Southampton NHS Treatment Centre
Referrals to Treatment Access Policy
Care UK Health Care Division
Controlled document
Copyright © Care UK 2011. All rights reserved.
Reference number
Southampton OP03
Version
V5
Key updates
Onward referral process
Updates in keeping with current 18 week and 6 week diagnostic
waiting times targets
Authors
Kathryn Dunning, Administration Manager
Francesca Cortvriend, Operational Manager
Date ratified
January 2016
Committee/individual
responsible
Administration Leads
Senior Management
Issue date
May 2017
Review date
May 2018
Target audience
Administration Teams
Clinical Managers
Clinicians
External interested parties – Clinical Commissioning Groups,
Patients, Referrers
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
Page |1
CONTENTS
Policy Statement ........................................................................................................................... 3
Southampton NHS Treatment Centre Exclusions Criteria ......................................................... 4
Minimum Data Set ......................................................................................................................... 5
18 Week Referral to Treatment (RTT) Guidance ......................................................................... 5
Referral for Direct Access Diagnostic Procedures..................................................................... 7
Summary of STC Referral, diagnostic and Admission Procedures .......................................... 7
GLOSSARY OF TERMS .............................................................................................................. 11
References .................................................................................................................................. 13
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
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Policy Statement
This policy will reflect the overall expectations of the Southampton NHS Treatment Centre (STC)
and the Sponsor CCGs of the current contract on the management and admissions into and
within the STC and defines the principles on which the policy is based.
This policy is intended to be of interest to and used by all those individuals who are responsible
for referring patients to the STC and those responsible for managing referrals. It will also be used
by all those individuals within the STC, including clinicians and administrative staff who have
responsibility for the patients’ progress along the care pathway.
This policy has been introduced to enable the STC to focus on delivery of the contractual 18
week patient pathway and ultimately to enable all patients to access treatment in a timely
manner.
Principles of the Policy
This policy highlights the key principles that govern effective and reliable referral and admission
management throughout the local health community.
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Referral for patients should be made when the patient is fit, ready and willing to be able to
undertake assessment and any necessary treatment in a timely manner
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The process of referral, diagnostic and admission management will be transparent to the
public and external organisations.
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The STC will use their Patient Administration System (PAS) to monitor patients through
their pathway against the 18 week contracted RTT pathway.
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Accuracy and reliability of waiting list and diagnostic information produced by the STC is
the responsibility of all staff in the STC who is involved in referral for outpatients and
diagnostics and admission management, or have access to the administration and upkeep
of patient access systems.

Consultant to Consultant Referrals – Referrals can be made internally or to another
provider within the same specialty or directly relating to the original reason for referral.
Referrals will be managed as a continuation of previous wait. Additionally a referral can
be made to aid the treatment of a patient that is an inpatient at the time of referral.
Urgent cases such as cancer however will be referred directly to University Hospital
Southampton NHS Foundation Trust (UHSFT) by STC. In all cases the patient and their
GP will be made aware of the plans for care.

Onward referrals may be made by STC where it is felt that the patient is best treated in
another organisation for any reason. Both the patient and the GP will be made aware of
the plans for care. This will include
a) Secondary condition where referral is only loosely associated with the original problem
b) Incidental findings, including those found in the course of pre-operative assessment
that do not impede anaesthesia or surgery.
Ref: Southampton OP03
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Review Date: May 2018
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In all the above circumstances case the patient will be offered choice of treatment location
and clinician
c) Bilateral procedure – Where the patient has been referred for a bilateral procedure this
will be performed when the patient is sufficiently well and recovered from the primary
operation in order to safely proceed. Where a decision is taken that a bilateral
procedure is required after the first procedure has been completed, the treating
clinician will contact the GP to inform them of the decision to proceed. The GP may
choose to intervene if they require further information.
