PATIENT ACCESS POLICY
CLINICAL POLICY – ACE522
Version Number: 1
Policy Owner: Director of Operations
Lead Director: Director of Operations
Date Approved: 22 November 2013
Approved By: Quality and Safety Assurance
Group
Review Date: 31 March 2015
Target Audience: All staff working within Clinical
Services
INDEX
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 1
Page No
1. Introduction
3
2. Purpose
3
3. Scope
4
4. Equality Impact Assessment
4
5. Waiting Time Targets
5
6. Principles & Procedures
6
7. Entitlement to NHS Treatment
10
8. Responsibility for achieving waiting times standards
10
8. 9. Approval and ratification process
10. Dissemination and implementation process
Appendix 1 - Brief descriptions of each of these possible stages
along the treatment pathway
Appendix 2 - Status Codes
Appendix 3 - Inter Provider Transfer (IPT) Administrative Minimum
Data Set form
10
10
11
15
16
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 2
1. Introduction
In England, under the NHS constitution, patients ‘have the right to access
services within maximum waiting times’. Whilst specific national waiting times
relate to consultant-led services only (which Anglian Community Enterprise
(ACE) CIC do not provide), both ACE and our commissioners, recognise
waiting times as a relevant indicator for service quality.
Furthermore, the national reporting of Referral to Treatment times for all Allied
Health Professionals will be required once the Community Information
Dataset (CIDS) is operational.
The principles applied in this policy have been informed by Allied Professional
Referral to Treatment Guide 20111.
2. Purpose
The purpose of this policy is to outline ACE requirements and standards for
managing patient access to its services. It covers booking, notice
requirements, patient choice and waiting list management. The length of time
a patient waits for their treatment and the notice and choice they have when
they book their treatment are indicators of the quality and efficiency of
services provided by ACE. Therefore all patient access and choice issues will
be dealt with systematically within the principles and spirit of this policy.
There are two main principles that serve as the foundation to this policy:

ACE will ensure that the management of patient access to services is
transparent, fair, equitable and managed according to clinical priority.

ACE will ensure that the administrative processes which patients use to
book appointments and treatment are simple, efficient and provide a
high quality service to patients.
The overall intent of this policy is to provide a clear, reliable and transparent
standard for patient access. By applying this structured and systematic
approach, ACE will ensure that patients receive a high quality service and
increase the likelihood of their choosing ACE for their consultations and
treatment.
This policy applies to all administration and clinical prioritisation processes
relating to patient access managed by ACE.
1
Community Information Programme: Allied Health Professional Referral to Treatment Revised Guide
2011, Community Information Programme, DH 22 December 2011
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 3
The scope of this policy is from a patient’s referral into ACE through their care
and treatment, to their discharge back to referrer (e.g. GP, other referrer). All
staff involved in a patient’s care and treatment should adhere to this policy.
The Director of Operations within ACE has corporate responsibility for
ensuring that the policy is effectively implemented through the Operational
Management structure and for updating the policy as and when necessary.
3. Scope
The detailed principles of this Patient Access Policy are as follows:
1. All patients will experience equality of access and impartiality while
waiting for their treatment
2. Patients will be treated in accordance with their clinical need or priority
(urgent or routine)
3. Clinical need or priority can only be determined by suitably qualified
clinical staff with authority to make those decisions
4. Patients should be fit, ready and available for treatment at the point at
which they are referred into the service
5. Patients will be able to have choice in the scheduling of their
appointments
6. Data concerning waiting lists and patient’s waiting times must be
secure, timely, accurate and subject to regular audit and validation.
7. Communication with individual patients and the wider public about
waiting lists and waiting times should be clear, informative and timely.
4. Equality Impact Assessment
This document has been assessed for equality impact. This policy is
applicable to every member of staff within Anglian Community Enterprise
irrespective of their race, ethnic origin, nationality, gender, culture, religion or
belief, sexual orientation, age or disability.
