaesthesia.
If a patient has a condition identified at pre-assessment which is easily resolved within 0-4 weeks,
(e.g. a cold) they will remain on the waiting list and the clock continues. If a condition is found which is
likely to take four weeks or more to resolve before the patient is fit for surgery / anaesthetic, the
patient should be removed from the waiting list and discharged back to their GP for re-referral for
when they are fit and ready for surgery.
5.10
Did Not Attend (DNA) - Booked Pre-Op Appointments
Patients who DNA pre-admission appointments (agreed with reasonable notice and aside from those
with specific clinical urgency e.g. cancer patients) will:





Be contacted to find out reasons for their DNA.
Have their notes reviewed clinically to ascertain whether discharging the patient is contrary to
their best clinical interest, or it is agreed that the patient is considered to be vulnerable
Be removed from the waiting list and referred back to their GP/ referring clinician in line with
the guidance section 2.2.3
Be sent a letter confirming the above with a copy sent to their GP/referring clinician.
Be offered another pre-assessment appointment if the patient is deemed to be vulnerable or it
is deemed to be in their best clinical interest
In circumstances that the clinician feels it would be detrimental to the patient’s health if a procedure is
not re-booked, then the patient must first be contacted to ascertain the reasons for DNA and to
ensure compliance to attend a rescheduled pre-assessment appointment.
5.11
Did Not Attend (DNA) – Inpatients & Day Cases
If a patient DNAs their pre-assessment appointment or admission, the guidance in section 2.2.3
should be followed, provided the reasonable offer was clearly communicated or agreed with the
patient if offered at shorter notice
Patients must be informed clearly in all Trust correspondence that in the event that they DNA either
their pre-op appointment or operation date, their circumstances will be clinically reviewed and they
may be referred back to their GP which would stop the clock and require a new referral. In
circumstances that the clinician feels it would be detrimental to the patient’s health if a procedure is
not re-booked, then the patient must first be contacted to ascertain the reasons for DNA and to
ensure compliance to attend a rescheduled procedure. The RTT clock continues to tick in this
circumstance.
5.12
Patient Initiated Delays
Where patients wish to delay treatment until a specific named doctor can see them, the clock keeps
ticking, which may lead to a breach as a result of them choosing to wait. The Referral to treatment
consultant-led waiting times Rules Suite makes it clear that where this occurs, the minimum
operational standards for 18 weeks allow for this (i.e. the breach is part of the 8% tolerance built into
the standard).
In such instances, patients should be offered the earliest possible appointment with the relevant
clinician.
Where patients make themselves unavailable for a period of 3 months or greater this should be
reviewed by the relevant clinician to determine if it is clinically appropriate to retain the patient on a
waiting list without clinical monitoring for this period of time. Where it is not deemed to be appropriate
to retain the patient, they will be discharged back into the care of their GP and re-referred when they
are ready and available to proceed.
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5.13
Cancellations
The Trust’s aim is to have all patients on the waiting list treated. It is inevitable however, that for a
variety of reasons and in exceptional circumstances some admission dates will be cancelled.
However, patients should be made aware at the time of being put onto the elective waiting list of the
need to be available for this treatment within the designated timeframes.
5.13.1 Patient Cancellations
Any patient cancellations up to the time of the admission are considered a cancellation not a DNA. A
new date will be agreed with the patient and the 18 week clock will keep ticking throughout this
period.
Patients will have the opportunity to cancel or change one agreed admission date) during their
pathway. Where a patient wishes to cancel and re-arrange two or more agreed admission dates, the
guidance in section 2.2.3 will be followed.
If an admission date has not already been agreed, and the patients has not responded to three
attempts to contact them after they become available to book an admission date, which should be on
different days and at different times, and the patient’s contact details have been verified by their GP
practice, their pathway will be closed (patient declined treatment) and the patient advised they should
return to their GP. All attempts to contact the patient should be documented and should include
written and verbal attempts. If they still wish to pursue treatment, they would need to be re-referred by
their GP. The Trust will have processes in place to ensure such patients are added to the waiting list
rather than have to attend an out-patient appointment if this is clinically appropriate.
5.13.2 Hospital Cancellations
If an agreed admission date is cancelled by the hospital at any stage up to and including the day of
admission, a new date should be agreed with the patient within seven days. This new date of
admission should be within 28 days (in the case of same day cancellations) or the 18 week breach
date, whichever is sooner. The 18 week clock will continue to tick throughout, until treatment/surgery
is started.
Patients, who are cancelled on the day of surgery for a short and measurable medical condition (e.g.
cold or urinary tract infection) which can be resolved within a four week period, will be cancelled and a
new date agreed. The RTT clock will continue to tick during this time and the patient remain on the
waiting list.
6 Diagnostic Tests
This section of the policy details the principles under which the Trust will govern access and choice of
date for diagnostic tests. It is intended to provide an outline of core rules established and an overview
of procedures to be followed
The internal operating standards and Direct Access for all diagnostic tests and appointments are that
the maximum time from date of request to test must be six weeks for all routine referrals and two
weeks for all urgent referrals. Patients awaiting a diagnostic test will be monitored and managed via
the appropriate PTL.
All employees working in, managing and reporting diagnostic waiting times need to be familiar with
the specific guidance underpinning diagnostic waiting times and performance reporting while also
understanding the impact of diagnostic pathways on other elective targets i.e. cancer and 18 weeks.
Delays in the diagnostic pathway due to patient choice which can be deducted from diagnostic waiting
time performance reporting cannot be adjusted for in either cancer or 18 week reporting, and so
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management of this stage of the pathway is critical to the timeliness and streamlining of the patient’s
pathway as a whole.
The following basic principles are therefore to be applied to the booking and management of all
diagnostic tests and test appointments.
6.1
Requesting and Booking Diagnostic Test Appointments

