Patient Access Policy
(Integrated Waiting List Management)
Developed in response to:
Contributes to Regulation
Type: Policy
Register No: 04055
Status: Public
18 weeks Rules and Guidance, Cancer Waits Guidance
NHS Operating Framework, Cancer Waiting Times
Guidance 1.0 November 2015
9, 12, 17
Consulted
Post/Committee/Group
Date
Lisa Marshall
Head of Acute Commissioning, Mid Essex CCG
August 2016
James Wilson
Deputy Director Clinical Commissioning, Mid Essex CCG
August 2016
Sandra Milligan
Mid Essex CCG
August 2016
Elizabeth Podd
Deputy Director of Commissioning, MEHT
August 2016
Penny Pickman
Head of Outpatients and Patient Access, MEHT
August 2016
Lesley Simpson
Interprovider Office Coordinator (Overseas & Private
Patients), MEHT
September 2016
Clive Gibson
Lead Nurse Safeguarding Adults & Dementia, MEHT
October 2016
Sandra Morton-Nance
Learning Disabilities Nurse Specialist, MEHT
October 2016
Robert Ghosh
Chief Medical Officer, MEHT
October 2016
Cathy Geddes
Chief Nursing Officer, MEHT
October 2016
Helen Clarke
Head of Governance, MEHT
October 2016
Professionally
Approved By
Technically
Approved by
Spencer Humphrys, Associate
Director of Operations (RTT)
Version Number
Issuing Directorate
Ratified by:
Ratified on:
Executive Management
Board Sign Off Date
Implementation Date
Next Review Date
Author/Contact for
Information
Corporate
Spencer Humphrys, Associate Director of Operations (RTT)
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Policy to be followed by
(target staff)
Distribution Method
Related Trust Policies (to be
read in conjunction with)
Outpatient Booking Officers, Patient Access Officers,
Medical Secretaries, Cancer Services Administrative and
MDT Coordinators
Intranet, Internet and website
13032 Pre-Operative Preparation Policy
Document Review History
Version
Brief Reason for Change or
No
Update
3.0
3.2 WD
4.0
4.3 WD
Working Draft
5.0
5.2
National RTT Programme actions
WD
5.3WD
5.4 WD
5.5 WD
Working Draft
Correction of wording section 8.5;
reduced the time of non-clinical
unavailability prior to discharge
to 21 days to match the clinical
guidelines; updated the overseas
section; updated the ‘Booking a
TCI’ section to match the updates
elsewhere in booking and contact
processes
Reviewed by
Active Date
Penny Pickman
Penny Pickman
Penny Pickman
March 2007
October 2009
July 2010
10 July 2014
31st July 2014
January 2016
Spencer
Humphrys
Penny Pickman
Spencer
Humphrys
10 June 2016
15th September 2016
27th September 2016
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Index
1.0
Purpose
Aims
Scope
National Operating Standards
RTT Access Policy – Quick Guide
1.1
2
3
Principles of the Access Policy
General points
2.1
Patients who are un-contactable
2.2
Patients who Did Not Attend (DNA) appointments
2.3
Patients cancelling appointments
2.4
Short Notice appointments
2.5
Reasonable offers
2.6
Clock Stops
2.7
Notice of Annual Leave and Study Leave
Outpatients
3.1
Methods of Referral
3.1.1
Traditional Referral Letters
3.1.2
E-Referrals (Choose & Book)
3.1.3
Central Referral Service (CRS)
3.1.4
TAL (Telephone Appointments Line) Referrals
3.1.5
Tertiary referrals
3.1.6
Consultant Referrals to other Trusts
3.1.7
Consultant Referrals from other Trusts
3.1.8
Consultant to Consultant Referrals within this Trust
3.1.9
Inappropriate referrals
3.2
Registration
3.3
18 week RTT Booking Timescales
3.4
Ministry Of Defence Patients
3.5
Private Patients
3.6
HM Prison Patients (HMP)
3.7
Overseas Visitors
3.8
Clinic Management
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4
3.8.1
Booking Capacity
3.8.2
Clinic Cancellations/Reductions/Reinstatements
3.8.3
Template Management
3.8.4
Follow up appointments
3.8.5
Partial Booking
3.8.6
Hospital Initiated Cancellations
3.8.7
Attendance Outcome Coding including DNAs and Cancellations
3.8.8
Discharge in an Outpatient setting
Elective Inpatients and Day Cases
4.1
Pre-operative assessment
4.2
Patients deciding about surgery
4.3
Decision to Admit
4.4
Adding patients to the Elective Waiting List
4.5
Who may select a patient for Admission from a Waiting List?
4.6
Bilateral Procedures
4.7
Patients from Satellite and Network Clinics
4.8
Adding Patients Seen Privately
4.9
Missed off the Waiting List
4.10
Process for Selection
4.11
Expedite Requests
4.12
Planned Waiting List
4.13
Electronic Waiting List documents (Inpatient/Day case)
4.14
Booking a TCI date
4.15
18 Week Clock New Clock
4.16
Hospital Cancellations of Operation on the day
4.17
Hospital Cancellations of Operation before the day
4.18
28 Day Rule
4.19
Patients Who Move Out Of the Area
4.20
Transfer of Treatment to another Consultant
4.21
Transfer between Waiting Lists within the Trust
4.22
Transfer to another NHS Provider/Private or Independent Hospital
4.23
Active Monitoring
4.24
Referrals which do no not start a clock
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5
Procedures which require Funding from the CCGs
6
Diagnostics
7
Entitlement to NHS treatment
8
Transfer of Private Patients
8.1
Patients Transferring from Private to NHS
8.2
Patients Transferring from NHS to Private
9
Monitoring of compliance
10
Reporting Breaches of the Policy
11
Implementation and Communication
12
Glossary and Definitions
Appendix A: Standard Operating Policies for Outpatients and Patient Access
Appendix B: Duties and responsibilities
Appendix C: Policy development
Appendix D: Policy delivery
Appendix E: Chief Executive Letter
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1.0
Purpose
The best interests of the patient are foremost and the Trust intends to ensure
efficient and equitable handling of referrals in line with waiting time standards and
the NHS Constitution. The Constitution sets out your rights as an NHS patient.
These rights cover how patients access health services, the quality of care you’ll
receive, the treatments and programmes available to you, confidentiality, information
and your right to complain if things go wrong. The constitution can be found by going
to https://www.england.nhs.uk/2013/03/26/nhs-constitution.
The purpose of this policy is to outline the Trust and Commissioner Requirements
and operating standards for managing patient access to secondary care services for
patients from referral to treatment, and discharge to primary care.
The policy covers the processes for booking, notice requirements, patient choice and
waiting list management for all stages of a referral to treatment pathway. Giving
patients more choice about how, when and where they receive treatment is one that
requires us to offer a more responsive service to our patients needs through quality
assurance. The length of time a patient waits for hospital treatment is an important
quality issue and is a visibly and public indicator of the efficiency of the hospital
services provided by the Trust.
This policy provides the basis for giving patients equitable access to health care,
whilst applying agreed rules and conditions that will help facilitate the delivery of
National targets and local contractual requirements. All targets defined within this
policy are in line with National standards. The Trust will ensure that the management
of patient access to services is transparent, fair and equitable and managed
accordingly to clinical priority. The policy will be applied consistently and without
exception across the Trust to ensure equity amongst its patients whilst taking
account of their clinical need.
This policy applies to all administration and clinical prioritisation processes relating to
patient access, including outpatient, inpatient, day case, therapies and diagnostic
services. Treating patients, delivering a high quality and efficient service as well as
ensuring prompt communication with patients are core responsibilities of the hospital
and the wider local health community.
This policy should be adhered to by all staff within the Trust who are responsible for
referring patients, managing referrals, adding to and maintaining waiting lists for the
purpose of progressing a patient through their treatment pathway.
Aims
The Patient Access Policy aims to:
•
•
Establish a clear and consistent approach for patient access by defining the
means by which patients may be referred to Trust services
Describe how the Trust will manage access to its services and ensure that the
pathway to treatment is fair for all and is compliant with the 18-week Referral to
Treatment (RTT) rules
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•
•
•
•
•
Ensure that patients receive treatment according to their clinical priority; both
suspected cancer patients and routine patients with the same clinical priority are
treated in chronological order, thereby minimising the time a patient spends on
the waiting list and improving the quality of the patient experience
Support the reduction in waiting times, reduction in cancelled operations and the
achievement of relevant waiting time targets
Improve the patient experience by reducing DNA’s (Did not attend) and
cancellations.
Provide a framework by which administration of waiting lists and bookings will be
managed.
Ensure that all the information relating to the number of patients waiting, seen
and treated is accurate and recorded on PAS (Patient Administration System)
and Somerset Cancer Register (SCR) for suspected cancer patients. The advice
given in the policy is, at all times, consistent with the national 18 Weeks rules
Scope
This policy applies to adult patients 16+. Children & Young Peoples access is
managed separately.
This policy only applies to the management of elective episodes of care. For the
management of Cancer pathways and access standards, please refer to the Cancer
Access and Operational Policy (available on the intranet)
All patients (except those on a cancer pathway) must be seen, diagnosed and
treated within 18 weeks from Referral to Treatment (RTT).