ACE is required to cater for all patients accessing services thereby having
systems in place to accommodate people who have disabilities and who are
unable to converse in English.
ACE has estates policies in place to ensure building access regulations are in
line with the Equality Act 2010
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 4
5. Waiting Time Targets
Targets for service waiting times have been negotiated locally between ACE
and their commissioners. Whilst ACE provides no ‘consultant-led’ services, it
does provide services defined as ‘onward referral’ or ‘interface’ which provide
intermediary levels of clinical triage, assessment and treatment between
traditional primary and secondary care.
ACE also recognise that patient waiting times are a useful quality indicator
and the following services are required to report formally against a waiting
time target:
Paediatric Rehabilitation (OT & Physio)
Paediatric Speech & Language Therapy
Specialist Health Visitor and Specialist Continence
Nurse
Occupational Therapy
Physiotherapy 2
Podiatry
Speech and Language Therapy (Adult Community)
Cardiac Rehab
COPD
Diabetes - Community
Heart Failure
Home Oxygen Assessment & Support Service
Pulmonary Rehabilitation
Occupational Therapy – Learning Disabilities
Physiotherapy – Learning Disabilities
Speech & Language Therapy – Learning Disabilities
Dietetics – Learning Disabilities
MSK Tier II
Tissue Viability
Urology Service
Enuresis Service (Nurse led element not MDT)
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
18 Week
6 Week
6 Week
6 Week
6 Week
ACE has agreed with commissioners that no patient will wait longer than 18
weeks however, the following services are excluded from formally reporting
18 week RTT performance due to the service either not providing any first
definitive treatment for a clinical condition, the service receiving all of their
referred patients after they have received first definitive treatment elsewhere,
the service being a pilot (and only when it is fully established and if negotiated
will it have the 18 week clock applied) or if the service is deemed as
2
The 18 week target for Adult Physiotherapy will apply for the year 2013/14. During 2013/14
the service will work with NEECCG to explore amending the target to 6 weeks from 1/4/14.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 5
unsuitable due to the responsiveness that is intrinsic in its existence. All
services will have internal monitoring of wait times.















Children’s Community Services (HV & SchN)
Rapid Response/Child Death
Looked After Children
Immunisation Team
Breastfeeding Team
Community Matrons
Community Nursing
Intermediate Care
Falls Prevention
Trim Point Team
Treatment and Screening Co-Ordination Team (TASC)
– MRSA
Community Hospitals
Minor Injuries Unit
ESD
End of Life Care Team
6. Principles & Procedures
6.1 Reasonable Notice
Patients will be offered an initial appointment date a minimum of 7 calendar
days from date of making the appointment where patients are required to
travel to a clinic delivered from premises other than their home.
In the event of ACE having very short notice appointments available these will
be offered to patients but they may refuse appointments at less than a week’s
notice without compromising their waiting list position.
For services which offer a direct response and have no waiting list, these
principles do not apply.
The services will aim to find a date appropriate for a patient’s clinical priority
and convenient to that patient.
6.2 Clinical Urgency
Patients will be classified as either routine or urgent.

Urgent – indicates that any delay in treatment will result in a loss
of clinical outcome
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 6

Routine – indicates that no loss of clinical outcome is expected if
the patient is treated in waiting time order and within maximum
waiting time standards
6.3 Receiving Referrals
All referrals which do not come via Choose and Book will be date stamped as
received on the date of receipt by the service.
All referrals should be registered within 1 working day of receipt by the
service.
Where referrals are sent in via the Choose and Book system, the appointment
clerk for the relevant specialty must ensure that the appropriate clinician
accepts or rejects the referral within 5 working days. The 18 week RTT start
date will begin on the date the patient converts their unique booking reference
number (UBRN) either directly from the referral point (ie GP practice) or via an
Appointments Line service.