Southampton NHS Treatment Centre Exclusions Criteria
Full information regarding inclusion/exclusion criteria may be found at:
http://www.careuk.com/sites/default/files/Southampton_NHS_Treatment_Centre_referral_guide.p
df
The majority of cases can be treated at the centre. However, there are a number of exclusion
criteria to ensure the safety of patients. Key areas where patients are not suitable for treatment
are:
•
•
•
•
•
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Under 16 years of age
High suspicion of cancer
Clinical emergencies
Patients with poorly controlled co-morbidities (further details on the referral criteria on
the website)
Pregnancy (unless procedure under local anaesthesia only)
BMI greater than 40 for patients undergoing procedures under general or regional
anaesthesia only: many procedures can be performed under local anaesthesia
(dental, gynaecological, minor general, urology and orthopaedic). Please contact the
treatment centre if you are unsure as to an individual patient’s suitability
In addition reference must be made to the Clinical Commissioning Procedures of Limited Clinical
Value guidance. Some procedures have specific inclusion criteria stated.
IFR Policy and
Procedure for CCGs 2016-17 update 4.pdf
In summary, the following patients are excluded from Southampton NHS Treatment Centre:
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Unstable Diabetes Mellitus
Hepatitis C positive
Patient/family history of Malignant hyperthermia
Central (neurological) sleep apnoea
Severe/Critical Aortic stenosis
Congestive Cardiac Failure- non compensated &/or recent episode
Severe COPD
Unstable angina
Recent myocardial infarction (<3 months)
Cardiomyopathy with ejection fraction < 30%
Severe systemic disease with functional limit: e.g. arrhythmias
Patients fitting American Society of Anaesthesia (ASA) categories 4 & 5 and unstable
3 category
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
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
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Patients with suspected allergies/anaphylaxis to routine anaesthetic drugs who have
not been formally tested
Documented failed intubation during previous general anaesthesia
Minimum Data Set
The following is required as the minimum data set (MDS) in order to register a patient with the
STC. Further required MDS including religion and ethnicity, etc. will be part of the MDS checked
on patient arrival at STC:
Non-Clinical MDS
NHS No
UBRN (unique booking reference number for all e-referral service referrals)
First Name
Surname
Date of Birth
Full postal address including post code
Contact telephone number
Referring GP Name
Practice Name
Practice Code
GP Code
AHP Name (if appropriate)
Referrer’s Address
AHP professional registration code (if appropriate)
Date of referral
Translation service required
Transport service required
Funding code (if applicable ie Procedures of Limited Clinical Value, Individual Funding Requests)
Clinical MDS
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Reason for referral
Examination finding/investigation results
Past Medical History
Current/Recent Medication
Clinical Warning (e.g. Allergies, blood borne viruses)
Additional Relevant Information
18 Week Referral to Treatment (RTT) Guidance
It is the responsibility of all members of staff to understand the 18 Week Principles and
Definitions. They must be applied to all aspects of individual specialty pathways and referrals.
Waits will be managed and measured accordingly.
1. Start of the 18 Week Pathway
An 18 week clock starts when any healthcare professional or service permitted by the CCG to
make such referrals, refers to:
a) A medical or surgical consultant led service, regardless of setting, with the intention that
the patient will be assessed and, if appropriate, treated before responsibility is transferred
back to the referring health professional or general practitioner;
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
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b) An interface or referral management or assessment service, which may result in an
onward referral to a medical or surgical consultant led service before responsibility is
transferred back to the referring health professional or general practitioner.
For referrals through e-Referral System (ERS) the start of the waiting period is at the point of
conversion of the Unique Booking Reference Number (UBRN). The STC provides a directly
bookable service.
Where ERS is not utilised the 18 week clock starts at the point at which the provider receives the
referral letter. If the referral is via an interim service such as a Clinical Assessment Service
(CAS) the clock start is from the point the CAS receives the referral. The CAS will make this date
available to the STC.
It is the responsibility of the referrer to provide to the STC any additional patient needs such as
communication services.
If the patient is being referred for a condition for which the likely surgical procedure is categorised
by the CCG as a Procedure of Low Clinical Value (PLCV) or requiring an Individual Funding
Request (IFR) the PLCV and IFR policies must be adhered to.
2. End of the 18 Week Pathway
Start of first definitive treatment is described as the start of the first treatment that is intended to
manage a person’s disease, condition or injury. The clock stops if the treatment that is started is
intended to avoid further intervention.