Wherever possible, the principles for patients on an 18 week pathway partial and full
booking will be applied and patients will be encouraged to agree their appointment
and admission dates and times in advance of their booking arrangements. The Trust
recognises that recommendations for good practice specify the notice period to
patients for these arrangements should where possible be a minimum of 3 weeks
with two dates offered.
The Trust will therefore expect that referring clinicians will have alerted their patients
to the appropriate pathway rules before the referral is made and will further highlight
to their patients the importance of them being available for any such appointments,
tests and admissions that may be required along the pathway. Full booking applies
to any new patients contacted and booked within 48 hours of their referral into the
Trust and also applies to rapid access patients. It also applies to any patient who
agrees the booking of their follow-up appointment when they leave the department
after their clinic appointment.
Wider and more detailed information on procedures is available through a range of
Patient Information Leaflets that are produced by the Trust for the patient.
National Operating Standards
95% of non-admitted patients will receive their first definitive treatment within 18
weeks of their initial referral.
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90% of admitted patients will receive their first definitive treatment within 18 weeks of
their initial referral.
92% of open pathways will be under 18 weeks (this has become the sole measure of
elective performance nationally)
There is no provision to pause or suspend an RTT waiting list clock under any
circumstances.
No patient will wait any longer than 6 weeks for a diagnostic test or procedure from
the date the decision is made.
1.1 Principles of the RTT Access Policy
Patients will be treated in order of clinical priority, and then in chronological order to
ensure equity of waiting times
We must take great steps to ensure the safety of vulnerable patients. As such,
children and vulnerable adults (including those in prison) are to be managed
differently to the standard policy. Where we would normally apply a waiting list
cancellation or DNA, these instances require further discussion with the patients
consultant and/or the safeguarding team to ensure clinical judgement is applied
We will keep patients fully informed of their journey throughout their journey. This will
include (but is not limited to):
Writing to the patient and their GP with the reasons regarding any waiting list
cancellation or discharge
Writing to the patient to inform them that they have been placed on a planned waiting
list, the rationale, and their expected admission date (EAD)
All offers, including rejected ones, must be entered and recorded on PAS as they are
made
Once a waiting list entry is closed, this should only be reinstated on an exceptional
basis which will first require approval by the inpatient manager, outpatient manager
or the Head of Access. If a patient changes their mind regarding going ahead with
surgery or is now deemed fit for surgery, a new waiting list entry should be created
on PAS
A DNA (Did Not Attend) is where a patient does not attend any appointment (TCI,
pre-op, diagnostic etc.) where they were given reasonable notice of the appointment
and did not let the Trust know of their non-attendance
A reasonable offer is defined as an offer with at least 21 days’ notice for
appointments from the date of offer to the date of appointment. Alternatively, an offer
is considered reasonable if a patient verbally accepts the offer of an appointment
with less than 3 weeks’ notice.
If a patient verbally accepts a short notice appointment, they must be made aware
that this will be recorded as a reasonable notice and accepted appointment
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Patient cancellation of appointments are deemed reasonable if:
•
•
For an outpatient appointment (including pre-op and diagnostics) the patient
contacts the Trust with 24 or more hours’ notice of their appointment day and
time
For an inpatient procedure (including day case procedures) the patient contacts
the Trust with seven days or more notice of their appointment day and time
Cancellation of any appointment with less notice than the above is deemed short
notice as the Trust is unlikely to be able to bring in an alternative patient to that
appointment, thus negatively impacting timeliness of treatment for other patients
For any procedure that requires funding, funding must be granted prior to the patient
being added to the waiting list
After having their clock stopped for any Reason Other Than Treatment (ROTT), any
patient can self-refer back to MEHT within 8 weeks for treatment of the same
condition, this will start a new clock from the day the patient contacts us. A clinical
decision will then be taken as to where they enter their journey again (i.e. if they
require a review OPD appointment before proceeding to the next stage of treatment)
General
Event
Impact on
clock
Action
RTT status
Patient is unavailable
(for clinical reasons)
for 21 days or longer
 Stop
Discharge to GP
1 – Discharge
Patient is unavailable
(for non-clinical
reasons) for 21 days
or longer
 Stop
Discharge to GP
1 – Discharge
Patient DNAs any
two appointments
(including diagnostics  Stop
and pre-op) in
journey
Discharge to GP
20 – DNA
discharge and
letter to GP
Patient cancels any
two appointments
(including diagnostics
 Stop
and pre-op) at short
notice throughout
their journey
Discharge to GP
1 – Discharge
Patient declines two
 Stop
Waiting List
Record all offers and discharge Cancellation
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reasonable notice
appointment offers
(e.g. OPD
appointment; TCI
date; pre-op
appointment)
Patient is uncontactable 1 for any
part of their pathway
Patient listed for
bilateral or
consecutive
procedures
back to their GP. GP or patient
can refer back when fit and
ready for treatment.
(WLC)

Continue
Send a ‘call-in’ letter to the
patient requesting the patient
calls the Trust within 14
calendar days. If they do not
contact the Trust within this
time, they will be discharged
back to their GP
1 – Discharge

Continue
When a patient is listed for
bilateral or consecutive
procedures, the first procedure
is to be added to the Inpatient
Waiting List (IPWL) and the
second or next consecutive
treatment is to be added to the
planned waiting list at the
same time
29 – On-going
pathway
 Stop
If on discussion with the
Consultant the pathways
conflict (i.e. one pathway must
be complete before the can
start) the patient should be
added to the planned waiting
list for the second procedure
Add to
planned
waiting list

Continue
If on discussion with
Consultant the pathways don’t
conflict (i.e. treatment can
occur simultaneously) all
clocks continue
29 – Ongoing
pathway
Patient is on multiple
separate clinical
pathways
1
A patient will be deemed as un-contactable after two attempts have been made to contact them, with at least
3 days separating the attempts, and at least one call being made after 17:00 on a weekday or at the weekend
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Outpatient Department
Event
Impact on
clock
Action
RTT status
Patient DNAs their
first new outpatient
appointment
 Stop
Discharge to GP 2
20 – DNA
discharge and
letter to GP
Patient is referred to
another Trust for
treatment
 Stop
Medical Secretary to complete
MDS form
28 – Clock
stop BMFD
Patient is referred to
another Trust for
opinion/review

Continue
Medical Secretary to complete
MDS form
29 – Ongoing
pathway
Discharge back to
GP
 Stop
Discharge to GP
1 – Decision
not to treat

Continue
Referral discharged once new
referral is on PAS
18 – Refer to
Clinician.
Same
condition
 Stop
Referral stopped, referral
discussed with Consultant and
if not clinically urgent (i.e.
cancer) the patient is to be
discharged to GP for the GP to
decide if referral warranted
1 – Discharge
Impact on
clock
Action
RTT status

Continue
Do not put patient on waiting
list. Patient given seven
calendar days to make a
29 – Ongoing
decision and call MEHT. MEHT pathway
to call patient on eighth day (if
the patient has not called) for
answer. If the patient wants to
Patient is referred to
a different specialty
for the same
condition
Patient is referred to
a specialty (same or
different) for a
different routine
condition
Elective Admissions
Event
Patient would like
time to consider if
they want to go
ahead with surgery
2
As stated in the general principles, if the patient is a child, vulnerable adult or on a cancer pathway, they
must be treated differently and offered a further appointment
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proceed, clock remains
 Stop
If patient decides not to
proceed with surgery (either by
calling in, or when called on
the 8th day), clock is to be
stopped
Waiting List
Cancellation
(WLC)
 Stop
If patient is un-contactable on
the eighth day, place on active
monitoring until the patient can
be reached for a decision and
then action as above. If the
patient is un-contactable 3, a
call in letter is to be sent to
patient requesting they contact
us within 14 calendar days. If
no contact, the patient will be
removed from the waiting list
and discharged back to their
GP
Active
monitoring
 Stop
If a patient wants longer to
think about surgery, place the
patient on active monitoring for
a further period 2 weeks
Active
monitoring
Patient cancels two
reasonable notice
TCI dates
 Stop
Remove from waiting list and
discharge to GP
Waiting List
Cancellation
(WLC)
Patient DNAs a TCI
date or cancels their
TCI date on the day
for a non-urgent /
unforeseen reason 4
 Stop
Remove from waiting list and
discharge to GP
Waiting List
Cancellation
(WLC)
3
A patient will be deemed as un-contactable after two attempts have been made to contact them, with at least
3 days separating the attempts, and at least one call being made after 17:00 on a weekday or at the weekend
4
Any patient potentially to be Waiting List Cancelled for on the day cancellation of their TCI date must be
discussed and agreed with the Inpatient Supervisor, Head of Patient Access or Associate Director of
Operations (RTT) prior to cancellation
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2 General points
2.1
Patients who are un-contactable
• A patient will be deemed as un-contactable after two attempts have been made to
contact them, with at least 3 days separating the attempts, and at least one call
being made after 17:00 on a weekday or at the weekend
• If the patient is un-contactable, a call in letter is to be sent to patient requesting they
contact us within 14 calendar days. If no contact, the patient will be removed from
the waiting list and discharged back to their GP
2.2
Patients who Did Not Attend (DNA) appointments
• A DNA (Did Not Attend) is where a patient does not attend any appointment (TCI,
pre-op, diagnostic etc.) where they were given reasonable notice of the appointment
and did not let the Trust know of their non-attendance
• A reasonable offer is defined as an offer with at least 21 days’ notice from the date of
offer to the date of appointment. Alternatively, an offer is considered reasonable if a
patient verbally accepts the offer of an appointment with less than 3 weeks’ notice.
o If a patient verbally accepts a short notice appointment, they must be made
aware that this will be recorded as a reasonable notice and accepted
appointment
• Patients who do not attend (DNA) any appointment will need their pathway reviewed
and the following actioned:
o If the DNA was of the first outpatient appointment and reasonable notice was
given, they will be reviewed with the clinician and if not against the patients
best clinical interests discharged back to the GP and the clock stopped.