Clinicians making a request for any diagnostic test must ensure that the clinical status of the
patient is clearly denoted on that request i.e. if the patient is on a routine, urgent or planned
(surveillance) pathway. For all urgent suspected cancer referrals the request must be clearly
marked as ‘suspected cancer’ in the clinical history section of the request form/electronic
template.

The request should be received in the relevant department within one working day of being
completed (in the case of pathology, accompanying the specimen) and the patient’s details
and date of the request are to be added to the diagnostic PTL to facilitate both proactive
monitoring and management of the patient’s pathway, and reporting of the diagnostic waiting
time target.

Where possible the request for examination should include the current status of the patients
18 week pathway, if the test is needed to achieve the pathway and if this is known by the
requesting clinician.

Patients recorded as day case activity for their diagnostic tests (e.g. Endoscopy Suite activity)
are to be added to the waiting list and to the admitted 18 week PTL.

All routine patients are to be contacted and agree an appointment date(s) within a maximum of
one week of the date of the request being made.

All urgent patients are to be contacted and agree an appointment date(s) within a maximum of
two working days of the date of the request being made.

Patients are to be offered dates according to their clinical status and at a date and time which
is convenient for the patient.

Contact must be made with the patient by telephone wherever possible. Three attempts must
be made to contact an “urgent” patient by telephone over a 24 hour period. If the patient has
been referred urgently the member of the team making the call must inform the patient that
they have been referred for an urgent appointment and encourage the patient to make an
early appointment.

The patient is to be sent a confirmation letter within 24 hours of agreeing the appointment.
The letter must be clear and informative and must include a point of contact and telephone
number to call if they have any questions relating to the appointment. The letter should explain
clearly the consequences should the patient cancel their appointments or fail to attend for the
diagnostic test(s) at the agreed time.

Where telephone contact cannot be made the patient is to be sent a letter requesting either
that they make contact with the relevant department to arrange the date and time for their
appointment, or offering the patient a date and time a minimum of five working days after the
letter is sent. Urgent test appointment letters must be sent by first class post (with
authorisation)