Where the referral was sent in via Choose and Book the accompanying
referral letter should be available preferably within 24 hours after the referral
is made, with a cut off period of 5 days. This letter will be printed and the
appointment details added before being sent to the relevant clinician for
acceptance and grading. Again, this should occur within 1 working day of the
referral letter being received by the service
6.4 Appointments
For an appointment to be deemed reasonable patients must be offered an
appointment with at least one calendar weeks’ notice. Patients may be
offered appointments at shorter notice but they may refuse such appointments
without compromising their waiting list position (see paragraph 6.1).
For clinically urgent appointments, two attempts to contact the patient will be
made via telephone within 2 working days of prioritisation of referral and then
an appointment will be made for them and the details posted to them.
For routine appointments, two attempts to contact the patient may be made
via telephone and then an appointment will be made for them and the details
posted to them within 5 working days of prioritisation of referral.
All appointments should be entered onto the recording system within 1
working day of the appointment being made.
All patients will be offered a choice of dates within the national waiting times
standard.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 7
For services which offer a direct response and have no waiting list, these
principles do not apply.
6.5 DNAs and Cancellations
A patient is said to have cancelled their appointment if they give more than 1
working day’s notification that they will not attend it or if they arrive more than
30 minutes late from their scheduled consultation time. A patient who does
not attend their appointment or gives less than 1 working days’ notice of nonattendance is said to have DNA’d their appointment.
When a patient DNAs an appointment the clock will be stopped. The service
will establish why the patient did not attend and they will be discharged unless
the patient is a vulnerable adult or child or there are safeguarding concerns.
If a patient cancels an appointment twice, then the patient is discharged back
to their referrer and the RTT clock stops.
If the clinician wishes to offer another appointment rather than discharge the
patient, the service lead must sanction this decision.
6.6 Vulnerable Patients and Safeguarding Issues
ACE will make every attempt to ensure that where safeguarding issues have
been identified or patients are considered vulnerable, they are supported to
attend their appointment. These patients will routinely be offered a second
appointment following DNA of a first appointment. For all referrals the clock
will be stopped following the DNA at the 1st appointment. A new RTT clock will
start on the date that the patient agrees the new appointment date
Patients who DNA a second appointment will usually be discharged back to
their GP/referrer however a clinician may at their discretion offer another
appointment rather than discharge the patient (the Service Lead must
sanction this decision).
Further guidance is available from the ACE Safeguarding Team and by
reference to ACE Safeguarding Child Protection Guidance No 5: Management
of Children and Young People Who Fail To Attend Appointments and the
Safeguarding Of Vulnerable Adults Policy.
6.7 Patients who need to leave before their consultation
Patients who attend for their appointment but have to leave prior to being
seen due to the clinic not being able to deliver their consultation within 30
minutes of their scheduled consultation time, will be offered a further date
whilst in clinic.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 8
6.8 Patients who are late for appointments
The service will attempt to see patients who attend for their appointment but
are more than 30 minutes late from their scheduled consultation time.
However, where it is not possible to see the patient, that patient will be
deemed to have cancelled their appointment.
6.9 Patients transferring from another Provider
Where a patient is transferring from another provider for the same condition
and first definitive treatment has not commenced, the patient transfers with
their original 18 week RTT start date, and their 18 week treatment target date
remains the same. The referring provider must ensure that the 18 week
minimum data set is completed and accompanies the referral into ACE
including clock start dates and any cancellation/suspension history. Only
where ACE is unable to establish the original 18 week RTT start date from the
referring provider will ACE assume that the date of referral into an ACE
service will be the date the 18 week clock starts.
Upon receipt of referral, if there is any cause for doubt that the patient will
receive definitive first treatment within 18 weeks then the Service Lead for that
service must be informed.
Patients who have received first definitive treatment at another provider who
are then subsequently referred to ACE as an ongoing part of their treatment
for the referred condition will be subject to an 18 weeks pathway through
ACE, the referral date being the date the 18 week clock starts from.