 If the patient is a child, vulnerable adult or on a fast track pathway they must
be given a second appointment
o If the DNA was a second DNA within the patients pathway (for any
appointment), they will be reviewed with the clinician and if not against the
patients best clinical interests discharged back to the GP and the clock
stopped
• If a further appointment is to be offered, the outpatient clock will restart from the date
the hospital and patient agree on a new appointment date.
• This decision must be made immediately to ensure that the appropriate RTT
outcome is recorded on PAS.
• If they are subsequently re-referred by their GP/GDP this would constitute a new
RTT clock start.
• New referral patients from other referring clinicians (e.g. consultant to consultant) will
also be referred back to the original referrer.
• E-referral patients who DNA follow the same pathway.
2.3
Patients cancelling appointments
• A patient may cancel their appointments as long as they give reasonable notice to
the Trust which allows us to use their space for another patient
• Patient cancellation of appointments are deemed reasonable if:
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• For an outpatient appointment (including pre-op and diagnostics) the patient contacts
• the Trust with 24 or more hours’ notice of their appointment day and time
• For an inpatient procedure (including day case procedures) the patient contacts the
• Trust with seven days or more notice of their appointment day and time.
o Cancellation of any appointment with less notice than the above is deemed
short notice as the Trust is unlikely to be able to bring in an alternative patient to
that appointment, thus negatively impacting timeliness of treatment for other
patients
• After a first short notice cancellation, the patient must be made aware that any
further short notice cancellations may result in them being discharged back to their
GP
• If a patient cancels two appointments with short notice throughout their journey they
will be clinically reviewed by their consultant and discharged back to their GP if it is
not against their best clinical interests
• As with patients that DNA as stated in our principles, children under the age of 18 or
Vulnerable Adults will be given greater leeway and offered a further appointment
2.4
Short Notice appointments
Appointment slots that become available at short notice will be offered in the first instance
to the next clinically urgent patient. If the slot cannot be filled by a clinically urgent patient
then it will be offered to appropriate routine patients who have been waiting the longest and
are willing to accept short notice.
2.5
Reasonable offers
• In accordance with the national guidance a ‘reasonable offer’ of admission involves
giving a patient the offer of 2 dates with at least 3 weeks’ notice of their appointment
from the date offered
• All dates offered are to be recorded on PAS/contact sheet
• If patient declines 2 reasonable offers, the patient will be removed from the waiting
list and referred back to the GP
• If a patient verbally accepts an appointment with less than three weeks’ notice, this is
also considered a reasonable notice offer
2.6
Clock Stops 
• Where there is a clinical reason why it is not appropriate to continue to treat the
patient at that stage, but to refer the patient back to primary care for on-going
management, then this constitutes a decision not to treat and should be recorded as
such and also stops a clock.
• Clock stops including (but are not limited to):
o When the patient receives the first treatment for the condition for which they
have been referred
o Patients who decline two reasonable offers for any appointments
o Patients who are clinically unavailable for 21 days or more
o Patients who are unavailable (for non-clinical reasons) for 21 days or more
o Patients who cancel two appointments throughout their journey at short notice
o Patients who DNA their first appointment
o Patients who DNA any two other appointments throughout their journey
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o Patients who DNA their TCI date or cancel the TCI date on the day for nonurgent reasons
• All patients will be managed according to their clinical urgency, and within the
operating standard. An admitted pathway means that the patient requires admission
to hospital, as either a day case or as an inpatient to receive their first definitive
treatment. A non-admitted pathway means that the patient receives their first
definitive treatment in outpatients i.e. a prescription for medication to treat the
referred condition.
• You can also have clock stops for non-treatment. The following are examples where
a patient’s clock stops for non-treatment reasons:
o Patient is returned to primary care as secondary care is not required i.e. the
condition can be managed by their GP
o A clinical decision is made to start a period of active monitoring (also known
as watchful wait)
o The patient could decline any treatment
o A clinic decision is made that treatment is not needed for any reason
• Whether it be clinical or patient decision to stop the clock for non-treatment, a letter
is to be sent to the patient and the patient’s GP
2.7
Notice of Annual Leave and Study Leave
• A minimum of 6 weeks’ notice of planned annual, study leave or On-Call
commitments must be given when a clinician requests a scheduled session (clinic or
theatre list) to be cancelled or reduced.
• Nothing is to be cancelled or reduced without the Service Managers approval
• All leave taken with less than 6 weeks’ notice must have a contingency plan for
seeing patients, i.e. another clinic or doctor.
• It is only after these actions that the authorised request should be actioned
3
Outpatients 
• Patients are administrated through the outpatient part of the RTT (Referral to
Treatment) pathway in three main stages. They are Registration, Booking and
Attendance.
• It is the function of the Referral Booking Management Service (RBMS) to ensure that
procedures are followed in order to appropriately record and code each of the three
stages; ensure compliance with the RTT rules and ensure that the Trust discharges
its clinical obligations within the appropriate time scales.
• The key outpatient internal operating standard is for not patient to have to wait more
than 8 weeks to first outpatient appointment, achieved on a disaggregated basis (i.e.
by specialty). The General Principles for Outpatients are that:
o Patients are seen in the order of clinical priority and date on the PTL.
o Patients have a single point of contact at the Trust – Referral Booking
Management Service for Outpatients and Patient Access Team for inpatients
and day cases.
o All referrals should be registered on PAS at the point of receipt of letter.
o Referrals should be accepted or rejected as appropriate within 5 working days
by the consultant and amended on PAS and e-referral if required.
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o There must be a new referral for a patient with an existing condition if the
request for further consultation is within 6 months (SOS) of the discharge from
the originating referral i.e. open appointments.
o Staff must abide by the parameters of the clinic structure (template) available,
unless vacancies occur thereby swapping new and follow up slots accordingly
to ensure full utilisation is maintained. This must only be done in conjunction
with the outpatient booking teams and the consultants.
o Cancelled slots must be given to the next longest waiting patient
o The Trust will operate a waiting list system based on taking patients in turn
except for emergencies and cancer patients.
o Patients should be given appointments in date order to ensure equity of
access
o When making the appointment, the booking on PAS must be linked to the
appropriate referral which has already been logged. Staff must ensure that
duplicate referrals are not created as this cause double counting and
miscalculation of a patient’s waiting time.
o The patient will be sent a confirmation letter or contacted by telephone
regarding their booked appointment. The letter must be clear and informative
and should include a point of contact to call if they have any queries or
concerns. The letter should explain clearly the consequences should the
patient cancel or fail to attend at the designated time.
o Where cancellations are initiated by the Trust , patients should be rebooked
as close to their original appointment as possible, i.e. within the Trusts internal
milestones.
o The policy of this Trust is that 6 weeks’ notice of clinic cancellations must be
given. Service managers must give authorisation for cancellations under 6
weeks.
3.1
Methods of Referral
3.1.1 Traditional Referral Letters 
•
•
•
Written referral letters may be received from GDPs and GPs who do not have
access to the E-referral facility. Submission of the full set of patient demographic
detail is required including home, work and mobile numbers.
Letters should be addressed to the Mid Essex Referral Centre rather than the
respective Consultants as this would create an unnecessary delay with the
processing of the referral. Letters, which are addressed to consultants, should be
sent on to the Mid Essex Referral Centre for scanning and processing.
Each letter must be date stamped on receipt. The clock start date recorded on
the PAS will be the date the referral letter is received by Mid Essex Referral
Centre.
3.1.2 E-Referrals (Choose & Book) 
•
Referrals and Bookings made via this means will be received on the basis that
the clinical letter will follow the referral via the Electronic Booking Service (EBS),
if not immediately, within 7 working days for routine referrals, 1 day for Fast Track
referrals, of the creation of the Unique Booking Reference Number (UBRN). The
referral letter will be sent as an attachment to the electronic referral within EBS.
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•
•
•
•
•
E-referral referral letters may not be printed anywhere else but centrally within the
Mid Essex Referral Centre. A paper copy is therefore not required and should not
be sent to the Trust. The recognised RTT start date in this instance is the date
the UBRN is converted to an appointment and is done automatically on the PAS.
Clinicians should review and accept or reject referrals within 5 days of receipt of
the e-referral letter appearing on their e-referral work list.
Clinicians are encouraged to nominate a deputy to undertake review of ereferrals in their absence however, if this is not carried out patients will be booked
a clinic appointment for attendance and must be seen.
If the UBRN cannot be converted into a booking, it can be deferred to the Trust
and becomes an Appointment Slot Issue. This happens in real time and a slot
must be found by the Trust so that it can be booked as soon as possible.
The 18-week clock starts the day the UBRN was deferred to the Trust.
Note: E-referrals may only be rejected on clinical grounds; if an e-referral is rejected the
GP/CRS (Central Referral Service) they will in turn notify the patient.