Where patients are not available for the proposed diagnostic test(s) within six weeks from the
date of the request, this will trigger a discussion with the clinician and the guidance in section
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2.2.3 should be followed. If the patient is to be discharged a discharge letter is to be sent to
the patient and to their GP or original referrer.
Adjustments to a diagnostic pathway (the six week pathway) for patient choice can only be applied if
the patient has turned down two offers of dates with three weeks notice. This does not mean that
patients should not be offered appointments earlier than three weeks.
6.2
Diagnostic Results Reporting
Subsequent results reporting must be available in time to allow progress through all likely stages of
the RTT pathway. Routine results will be made available within five working days of the
examination and for urgent cases less than 24 hours. Separate standards apply for turnaround times
(TATs) in line with Royal College of Pathologists (RCPATH) guidance, and there are clinical reasons
(e.g. sending samples off site, waiting for bacteriology specimens to grow, and fixing histology
specimens in formalin) why these timescales will not always be achievable. It is essential to receipt all
specimens in the Pathology Laboratory within one working day.
6.3
Managing Patient and Hospital Cancellations

Where diagnostic test appointments are cancelled by the Trust patients should be re-booked
as close as possible to their original appointment date and within one week of the cancellation
date.

If a patient cancels their diagnostic test appointment and does not wish to have another
appointment this must be brought to the immediate attention of the clinical team and
consultant and a decision must be made regarding the appropriate action to be taken. If this
results in the patient being discharged a letter must be sent to the patient and to their GP
and/or original referrer from the responsible consultant.

Patients who cancel their diagnostic test appointment should be re-booked as close to their
original appointment as possible, and within one week of the cancellation date. Patients
should be reminded that if they cancel this appointment for a second time they may need to
return to their GP for re-referral.

Where a patient cancels their test appointment for a second time, this will trigger a discussion
with the clinician and the guidance in section 2.2.3 will be followed. If the patient is to be
discharged a discharge letter is to be sent to the patient and to their GP and/or original referrer
from the responsible consultant.

Where a patient DNAs their diagnostic test appointment, this will trigger a discussion with the
clinician and the guidance section 2.2.3 will be followed. If the patient is to be discharged a
discharge letter is to be sent to the patient and to their GP or original referrer from the
responsible consultant. Where it is agreed that the patient is to be re-booked the next
appointment must be within one week of the original appointment date.
6.4
Patients due to have Planned Diagnostic Procedures

Planned waiting lists are to be reviewed on a weekly basis to identify all patients due to be
contacted for a planned (surveillance) procedure in six weeks’ time

Patients on this forward-look list are to be contacted according to the principles outlined in the
above sections and are to be offered dates within a week on either side of the planned test
date

In the event that a date cannot be given to the patient for the diagnostic test (other than for
reasons of patient choice) the patient is to be added to an active waiting list i.e. the six week
diagnostic test PTL and are to be reported as being on an elective diagnostic waiting list i.e.
must be reported on the monthly or quarterly diagnostic waiting time return.
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7 Duties and Responsibilities of Individuals and Groups
7.1
Chief Executive
The Chief Executive is ultimately responsible for the implementation of this document.
7.2
Trust Board
Whilst responsibility for achieving targets lies with the Divisions, the Executive and ultimately the
Trust Board, all staff with access to and a duty to maintain referral and waiting list information
systems are accountable for their accurate upkeep.
7.3
Divisional Directors
The Divisional Directors are accountable for implementing and monitoring waiting list management,
and ensuring compliance with the policy and targets within their Division.
They, supported by expertise from the Informatics Team, are responsible for ensuring that data is
accurate and the reporting against targets reflects the true position.
7.4
Ward Managers, Matrons and Managers for Non Clinical Services
All Ward Managers, Matrons and Managers for Non Clinical Services must ensure that employees
within their area are aware of this document; able to implement the document and that any
superseded documents are destroyed.
7.5
Document Author and Document Implementation Lead
The document Author and the document Implementation Lead are responsible for identifying the need
for a change in this document as a result of becoming aware of changes in practice, changes to
statutory requirements, revised professional or clinical standards and local/national directives, and
resubmitting the document for approval and republication if changes are required.
Target Audience – As indicated on the Cover Page of this Document
7.6
The target audience has the responsibility to ensure their compliance with this document by:



7.7
Ensuring any training required is attended and kept up to date.
Ensuring any competencies required are maintained.
Co-operating with the development and implementation of policies as part of their normal
duties and responsibilities.
Referrer
The Trust relies on all referring clinicians to the Trust ensuring that patients understand their
responsibilities and potential pathway steps and timescales when being referred. This will help ensure
that patients are referred under the appropriate clinical guidelines, aware of the speed at which their
pathway may be progressed, and are in the best position to accept timely and appropriate
appointments. Therefore the Trust expects that, before a referral is made, the patient is ready, willing
and able to attend for an appointment and undergo any treatment that may be required. This will
include being both clinically fit for assessment and possible treatment of their condition. This is the
responsibility of the referring clinician, e.g. the GP.