The End of the patients’ 18 week wait would include:
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Treatment as an inpatient or day case
Treatment/discharge within the outpatient setting, i.e. surgery is not required or the patient
is treated as a day case
First Line Treatment of pain where pain management is defined as the definitive
treatment, e.g. medical management of pain.
Decision not to treat in secondary care and return of patient to primary care.
Active Monitoring – defined as a situation where a diagnosis has been reached but a
period of active monitoring of the patient is deemed clinically appropriate. If a patient
subsequently required further treatment after this monitoring period a new 18 week
pathway would begin.
Patient Declines Treatment – if the clinician decides treatment is appropriate but the
patient declines treatment. The date the patient declines treatment should be used as the
end date for the RTT clock.
Did Not Attend (DNA) and Patient Cancellations. Every effort will be made to support
patients attending their appointments. The team will attempt contact with a patient to
ascertain the reasons behind the DNA/cancellation and if appropriate a further
appointment may be offered. If all attempts at contact fail or if the patient does not wish to
attend, the STC will inform the GP and refer the patient back to them. It is important that
the patients GP is kept informed that their patient potentially has outstanding care needs.
Discharge back to the care of the GP will stop the 18 week clock. Upon completion of an
18 week pathway, a new clock only starts:
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
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a) When a patient becomes fit, willing and ready for the second of a consultant-led
bilateral procedure.
b) Upon the decision to start a substantively new or different treatment that does not
already form part of that patient’s agreed care plan, e.g. should a patient require a
related surgery/treatment the consultant will inform the referring GP via letter and
continue with
surgery. If the treatment is considerably different a new referral will be required.
c) Upon a patient being re-referred in to a medical or surgical consultant-led interface,
i.e. after a period of active monitoring.
d) At the first point of contact after a patients first DNA and only if it is deemed there is a
good reason for the patient pathway to be re-instated.
Referral for Direct Access Diagnostic Procedures
In the case of referral to the direct access service for endoscopic procedures patients will be
given a To Come In date (TCI) within 6 weeks following receipt of referral to the STC. The
service will also be available for booking via the e-Referral system.
It is expected that a patient referred for to the direct access service will be discharged back to the
referrer following completion of the endoscopic procedure. The responsible endoscopy
consultant may request the patient returns for a further procedure within a short period of time to
review the condition. Patients may be reviewed should their condition warrant that they are seen
over a period of time under a surveillance programme. In this case the patients GP will be
informed that the patient is on the surveillance programme and the Endoscopy Department staff
at the STC will be responsible for managing appropriate and timely recall and for updating the
patients GP with results.
Other aspects of the 6 week patient pathway will follow the same guidelines as for patients on an
18 week pathway.
Summary of STC Referral Admission Procedures for Patients on an 18 Week Pathway
This section gives a brief summary of referral, diagnostic and admission management procedures
in place at the STC.
A. Outpatient Referrals
Methods currently employable to access services:
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Directly bookable via referral to the e-Referral System (ERS)
Paper referral letters (post and fax) from GP and GDP practices and Tier 2 services who
are not using the directly bookable e-Referral Service.
Email via the nhs.net email system
To note – the NHS Standard Contract will require that all referrals be made via ERS by
September 2018
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
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Reasonableness of Appointment:
For patients not appointed through ERS the STC should offer appointments with at least three
weeks’ notice, although patients can still take an earlier appointment if they wish. Appointments
should be available and offered for a period up of six weeks. The patient should be offered up to
three appointments within this period if the first appointment offered is not suitable. Every effort
will be made to see patients in a timely manner. However in some cases a patient may choose to
postpone their appointment until week six, subject to negotiation. After this time every effort will
be made to arrange a mutually convenient appointment with the patient, however if they are
unable to accept any appointment within 8 weeks they will be discharged back to the referrer.
Under the 18 week guidance the STC is unable to pause the clock for patients who choose
to delay appointments.
Open Referrals:
Referrals should in the majority of cases be addressed on a specialty or sub specialty basis
rather than to named consultants. This is to ensure that the delivery of the referral to treatment
time is not compromised.