3.1.3 Central Referral Service (CRS)
•
•
•
•
Referrals are sent from the GP’s electronically by either fax or email.
Referrals are then triaged by local GP’s with special interests e.g. Cardiology,
Dermatology within 7 working days.
The patient will be contacted by one of the CRS administrative team to book an
appointment using the E-referral system. If unable to reach the patient on the
contact numbers provided a hospital request letter will then be sent to the patient.
The letter will include a list of choice providers for their appointment.
The patient will be advised to make their appointment via the E-referral National
Booking Service which can be accessed by either the Internet or Telephone.
3.1.4 TAL (Telephone Appointments Line) Referrals 
•
CRS/GP’s who are using the E-referral facility but unable to book an appointment
either due to service restriction or system breakdown can refer via email to the
TAL appointment account [email protected].
3.1.5 Tertiary referrals 
•
In order to ensure appropriate RTT pathway clock starts, all tertiary referrals will
be processed through the Mid Essex Referral Centre.
3.1.6 Consultant Referrals to other Trusts 
•
Tertiary referrals to other trusts must only be made when directly related to the
original referral reason. It must be made on the standard Letter manager
Template on Info-flex and a completed MDS (minimum data set) sent.
3.1.7 Consultant Referrals from other Trusts 
•
•
Referrals may only be received from other Trusts if the following two fundamental
pieces of information are submitted
The referral to this Trust is directly relating to the reason for the original referral to
the referring consultant. Full set of demographic details, RTT clock start date and
patient’s current RTT status on the Minimum Data sent (MDS)
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•
Clock start dates for referrals received from other Trusts will be dependent on the
referring consultant explaining whether the reason for this referral is due to either
an existing condition; treatment has been started on an existing condition or, a
new condition
3.1.8 Consultant to Consultant Referrals within this Trust 
•
•
It has been agreed with commissioners for a consultant-to-consultant referral refer patients back to their GP when new reasons for referral are identified.
Internal consultant-to-consultant referrals may be submitted to the receiving
consultant in an appropriate referral letter, the referral source must be clearly
documented on the Infoflex letter.
It must be made clear on the referral letter that this is a continuation of an existing
RTT pathway and not for a newly identified condition unless the following have
been identified:
o Diagnosis of Cancer is confirmed (transfer to 31 day pathway) or suspected
(Consultant Upgrade to 62 day pathway)
o Urgent problems for which delay would be detrimental to the patient’s health –
the expectation here is that the patient needs to be seen urgently. This should
also be clearly documented in the patient’s notes.
o For Ministry of Defence patients
o If the referral is part of a clinical network agreed managed pathway
o For Palliative care
o For a Paediatric Specialty
o For Pre-operative Assessment, including assessment in other specialties such
as Cardiology
o Pregnant patients who need review by other specialists as a result of their
pregnancy
o Cross referral within the same department with sub-specialty interests for the
same condition
o All requests or referrals for tests / investigations alone are also exempted from
these restrictions.
3.1.9 Inappropriate referrals 
•
3.2
If a consultant deems a referral to be clinically inappropriate, it must be sent back
to the referring GP with an explanation why. The referral decision must be
updated and discharged accordingly. If a referral has been made and the special
interest of the consultant does not match the needs of the patient, the consultant
should cross refer the patient to the appropriate colleague where such a service
is provided by the Trust
Registration
• All referrals will be checked against the Patient Master Index (PMI) on PAS. If the
patient is already registered on PMI the details must be checked and amended
accordingly. If the patient is not registered on the PAS, full details will be entered on
to PAS to allocate a hospital number.
• Referrals with no NHS number should be checked on the National Summary Care
Record by department staff. The GP and/or Data Quality Team should be contacted
for clarity on any details.
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• Any missing demographic data highlighted on CDS error reports are added by the
Data Quality Team.
• Patients referred via E-referral where an NHS number cannot be found will be
allocated a “Y” number on PAS registration.
• The original copy of the referral letter will be held within the Mid Essex Referral
Booking Management Centre for the use and ease of reference of the Consultant
involved.
• Referrals will be scanned and forwarded to the relevant Specialty group email
account for Consultant grading. This is to be actioned within 7 days on receipt of the
referral.
3.3
18 week RTT Booking Timescales 
• All referrals will be received into the Mid Essex Referral Centre to firstly establish
whether there is an RTT clock start or not and where necessary, establish the clock
start date and placed on the pending outpatient waiting list (dummy).
• The Mid Essex Referral team will scan the letter and send electronically to the
Specialty group for the relevant consultant/clinician for acceptance/clinical
prioritisation within 7 days from receipt. The Referral is then returned electronically
to the email account [email protected] for booking.
• Communication with the patient will be initiated as soon as the clinician has indicated
the relevant pathway. Where possible, patients should be offered the earliest
available mutually convenient appointment date adhering to target timeframes,
clinical priority and “in turn”. Relevant comments are to be recorded in the
comments field on PAS.
• Any patients that cannot be contacted on two separate occasions are sent a first
available appointment and asked to ring in and confirm attendance where possible.
• Following confirmation with the patient of their appointment this is then verified on
PAS.
• When patients have been referred on to the outpatient waiting list they may not be
expedited unless there is a late notice cancellation or consultant agrees to expedite.
3.4
Ministry Of Defence Patients
• All Ministry of Defence (MOD) referrals are sent to Mid Essex Referral Centre and
processed as other referrals. Priority will be given where GP’s state that the patient
is a war veteran.
3.5
Private Patients
• If a patient has been seen privately, either in this Trust or at a private hospital they
may be referred by letter in the usual way by either the consultant or their GP and
will be allowed to enter the NHS service at whatever stage they have reached in their
pathway.
• Private patients are recorded on PAS under the referral as PP for a Private patient,
then the appointment type as P for a new appointment or OP for a review
appointment.
• It is important to ensure that the parameters of equity are observed and patients who
have transferred from the private sector are not disadvantaged and are allowed to
enter the RTT at the appropriate part of the pathway as a new clock start.
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3.6
HM Prison Patients (HMP) 
• Referral for HMP patients are processed via the same means as any other manual
referral. However, the Healthcare Department is contacted by telephone and the first
convenient appointment arranged in order to minimise the risk of cancellations.
• Where the prison cannot facilitate the Prisoner appointment within an appropriate
timeframe, Adult safeguarding need to be involved as to identify if a safeguarding
referral is indicated
3.7
Overseas Visitors
• An overseas visitor - a person who is not ordinarily resident in the UK. Residency is
defined as – Living lawfully in the UK.
• Treatment is currently free at point of contact for all patients in an A&E department.
However, once a patient is referred to an outpatient clinic (or added to an elective
waiting list) or admitted as an emergency to a ward, this treatment is no longer free
for an overseas visitor unless evidence can be shown that they:
o Own an EHIC Card (European Health Insurance card)
o Or are entitled to care under a reciprocal agreement
o Or they have an appropriate visa entitling them to care
• All patients without exception should be asked ‘Have you lived in the UK for the past
12 months on a properly settled basis’ and asked to provide evidence of residency in
the UK to prove entitlement to free NHS treatment within secondary care for
example; a contract of employment if employed; Utility bill; Tenancy agreement or
Bank Statement along with their Passport or Identification card for EU Citizens.
• If a patient has not lived in the UK for the past 12 months or cannot provide evidence
of residency the Interprovider Officer (IPO) must be contacted to interview the
patient, before treatment commences (unless this treatment is clinically urgent).
• The above question must be asked of all patients at each point of contact with the
Trust. This is a legal responsibility of the Trust and is therefore the responsibility of
all who have first line contact with patients, be it in outpatients or on a ward.
3.8
Clinic Management
3.8.1 Booking Capacity
• Where the number of patients referred through means other than E-referral
exceeds the available capacity within a speciality the clinician will be emailed on a
weekly basis by the Outpatient Services manager.
• If no response in a week the Outpatient Services manager escalates to Head of
Outpatients who then meets with the clinicians to agree a resolution
3.8.2 Clinic Cancellations/Reductions/Reinstatements
• These should be initiated with written approval on the appropriate electronic form
by the relevant service.
• The process will ensure that the lead will be advised of the impact of such changes
prior to authorisation.
• The necessary changes will be implemented within 2 working days of receipt of the
authorisation.
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3.8.3 Template Management
• Clinic templates are co-ordinated centrally by the Template Co-ordinator.
• In order to accurately record patient activity and properly attribute work undertaken
by clinicians in the out patients service, it is vital that a minimum of 6 weeks’ notice
and the longest possible notice period to changes to services are provided by the
Lead Clinicians and where appropriate that engagement takes place during the
planning stage so that transitional periods may be dealt with effectively.
• All Template request forms must be approved by the Clinical Lead/medical staffing
officer for either amendment to existing templates or the creation of new templates.
• New templates involving the creation of new outpatient capacity assigned for
previously booked patients will require 6 weeks’ notice for administrative workload
to phase in the new schedules.
• New templates involving the creation of new capacity to book patients not
previously assigned appointments will be initiated within 48 hours of receipt of
approval.
• Amendments to existing templates should be given 6 weeks’ notice and will be
initiated on receipt of approval from the Clinical Lead/medical staffing officers. The
changes will be phased in 6 weeks ahead.
• Changes and additional Nurse Led clinics will be approved by the Lead/Heads of
Nursing.