Referrers must provide accurate, timely and complete information within their referral.

Wherever possible, referrals should be made electronically through the e-Referral service.

After a referral has been made, the referrer must inform the hospital if the patient no longer
wishes or requires to be seen.
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
7.8
The referrer must appropriately manage any patients who are discharged by the Trust
following a DNA or cancellations of their appointment
Administrative Employees in all Clinical Divisions
Division administrative employees including back office employees, receptionists and booking
officers, are responsible for and accountable through the Divisional management structure for
compliance with all aspects of this policy. Employees will attend appropriate training tailored to their
role.
7.9
Operational Management Teams
Operational Management Teams through their Divisional Director and Associate Medical Director are
responsible for achieving access targets, and for ensuring that appropriate capacity is in place to
meet demand.
7.10
All Clinical Employees
All clinical employees are responsible for ensuring they comply with their responsibilities as outlined in
this Policy.
Employees involved in managing patients’ pathways for elective care must not carry out any action
about which they feel uncertain, or that could contradict this policy. They should escalate their
concerns / uncertainties to their manager in the first instance.
8
Monitoring Compliance and Effectiveness of Implementation
The arrangements for monitoring compliance are outlined in the table below: Measurable
policy
objectives
Monitoring /
Monitoring
audit method responsibility
(individual /
group
/committee)
Frequency of
monitoring
Reporting
arrangements
(committee /
group to which
monitoring
results are
presented)
What action
will be taken
if gaps are
identified?
Performance of
the Trust against
the national RTT
standards in
line with national
policy and
reporting
requirements
Review
Divisional
performance in Directors
weekly PTLs
and
Operational
Performance
report
Weekly (PTL)
and monthly
(Performance
Review,
Executive
Committee,
Trust Board)
Division
Management
Team meeting
Executive
Committee
Trust Board
Action plan
to be agreed
between the
Executive
and relevant
Division
9
9.1
Review Date, Arrangements and Other Document Details
Review Date
This document will be fully reviewed every three years in accordance with the Trust’s agreed process
for reviewing Trust -wide documents. Changes in practice, to statutory requirements, revised
professional or clinical standards and/or local/national directives are to be made as and when the
change is identified.
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9.2
Regulatory Position
This policy is based around core principles established within the NHS Constitution (Ref 3), which
states the rights patients, the public and employees are entitled to. The NHS Constitution is a
document enshrined in law, and as such all NHS providers are bound to take account of the
document in all aspects of their operations.
As set out in the NHS Constitution, patients have a right to access certain services commissioned by
NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer
patients a range of suitable alternative providers if this is not possible.
In addition to the NHS Constitution, individual acts of parliament shall dictate the approach NHS
Trusts must take in providing access to public services. In particular the 2010 White Paper Equity
and Excellence: Liberating the NHS reaffirmed the commitment to provide patients with more choice
in NHS systems. This includes in particular an extension from choice of NHS provider, to choice of
consultant-led team where clinically appropriate from April 2011.
Any future guidance about the patient access or patient choice from the Department of Health or
commissioners will supersede any guidance in this document.
CQC (Care Quality Commission) regulate the Trusts activity and its right to provide services.
9.3
References, Further Reading and Links to Other Policies
The following is a list of other policies, procedural documents or guidance documents (internal or
external) which employees should refer to for further details:
Ref. No. Document Title
Document Location
1
Referral to treatment consultant-led waiting times https://www.gov.uk
Rules Suite (October 2015)
2
NHS Operating Framework 2012/13
https://www.gov.uk
3
NHS Constitution 2010
https://www.gov.uk
4
Equity and Excellence: Liberating the NHS 2010 (DH) https://www.gov.uk
5
Monitor Framework
https://www.gov.uk
6
Child Protection and Safeguarding Policy
T:\Trust-wide Documents
7
Allied Health Professional Referral to Treatment T:\Trust-wide Documents
Revised Guide 2011
8
Guidance on Implementing The Overseas Visitors T:\Trust-wide Documents
Hospital Charging regulations
9
Cancer Waiting Time Guidance
10