6.10 Patients transferring from the private sector to the NHS
Patients can choose to convert between an NHS and private status at any
point during their treatment without prejudice, however their treatment must
not be expedited other than for clinical reasons. Patients who are eligible for
NHS treatment and have been seen privately and ask to go on to the NHS
waiting list must be listed at the time the decision to treat is agreed with no
delays. They do not need an NHS reassessment before being added to an
NHS waiting list.
The 18 week clock continues to tick with the start date being the date that the
patient’s referral is accepted by the NHS provider.
6.11 Patients transferring to another provider
Patients may be referred out from ACE to another provider to commence or
continue their care. When this occurs the patient transfers with their original
18 week RTT start date, and their 18 week treatment target date remains the
same if ACE have not commenced first definitive treatment for the patients
referred condition. The person (admin or clinician) referring the patient on
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 9
must include their 18 week minimum data set with the information sent to the
receiving provider.
The following list of services has a traditionally high onward referral rate to
alternative providers for delivery of first definitive treatment. In order to
ensure patients receive their treatment within 18 weeks from referral these
services should endeavour to see the patient within 6 weeks of referral and,
where appropriate, to onward refer to an alternative provider within 2 working
days of that initial appointment. Performance against these standards will be
monitored for these services:




Tier 2 Musculoskeletal Service
Tissue Viability
Urology
Enuresis Service (Nurse led element, not MDT)
7.0 Entitlement to NHS Treatment
It will be assumed that patients that are referred from an external source (e.g.
GPs, acute trust etc) will have had their eligibility to receive NHS treatment
confirmed by that external source and therefore ACE will only check eligibility
for those patients that self-refer to an ACE service.
For patients that self-refer to an ACE service and for patients that have no
NHS number, ACE will check every patient’s eligibility to receive NHS
treatment in accordance with and following the guidance contained within the
Department of Health website.
8.0 Responsibility for achieving waiting times standards
It is the Assistant Directors Operations responsibility to ensure that patients
do not breach the national and locally agreed waiting times standards in their
service areas. They must liaise with relevant staff to ensure that patients are
booked on time, with sufficient notice, and in order and that each patient’s
treatment status is accurately recorded at every stage in their pathway
9.0 Approval and ratification process
The policy is approved and ratified by the Management Executive Committee
10.0 Dissemination and implementation process
This policy will be shared via the intranet. Training for RTT will be delivered by
the SystmOne team.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 10
Appendix 1
Brief descriptions of each of these possible stages along the treatment
pathway
Starting the Clock
Referral received
(Status Code: First Activity 10)
An RTT clock starts on the date that a referral for a patient is received by the
service.
Transfer from another healthcare provider
(Status Code: First Activity 10)
A patient will sometimes be transferred from another healthcare provider
without having received first definitive treatment from that provider. In this
case their original RTT clock continues and their original RTT date remains
valid for ACE.
Transfer from a consultant-led service within another healthcare
provider
(Status Code: Referral from Consultant 12 / Subsequent Activity 20)
A patient will sometimes be transferred from a consultant led service within
another healthcare provider without having received first definitive treatment
from that provider. In this case their original RTT clock continues and their
original RTT date remains valid for ACE.
Stopping the Clock
First definitive treatment given - Clock stop
(Status Code: First definitive treatment 30)
This is the point at which the patient receives their first definitive treatment. A
patient’s First Definitive Treatment is an intervention intended to manage a
patient’s disease, condition or injury and avoid further intervention. This stops
the RTT clock started by the referral.
Transfer to another healthcare provider
(Status Code: 21)
A patient will sometimes need to be transferred to another healthcare provider
without having received first definitive treatment from ACE. In this case their
original RTT clock continues and their RTT date remains valid for the new
provider. This is an Inter Provider Transfer and the service will complete an
Inter Provider Transfer (IPT) Administrative Minimum Data Set form.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 11
Following transfer to the other provider, the RTT clock will be stopped using
Code 34 ‘Decision Not to Treat’.