3.8.4 Follow up appointments
• The Trust operates on the basis that:
• Patients should not be recalled for follow-up appointments unless absolutely
essential.
• Underpinning this principle, the Trust should be matching new to follow-up ratios as
per the contracts with the CCG. When a clinician decides it is necessary to see the
patient again in clinic the patient, where possible, will be booked within the
timeframe proposed by the clinician.
• Where the appointment is not within the 6 week booking rule, the patient will be
placed onto a pending follow up waiting list (Partial booking) and then booked 6
weeks prior to the appointment date due.
3.8.5 Partial Booking
• The Trust operates a Partial Booking system for follow ups
• All appointments where the patient is to be seen in 6 weeks or under are booked at
the reception desk when the patient leaves clinic.
• The same applies for vulnerable patients and those where their medical condition
requires a firm appointment or series of appointments to be booked
• The only exception being is where clinic capacity does not exist. A patient that
remains undated beyond 6 weeks of the due by date are reviewed by the clinician
to risk assess( See standard Operating procedure Appendix 6) Patients are held
on waiting lists by Clinician / specialty . .
• Above applies for all specialties with the exception of Haematology and Nurse Led
clinics (full booking)
• Patients requiring appointments over 6 weeks ahead are added to a waiting list and
an appointment 6 weeks’ prior to their due date is arranged where capacity allows.
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• If a patient does not attend their follow up appointment, the clinician will review the
notes in the clinic setting and decide if a further appointment should be booked if
urgent.
• If the review appointment is however considered non urgent after clinical review a
further appointment may be offered and the clock will remain on-going if the patient
was not offered 3 weeks’ notice.
• This applies only to those patients who have not already had a clock stop as a
result of, for example, 1st definitive treatment.
• This decision must be made immediately to ensure that the appropriate outcome is
recorded for the clinic coding.
• If not then the patient will be discharged and referred back to the care of their
GP/GDP and the RTT clock will be stopped at time of decision to discharge.
• Specific patients (including children) can only be discharged back to GP with an
agreement by the Clinician.
3.8.6 Hospital Initiated Cancellations
• If the Trust cancels a patient’s outpatient appointment the clock continues to tick.
For new referral appointments cancelled, the revised appointment must not breach
the current waiting time standard.
• Cancellation of a follow up appointment will result in rebooking and the new date
must take account of the clinical prioritisation, whilst also avoiding the potential to
breach the RTT standard.
• Particular attention by specialty teams must be paid to appointments that may
potentially be cancelled where ‘clock stopping’ treatment was planned to be carried
out in clinic. This would avoid potential breaches under these circumstances.
• The Trust standard is for clinicians to provide a minimum of 6 weeks’ notice and in
line with this, every effort should be made to predict clinician absences and
therefore reduce the need to cancel outpatient appointments.
• Wherever possible, patients who have been cancelled once should not be
cancelled for a second time unless as a result of clinical reprioritisation there is no
other option.
• All clinic cancellations require authorisation by the Clinical Lead/medical staffing
Coordinator with an approved copy of the clinic cancellation request. No patients
are to be cancelled until this form has been sent to the Template Co-ordinator.
• If a clinic has to be unavoidably cancelled, it is essential that effective liaison takes
place between the Clinician, Lead Manager/Service Manager, outpatient nursing
staff, and the Outpatient administration team to ensure capacity is replaced.
• If an agreed appointment needs to be cancelled in less than 6 weeks’, the patient
will be contacted by the Mid Essex Appointment Centre Team who will agree an
alternative date and time within the waiting time standard which is pertinent at that
time. This will then be recorded on the hospital’s Patient Administration System
(PAS).
3.8.7 Attendance Outcome Coding including DNAs and Cancellations
• It is the responsibility of the clinical staff in the outpatient clinic to accurately report
any procedures or treatment undertaken and identify the appropriate referral to
treatment (RTT) outcome code on the outcome form.
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• Given the importance of accurate and timely RTT coding responsibility for the
process is a collaboration of the multi-disciplinary team.
• Clinic outcome forms can only have one outcome.
• Clinic staff should ensure that at the end of a clinic, that all patients have a
recorded outcome and the relevant outcome form is signed by the clinician.
• The receptionist must ensure that all information is accurately entered into PAS and
signs the outcome form once procedure has been recorded.
• The medical secretary will support the outpatient team in addressing missing RTT
outcomes and procedures/treatments within 48 hours of the clinic date to enable all
cashing up to be completed and updated on PAS.
3.8.8 Discharge in an Outpatient setting 
• Where a patient has been discharged following treatment in an Outpatient setting a
patient can self-refer back to the clinician for the same condition within 6 months of
the clinic discharge
• A patient that has been discharged for over 6 months will have to return to their
general Practitioner to be re referred
4
4.1
Elective Inpatients and Day Cases 
Pre-operative assessment
• The majority of patients will complete a health questionnaire prior to being added to
the waiting list. The Anaesthetic Assessment Unit (AAU) will decide from the details
on the completed health questionnaire whether an appointment is necessary, and if it
is, whether this is a Nurse-led or Consultant-led appointment
• As a general principle, patients should not be added to the inpatient waiting list until
they have been declared fit for surgery by the Anaesthetic Assessment Unit or if they
are a local anaesthetic patient not requiring AAU review
• Patients requiring pre-operative assessment should be seen and assessed within
three weeks of referral
4.2
Patients deciding about surgery 
• If a patient wishes to consider having surgery or not, they will be given seven
calendar days (outcome code 7) to decide whether to proceed with treatment
• The process for management of the patients and the four outcomes is detailed in the
below table:
Impact on
clock
Action
RTT status

Continue
Patient given seven calendar days to make a
decision and call MEHT. MEHT to call patient on
eighth day (if the patient has not called) for
answer about surgery. If the patient wants to
proceed, clock remains
29 – Ongoing
pathway
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 Stop
If patient decides not to proceed with surgery
(either by calling in, or when called on the 8th
day), clock is to be stopped
Waiting List
Cancellation
(WLC)
 Stop
If patient is un-contactable 5* on the eighth day,
place on active monitoring until the patient can be
reached for a decision and then action as above.
If the patient is un-contactable, a call in letter is to
be sent for the patient to contact us within 14
calendar days. If no contact, the patient will be
removed from the waiting list and discharged
back to their GP
Active monitoring
 Stop
If a patient wants longer to think about surgery,
place the patient on active monitoring for a further
period 2 weeks
Active monitoring
* A patient will be deemed as un-contactable after two attempts have been made to contact
them, with at least 3 days separating the attempts, and at least one call being made after
17:00 on a weekday or at the weekend
4.3
Decision to Admit
Patients may only be added to the elective waiting list under the following criteria that the
patient is clinically ready (e.g. fit) and available for treatment/surgery.
4.4
Adding patients to the Elective Waiting List 
• Prior to adding to the waiting list on PAS, the patients’ clock start date must be firstly
validated.
• The patient will then be added with correct clock start recorded onto PAS and
contact sheet by the Patient Access Officer.
4.5
Who may select a patient for Admission from a Waiting List?
• Consultant medical staff are responsible for the content of their Admission lists.
However, this responsibility for allocating admission dates may be delegated to
others including non-medically trained staff such as Patient Access Officers and
Management. This must be on the basis of clinical priority, “in turn” selection and
pre-agreed case mix and in consultation with the clinician responsible for the theatre
session.
• Clinicians must not place a patient on a waiting list to reserve a place against the
possibility that treatment may be necessary in the future.
• Patients who are not fit for treatment for a period of longer than 21 days should not
be listed and should be referred back to their GP/GDP. This may be identified at any
stage of the 18-week pathway.
5
A patient will be deemed as un-contactable after two attempts have been made to contact them, with at least
3 days separating the attempts, and at least one call being made after 17:00 on a weekday or at the weekend
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• Patients who are deemed unfit for surgery due to anaesthetic reasons should be
referred by the clinician to the consultant Anaesthetist for review.
• Post assessment, written communication to the referring clinician with regards to the
fitness of the patient for surgery will be provided.
• If deemed fit for surgery then this will be the “date of decision to admit” at which point
the patient can be added to the waiting list taking note of any specifics needed.
4.6
Bilateral Procedures
• A bilateral procedure is a procedure that is performed on both sides of the body at
matching anatomical sites.
• Examples include
• Cataract removals and hip or knee replacements.
• Consultant-led bilateral procedures are covered by 18 weeks with a separate clock
for each procedure.
• The 18 Week clock for the first consultant-led bilateral procedure will stop when the
first procedure is carried out.
• Patients for bilateral procedures will be placed on a planned waiting list with the
expected admission date.
• When the patient reaches the expected admission date they will be added to the
elective waiting list for the second consultant-led bilateral procedure, a new 18¬
Week clock will start.
• Patients requiring bilateral procedures should be added onto the waiting list one
procedure at a time.
4.7
Patients from Satellite and Network Clinics
• Patients will be asked to complete a Health Questionnaire (HQ) at the satellite clinic
and this will be forwarded to the Patient Access Officer together with the TCI form.