Armed Forces Covenant
https://www.gov.uk
11
Managing Child Missed Health Appointments Policy
T:\Trust-wide Documents
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
9.4
Consultation Process
The following is a list of consultees in formulating this document and the date that they approved the
document:
Job Title / Department
Date
Consultee
Document Contents
RTT Training Group Members (Managerial representation from
Planned Care and Diagnostic and Outpatient Divisions and
Informatics team)
16/05/16
Swindon and Wiltshire CCGs
11/08/2016
Agreed
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Document Title: Elective Patient Access, Booking and Choice of Date Policy
Appendix A – Equality Impact Assessment
Equality Impact Assessment
Our Vision
Are we Treating Everyone Equally?
Define the document. What is the document about? What outcomes
are expected?
Consider if your document/proposal affects any persons (Patients,
Employees, Carers, Visitors, Volunteers and Members) with
protected characteristics? Back up your considerations by local or
national data, service information, audits, complaints and
compliments, Friends & Family Test results, Staff Survey, etc.
Great Western Hospitals NHS Foundation Trust wants its services and
opportunities to be as accessible as possible, to as many people as possible, at
the first attempt.
Age
If an adverse impact is identified what can be done to change this?
Are there any barriers? Focus on outcomes and improvements. Plan
and create actions that will mitigate against any identified inequalities.
Sexual
Orientation
Disability
If the document upon assessment is identified as having a positive
impact, how can this be shared to maximise the benefits universally?
Sex
Trust Equality and Diversity Objectives
Better
health
outcomes
for all
Improved
patient
access and
experience
Empowered
engaged
and
included
staff
Inclusive
leadership
at all levels
9 Protected
Characteristics
Gender Reassignment
Marriage
and
Civil
Partnership
Religion
or Belief
Race including
Nationality
and
Ethnicity
Pregnancy
and
Maternity
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Appendix B – Quality Impact Assessment Tool
Purpose - To assess the impact of individual policies and procedural documents on the
quality of care provided to patients by the Trust both in acute settings and in the community.
Process -The impact assessment is to be completed by the document author. In the case
of clinical policies and documents, this should be in consultation with Clinical Leads and
other relevant clinician representatives.
Risks identified from the quality impact assessment must be specified on this form and the
reasons for acceptance of those risks or mitigation measures explained.
Monitoring the Level of Risk - The mitigating actions and level of risk should be monitored
by the author of the policy or procedural document or such other specified person.
High Risks must be reported to the relevant Executive Lead.
Impact Assessment
Please explain or describe as applicable.
1. Consider the impact that your document will have on our It will support the delivery
ability to deliver high quality care.
2. The impact might be positive (an improvement) or negative Positive
(a risk to our ability to deliver high quality care).
3. Consider the overall service - for example: compromise in Potential capacity issues
one area may be mitigated by higher standard of care may arise
overall.
4. Where you identify a risk, you must include identify the Capacity and demand
mitigating actions you will put in place. Specify who the lead risk is managed by the
for this risk is.
Divisional Directors
Impact on Clinical Effectiveness & Patient Safety
5. Describe the impact of the document on clinical Neutral
effectiveness. Consider issues such as our ability to deliver
safe care; our ability to deliver effective care; and our ability
to prevent avoidable harm.
Impact on Patient & Carer Experience
6. Describe the impact of the policy or procedural document on Improve patient
patient / carer experience. Consider issues such as our experience by reducing
ability to treat patients with dignity and respect; our ability to delays and cancellations
deliver an efficient service; our ability to deliver personalised
care; and our ability to care for patients in an appropriate
physical environment.
Impact on Inequalities
7. Describe the impact of the document on inequalities in our Neutral
community. Consider whether the document will have a
differential impact on certain groups of patients (such as
those with a hearing impairment or those where English is
not their first language).
Note: This document is electronically controlled. The master copy of the latest approved version is maintained by the owner
department. If this document is downloaded from a website or printed, it becomes uncontrolled.
Version 1.0
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Printed on 14/07/2017 at 2:29 AM