Patient DNAs first appointment
(Status Code: Patient DNA 33)
When a patient DNAs their first appointment following the initial referral, the
clock will be stopped. The service will establish why the patient did not attend
and they will be discharged unless the patient is a vulnerable adult or child or
there are safeguarding concerns.
Where it is more appropriate not to discharge the patient, the service will offer
the patient another appointment and a new RTT clock will start on the date
that the patient agrees the new appointment date
If the patient DNA’s a second appointment they will usually be discharged
back to the referrer and the clock stopped. If the clinician wishes to offer
another appointment rather than discharge the patient, the Service Lead must
sanction this decision.
Further guidance is available from the ACE Safeguarding Team and by
reference to ACE Safeguarding Child Protection Guidance No 5: Management
of Children and Young People Who Fail To Attend Appointments and the
Safeguarding Of Vulnerable Adults Policy.
Patient DNA’s any other appointment prior to first definitive treatment
(Status Code: Patient DNA 33)
When a patient DNAs any other appointment, prior to first definitive treatment,
the clock will be stopped. The service will establish why the patient did not
attend and they will be discharged unless the patient is a vulnerable adult or
child or there are safeguarding concerns.
Where it is more appropriate not to discharge the patient, the service will offer
the patient another appointment and a new RTT clock will start on the date
that the patient agrees the new appointment date
Patient cancels an appointment twice in a single pathway - Clock stop
(Status Code: Decision not to treat 34)
If a patient cancels an appointment twice (ie notifies the service of nonattendance more than 24 hours before the appointment is scheduled)
regardless of whether it is a first or subsequent appointment, then the patient
is discharged back to their referrer and the RTT clock stops. If the clinician
wishes to offer another appointment rather than discharge the patient, the
service lead must sanction this decision.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 12
Patient declines or fails to comply with advised/offered treatment - Clock
stop
(Status Code: Patient Refused Treatment 35)
Where a patient refuses to accept the treatment offered or comply with
advised treatment this will constitute a clock stop. However, if the patient is
considered vulnerable, and discharging them from the service is
inappropriate, a period of active monitoring can be implemented.
Patient unfit for treatment - Clock Stop
(Status Code: Decision not to treat 34)
If a patient is unfit for treatment and the period of sickness is likely to be more
than 3 weeks, the patient may be discharged back to the original referrer until
deemed fit for treatment
Patient unfit for treatment – Clock Continuation
If the patient is expected to be unfit for up to 3 weeks their RTT clock will
continue to run. The service will record an ‘Earliest Clinically Appropriate
Date’ which will be used to calculate the actual waiting time. Patients showing
as waiting longer than the RTT target time in these circumstances will not be
considered a breach.
Decision not to treat/ no treatment required - Clock stop
(Status Code: Decision Not to Treat 34)
This would typically involve discharge back to the GP / referring agent, where
it is not appropriate to start an Inter Provider Transfer.
Patient Died - Clock stop
(Status Code: 36)
The patient’s referral would be closed and the patient discharged which stops
the RTT clock.
Inappropriate Referral – Decision not to treat
(Status Code: 34)
If a referral is deemed in appropriate the referral will be returned to the
referrer and the clock stopped.
Active Monitoring
Start of a period of active monitoring initiated by the patient or the Care
Professional - Clock stop
(Status Code: Patient-Led Activity Monitoring 31; Clinician-Led Activity Monitoring 32)
Active monitoring is where it is clinically appropriate to monitor the patient
without clinical intervention or further diagnostic procedures, or where a
patient wishes to continue to be reviewed as an outpatient, or have an open
appointment, without progressing to definitive treatment.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 13
Active monitoring can be initiated by either the patient or the clinician. The
start of a period of active monitoring stops the RTT clock started by that
patient’s initial referral.
It is not appropriate to use active monitoring for patients that wish to delay an
appointment.