• The Health Questionnaire should be forwarded to the appropriate Pre-Operative
Preparation service that will make arrangements to send the patient a Pre-Operative
appointment:
• AAU – all General Surgery, Breast, Colorectal, ENT, Upper GI, Urology, Oral
Surgery and Vascular patients
• Orthopaedics (PrOP service)
• Plastics & Burns (PrOP service)
• Gynaecology (PrOP service)
4.8
Adding Patients Seen Privately
• Patients who have had a private outpatient appointment but have elected to have
NHS inpatient treatment should be treated in the same way as patients who have
had an NHS consultation e.g. they should be added to the list without delay from the
date the referral is received from the private provider. This will be their RTT start
date.
• Referrals received by medical secretaries should be date stamped and taken directly
to the Mid Essex Referral Centre.
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4.9
Missed off the Waiting List 
• If a patient contacts the Hospital to enquire about their operation and the Patient
Access Officer/Secretary notice that the patient is not on a Waiting list the patient will
be advised that the matter will escalated to the Patient Access Supervisor and that a
full investigation will start immediately.
• Once the Patient Access Supervisor confirms that the patient has been missed off
the Waiting list the matter is escalated to the Lead Manager who escalates to the
Director for Operations.
• The patient is then added to the Waiting List from the original clock start date.
• Where the patients pathway has/or is close to exceeding 18 weeks, the first available
date will be offered to the patient.
• The patient will be contacted by telephone and informed, an explanation will be
given.
• If a patient has been missed off the Waiting list a Datix report is completed and the
events will be recorded on the patients contact log.
4.10 Process for Selection
• The process must take account of clinical urgency; maximum wait times and viability
of appropriate resources. It is also crucial that clinicians and other staff involved in
the selection of patients for admission have access to up-to-date RTT lists for
appropriate ‘in turn’ selection.
• There is a zero tolerance of any patient waiting more than 52 weeks. Any patients
approaching 26 weeks must be escalated to the patient access supervisor and if
necessary to the Patient Access Manager if a treatment plan cannot be agreed with
the relevant consultant.
• Any patient waiting over 40 weeks must be reported to the Director of Operations
and discussed at the weekly 18 week meeting as failure to treat patients within 52
weeks results in a £5,000 fine. This fine occurs for each month past 52 weeks that
they remain untreated.
• In the event that a patient waits over 52 weeks this must be reported through the
Trust’s internal incident reporting process.
4.11 Expedite Requests
• Patients whom have been listed on an in-patient/day case waiting list may not be
expedited unless a written request is received and accepted by the relevant
consultant.
• The GP may also refer back to the clinician requesting the patient be reviewed
urgently in the clinic for a further decision on the urgency to be made.
4.12 Planned Waiting List
• Patients who are added to the waiting list for a planned procedure are outside the
scope of 18 weeks. By planned, this means an appointment/procedure or series of
appointments/procedures as part of an agreed programme of care which is required
for clinical reasons. This may entail treatment to be carried out at a specific time or
repeated at a specific frequency.
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• Planned activity is also sometimes called “surveillance”, “re-do” or “follow-up”.
Examples include 6 month repeat colonoscopy following removal of a malignancy,
tumour or polyp.
• Patients should only be included on planned waiting lists if there are clinical reasons
why the patient cannot have the procedure or treatment until a specified time.
• More complex procedures have a standard operating procedure in place ( see
appendix 7 )
• Less complex cases do not have a standard operating procedure in place, see
examples included:
o “Check” endoscopic procedures
o Removal of screws/metal work
o Age/growth related surgery
o Investigation/treatment sequences
• When adding patients to the elective planned waiting list, the Consultant specified
timescale is to be recorded under expected admission date (which in this case
actually is a maximum waiting time) to ensure the patient is still selected in turn.
• If the patient has not been treated within the expected admission date, the patient
will be placed on an 18 Week pathway with a clock start commencing from their
expected admission date.
4.13 Electronic Waiting List documents (Inpatient/Day case)
• When the decision to admit (treat) has been made a TCI form must be completed
only by the clinician. The patient should be entered onto the appropriate ‘P’ PAS
waiting list within 48 hours of the TCI form being written.
• Once the patient is deemed as Green/Amber by the Pre-operative preparation team
and no funding is required the patient should be transferred onto the appropriate
normal waiting list. TCI documents received by any authorised person to add to the
relevant waiting list must only enter the details to PAS if the document has been
correctly completed.
• Any incomplete TCI documents must be immediately returned to the clinician who
has made the decision to admit/treat for clarity/correction.
4.14 Booking a TCI date 
• All patients must be offered appointments with reasonable notice
• If a patient is un-contactable, the process out lined in section 6.1 must be followed
(“If a patient is un-contactable”).
• TCI dates will not be offered cold (i.e. a letter with an unconfirmed date sent)
o In the case of no contact with reference to Children or Vulnerable Adults the
appropriate consultant and Safeguarding Team should be advised and an
appropriate course of management agreed
• All booking should take place to enable the RTT pathway to be achieved.
• Dates and times of calls as well as the dates and times offered for the procedure
must be entered onto the patient contact log and PAS in real time to form part of an
audit trail.
• Where a patient declines the offer of the procedure or fails to contact the Trust every
effort must be made to book the next in turn patient to ensure full utilisation of theatre
capacity.
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• Patients who decline two reasonable offers will be removed from the waiting list and
the clinician will decide whether to refer back to GP or re add to waiting list with a
new clock.
4.15 18 Week Clock New Clock 
•
A new clock would start when a decision to treat is made following a period of
active monitoring (in previous guidance also known as watchful waiting). If a
patient is subsequently referred back to a consultant-led service, then this referral
starts a new clock.
4.16 Hospital Cancellations of Operation on the day 
• The hospital will only cancel a patient’s admission on the day when it is not possible
to carry out the procedure/treatment. For example: -Lack of available beds;
unexpected absence of key staff; intake of emergency cases; patients deemed unfit
for treatment/surgery.
• If the patient’s admission needs to be cancelled on the day the Lead Nurse for the
specialty and the lead nurse for theatre communicate with the Patient Access
Supervisors to inform them which patients have been cancelled and the reasons for
cancellation. The 28 day rule will then apply.
• If patients admission is cancelled on the day for non-clinical reasons this must be
recorded as ‘Cancelled Elective Admission’ (CEA) on PAS. The original waiting list
add date (WLA) must be manually entered.
• There is a zero tolerance of urgent patients being cancelled more than once on the
day of the operation and also a zero tolerance of routine patients being cancelled
more than twice.
4.17 Hospital Cancellations of Operation before the day 
• If the patient’s admission needs to be put on standby/cancelled the day before the
Lead Nurse for the specialty will select potential patients suitable for cancellation with
the Patient Access Supervisor. The Patient Access Officers will contact the selected
patients and inform the Consultant.
• Where cancellations due to lack of beds are deemed necessary, priority will be given
to clinically urgent cases, patients that were on a 28 day rule and 52 week waiters.
• Any potential cancellation must be discussed with the Lead Manager for Theatres in
the first instance and the Director for Operations will then be notified.
• In the event of a cancellation going ahead the Lead Manager for Theatres, must
liaise with relevant Patient Access Manager of the Specialty regarding the outcome.
• Urgent patients cancelled before the day of admission will be given a new date at the
earliest opportunity with the appropriate clinical priority.
• Routine patients will be given a new date taking into account the relevant waiting
time standard and the potential for breach.
• In the event that the hospital cancels a patients’ admission date (TCI) the clock will
continue.
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4.18 28 Day Rule 
• All patients that are cancelled on the day of admission for non-clinical reasons must
be offered a date within 28 days of their cancellation.
• If the patient is offered a date within the 28 days, but declines the date they will be
offered the next available date that the patient is available, which may exceed the 28
days.
• If it is not possible to offer the patient a new date within 28 days for example; if the
surgeon is on Annual Leave, the patient must be offered an alternative surgeon
and/or a suitable alternative provider (subject to suitability and fitness etc.) This must
be reported on the 28 day report with a plan for treatment which is discussed at the
weekly 18 week meeting.
• The 28 day rule is applicable unless the remainder of the 18 Week pathway is
shorter.
4.19 Patients Who Move Out Of the Area 
• When a patient moves from the area covered by the hospital they may wish to
transfer their treatment to a provider closer to their new home.
• If the patient chooses to remain on the Trust’s waiting list there is no change in
status and the RTT clock continues to tick.
• Patients choosing to transfer their care to a new Trust as a result of their move out of
our area will be discharged to the care of their GP. This will result in a clock stop.
• They may then be referred by the releasing clinician as appropriate (possibly to the
new Trust) and the clock will be transferred to the new Trust.
4.20 Transfer of Treatment to another Consultant
• Occasionally it may be necessary to transfer a patient’s treatment to another
Consultant (e.g. Consultant sickness/no longer at the Trust/capacity).
• In such circumstances the Trust should seek permission from the patient to transfer
their care to another named Consultant team.
• If the patient is in agreement, waiting times are unaffected and PAS must be updated
by adding the appropriate Waiting List Transfer.
• If necessary, an outpatient appointment is made within one month and this must be
clearly documented in the case notes and on PAS.
• Under the above circumstances the RTT pathway remains on-going.
• Should the patient choose to decline this offer and no other Consultant team are able
to perform the procedure, the patient should be informed and referred back to their
GP/GDP and removed from the Waiting List. This will result in a clock stop.
4.21 Transfer between Waiting Lists within the Trust 
• This may be appropriate where the patient has been added to a waiting list for a
specific procedure and it is subsequently possible to treat the patient sooner or more
effectively in an alternative manner (e.g. as day case instead of an inpatient).
• If a transfer will result in treatment by a different Consultant the patient has the right
to refuse the transfer.
• If the patient does refuse to be transferred to the care of a different Consultant, their
status on the waiting list should not be affected.
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4.22 Transfer to another NHS Provider/Private or Independent Hospital 
• Patients may be transferred from the waiting list of one provider to another provider
for their treatment. The transfer must always be with the consent of the patient and
provider.
• Patients transferred on an 18 week RTT to another provider must have a completed
MDS by the medical secretary and then transferred via the Inter-provider office.
4.23 Active Monitoring
• The concept of active monitoring (watchful waiting) stops the clock and caters for
periods of care without new clinical intervention e.g. three monthly routine check-ups
for diabetic patients.
• This is where it is clinically appropriate to monitor the patient in secondary care
without treatment or further diagnostic procedures, or where the patient makes a
decision to be reviewed as an outpatient, or have an open appointment, without
progressing to more invasive treatment. Active monitoring (watchful waiting) can be
initiated by either the patient or the clinician.
• If after a period of active monitoring, a decision is made that treatment is now
appropriate, a new pathway starts (new treatment plan), this is then a new pathway
and the patient must receive treatment within a maximum of 18 weeks.
4.24 Referrals which do no not start a clock
• Referrals to antenatal services, obstetrics, healthcare science or mental health
services that are not medical or surgical consultant-led (including multi-disciplinary
teams and community teams run by mental health trusts) irrespective of setting
• Diagnostic services if the referral is not part of a straight to test arrangement i.e.
open access endoscopies
5
Procedures which require Funding from the CCGs 
• There are a number of procedures deemed of low priority or low clinical
effectiveness. Any patient requiring these procedures, tests or interventions must
have confirmed funding (on an individual basis) from the CCG prior to booking the
appointment. Lists of these procedures can be obtained through the Interprovider
Office (IPO) or directly sourced from the CCGs website.
• Any requests for funding must be actioned and logged through the IPO, a branch of
the Trust contracts team. The following timescales, requirements and processes
apply:
o The clinic letter and a copy of the waiting list form must be sent to the IPO
within 5 working days of the clinic date
o The Outpatient appointment outcome must be entered as “awaiting funding
approval” (outcome code 34). The 18 Week Pathway will continue whilst
funding is sought
o Funding requests must be sent to the relevant CCG within two weeks (10
working days) from the clinic date to avoid any unnecessary waiting for the
patients
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o The date the request for funding is made will be logged on the IPO funding
system
o If funding is approved the patient’s notes will be returned to the Admissions
office where the patient to be placed on the waiting list.
o If funding is refused the patients notes will be returned to the Admissions
office and the patient will be discharged. It is CCG’s responsibility to inform
the patient if a funding request has been refused.
o A reminder email will be sent to the CCG if by the third day the IPO has not
received a response (as per the contract). If no response is received, the
patient’s notes will be returned to the Admissions office where the patient is to
be placed on the waiting list.
o If the CCG’s request additional information from the GP, the patient will be
discharged back to the care of their GP until funding has been agreed. The
patient and the Consultant will be kept updated.
o If it is decided that the funding request is to go to the CCG’s funding panel the
patient will be discharged back to the care of the GP until the decision to
approve is made.
6
Diagnostics
• Referral for all diagnostics test must be made via the PAS electronic system or by
appropriate process set by each department.
• Where possible, once patients have been referred for a diagnostic test after being
seen in the outpatient clinic, they should be able to book their diagnostic appointment
before leaving the hospital.
• The National maximum waiting times for Diagnostic investigations are:
o Cancer patients - 2 weeks
o Urgent patients - 4 weeks
o Routine request - 6 weeks
• If a patient is not able to book their diagnostic test prior to leaving the hospital, the
patient must be contacted by telephone to agree a date for their diagnostic test. If
the patient is not available on the first phone contact, a second attempt the following
day at a different time is to take place.
• If the patient is still not available, an appointment letter (with date and time) will be
sent to the patient within 24 hours for all urgent/cancer referrals, and 48 hours for
routine, requesting them to ring the department if the appointment is not convenient.
• When offering routine dates to patients for diagnostic tests, 3 weeks’ notice must be
given wherever possible with a choice of two dates. If the patient refuses these
dates, this must be recorded on all relevant systems.
• Patients who cancel an offer of a diagnostic appointment date will be able to discuss
another date for their procedure within their RTT pathway. PAS will be updated to
reflect the cancelled appointment date.
• Further dates should be offered to support patient choice and to accommodate the
patient’s diagnostic test being performed up to the 6 week point in the diagnostic
pathway and 2 week rule for cancer patients.
• If a further date cannot then be agreed within the target pathway, the patient will be
referred back to the GP or referring clinician.
• Patients whom have agreed their appointment date but with short notice (i.e. less
than 2 weeks), but then cancels, a further offer of a date will be made.
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• If a patient does not attend where the patient has had a choice of date and time of
the appointment, the attendance will be recorded as a DNA and the requesting
clinician will be informed with a view to the patient being referred back to the GP and
discharged.(Excludes cancer patients)
• If the period of notice provided by the patient for a cancellation is not within a
reasonable time i.e. on the day of the procedure taking place, or is deemed invalid,
the cancellation will be recorded and the patient may be returned to the care of the
GP and discharged. (Excludes cancer patients).
• For patients where the requesting clinician is the GP/GDP, and the patient is
monitored as being within the RTT pathway, the relevant diagnostic department will
refer the patient back to the GP/GDP after discussion with the clinician, and the clock
will be stopped.
• For patients where the requesting clinician is the GP/GDP, and the patient is not
monitored as being within the RTT pathway, the relevant diagnostic department will
refer the patient back to the GP.
• Monitoring of the timeframes is the responsibility of the relevant Lead Manager for
the diagnostic area.
7
Entitlement to NHS treatment
• The Trust has a legal obligation to identify patients who are not eligible for free NHS
treatment. The NHS provides healthcare for people who live in the UK. People who
do not normally live in this country are not automatically entitled to use the NHS free
of charge – regardless of their nationality or whether they hold a British Passport or
have lived and paid National Insurance contributions and taxes in this country in the
past.
• All NHS Trusts have legal obligation to:
o Ensure that patients who are not ordinarily resident in the UK are identified
o Assess liability for charges in accordance with Department of Health
Overseas visitors Regulations
o Charge those liable to pay in accordance with Department of Health Overseas
Visitors Regulations
o The Human Rights Act 1998 prohibits discrimination against a person on any
ground such as race, colour, language or religion. The way to avoid
accusations of discrimination is to ensure that everybody is treated the same
way.
o The Trust needs to check every patient’s eligibility. An NHS card or number
does not give automatic entitlement to free NHS treatment.
8
8.1
Transfer of Private Patients
Patients Transferring from Private to NHS
Patients can choose to convert between an NHS and private status at any point during their
pathway without prejudice. Patients wishing to transfer from the private service to the NHS
must be referred by the Clinician or their GP.
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8.2
Patients Transferring from NHS to Private
NHS patients already on a waiting list opting to have a private procedure must be removed
from the NHS waiting list. A new referral must be created – NHS to private and a waiting
list entry as private patient must be entered.
9
Monitoring of compliance
• Compliance to this policy will be reviewed through a random audit of patient
pathways. This audit will occur at least once per quarter, where at least 50 patient
pathways will be reviewed and validated to ensure consistency of policy application.
• The overarching patient access metrics (such as 18 week standard compliance and
performance) will be formally reviewed and challenged as follows:
o Twice per week at operational / patient detail level in the 18 week / Elective
Care meeting
o Once per month at the access meeting in collaboration with the CCG,
accountability meetings with the Executive board and the Trust Board itself
10 Reporting Breaches of the Policy
Any breach of this Policy that results in harm to a patient must be recorded on the Trust
incident reporting system, DATIX. Whoever identifies the risk event must complete the online form. Furthermore, any patient that waits in excess of 52 weeks for their first definitive
treatment, at the point of treatment, will have a DATIX completed. The ensuing investigation
will ascertain if any harm occurred and what needs to change for future patients to avoid
unnecessary waiting. This root cause analysis review will be shared in the Trust and with
the CCG.
11 Implementation and Communication
• Following ratification the policy will be uploaded to the intranet and website and
notified to staff in Focus (the Trust magazine).
• The author is responsible for notifying all key implementers
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12 Glossary and Definitions
18
18 week
RTT
(Referral to
Treatment)
18-week Referral to Treatment (RTT) is the period of a consultant-led
treatment from referral for non-urgent conditions.
Active
monitoring
A patient’s RTT clock may be stopped where it is clinically appropriate to
start a period of monitoring in secondary care without a clinical
intervention or diagnostic procedures at that stage. A new clock would
start when a decision to treat is made following a period of active
monitoring (in previous guidance also known as watchful waiting). Where
there is clinical reason why it is not appropriate to continue to treat
the patient at that stage, but to refer the patient back to primary care for
ongoing management, then this constitutes a decision not to treat and
should be recorded as such and also stops a clock.
Active
Waiting List
Patients
Patients awaiting elective admission for treatment and are currently
available to be called for admission.
Admission
The act of admitting a patient for a day case or inpatient procedure.
Admitted
Pathway
A pathway that ends in a clock stop for admission (day case or inpatient).
Bilateral
(procedure)
A procedure that is performed on both sides of the body, at matching
anatomical sites. For example, removal of cataracts from both eyes.
Care
Professional
A person who is a member of a profession regulated by a body
mentioned in section 25(3) of the NHS Reform and Health Care
Professions Act 2002.
Clinical
Decision
A decision taken by a clinician or other qualified care
professional, in consultation with the patient, and with reference to local
access policies and commissioning arrangements.
Consultant
A person contracted by a healthcare provider who has been appointed by
a consultant appointment committee. He or she must be a member of a
Royal College or Faculty. The operating standards for referral to
treatment exclude non-medical scientists of equivalent standing within
diagnostic departments.
ConsultantLed
A consultant retains overall clinical responsibility for the service, team or
treatment. The consultant will not necessarily be physically present for
each patient’s appointment, but he/she takes overall clinical responsibility
for patient care.
A
B
C
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D
E
Date
Referral
Received
(DRR)
The date on which a hospital receives a referral letter from a GP. The
waiting time for outpatients should be calculated from this date.
Day cases
Patients who require admission to the hospital for treatment and will need
the use of a bed but who are not intended to stay in hospital overnight.
DNA – Did
Not Attend
In the context of the operating standards, this is defined as where a
patient fails to attend an appointment or admission without prior notice.
Decision to
Admit
Where a clinical decision is taken to admit the patient for either a day
case or inpatient procedure.
Decision to
Treat
Where a clinical decision is taken to treat the patient. This could be
treatment as an inpatient or day case, but also includes treatments
performed in other settings e.g. as an outpatient.
E-referral
A national electronic referral service that gives patients a choice of place,
date and time for their first consultation in a hospital or clinic.
First
Definitive
Treatment
An intervention intended to manage a patient’s condition, disease or injury
and avoid further intervention. What constitutes First Definitive
Treatment is a matter for clinical judgement, in consultation with others as
appropriate, including the patient.
Fit (and
ready)
A new patient pathway and clock should start once the patient is fit and
ready for treatment. In this context, fit and ready means that the clock
should start from the date that is clinically appropriate for the patient to
undergo that procedure, and from when the patient says they are
available and will be for the foreseeable future.
Incomplete
waiting time
standard
This is the main operational standard now driven for. This is the number
of currently open (or incomplete) pathways at any given time (i.e. the
number of pathways open under 18 weeks against the number of
pathways open above 18 weeks)
Interface
Service (non
consultantled
All arrangements that incorporate any intermediary levels of clinical triage,
assessment and treatment between traditional primary and secondary
care.
Interface
service
The operating standard relates to consultant-led care. Therefore, the
definition of the term “interface” within the context of the operating
standards does not apply to similar “interface” arrangements
established to deliver traditionally primary care or community provided
services, outside of their traditional setting. The definition of the term
does not also apply to referrals to “practitioners with a special interest”
for triage, assessment and possible treatment except where they are
working as part of a wider interface service type arrangements as
F
I
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described above.
Indirectly
Bookable
Services)
Some provider services are not directly bookable through E-referral so
patients cannot book directly into clinics from a GP practice. Instead they
contact the hospital by phone and choose an appointment date. This is
defined as an Indirectly Bookable Service.
Inpatient
These are patients that have been formally admitted in to the hospital in
to a bed.
Nonadmitted
pathway
A pathway that results in a clock stop for treatment that does not require
an admission or for “non treatment”.
NonConsultant
Led
Where a consultant does NOT take overall clinical care for the patient.
O
Operational
Standards
These are the standards of treatment which we aspire to deliver for
our patients. Oftentimes these are waiting time standards, used as a
proxy for good clinical care. The core standard for elective care is the
incomplete pathway standard.
P
Patient
Tracking List
(PTL)
The PTL is a list of all patients (both inpatients and outpatients) currently
on an elective pathway of care
R
Referral
Management
or
assessment
Service
Referral management or assessment services are those that do not
provide treatment, but accept GP (or other) referrals and provide advice
on the most appropriate next steps for the place or treatment of the
patient. Depending on the nature of the service they may, or may not,
physically see or assess the patient.
S
Straight to
Test
A specific type of direct access diagnostic service whereby a patient will
be assessed and might, if appropriate, be treated by a medical or surgical
consultant-led service before responsibility is transferred back to the
referring health professional.
TCI (To
Come In)
date
The offer of admission, or TCI date, is a formal offer in writing of a
date of admission. A telephone offer of admission should not normally
be recorded as a formal offer unless it is confirmed with a letter as
well (if time allows).
Therapy
Where a consultant-led or interface service decides that therapy (for
example physiotherapy, speech and language therapy, counselling) or
healthcare science (e.g. hearing aid fitting) is the best way to manage
N
T
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the patient’s disease, condition or injury and avoid further intervention.
Appendix A: Standard Operating Policies for Outpatients and Patient Access
•
•
All standard operating policies and procedures for Outpatients and Patient Access
are stored in the following folder:
o S:\OutpatientsDept\outpatients\SOP
These will all be uploaded on to the intranet by the end of June 2016 for ease of
access and version control management.
Appendix B: Duties and responsibilities
Everyone involved in patient access should have a clear understanding of his or her roles
and responsibilities. This policy defines those roles and responsibilities and establishes a
number of good practice guidelines to assist staff with the effective management of patients
requiring outpatient, diagnostics, in-patient and/or day case treatment.
•
•
•
•
•
•
•
•
The Chief Executive has overall responsibility and accountability for delivering
access targets as defined in the NHS Plan, NHS Constitution and Operating
Framework.
The Chief Operating Officer has delegated accountability for the delivery of all
waiting time standards of care
The Associate Director of Operations (RTT) is responsible and for the monitoring
and delivery of elective care performance for the Trust
All Associate Directors’ of Operations are responsible for ensuring the clinical
directorates deliver the activity required to meet the National and locally agreed
standards
Service Managers are responsible for the local monitoring of performance in the
delivery of the RTT, ensuring specialities deliver capacity to meet activity
demands and sustain the activity levels required to meet standards
Hospital Consultants and Clinical Nurse Specialists have a shared responsibility with
their Service Managers for managing their patients waiting times in accordance
with the maximum guaranteed waiting time for patients on an 18 week referral to
treatment pathway and suspected cancer pathways
Patient Access Teams - The contact centre is responsible for arranging
appointments and for carrying out the operating procedures for the administration
of the patient’s referral and for entering all information onto the PAS system
accurately. They are responsible for ensuring waiting lists are managed to
comply with this policy
All staff will ensure that any data created, edited, used, or recorded on Trust IT
systems within their area of responsibility is accurate and recorded in accordance
with this policy and other related Trust policies (such as Information Governance)
Appendix C: Policy development
•
Associate Director of Operations (RTT) is responsible for ensuring this policy
remains current and reflects any changes in national guidance
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•
Any significant changes to the impact of the policy (i.e. excluding significant changes
to the presentation of the policy) will be agreed and ratified with the CCG
Appendix D: Policy delivery
•
•
•
It is the responsibility of the Clinical Directors and Associate Directors of Operations
to ensure that all staff within their Specialties are aware and comply with this
policy
It is the responsibility of the Head of Outpatients and Patient access to ensure that
the outpatient and patient access teams comply with this standard and maintain
consistently high data quality
The Patient Access team will monitor Data Quality and undertake audits to ensure
compliance with this policy
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Appendix E
Dear Patient
Important information about your treatment with us
There is some important information below about your treatment – which we aim to start
within 18 weeks of your GP referring you – but first I would like to say thank you for
choosing our Trust for your treatment. We hope your experience will show you made the
right choice.
We will start your first treatment within 18 weeks
We aim to start your first treatment within, at the longest, 18 weeks from when your GP
referred you to us. This means that if you need an operation, you will be admitted to
hospital within a maximum of 18 weeks or, if your treatment can be given in an outpatient
clinic, it will be started within that time. (Of course if your consultant decides that your
treatment is needed urgently, it will be started much more quickly).
But we can only keep this promise with your help - you must make yourself available and
attend appointments
During the time leading up to your treatment, it is vital that you are available for
appointments, tests and treatment. Wherever possible, we will give you the opportunity to
agree the date and time of your visits to make it easier for you to attend. However, if you
are unable to attend an agreed appointment or come for your treatment, then please tell us
straightaway so that we can offer that appointment to another patient. Your appointment
letter explains how to contact us to do this. If you do not attend for your first appointment,
you may be referred by us back to the care of your GP. If you need an operation, you must
be fit and well enough to undergo that operation within 18 weeks of referral. If you may
need an operation, your GP is likely to have already assessed your general fitness. If you
are not fit enough to undergo surgery you will be returned to the care of your GP, until you
meet the criteria to proceed.
We will try and avoid postponing your appointment wherever possible
There are occasions when we may have to cancel an appointment or your treatment, due to
unforeseen circumstances. We try to avoid this at all times if possible, but if this happens
we will contact you promptly to agree an alternative date.
The next steps in your care
We encourage patients to be involved in their care. Please ask our staff about the next
steps towards your first treatment when you come for appointments or tests. We also
welcome any comments or suggestions you have about our services, as feedback from you
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helps us to improve our services for everyone. Finally, I welcome you to the hospital and
hope that your experience of our services is as pleasant as possible.
Clare Panniker
Chief Executive
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