Patients who cannot be contacted on referral:
Patients who cannot be contacted at the first attempt will be telephoned once more the next day.
One call will be made after 6pm. If telephone contact is unsuccessful a letter will be sent to the
patient requesting they make contact with the Booking team. If contact is not received from the
patient after 10 days the patient will be discharged back to the referrer.
Did Not Attend:
Every effort will be made to support patients attending their appointments. The team will attempt
contact with a patient to ascertain the reasons behind the DNA/cancellation and if appropriate a
further appointment may be offered. If all attempts at contact fail, or if the patient does not wish
to attend, the STC will inform the GP and refer the patient back to them. It is important that the
patients GP is kept informed that their patient potentially has outstanding care needs. Discharge
back to the care of the GP will stop the 18 week clock.
Can Not Attend:
As above
B. Outcomes from Pre-Assessment
Patients who have been listed for surgery and attend a pre-assessment will be offered a surgery
date providing they are fit for the procedure.
When a patient is admitted for surgery, it is the final stage of the referral to treatment episode and
the clock will stop on that date. A patient may however choose to be admitted for surgery outside
of the 18 week contract period.
The decision to add patients to the waiting list will be made by the consultant after discussion with
the patient. Patients will only be added to the waiting list if there is an expectation of treating
them and when the patient has accepted the clinicians’ advise on elective treatment. The patient
will be added to the waiting list within one working day of the Decision to Admit (DTA).
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
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C. Diagnostic Appointments
A diagnostic test is defined as a test or procedure used to identify a person’s disease or condition
and which allows for a medical diagnosis to be made. A diagnostic test may be required as part
of the patient’s pathway to enable a treatment plan to be made. In this case the treatment time
clock continues until such time a treatment or decision not to treat is made, or the patient is not
ready, willing and able.
Diagnostic appointments are subject to the same guidelines as for outpatient and treatment
appointments. However, the maximum standard waiting time for diagnostic tests is 6 weeks.
If a patient cancels or fails to attend their diagnostic appointment that has been offered under “
reasonableness criteria” (usually 3 weeks’ notice) then the diagnostic waiting time for that test is
set to zero and the waiting time starts again from the date of the appointment that the patient
cancelled or missed.
Patients who do not meet the inclusion criteria
Wherever possible the Treatment Centre staff will onward refer the patient to the appropriate
setting for the care of the patient and inform the GP of their actions. If this is not clear or known
and the patient cannot be treated at Southampton Treatment Centre, the patient will be
discharged back to their GP to be managed in primary care. The discharge letter will make it clear
to the GP why the patient has been discharged.
Patients not fit for surgery or clinically initiated delays
If a patient is not fit for surgery the STC will ascertain the nature and likely duration of the delay.
If the reason is that the patient has a secondary condition that itself requires active treatment they
will be either discharged back to the care of their GP or will be actively monitored for their original
condition. Either action results in the 18 week clock being stopped. A re-referral to the STC will
be required in the event the patient’s condition has been managed so that they meet the STC
criteria.
If the reason is transitory, e.g. a cold or flu, the patient will be offered a further surgery date within
four weeks. This will allow patients with minor acute clinical reasons for delay time to recover and
the clock will continue to run during this time.
Patients who choose to delay their admission ( excluding diagnostic tests)
It is the expectation that patients will only be referred to the STC if they are able to undertake
their treatment within 18 weeks. However a patient may choose to delay treatment longer than
the reasonable offered surgery date. The clock is not paused.
STC administration staff will endeavour to agree a mutually convenient treatment date with the
patient in an appropriate time frame. Ideally treatment will take place within 18 weeks. However
this may be extended in specific circumstances based on an assessment of an individual case.
Patients cannot choose to wait indefinitely and if treatment cannot take place in a timely fashion,
the patient will be removed from the list and asked to contact us once they are ready to proceed.
This may necessitate certain appointments (assessments) being repeated.
Patients who need a procedure the STC is not currently contracted to perform
These patients will be onward referred as appropriate and the GP and patient informed
Ref: Southampton OP03
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Review Date: May 2018
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Patients where surgery is not indicated
These patients will be discharged back to the referrer and the referral to treatment clock will be
stopped.
Confirmation to the patient
Every patient will be sent written confirmation of the date of their admission.
Reasonableness of dates for admission
Reasonableness for admission is defined as being 3 weeks’ notice although patients can choose
an earlier date if they so wish. A maximum of 3 separate dates can be offered.
Cancellations on day of surgery/treatment
It is the expectation that no patient will be cancelled by the STC on the day of surgery for nonclinical reasons however in extreme circumstances patients must be booked a new date either
within 28 days or before their 18 week breach date if this is shorter than 28 days.
Bi-lateral procedures
If the referral is for a bi-lateral condition the clock stops when the first treatment starts. A new
“referral to treatment” clock starts when the patient becomes fit and ready for the second
operation. A second referral is not required.
If the referral is not for a bi-lateral condition but is deemed necessary by the consultant a letter
will be sent to the referrer informing them that surgery will be performed on the other side. It will
not be necessary to wait for contact from the originating referrer before treatment is give.
GLOSSARY OF TERMS
For the purposes of the policy, the following terms have the meanings given below:
UHSFT
University Hospital Southampton Foundation
Trust
e-Referral System (ERS)
A method of electronically booking a patient
into the hospital of their choice.
Decision to Admit date (DTA)
The date on which a consultant decides a
patient needs to be admitted for an operation.
To Come In Date (TCI)
The offer of admission or TCI date is a formal
offer in writing of a date of admission. Usually
telephone offers are confirmed by a formal
written offer.
Date Referral Received
Ref: Southampton OP03
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Review Date: May 2018
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The date on which a hospital receives a referral
letter from a GP. The waiting time for
outpatients
Inpatients
Day cases
Did Not Attend (DNA)
Could Not Attend (CNA)
First Definitive Treatment
Reasonable Offer
Referral to Treatment (RTT)
Active Monitoring
Patients who require admission to hospital for
treatment and are intended to remain in
hospital for at least one night.
Patients who require admission to the hospital
for treatment and will need the use of a bed but
who are not intended to stay overnight.
Patients who have been informed of their date
of admission or other appointment and who
without notifying the hospital did not attend the
appointment.
Patient who, on receipt of reasonable offer(s)
notify the hospital that they are unable to
attend.
An intervention intended to manage a patient’s
disease, condition or injury and avoid further
intervention. What constitutes first definitive
treatment is a matter for clinical judgment, in
consultation with others as appropriate,
including the patient.
For an offer of an appointment to a patient to
be deemed reasonable, the patient must be
offered the choice of dates within the
timescales referred to for outpatients,
diagnostics and treatment.
Instead of focusing upon a single stage of
treatment the referral to treatment pathway
addresses the whole patient pathway from
referral to the start of the treatment.
A referral to treatment clock may be stopped
where it is clinically appropriate to start a period
of monitoring in secondary care without clinical
intervention or diagnostic procedures.
A new referral to treatment clock would start
when a decision to treat is made following a
period of active monitoring.
Fit and Ready
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
A new clock starts when a patient is fit and
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ready. In this context, fit and ready means that
the clock should start from the date that it is
clinically appropriate for the patient to undergo
the procedure and from when the patient says
they are available.
Procedures of Limited Clinical Value
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
A range of procedures determined by the
clinical commissioning groups with reference to
expert clinical advice that require prior
authorisation prior to treatment
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References
Department of Health, Referral to Treatment Consultant-led Waiting Times, Rules Suite DOH
October 2015
Diagnostics Frequently Asked Questions on completing the “Diagnostic Waiting Times and
Activity” monthly data collection Feb 2015, Analytical Service (Operations)
The policy guardians are identified below and are responsible for the accuracy of the
information contained in this document.
Author
Service Manager
Divisional Clinical Governance Manager
Divisional Medical Director
The following positions are responsible for the implementation of this policy and for
ensuring its timely review:
Service Manager
Lead Clinician
Other ________________________________________________
(Job title and name)
Ref: Southampton OP03
Date: May 2017
Authors: Operations Manager/Administration Manager
Version No: 5
Review Date: May 2018
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