End of active monitoring - Clock start
(Status Code: Activity monitoring ended 11)
If after a period of active monitoring, the patient or the Care Professional then
decides that treatment is now appropriate, a new RTT clock starts. This new
clock starts at 0 weeks; it does not restart at the point at which the previous
clock was stopped. There is then a new RTT period in which the patient must
receive their first definitive treatment.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 14
Appendix 2
Status Codes
The following treatment status codes are available and one must be recorded:
Code Clock Status
10
First Activity
11
12
Active
monitoring
ended
Referral from
Consultant
20
Subsequent
activity
21
Transfer to
another
provider
30
First definitive
treatment
31
Patient led
active
monitoring
Treatment Status
First activity in a RTT period where the First Definitive
Treatment will be a subsequent activity
The start of a new RTT period (following a decision to
treat) after a period of active monitoring has been
ended
RTT status used following a referral in (inter provider
transfer) from a consultant led service where the RTT
clock has already started for the same condition
An activity after the clock has started for an inter
provider transfer in but before the first definitive
treatment or decision to stop the clock
RTT status used if the patient is being transferred to
another provider (inter provider transfer). A further
RTT status code (34 Decision Not to Treat) must also
be added to the pathway in order to stop the clock.
First definitive treatment is the first clinical
intervention intended to manage a patient’s disease,
condition or injury and avoid other clinical
interventions. What constitutes first definitive
treatment is a matter of clinical judgement in
consultation with others, where appropriate, including
the patient.
Active Monitoring will commence when a decision is
made (and agreed with the patient) that it is clinically
appropriate to start a period of monitoring, possibly
whilst the patient receives symptomatic support, but
without any specific or significant clinical intervention
at this stage. The start of Active Monitoring will end a
RTT period. If a decision to treat is made during
Active Monitoring, this will end the Active Monitoring
and will start a new RTT period.
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
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32 Clinician led
active
monitoring
33 Patient DNA
34 Decision not
to treat
35 Patient
refused
treatment
36 Patient died
Active Monitoring will commence when a decision is
made (and agreed with the patient) that it is clinically
appropriate to start a period of monitoring, possibly whilst
the patient receives symptomatic support, but without any
specific or significant clinical intervention at this stage.
The start of Active Monitoring will end a RTT period. If a
decision to treat is made during Active Monitoring, this will
end the Active Monitoring and will start a new RTT period.
When a patient DNAs the clock should be stopped. The
service needs to establish the reason why the patient
DNA’d the appointment. Where it is more appropriate not
to discharge the patient, the service needs to offer the
patient another appointment, then the RTT clock can be
nullified and a new RTT clock would start on the date that
the patient agrees the new appointment date. If no further
appointment is offered the patient will be discharged.
The service decides not to treat in accordance with the
access policy and discharges the patient back to the
referrer.
Patient declined the offered treatment
Patient dies before treatment
22 November 2013
Owner: Director of Operations
Approved by: Quality and safety Assurance Group
Review Date: 31 March 2015
Page 16
Appendix 3
REFERRING ORGANISATION TO COMPLETE AND SEND WITH REFERRAL
Referring Organisation Name:
Code:
Referring Organisation
Referring Clinician:
Contact Name:
Referring Treatment Status Code: 21
Contact e-mail:
Contact Phone Number:
PATIENT DETAILS
Patient's Surname:
Patients Forename:
Patients Title:
Date of Birth:
NHS Number:
REFERRAL TO TREATMENT INFORMATION
Patient Pathway Identifier:
(Generated with original referral)
Allocated by:
(Org code that receive original
referral that started the clock)
Is the patient on an 18 weeks RTT pathway? YES / NO
Is this referral the:
* Start of a new pathway (new condition or change of treatment)
* Continuation of an active pathway (1st definitive treatment not given)
Date of decision to refer to receiving organisation:
Clock Start:
(Date patient started on existing pathway or the date of this referral if it starts a new
pathway)
List of all organisations involved in the 18 weeks pathway:
Receiving Organisation details:
Name:
Date received: