Refreshed 18 week clock rules
18 week
Document Record ID Key
Sub-Prog /
Project
<Insert>
<Insert Document Record ID Key>
Prog. Director
Nick
Chapman
Status
Change paper
Owner
Mark
Svenson
Version
1.0
Author
Sandra
Musgrave
Version Date
11 April 2008
18 Weeks Rules Suite
Refreshed 18 week clock rules
Change to an Information Standard
Refreshed 18 week clock rules
Amendment History:
Version
Date
Amendment History
0.1
First draft for comment
0.3
Submitted to ISB
0.5
Circulated for comments
0.6
Final submission to ISB
1.0
Final version for publication
Reviewers:
This document must be reviewed by the following:
Name
Signature
Title / Responsibility
Date
Version
Date
Version
18 week Senior
Management Team
Approvals:
This document must be approved by the following:
Name
Signature
Nick Chapman
Title / Responsibility
SRO
Document Status:
This is a controlled document.
Whilst this document may be printed, the electronic version maintained internally by the owning
department is the controlled copy. Any printed copies of the document are not controlled.
Related Documents:
These documents will provide additional information.
Ref no
Doc Reference Number
Title
Version
DSC Notice: 30/2007
NHS Improvement Plan
Gateway reference 6468
Tackling Hospital Waiting: the 18 weeks patient
pathway, An Implementation Framework
DSC Notice: 17/2006
DSC Notice 18/2006
Information Standards Board For Health And Social Care Submission
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DSC Notice 18/2007
Glossary of Terms:
List any new terms created in this document or any short forms (abbreviations, acronyms).
Term
Acronym
Definition
EROD
EROD
Earliest reasonable offer date
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Table of Contents
1.
Standard Demographics ............................................................................................................................ 5
1.1.
Name of Standard............................................................................................................................. 5
1.2.
Sponsors........................................................................................................................................... 5
1.3.
Developers........................................................................................................................................ 5
1.4.
Commercial Issues ........................................................................................................................... 5
1.5.
Customer Need................................................................................................................................. 6
2. Purpose and Scope ................................................................................................................................... 6
2.1.
Change Overview ............................................................................................................................. 6
2.2.
Purpose ............................................................................................................................................ 8
2.3.
Scope................................................................................................................................................ 8
2.3.1.
What will the proposed standard be used for?.......................................................................... 8
2.3.2.
Who is the subject? .................................................................................................................. 9
2.3.3.
Who will use it?....................................................................................................................... 10
2.3.4.
How will it be used in routine existing working practices?....................................................... 10
2.3.5.
Where will it be used?............................................................................................................. 11
2.4.
Out of Scope ................................................................................................................................... 12
2.5.
Performance Characteristics........................................................................................................... 12
3. Business Justification .............................................................................................................................. 12
3.1.
Strategic Fit..................................................................................................................................... 12
3.1.1.
Criteria under which the proposed change is submitted ......................................................... 12
3.1.2.
Business justification .............................................................................................................. 12
3.1.3.
When is the NHS required to adhere to the proposed change by?......................................... 13
3.1.4.
Review of Central Returns (ROCR) Submission Plan ............................................................ 13
3.2.
Relationship to the National Programme for IT (NPfIT)................................................................... 13
3.3.
Operational Fit ................................................................................................................................ 14
3.3.1.
Concept of Operation.............................................................................................................. 14
3.4.
Impact and Implications .................................................................................................................. 17
3.4.1.
Implications to stakeholders ................................................................................................... 17
3.4.2.
Analysis of replacement of existing standards ........................................................................ 18
3.5.
Known Standards............................................................................................................................ 18
3.5.1.
Existing standards with a related purpose and scope............................................................. 18
3.5.2.
Assessment to include or eliminate ........................................................................................ 18
3.6.
Interdependencies .......................................................................................................................... 18
3.6.1.
Existing or planned standards................................................................................................. 18
3.6.2.
Projects, programmes or organisations .................................................................................. 18
3.7.
Consultation and Support ............................................................................................................... 18
3.8.
Governance .................................................................................................................................... 20
4. Change Specification and Implementation .............................................................................................. 21
4.1.
Change Specification ...................................................................................................................... 21
4.2.
Implementation Evaluation Report .................................................................................................. 26
4.3.
Implementation Roll Out Plans ....................................................................................................... 26
Allocated responsibilities; ............................................................................................................................ 26
4.4.
Migration Plans ............................................................................................................................... 27
4.5.
Human Behavioural, Organisational and Technical User Implementation Guidance ...................... 27
4.6.
Safety.............................................................................................................................................. 28
4.7.
Maintenance and Update Process Plans ........................................................................................ 28
4.8.
Conformance Tests Specification ................................................................................................... 28
Appendix A...................................................................................................................................................... 30
Sponsor Statement(s).................................................................................................................................. 30
Appendix B...................................................................................................................................................... 31
NHS Connecting for Health - Technology Office Statement ........................................................................ 31
Appendix C...................................................................................................................................................... 32
Appendix D...................................................................................................................................................... 34
Appendix E...................................................................................................................................................... 35
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Information Standards Board for Health and Social Care
Change to an Information Standard
Submission Toolkit for Standard Developers
The purpose of a Change submission is to demonstrate a clear need for a change to a given NHS
Information Standard. The intended audience for the document(s) is the NHS, its partners and suppliers
- not merely the NHS Information Standards Board.
At this stage, the submitted document needs to provide sufficient detail so that appraisers (and intended
audience) understand the purpose of the proposed change and how it is to be used).
Please refer to the document, “ISB Submission Guidance Notes for Changes to Information Standards v1.0 – 3 July 2007” for information on how to complete this form.
1.
Standard Demographics
1.1. Name of Standard
Refreshed 18 week clock rules
1.2. Sponsors
Nick Chapman,
National Director 18 week,
RSU Account Director,
Department of Health
1.3.
Developers
James Beyer
18 week Programme
Department of Health
Rachel McDonald
Analysis 18 week,
Knowledge & Intelligence,
Department of Health.
Nicholas Oughtibridge
Content Manager - NHS Data Model and Dictionary Service
NHS Connecting for Health
Sandra Musgrave
National Implementation Lead 18 week Measurement
Department of Health
1.4. Commercial Issues
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There are no commercial licensing issues, intellectual Property Rights issues or other relevant
undertakings which impact on the standard being used within the NHS.
1.5. Customer Need
The 18 week Referral to Treatment pathway is about improving patients’ experience of the NHS,
ensuring all patients receive high quality elective care without any unnecessary delay.
The purpose of this submission and the subsequent DSCN is to inform the NHS and their system
suppliers of the changes required to support the updated 18 week clock rules contained within the 18week rules suite.
The rules refresh were a response to publication of the operational standards and the decision on clock
pauses and requests made by clinicians, patients and the service. Clinical forums, Royal Colleges,
patients’ forums, surveys, supported the changes
.
The 18 week rules suite aims to set out clearly and succinctly the rules and definitions for 18 week in
order to ensure that each patient’s 18 week clock starts and stops fairly and consistently. It is not a new
set of rules and definitions.
The purpose of the refreshed rules is to clarify the existing rules and definitions where further clarity was
needed and to ensure consistent application across the service. To provide the NHS with a simple
framework to work within, with autonomy to make sensible clinically based decisions on their application
in line with the patients’ experience of their care.
Definitions used within the submission
2.
•
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).
•
Decision to admit - Where a clinical decision is taken to admit the patient for either a day case or
inpatient stay.
•
Non-admitted pathway - A pathway that results in a clock stop for treatment that does not require
an admission or for ‘non-treatment’.
•
Pause/ clock pause - The act of pausing a patient’s 18 week RTT clock. Clocks may only be
paused for non-clinical reasons and only where a patient chooses to wait longer for admission
than two reasonable offers made by the provider.
•
Reasonable offer - an offer of a time and date three or more weeks from the time that the offer
was made.
Purpose and Scope
2.1. Change Overview
It is recognised that for some patients, 18 week is inconvenient or clinically inappropriate. Namely, this
relates to the following three types of patients:
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•
•
•
Patient choice – patients who choose not to accept earliest offered appointments along their
pathway or choose to delay treatment
Co-operation - patients who do not attend appointments along their pathway
Clinical exceptions - patients with clinically complex conditions and/or co-morbidities unsuitable to
be treated within 18 week
The changes contained within this submission aim to support these three categories of patients through
a combination of adjustments and an operational tolerance. Clock pauses will be used to reflect patient
choices during the admitted phase of an admitted pathway. The other elements will be covered by the
operational tolerance. RTT performance from March 2008 onwards will be judged on this basis across
the whole of the NHS.
The changes detailed within this submission can be identified as being:
• Changes to the 18 week guidance
• Changes to 18 week standards
• Changes to the scope of Referral to Treatment Period measurement
Full details of the changes and the categories within which the changes are defined will be provided later
in the submission.
The refreshed clock rules that have been developed refine the previous well-established 18 week clock
rules. They set out clearly and succinctly the rules and definitions for 18 week to ensure that each
patient’s 18 week clock starts and stops fairly and consistently. They do not attempt to provide detailed
guidance on how the rules should apply in every situation, but instead provide the NHS with a
framework.
The clock rules and definitions remain entirely consistent with the previously published version (updated
clock rules – December 2006). The principal variations are:
•
•
•
•
That, as anticipated in the December 06 clock rules, clocks for admitted patients may be
paused to take into account delays introduced because patients turn down offers of
admissions made with reasonable notice.
Further clarity over the definition of active monitoring.
Further clarity over where a clock starts and stops on referral to an interface or referral
management/assessment service.
Further clarity on patient DNAs.
Appendix 1 contains the complete 18 week Rules Suite – national clock rules.
The submission also contains details of the proposal to extend the scope of measurement beyond the 18
week target. In the first instance this would be for direct access audiology referral to secondary care.
Referral to Treatment Measurement would cover the time between referral from a consultant led service,
interface service and initially a direct access audiology service in secondary care. The Referral to
Treatment period would be a subset of Referral to Treatment measurement. The Referral to Treatment
period would then contain target patients i.e. those that met the criteria of an 18 week patient and would
be reported on within the 18 week central monitoring returns, and those patients that were outside 18
week – in this instance audiology, which would not be reported upon within the 18 week central
monitoring returns. The previously approved Audiology DSCN and this submission are interdependent.
Guidance on how the RTT statuses relate to direct accesses audiology patients will be included within
the Technical section of the Audiology DSCN which will be submitted to ISB following approval of this
submission.
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Development of the refreshed rules highlighted changes that were required to the data dictionary to
ensure that the data dictionary definitions reflect the refreshed clock rules, previous submissions and the
change of scope.
2.2. Purpose
The fundamental reason for ‘18 week’ is for patients to feel the difference in the service they receive and
to allow the service to take waiting times ‘off the table’ as an issue for patients.
The NHS cannot claim success in achieving 18 week if patients do not feel it was achieved for them.
The primary measure of success will therefore be what patients tell us about their care and experience of
elective care services. This will be underpinned by the NHS reported Referral to Treatment times for
admitted and non-admitted patients.
The refreshed 18 week clock rules will be used to:
•
Improve the patient’s experience of the NHS by ensuring all patients receive high quality
elective care without any unnecessary delay.
•
Ensure that each patient’s 18 Week clock starts and stops fairly and consistently, through the
application of consistent rules supported by National implementation guidance.
•
Provide the NHS with a framework to work within in making local decisions on the application
of the refreshed rules that are clinically sound and developed as a result of consultation
between clinicians, providers, commissioners and patients.
•
Support defining the success of 18 week, through achievement of the December 2008 RTT
target of:
o 90% of admitted patients to start their treatment within 18 week of referral, with
sufficient data completeness to make the result valid.
o 95% of non-admitted patients to start their treatment within 18 week of referral, with
sufficient data completeness to make the result valid.
2.3. Scope
2.3.1.
What will the proposed standard be used for?
The refreshed 18 week rules published in November 2007 announced that RTT clocks for admitted
patients might be paused to take into account delays introduced because patients’ turn down offers of
admissions made with reasonable notice.
Delivery of the March 2008 RTT milestone for admitted pathways (85% within 18 week) will be assessed
on an adjusted basis, i.e. excluding any periods of clock pause. Adjustments do not apply to nonadmitted pathways.
Monitoring of adjusted RTT times for admitted pathways will be introduced on a voluntary basis from
January 2008 for both the monthly RTT collection and the weekly 18 week PTL. For the monthly
collection, adjusted data for January and February may be submitted through Unify2 on a voluntary basis
(during February and March respectively). The submission of adjusted monthly data will be mandatory
from March 2008 onwards.
The proposed standard will be used to support implementation of the refreshed 18 week clock rules. The
standard will identify changes to the 18 week guidance, scope, standard and data dictionary definitions,
with the overall objective of supporting organisations in meeting their mandatory reporting requirement of
submitting adjusted monthly RTT data from March 2008.
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The adjusted RTT data may then be used to:
•
•
•
•
•
To inform organisations on their local performance and progress.
To inform work on service redesign.
To inform DH on progress towards delivery.
For performance management.
For more complex analysis/modelling work.
2.3.2.
Who is the subject?
Clarification is given of those patients and referral routes, which would give rise to a Referral to
Treatment period.
The standard will include all patients within the scope of the measurement that start an RTT clock
following referral:
•
A consultant led service, regardless of the setting, with the intention that the patient will be
assessed and, if appropriate, treated before responsibility is transferred back to the referring
health professional or general practitioner.
•
An interface or referral management or assessment service, which may result in an onward
referral to a consultant led service before responsibility is transferred back to the referring health
professional or general practitioner.
•
A direct access audiology referral in secondary care.
Upon completion of an 18 week Referral to Treatment period, a patient would become eligible for a new
18 week RTT period when:
•
The decision is made to start a substantively new or different treatment that does not already
form part of that patient’s agreed care plan.
•
A patient is re-referred in to a consultant-led; interface; or referral management or assessment
service as a new referral.
•
A decision to treat is made following a period of active monitoring.
•
A patient rebooks their appointment following a first appointment DNA that stopped and nullified
their earlier clock.
The initial referral may be from any care professional or service permitted by an English NHS
commissioner to make referrals, this would include:
• General Practitioner
• Ophthalmic optician
• Orthoptist
• Accident and Emergency Departments including Minor Injuries Units and Walk In Centre (where
the patient is transferred to an elective pathway).
• Genito-urinary medicine clinics
• National Screening Programmes
• Other care professionals where Primary Care Trusts have commissioned this referral route
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Any other referrals, including self-referrals made by the patient, where Primary Care Trusts have
commissioned this referral route, where these pathways have been agreed locally by commissioners and
providers and once the referral is ratified by a care professional.
2.3.3.
Who will use it?
The standard will be used by all NHS provider organisations in order to support the collection of data for
the mandatory submission of clock pause adjusted RTT data for admitted patients.
The following staff groups / organisations will need to be familiar with the refreshed clock rules and their
implications:
• Information Departments
• Clinicians
• Administrative staff
• 18 week Implementation teams
• Primary Care Trusts
• Strategic Health Authorities
• PCTs
• PAS suppliers
• Strategic Health Authorities
The standard will also have implications for those staff involved in the measurement of waiting times
outside the existing scope of 18 week target patients, in the first instance direct access audiology
patients.
2.3.4.
How will it be used in routine existing working practices?
The standard will be used by all NHS provider organisations in order to support the collection of data for
the mandatory submission of clock pause adjusted RTT data for admitted patients and to ensure that
each patient’s 18 week clock starts and stops fairly and consistently.
NHS Provider Organisations will need to comply with:
•
Monitoring of adjusted RTT times for admitted pathways. This is a voluntary submission from
January 2008 for both the monthly RTT collection and the weekly 18 week PTL. The submission
of adjusted monthly data will be mandatory from March 2008 onwards.
•
Local application of the rules within the framework and guidance of the national rules and in line
with what is in the best interests of the patient. These decisions will be based on clinical
judgement and in consultation with other NHS staff, commissioners and patients.
The standard will have implications for all NHS staff involved in any aspect of 18 week measurement and
data collection, most particularly:
•
Clinicians - it is for the NHS locally to decide how these rules are applied to individual patients,
pathways and specialties, based on clinical judgement and in consultation with other NHS staff,
commissioners and, of course, patients. Care professionals whose clinical decisions may affect
18 week clocks must be able to discuss and explain 18–weeks with their patients.
•
Information Departments – the standard provides clarification for NHS provider organisations of
the mandatory reporting requirements. The submission of adjusted data for admitted patients will
be mandatory from March 2008. Approval of the change of scope of the standard would require
information departments to identify target and non-target 18 week patients so as to only report
those patients within the target criteria.
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•
Administrative staff - will need to be aware of the implications of the changes particularly to
guidance and the recording of clock pauses. They may be required to record patient choice,
patient compliance, and advise of the changes of definition and the implications to the patients’
treatment period.
•
18 week Implementation teams - will use the standard to communicate the changes across the
organisation, providing additional training and support when identified.
•
Primary Care Trusts – clarity is provided within the guidance on the inclusion of interface services
and their reporting requirements. The PCT’s role will be pivotal in coordinating and documenting
local application and implementation of the refreshed rules.
•
Strategic Health Authorities and PCTs - will use the standard to ensure consistent application of
the rules and provide validation of RTT adjusted admitted data submissions.
•
PAS suppliers – the guidance provides a clear definition of the ‘earliest reasonable offer date,’
EROD. The inclusion of EROD within PAS systems will provide the means of recording patient
pauses. EROD was approved in DSCN 09/2007. Issues relating to implementation of EROD and
inclusion within existing PAS systems will be included later in the submission.
•
The Department of Health, Strategic Health Authorities and Primary Care Trusts will use the
adjusted admitted RTT data and the non-admitted RTT data submissions to manage delivery of
18 week and contract performance.
The submission seeks to introduce the concept of a referral to treatment measurement that will support
the direct access audiology collection. This will allow non 18 week pathways to be recorded in fields
previously used for 18 week pathways only, thereby expanding the scope of referral to treatment
measurement. If this change is not made then trusts that need to take data on direct access audiology
referrals from their PAS system, rather than via audiology specific patient management systems (Audit
base or Practice Navigator) will be unable to record the data. As we move towards the use of SUS, and
trusts move towards increased use of their PAS, more and more trusts will need to make use of their
PAS systems for this purpose. This may jeopardise accurate reporting for both 18 week and the new
Audiology Direct Access, meaning that both centrally and locally, the reporting and management of the
waits may be less effective.
2.3.5.
Where will it be used?
The standard will be used in all areas of the provider organisation where a decision on an 18 week
patient’s pathway is made. This will means that the data capture systems implemented to record clock
starts and stops using the original rules may need to be modified and provide additional guidance to
meet the requirements of the refreshed rules.
In the majority of cases, it will be clear how the national 18 week rules should apply. Where there is
doubt, or where decisions on their application are finely balanced, then Local health Communities will
need to make local decisions within the framework of national rules. Local policies should be publicly
available and clearly communicated to the patient. They should be clearly defined and specifically
protect the clinical interests of vulnerable patients having been agreed with clinicians, commissioners,
patients and other relevant stakeholders.
As described in section 2.3.3, this new concept of referral to treatment measurement will mean that we
will be able to record and differentiate between those patients on an 18 week pathway and those
patients on a direct access pathway. This will enable accurate recording of data for both 18 week and
the audiology direct access.
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2.4. Out of Scope
Patients that are not on an 18 week pathway or direct access audiology pathway. This will include any
referral that is not to an interface service; referral management or assessment service; or consultant led
service:
• Non-elective patients
• Planned procedures usually as part of a planned sequence of clinical care, where for example an
emergency admission may result in a series of further planned admissions to complete the
course of treatment.
• Activity after the start of first definitive treatment
• Referrals from non-English commissioners
• Referrals to mental health trusts community services and PwSIs unless they are working as part
of an interface service
2.5. Performance Characteristics
The changes proposed within this change paper were developed in order to support the monitoring of
Department of Health Public Service Agreement (PSA) target 13, “By
2008, no one will wait longer than 18 week from GP referral to hospital treatment …”,
Guidelines for determining a patient’s Referral To Treatment waiting time were set after a discussion at
the SHA Directors of Performance meeting in 2006. These were confirmed in writing by the National
Director for 18 week and became the basis for the formal monitoring of Referral To Treatment waiting
times that became mandatory in January 2007.
The refreshed rules were discussed, agreed and supported by SHA Directors of Performance.
The proposals have been tested and implemented following vigorous discussion and consultation with
the early achiever organisations. Full details of the consultation and implementation pilot are included in
sections 3.7 and 4.2 of the submission.
The changes contained within this standard represent a change to administrative procedures supporting
organisations complying with the principles of 18 week RTT measurement.
3.
Business Justification
3.1. Strategic Fit
3.1.1.
Criteria under which the proposed change is submitted
The proposed Information Standard supports the delivery of an agreed government manifesto, PSA
target and the NHS Operating Framework involving the necessary use of technology.
3.1.2.
Business justification
The refreshed 18 week clock rules provide additional clarification and guidance for those involved in
measurement of the 18 week pathway. They support the correct measurement and reporting of referral
to treatment times, and also ensure that the principles of 18 week are adhered to by all organisations
concerned.
The fundamental reason for ‘18 week’ is for patients to feel the difference and to finally take waiting
times ‘off the table’ as an issue for patients. The NHS cannot claim success in achieving 18 week if
patients do not feel it was achieved for them. The primary measure of success will therefore be what
patients tell us about their care and experience of elective care services.
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The measure of delivery for organisations against which progress will be judged will continue to be the
monthly referral to treatment data for admitted and non-admitted patients. Results for admitted and nonadmitted patients will not be aggregated; therefore success has to be achieved for each patient group
separately.
It is recognised that for some patients, 18 week is inconvenient or clinically inappropriate. This relates to
the following three types of patients:
•
•
•
Patient choice – patients who choose not to accept earliest offered appointments along their
pathway or choose to delay treatment.
Co-operation - patients who do not attend appointments along their pathway.
Clinical exceptions - patients with clinically complex conditions and/or co-morbidities unsuitable to
be treated within 18 week.
These three categories of patients will be dealt with by a combination of adjustments and an operational
tolerance. Clinical exceptions and co-operation will be covered by the operational tolerance. Clock
pauses will be used to reflect patient choices during the admitted phase of an admitted pathway.
While the 18 week target is for achievement by December 2008, a number of milestones and standards
are in place for achievement by NHS organisations during 2007/08. These were set out in the NHS
operating framework 2007/08 (December 2006) and in Tackling hospital waiting: the 18 week pathway
(May 2006).
Delivery of the March 2008 RTT milestone for admitted pathways will be assessed on an adjusted basis,
i.e. excluding any periods of clock pause.
3.1.3.
When is the NHS required to adhere to the proposed change by?
The submission of adjusted monthly RTT data will be mandatory from March 2008 onwards. The
timetable will be the same as the current monthly RTT timetable. A full timetable will be issued.
3.1.4.
Review of Central Returns (ROCR) Submission Plan
The 18 week measurement team within DH will pursue this separately and commence discussions with
ROCR.
3.2. Relationship to the National Programme for IT (NPfIT)
For 18 week, the Secondary Uses Services (SUS) facility will be the tool that allows the NHS to
measure/track, both retrospectively and prospectively, the progress of individual patients along their 18
week pathway. SUS Release 3 (Landing) was implemented in December 2007, from which time
providers can start to report the data . 18 week reporting will be available with Release 3 (Reporting)
from April 2008.
In moving towards this vision, one of the main issues is to balance the short-term deliverables with the
long-term vision, and to ensure that a series of incremental steps can be taken building towards the goal.
SUS will build RTT pathways from Clock Start to Clock Stop based on linking together the patient events
available within SUS. This will be based on the Pathway Identifier and Referral to Treatment (RTT) data
items for 18 week pathways mandated in Version 6 of the Commissioning Data Set (CDS) schema. Until
CDS schema 6 is fully implemented, SUS will support a ‘mixed economy’ of Trusts submitting the new
data and those that have not implemented it, and create linked patient 18 week pathways, based on an
algorithm to identify linked events and key dates. Reports will be available to the NHS with SUS Release
3 Reporting from April 2008.
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In order to implement 18 week reporting through SUS there are a number of steps the NHS need to take
to ensure technical readiness.
A programme of work is in place to offer national support to local organisations and their systems
suppliers to modify systems in accordance with previous DSCNs.
The main (but not only) themes are:
•
•
•
•
Suppliers of Patient Administration Systems (PASs) are modifying their systems to allow the
capture of 18 week data (in accordance with DSCN 18/2006)
Suppliers of PASs are modifying their systems to allow the production of CDSv6, to support the
reporting of 18 week data (in accordance with DSCN18/2007)
Suppliers of PASs are modifying their systems to support the use of Earliest Reasonable Offer
Date (in accordance with DSCN 09/2007)
Suppliers of ‘middleware’ solutions – which actually make submissions to SUS – are modifying
their systems to allow the submission of CDSv6 to SUS
In addition to satisfying the reporting requirements of 18 week, these PAS modifications will support NHS
organisations in the operational management of the patients along the 18 week pathway.
The Information Centre has developed a data quality dashboard. This measures the quality of certain
key data items used in an algorithm developed to link CDS records into Referral to Treatment pathways
for patients before the new 18 week data items are routinely submitted to SUS in CDS version 6.
This will indicate the level of errors in the data submitted as CDS V5 by Providers and will be used to
drive an improvement in data quality prior to migration to CDS V6.
3.3. Operational Fit
3.3.1.
Concept of Operation
The changes proposed as a result of the updated 18 week clock rules, the implementation of patient
initiated delays and the intention of using RTT as a means of monitoring direct access audiology can be
categorised as:
• Changes to guidance
• Changes of standard
• Changes to scope
• New or changes of definition in the data dictionary – business
Changes to guidance
These are not a new set of rules and definitions. The purpose of them is to clarify rules and definitions
where further clarity was needed. The clock rules and definitions remain entirely consistent with the
previously published version (updated clock rules – December 2006). As previously detailed, there are a
few areas that are of greater significance than others. Operational implementation of the revised
guidance would require the development of a planned training programme aimed at all NHS provider
staff involved in 18 week delivery to ensure consistency of implementation and maintain confidence and
competence in interpretation of the required RTT information.
Change of standard
As anticipated in the December 06 clock rules, the refreshed 18 week clock rules identify that a clock
may be paused where:
•
A decision to admit has been made, and the patient has declined at least 2 reasonable
appointment offers for admission. The clock is paused for the duration of the time between the
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earliest reasonable offer and the date from which the patient makes themselves available again
for admission.
Whilst there are strong arguments for allowing clocks to be paused throughout a patient’s 18 week
pathway where patients choose to delay their care, the practicalities of measuring and reporting such
patient initiated pauses mean that this is only feasible at the admission for treatment stage. Clocks may
not be paused for patient initiated delays at any other part of the 18 week pathway.
The “Earliest Reasonable Offer Date” data item, which was introduced into Commissioning Data Sets v6
from October 2007 (see Data Set Change Notice 09/2007 for further information), can be used to record
the earliest reasonable offer given to the patient. The value in this field can then be used as the start of
the clock pause.
The clock restart date (i.e. the end of the pause) should be the date that the patients make themselves
available again. The date of admission accepted by the patient can be used but only if:
• The clock restart date is clearly communicated to the patient.
• The time between the patient becoming available and the admission date is limited
It is recognised that, in the short term, while the use of earliest reasonable offer is being established to
pause pathways, it may be helpful for trusts to use the method employed by some of the early achiever
sites to adjust RTT pathways. Details are provided below:
When reporting inpatient stages of treatment waits, there are two types of adjustment that may be
applied - clock resets and suspensions. Suspensions will be either clinical suspensions or social
suspensions. Clinical suspensions and clock resets are not applicable to RTT. A social suspension
identifies the period a patient makes themselves unavailable for an admission and so is being used by
the early achievers to adjust admitted pathways. This requires the provider to be able to separately
identify social suspensions from other adjustments. This method should only be used in the short term
and providers should move to recording the pause due to a patient turning down two reasonable offers
as soon as possible.
To enable the reporting of adjusted waits in the short term:
• Identify those patients who had a period of suspension during their admitted pathway
• Differentiate between those patients who had had a clinical suspension and those who had had a
social suspension. For those patients who had both a clinical suspension and a social
suspension, it is only the social suspension that is relevant in the context of adjustments.
• For those patients with a period of social suspension during their pathway, identify the length of
adjustments in reporting a Korner inpatient stage of treatment wait.
• Identify the length of social suspensions during each pathway where a social suspension has
occurred.
• Deduct the length of the social suspension from the reported unadjusted pathway wait.
• Report the adjusted wait for those patients with an adjustment and the unadjusted wait for those
where no adjustment is applicable.
In the long term DH continues to work with Connecting for Health to enable RTT measurement, including
the accurate measurement of clock pauses.
Provider organisations will be required to report the following:
• Monthly RTT data
Organisations will continue to submit the usual RTT monthly return (for unadjusted admitted
pathways, non-admitted pathways and incomplete pathways) through Unify2 as now. The facility to
submit adjusted RTT times will be via a separate monthly data collection template within Unify2.
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Adjusted monthly RTT data for January and February may be submitted through Unify2 on a
voluntary basis (during February and March respectively). The submission of adjusted monthly RTT
data will be mandatory from March 2008 onwards. The timetable will be the same as the current
monthly RTT timetable. A full timetable was issued in January 2008.
Data for completed admitted pathways should be submitted on the adjusted data form. Where clock
pause/s were applied along the pathway, the adjusted RTT time should be reported. For pathways
where no clock pause occurred, the unadjusted RTT time should be reported. The total number of
completed pathways reported in the adjusted data monthly form should equal the total number of
completed pathways reported in Part 1a (completed admitted pathways) of the usual monthly RTT
return.
• 18 week PTL data
Organisations should be completing their 18 week PTL on an adjusted basis from the week ending
2nd March 2008 onwards, and earlier if possible. The process for submitting the adjusted PTL via
Unify2 will be the same as for unadjusted data. Organisations will not be asked to submit both
adjusted and unadjusted PTLs - the adjusted PTL should replace the unadjusted PTL by week
ending 2nd March 2008.
The implications of this change of scope to stakeholders are included within impact and implications.
Change of scope
Part of this change will be the introduction of the concept of referral to treatment measurement. This will
mean that referral to treatment times can be measured for all patients, regardless of whether they are on
an 18 week or non 18 week pathway. PAS users will therefore need to differentiate between two types of
pathways, 18 week pathways and non 18 week pathways, in this instance, direct access audiology
pathways. Reviewing the treatment function code recorded for the patient pathway would differentiate
direct access audiology pathways and ENT 18 week target pathways.
Changes to the Data Dictionary
The following changes and additions have been made within the NHS Data Model and Dictionary in
order to support the 18 week rules suite.
The data set change notice provides definitions of:
•
•
•
•
•
•
18 weeks target – defines which Referral To Treatment Periods are included in the 18 week
target
Consultant led services and activity - Introduces definitions of Consultant Led Services and
Consultant Led Activity which are consistent across 18 week, Reference Costs and Payment by
Results.
Active Monitoring – provides a definition of active monitoring which is consistent with existing
Cancer definitions.
Reasonable Offers – introduces a business definition of a Reasonable Offer and a new logical
attribute reasonable offer indicator.
Interface services – defines referrals to interface services start an 18 week referral to treatment
period.
Clock Pauses - Introduces how the referral to treatment time may be adjusted to exclude the
duration of the time between the earliest reasonable offer for admission for first definitive
treatment and the date from which the patient makes themselves available again for admission
provided the patient has declined at least 2 reasonable appointment offers for admission for first
definitive treatment.
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The proposed changes to guidance, standard, scope or the introduction of new or changes of definition
in the data dictionary would have no impact on existing confidentiality and security, legal and
professional rules relating to the implementation of this standard.
If the changes contained within the standard were not approved:
•
Patients would continue to experience unnecessary delays in elective care.
•
There would be continued variation in the application of national rules with no facility to work
within the rules and guidance to provide a service catering to the needs of the local health
community.
•
The engagement and commitment of clinicians, providers, commissioners and patients who
have supported the development of the refreshed rules would be compromised.
•
Measurement and delivery of 18 week would be compromised.
•
Patient experience of 18 week (and the NHS) would remain negative with regard to waiting
times
•
Patients wishing to express their option of Choice would be disadvantaged.
3.4. Impact and Implications
3.4.1.
Implications to stakeholders
Will allow providers to submit adjusted RTT data, which takes into account patient choice.
This would be an additional RTT data collection, since for a limited period providers would be asked to
report both adjust and unadjusted admitted RTT data.
•
A review of data capture mechanisms would be needed to ensure that adjustments clock stops
and starts were being recorded accurately and consistently.
•
Additional training and support to clinical, information and administrative staff would be required
to ensure consistent application of the rules.
•
There would be an additional cost and burden associated with the additional data submission.
•
Implementation of Earliest Reasonable Offer Date will have implications to PAS suppliers and
providers.
•
Communication to all stakeholders of the changes, particularly patients in explaining their role
and responsibility for receiving treatment.
•
Increased emphasis on clinical engagement and local interpretation, implementation will require
clarification of roles and responsibilities within local health communities.
•
Roles and responsibilities of SHA Leads and DOPs in delivering 18 week.
As stated previously in the submission the rules refresh provides the NHS with a simple framework to
work within, with autonomy to make sensible clinically based decisions on their application in line with
the patients’ experience of their care. Implicit within this approach is a move to facilitating local resolution
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of issues, supported by the Department of Health. The DH would focus would be on providing guidance
on national 18 week issues and supporting SHAs to deliver the target.
Further details of the implications of implementation are included within section 4.2 of the submission.
As indicated earlier in the submission both stakeholders and patients will benefit from the implementation
of the standard particularly through the inclusion of patient choice at admission and in the monitoring of
non 18 week target waits for audiology.
The use of early achievers allowed us to assess the impact of this standard, and whilst initial training and
recording issues have been identified, we do not envisage an ongoing major impact, since the majority of
the data is already stored. The task will be extracting the data from the relevant systems automatically.
3.4.2.
Analysis of replacement of existing standards
The clock rules and definitions remain entirely consistent with the previously published version (updated
clock rules – December 2006). The standard provides additional guidance and clarification on the
existing standards; it does not replace an existing standard.
3.5. Known Standards
3.5.1.
Existing standards with a related purpose and scope
Existing standards with a related purpose and scope include:
•
•
•
•
•
DSCN 17/2006,
DSCN 18/2006,
DSCN 9/2007,
DSCN 18/2007,
DSCN 30/2007
The requirement to refresh the 18 week rules in order to clarify the existing rules and definitions where
further clarity is needed has been well recognized and documented earlier in this submission.
The national Audiology PTL and WT data set is intended to collect a set of performance information on
RTT pathways of patients receiving audiology treatment in England who are not already included in the
18 week data collection.
3.5.2.
Assessment to include or eliminate
This section is not applicable to this submission
3.6. Interdependencies
3.6.1.
Existing or planned standards
This section is not applicable to this submission
3.6.2.
Projects, programmes or organisations
This section is not applicable to this submission
3.7. Consultation and Support
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The changes and clarification contained within the 18 week rules refresh have been at the request of
clinicians, patients and NHS providers.
There has been extensive consultation in their development that has included:
•
The 18 week Task Force monitored and supported development of the standard. This group
contains representatives from the key 18 week work programmes.
•
Consultation was undertaken with the following Department of Health teams:
o 18 week Navigation
o 18 week Measurement,
o Choose and Book,
o Connecting for Health
o 18 week Intensive Support
o Data Dictionary
•
PAS suppliers have been engaged.
•
Clinical engagement has included:
o Discussions with individual Royal Colleges, including the Royal Colleges of Orthopaedics
and Ophthalmology
o Presentations and discussions with the 18 week Clinical Advisory Group
o Discussions with the 18 week National Clinical Lead and Diagnostic Clinical Leads
•
National presentations by the 18 Weeks National Implementation Director have included
progress reports on development of the rules refresh.
•
Health Service Journal national conference, 18 week rules master class supported by DH.
•
Regular presentations and progress reports to SHA 18 week leads and SHA Directors of
Performance.
•
The early achievers local health communities have supported the development and piloting of the
rules refresh. Comments received from this group continue to inform development and guidance.
The project reference group have worked particularly closely with the Derby Hospitals NHS
Foundation Trust.
SHA
East Midlands
PCT
Derbyshire County PCT
Derby City PCT
Acute Trust(s)
Chesterfield Royal Hospital NHS Foundation Trust
Derby Hospitals NHS Foundation Trust
(other Trusts to be brought in as far as possible)
North West
South Coast
South West
West Midlands
Blackpool PCT
Bolton PCT
Blackpool, Fylde and Wyre Hospitals NHS Trust
Bolton Hospitals NHS Trust, Greater Manchester
Surgical Centre (BMI)
Manchester PCT
Central Manchester and Manchester Children’s
University Hospitals NHS Trust
Western Cheshire PCT
Countess of Chester Hospital NHS Foundation Trust
Halton and St Helens PCT St Helens and Knowsley Hospitals NHS Trust
Knowsley PCT
Eastern and Coastal Kent East Kent Hospitals NHS Trust
PCT
Torbay Care Trust
South Devon Health Care NHS Trust
Somerset PCT
Yeovil District Hospital NHS Foundation Trust
Taunton and Somerset NHS Trust
Walsall Teaching PCT
Walsall Hospitals NHS Trust
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SHA
Yorkshire and
the Humber
PCT
Herefordshire PCT
Doncaster PCT
Acute Trust(s)
Hereford Hospitals NHS Trust
Doncaster and Bassetlaw Hospitals NHS Foundation
Trust
•
Development of the rules refresh was supported by the development of a project reference group
that report to Task Force. The group consisted of representatives from 18–weeks:
o Measurement
o Intensive support
o Service transformation
o Engagement/Communication
o Orthopaedic Implementation
o Policy and Programme
•
The measurement section of the 18 week website has been redesigned to coincide with the
publication of the 18 week rules suite. The website contains documentation to support
implementation of the refreshed rules. Further updates will flagged through the news section of
the website.
The measurement website can be accessed at:
http://www.18weeks.nhs.uk/public/default.aspx?load=How-do-I-measure-and-monitor-18 week
Queries can be posted at the specific data queries help line on:
[email protected]
Evidence from the consultation exercise identified that not all system suppliers had yet implemented
Earliest Reasonable Offer Date.
It is recognised that, in the short term, while the use of EROD is being established to pause pathways, it
may be helpful for trusts to use the method employed by some of the early achiever sites to adjust RTT
pathways. DH continues to work with Connecting for Health to enable RTT measurement, including the
accurate measurement of clock pauses.
The use of EROD to record clock pauses is an interim solution the pilot sites that did not have access to
EROD developed workarounds with SUS providing the ultimate means of recording clock pauses.
DH will continue to work with system suppliers with regard to implementing EROD.
There has been regular consultation with suppliers band we have also worked closely with the SUS team
within CfH and with SUS programmers from BT.
3.8. Governance
Project Governance
To support the development and implementation of the standard the following project governance
arrangements were implemented:
The 18 week Taskforce has overseen the development of the refreshed rules at the highest level.
Chaired by Nick Chapman, National Director of 18 week, the 18 week Taskforce includes
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representatives from all key 18 week work streams. Taskforce have received regular verbal updates on
the progress of the project with formal reports/presentations to the Board on request.
A Project Team, consisting of representatives from: 18 week Measurement Team, Connecting for
Health, 18 week Navigation team and the IST, oversaw the day-to-day management and development of
the Standard. Contributions to the project team were received from PAS suppliers and the 18 week Early
Achievers.
•
Security -There are no security issues attached to the change of the standard other than those
that have been previously identified and are being addressed through the 18 week programme.
•
Confidentiality and consent - There are no additional confidentiality or consent issues attached to
the change of the standard other than those that have been previously identified and are being
addressed though the 18 week programme.
•
Existing legislation guidelines and standards relating to governance - None
•
Ethics - The change to the standard raises no ethical issues.
4. Change Specification and Implementation
4.1. Change Specification
The changes detailed within this submission can be identified as being:
•
•
•
•
Changes to the 18 week guidance
Changes to 18 week standards
Changes to the scope of Referral to Treatment Period measurement
New or changes of definition in the data dictionary – business
Change of guidance
The guidance developed to support the refreshed 18 week clock rules is intended to support the NHS
when deciding how to apply the national 18 week rules locally. It outlines the principles that underpin the
national 18 Week rules; provides explanation of and rationale behind each of the rules, and gives worked
examples of how they may be applied locally. It does not attempt to provide comprehensive guidance on
how to apply the rules to every local scenario, but instead provides the information and worked examples
of how the rules may apply to various scenarios so that these decisions can be made locally and
consistently.
In the majority of cases, it will be clear how the national 18 week rules should apply. However, where
there is doubt, or where decisions on their application are finely balanced, then local decisions should be
made within the framework of national rules and in line with what is in the best clinical interests of the
patient, and how the patient would perceive their waiting time being the key determining factors.
The clock rules and definitions remain entirely consistent with the previously published version (updated
clock rules – December 2006). Guidance provided on the following areas has however been amended
to provide further clarification:
Active
monitoring
18 week rules suite definition
An 18 week clock may be stopped
where it is clinically appropriate to
start a period of monitoring in
secondary care without clinical
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Principle change and justification
Feedback from various sources identified that
there were a variety of interpretations of
watchful waiting/active monitoring (now
described just using the term active
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intervention or diagnostic procedures
at that stage.
An Active Monitoring Period is
defined as a period during the patient
pathway in secondary care. It will
commence when a decision is made
(and agreed with the patient) that it is
clinically appropriate to start a period
of monitoring in secondary care,
possibly whilst the patient receives
symptomatic support, but without any
specific or significant clinical
intervention at this stage.
Active monitoring may be initiated by
either a care professional or the
patient. The start of Active Monitoring
will end a referral to treatment period.
During an active monitoring period
the patient will remain under the care
of a consultant, although the GP will
be updated with the progress of their
patient.
If a decision to treat is made during
an Active Monitoring Period, this will
end the Active Monitoring Period and
will start a new referral to treatment
period.
Principle change and justification
monitoring.)
The original framework was reviewed in which
watchful waiting/active monitoring could only
be applied after diagnosis. In line with cancer
active monitoring the revised guidance
identifies that it is appropriate to start a period
of active monitoring when clinical opinion is
that it is appropriate.
Stopping a patient’s clock for a period of active
monitoring requires careful consideration on a
case by case basis and its use needs to be
consistent with the patient’s perception of their
wait.
In these instances the clinician should be able
to explain to the patient and be comfortable
with the approach.
This guidance is clinically defined and was
tested and discussed with national clinical
leads and is consistent with the definitions and
guidance issued for active monitoring for
cancer referrals.
It reflects the need to ensure that national
measurement reflects the actual realities of
clinical decision-making on the ground, and to
identify waits due to resource constraint, and a
wait because a positive clinical decision has
been made that this would be the best course
of action at that stage for a patient.
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 ongoing management, then this
constitutes a decision not to treat and
should be recorded as such and
would stop an 18 week clock.
Consultant led
service
First definitive
treatment
If a patient is subsequently referred
back to a consultant-led service, then
this referral starts a new 18 week
clock.
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.
An intervention intended to manage a
patient’s disease, condition or injury
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Guidance consistent with previous guidance,
new supporting information included in the
Data Dictionary for the purpose of 18 week as
not previously included.
Consultation being undertaken with PBR to
ensure consistency.
Guidance consistent with previous guidance,
new supporting information included in the
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Interface
service
18 week rules suite definition
and avoid further intervention. What
constitutes First Definitive Treatment
is a matter for clinical judgement, in
consultation with others as
appropriate, including the patient.
Principle change and justification
Data Dictionary for the purpose of 18 week as
not previously included.
Is defined as:
All arrangements that incorporate any
intermediary levels of clinical triage,
assessment and treatment between
traditional primary and secondary
care.
Feedback from various sources identified that
there were a variety of interpretations of what
defined an interface service. The rules in
relation to clock starts on referral to interface
services have not been changed.
The 18 week target relates to
hospital/consultant led care.
Therefore, the definition of the term
‘interface service’ within the context
of 18 week does not apply to similar
‘interface’ arrangements established
to deliver primary, community or
direct access services, outside their
traditional setting.
The definition of the term also does
not apply to:
•
Non consultant-led mental
health services run by Mental
Health Trusts.
•
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 described
above.
Decisions must be taken locally about whether
a particular service model falls within the
definition of an interface service or not. We
recognise however, that this may be a finely
balanced judgement, particularly when
deciding if a practitioner with a special interest
is working as part of a wider interface service
type arrangement or not. The intention of the
definition to exclude referrals to individual
PwSIs starting an 18 week clock (although
they, in principle meet the definition of an
interface service in that they triage, assess and
treat patients) was made for two reasons:
• Recognition that measuring clock
starts for referrals to PwSIs would be
prohibitively difficult and expensive to
implement.
•
Avoiding over extending the scope of
18 week into the delivery of primary
care services.
Without starting clocks for referrals to interface
services, 18 week would be harder to achieve
as hospitals case mix shifts to dealing with the
more complex cases that can only be
undertaken by consultants in an acute setting.
Excluding these successes would not
accurately reflect the achievements of the NHS
in reducing waiting times and would not
provide an incentive to bring services closer to
home where this is clinically appropriate.
We would see PCT providers as being
equivalent to an interface service, therefore
they would start an 18 week clock in the same
way as would happen within the 18 week
target.
Supporting information that defines both
GpwSI and interface services for the purpose
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18 week rules suite definition
Direct Access
Referral
Earliest
reasonable
offer date –
EROD
Principle change and justification
of 18 week are included in the Data Dictionary.
These definitions have not previously been
included.
A Direct access referral is any referral For audiology data collection purposes this
that is not made to a consultant – led means that patients referred to audiology
provider services from any consultant-led
service; an interface service ;or a
service are already on an 18 week pathway,
referral management or assessment
and are therefore not included in the direct
service (as defined in the 18 week
access audiology collection.
rules suite).
A reasonable offer is defined as an
offer of a time and date three or more
weeks from the time that the offer
was made.
An RTT clock may be paused only
where a decision to admit for
treatment has been made, and the
patient has declined at least two
reasonable offers for admission.
DNA
DNA (sometimes known as an FTA –
Failed to attend). In the context of 18
week, this is defined as where a
patient fails to attend an
appointment/admission without prior
notice
The direct access audiology data required
consists of referral to treatment times for
patients using direct access audiology services
(i.e. data for those patients who are directly
referred from primary care and community
care to the audiology service for both
diagnostic assessment and treatment and are
therefore not referred to and under the care of
a medical consultant).
The definition of reasonable offer has been
developed as part of the submission ‘Earliest
reasonable offer date’. This national guidance
that is not subject to local agreements between
providers and commissioners.
The EROD field will be used to record clock
pauses. The EROD field will only be populated
when a clock pause is being applied, in this
instance the EROD field would be populated
with the date of the earliest date reasonable
offer given to the patient.
Feedback received at events and through the
18 week mailbox and other routes identified
that further clarification of the rule was
required.
The December 2006 rules DNAs as being
applicable for the first outpatient appointment.
In many cases this contradicted locally agreed
access policy.
Following discussion with clinical leads it was
agreed that DNA for the 1st appointment would
continue to stop the clock, subsequent DNAs
would be clinically reviewed and where
clinically appropriate discharged to the referrer
– stopping the clock.
Previous clock rules stated that there was
legislation that prevented stopping clocks for
children. We do not feel that this is now the
case. All first appointment DNAs stop (and
nullify) a clock. A new one starts when the
patient rebooks (or is referred back into the
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18 week rules suite definition
Principle change and justification
service).
For subsequent appointment DNAs then it is
the act of discharging the patient that stops the
clock, not the act of DNA ing. The guidance
provides further caveats around when
discharge may be appropriate.
Change of standard
As anticipated in the December 06 clock rules, clocks for admitted patients may be paused to take into
account delays introduced because patients turn down offers of admission for treatment made with
reasonable notice.
The updated 18 Clock rules identify that a clock may be paused where:
A decision to admit has been made, and the patient has declined at least 2 reasonable appointment
offers for admission. The clock is paused for the duration of the time between the earliest reasonable
offer and the date from which the patient makes themselves available again for admission.
Whilst there are strong arguments for allowing clocks to be paused throughout a patient’s 18 week
pathway where patients choose to delay their care, the practicalities of measuring and reporting such
patient initiated pauses mean that this is only feasible at the admission for treatment stage. Clocks may
not be paused for patient initiated delays at any other part of the 18 week pathway.
Therefore, only where a decision to admit a patient for day case or inpatient treatment has been made,
may a clock be paused. Clocks may be paused for social reasons only. There is no facility for pausing
clocks due to clinical delays, where there is a clinical reason why a patient cannot be admitted but that it
would not be appropriate to stop the patients clock and ‘actively monitor’ the patient, then the patients
clock would keep ticking until start of treatment. Where such instance mean that treatment cannot be
started in 18 week or less from initial referral, then this may constitute a clinical exception to 18 week,
which is also accounted for within the operational standards.
Once a decision to admit has been made, patients should, of course, be offered the earliest available
dates to come in, as appropriate. However, where patients decline these offers, then, for a clock to be
paused, they must be offered at least 2 appointments with at least 3 weeks notice. If the patient also
declines these offers, then their clock may be paused from the date of the earliest reasonable offer. In
order to ensure that the patient’s perception of their wait mirrors NHS reported referral to treatment
times, it is vitally important that patients are aware of the effect of their decisions to delay upon their 18
week clock. Therefore clock pauses should only be used on the proviso that the start date of the clock
pause is communicated to the patient.
Where a patient makes themselves unavailable for admission for a longer period of time, for example a
patient who is a teacher who wishes to delay their admission until the summer holidays, then this may
mean that offering actual dates which meet the reasonableness criteria would be inappropriate (as the
patient would be being offered dates that the provider already knew they couldn’t make). In these
circumstances, the clock should be paused from the date of the earliest reasonable offer that the
provider would have been able to offer the patient.
Where known, the end of the pause period should also be communicated to the patient and the patient
should be made aware of the effect of their patient initiated pause is on the ’target’ date for them to start
treatment within.
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Changes to the scope of Referral to Treatment Period measurement
The submission also contains details of the proposal to extend the scope of measurement beyond the 18
week target. In the first instance this would be for direct access audiology referral to secondary care.
Referral to Treatment Measurement would cover the time between referral from a consultant led service,
interface service and initially a direct access audiology service in secondary care. The Referral to
Treatment period would be a subset of Referral to Treatment measurement. The Referral to Treatment
period would then contain target patients i.e. those that met the criteria of an 18 week patient and would
be reported on within the 18 week central monitoring returns, and those patients that were outside 18
week – in this instance audiology, which would not be reported upon within the 18 week central
monitoring returns. The previously approved Audiology DSCN and this submission are interdependent.
Guidance on how the RTT statuses relate to direct accesses audiology patients will be included within
the Technical section of the Audiology DSCN which will be submitted to ISB following approval of this
submission.
The identified SUS solution is that if the Treatment Function Code for audiology is present with a status
of RTT start the pathway will not be counted as falling within 18 week. So pathways that are all
audiology will not be counted, but pathways that start with an ENT consultant will start an 18 week RTT.
Where a patient starts in direct access audiology and is then referred to an ENT consultant, the
audiology RTT clock will be stopped and an 18 week RTT clock started.
New or changes of definition in the data dictionary – business
All changes made to the NHS Data Model or Dictionary is detailed in the attached Change Paper, CP
935.
4.2.
Implementation Evaluation Report
See Appendix 3
4.3.
Implementation Roll Out Plans
Implementation roll out plan for the change:
Allocated responsibilities;
• Communications plan
The communication of the changes within the standard has included:
•
•
•
•
•
•
•
Attendance at SHA Leads and Directors of Performance meetings.
Re-launch of the 18 week website 18 week rules suite and monthly updates to the 18 week
bulletin.
Information in the Chief Executive bulletin.
Agenda item at Task force for discussion and agreement.
Attendance at monthly IST meetings.
Inclusion in all regular calls with IT suppliers.
Continued support to and feedback from Early Achiever organisations.
The future focus of the implementation roll out will be to ensure that all organisations have access to the
required information and support networks.
•
Timescales
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Monitoring of adjusted RTT times for admitted pathways was introduced on a voluntary basis in
January 2008 for both the monthly RTT collection and the weekly 18 week PTL. For the monthly
collection, adjusted data for January and February will be submitted through Unify2 on a voluntary
basis (during February and March respectively). The submission of adjusted monthly data will be
mandatory from March 2008 onwards.
•
Training and Education
Before being introduced the changes were piloted by the Early Achiever organisations these pilots
have provided useful learning which has been included within the guidance. The developers continue
to work with the pilot sites and will share future learning across the NHS through the 18 week
website.
The guidance referred to in section 4.5 of the submission can be found at:
http://www.18weeks.nhs.uk/public/default.aspx?main=true&load=ArticleViewer&ArticleId=1104
•
Audiology implementation
The data dictionary changes around allowing the 8 weeks fields to be used for non-18 week
pathways will be explained to the service at the same time as the rest of the technical information
regarding the new audiology data collection is disseminated. It will form part of the technical
mandating DSCN relating to the audiology collection which is currently outstanding, and at that time
guidance will also be placed on the 18 week website and the Unify2 data collection tool to explain to
the service how this will work. At that time we will need to produce detailed guidance around
specifically how the NHS will be able to differentiate between 18 week target, and non 18 week
target pathways. This will essentially revolve around treatment functions and clinic codes, and there
will need to be a degree of local interpretation depending on the exact way in which the
relevant fields are used, but we accept that there will be a need for central guidance."
4.4.
Migration Plans
The changes identified within this submission are either guidance or definitional changes that do not
require system changes or the required system changes have been included within the previous CDS v6
submission.
4.5.
Human Behavioural, Organisational and Technical User Implementation Guidance
A series of supporting guidance, the 18 week rules suite have been developed to support the
implementation of the refreshed 18- weeks clock rules. These include:
•
The 18 week rules suite - definitions,
The aim of this document is to provide clear and unambiguous definitions of terms used where
they have a particular meaning within the context of 18 week.
•
The 18 week rules suite – measuring success
Measuring success defines how the success of 18 week will be measured. This sets out how,
ultimately, we will judge the success of 18 week by what patients tell us, underpinned by referral
to treatment times for admitted and non-admitted patients.
•
The 18 week rules suite – national clock rules
This documents aims to set out clearly and succinctly the rules for 18 week to ensure that each
patient’s 18 week clock starts and stops fairly and consistently. It does not attempt to provide
detailed guidance on how the rules should apply in every situation, but provide the NHS with a
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framework to work within to make clinically sound decisions locally about applying them, in
consultation between clinicians, providers, commissioners and, of course, patients.
•
The 18 week rules suite - a ‘how to’ guide to applying national 18 week rules locally
The ‘how to’ guidance is intended to support the NHS in deciding how to apply the national 18
week rules locally. It outlines the principles that underpin the national 18 week rules; provides
explanation of and rationale behind each of the rules, and gives worked examples of how they
may be applied locally. It does not attempt to provide comprehensive guidance on how to apply
the rules to every local scenario, but instead provides the information and worked examples of
how the rules may apply to various scenarios so that these decisions can be made locally and
consistently.
•
The 18 week rules suite - a ‘how to’ measure 18 week guide
The intended audience for this document is primarily NHS staffs who are involved in any aspects
of 18 week measurement and data collection. This will include staff within trusts, Primary Care
Trusts (PCTs) and Strategic Health Authorities (SHAs).
This document provides further guidance on the measurement implications of the refreshed rules.
Information is provided on capturing and recording data on clock starts, clock stops, clock pauses
and on calculating Referral to Treatment (RTT) times. The structure of this document follows the
six rules defined in the refreshed18 week clock rules.
4.6.
Safety
The safety issues previously identified in relation to 18 week will not be compromised by the changes
proposed within this standard.
The DH will continue to work to resolve identified safety issues.
It is not anticipated that the proposals contained within this submission would have a negative impact on
patient safety by opening a risk of inappropriate recording of extended waits. Only the patient may
choose to pause their clock for social reasons. The introduction of tolerances and pauses are to protect
the clinical safety of patients. Without them, patients may be ‘pushed through‘ in 18 week when it would
be inappropriate (either socially or clinically to do so). The patient survey will also help mitigate this.
4.7.
Maintenance and Update Process Plans
The collection of both adjusted and unadjusted admitted RTT data through unify 2 will be ongoing (but
will eventually be collected via SUS).
The NHS Finance, Performance and Operations directorate will be responsible for performance
managing the waits picked up through this collection, and for providing clarity around policy guidance.
Once approved, K&I will manage the data collection, in DH, on an ongoing basis. A mailbox will be
maintained for data queries. The same publication/dissemination process as at present will apply to
future versions of the standard.
DH are the owners of the content; CfH maintain the technical aspect of the content and maintain the data
standard from a technical perspective.
4.8.
Conformance Tests Specification
Conformance to the clarified rules and administrative procedures will be monitored on an ongoing basis.
If providers did not follow the agreed procedures they would be misreporting their RTT figures. This will
in part need to be self policed and they are expected as with all Waiting Time reports, to follow the
national guidance.
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Conformance testing will need to be performed in organisations in order to confirm that the performance
criteria identified within the scope of the standard are being met.
This would require referring and receiving providers to demonstrate that:
•
Each patient’s 18 Week clock starts and stops fairly and consistently, through the application
of consistent rules supported by National implementation guidance.
•
Clock pauses are used to reflect patient choices during the admitted phase of an admitted
pathway.
•
They have achieved the December 2008 RTT target of:
o
o
•
90% of admitted patients to start their treatment within 18 week of referral, with
sufficient data completeness to make the result valid.
95% of non-admitted patients to start their treatment within 18 week of referral, with
sufficient data completeness to make the result valid.
Audiology waiting times for non 18 week target patients are being recorded.
The success of the NHS is in delivering the 18 week target will be measured through listening to what
patients tell us, underpinned by NHS reported referral to treatment times (RTT). We are currently
piloting a patient experience survey with the expectation that a full survey will be in place from the spring
of 2008. After further piloting we may issue guidance on the results and how these relate to NHSreported RTT data. Where appropriate, we may also issue clarifications on the interpretation of rules or
definitions where there is a lack of clarity in the NHS
The Department of health is currently working with the Healthcare Commission (HC) to develop 2007/08
indicators for the 18 week GP referral to treatment target – for PCTs and Trusts.
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Appendix A
Sponsor Statement(s)
Richmond House
79 Whitehall
London
SW1A 2NS
Tel: 020 7210 5811
Switchboard 020 7210 3000
14th February 2008-02-14
Professor Martin Severs
Chairman, NHS Information Standards Board,
Princes Exchange,
Princes Square,
Leeds,
LS1 4HY.
Dear Professor Severs,
Re: Refreshed 18 week clock rules, change to an information standard
I am writing to you in support of the work that has been undertaken in changing the existing standard to
support implementation of the 18 week Rules Suite and to introduce the concept of referral to treatment
measurement, which will allow referral to treatment times to be measured for all patients, regardless of
whether they are on an 18 week or non 18 week pathway.
The refreshed rules provide the NHS with a simple framework within which clinically sound decisions can
be made locally about applying the rules, in consultation between clinicians, providers, commissioners
and, of course, patients. They set out clearly and succinctly the rules and definitions for 18 week to
ensure that each patient’s 18 week clock starts and stops fairly and consistently.
This is an important part of the continued work to support 18 week measurement. The work undertaken
on defining this standard has strong support from the service. Mandating this additional adjusted data
collection and the extension of the scope of measurement beyond 18 week target for direct access
audiology will support defining the success of 18 week through achievement of the December 2008 RTT
target and improve the patients experience of the NHS by ensuring all patients receive high quality
elective care without any unnecessary delay.
Yours sincerely
Nick Chapman
National Director, 18 week
RSU Account Director
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Appendix B
NHS Connecting for Health - Technology Office Statement
From: [email protected] [mailto:[email protected]]
Sent: 14 March 2008 14:54
To: [email protected]
Cc: [email protected]; [email protected]
Subject: 18 weeks Clock Rules
Jane
I am writing to you in support of the change submission relating to the
standard to support implementation of the 18 Weeks Rules Suite and to
introduce the concept of referral to treatment measurement, which will allow
referral to treatment times to be measured for all patients, regardless of
whether they are on an 18 week or non 18 week pathway.
I can confirm that the Technology Office is working closely with the DH and
the developers for this standard and supports the submission to ISB of the
standard.
We will continue to work with them to progress further plans for the
reporting of 18 week waits through changes to local systems and the
analysing of information through the Secondary Uses Service (SUS).
Regards
Jeremy
Jeremy Thorp
Director of Business Requirements
Technology Office
NHS Connecting for Health
e-mail: [email protected]
Tel: PA Hayley Miller (+44) 113 397 3235
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Appendix C
Clock Rules
THE 18 WEEKS RULES SUITE - NATIONAL CLOCK RULES
Clock Starts
1. An 18 week clock starts when any care professional or service permitted by an English NHS
commissioner to make such referrals, refers to:
a) a consultant led service, regardless of setting, with the intention that the patient will be assessed
and, if appropriate, treated before responsibility is transferred back to the referring health
professional or general practitioner;
b) an interface or referral management or assessment service, which may result in an onward
referral to a consultant led service before responsibility is transferred back to the referring health
professional or general practitioner;
2. An 18 week clock also starts upon a self-referral by a patient to the above services, where these
pathways have been agreed locally by commissioners and providers and once the referral is
ratified by a care professional.
3.
Upon completion of an 18 week referral to treatment period, a new 18 week clock only starts:
a) upon the decision to start a substantively new or different treatment that does not already form
part of that patient’s agreed care plan;
b) upon a patient being re-referred in to a consultant-led; interface; or referral management or
assessment service as a new referral;
c) when a decision to treat is made following a period of active monitoring.
d) when a patient rebooks their appointment following a first appointment DNA that stopped and
nullified their earlier clock
Clock Pauses
4. A clock may be paused only where a decision to admit has been made, and the patient has declined
at least 2 reasonable appointment offers for admission. The clock is paused for the duration of the
time between the earliest reasonable offer and the date from which the patient makes themselves
available again for admission.
Clock Stops
Clock stops for treatment
5. A clock stops when:
a)
First definitive treatment starts. This could be:
i. Treatment provided by an interface service;
ii. Treatment provided by a consultant-led service;
iii. Therapy or healthcare science intervention provided in secondary care or at an
interface service, if this is what the consultant-led or interface service decides is the
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best way to manage the patient’s disease, condition or injury and avoid further
interventions;
b)
A clinical decision is made and has been communicated to the patient, and subsequently their
GP and/or other referring practitioner without undue delay, to add a patient to a transplant list.
Clock stops for ‘non-treatment’
6. An 18 week clock stops when it is communicated to the patient, and subsequently their GP and/or
other referring practitioner without undue delay that:
a) It is clinically appropriate to return the patient to primary care for any non consultant-led treatment
in primary care;
b) A clinical decision is made to start a period of active monitoring;
c) A patient declines treatment having been offered it;
d) A clinical decision is made not to treat;
e) A patient DNAs their first appointment following the initial referral that started their 18 week clock,
provided that the provider can demonstrate that the appointment was clearly communicated to
the patient1.
f)
A patient DNAs any other appointment and is subsequently discharged back to the care of their
GP, provided that:
the provider can demonstrate that the appointment was clearly communicated to the patient;
discharging the patient is not contrary to their best clinical interests;
discharging the patient is carried out according to local, publicly available, policies on DNAs.
These local policies are clearly defined and specifically protect the clinical interests of
vulnerable patients (e.g children) and are agreed with clinicians, commissioners, patients and
other relevant stakeholders.
1
DNAs for a first appointment following the initial referral that started an18 week clock nullify the patient’s
clock (i.e. it is removed from the numerator and denominator for Referral to Treatment time measurement
purposes).
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Appendix D
Letter of support from PBR
Sandra
To confirm our conversation. I am content with the agreement reached with
Nicholas on the definition of consultant led activity.
Thanks
Chris Watson
Deputy Director of Financial Reforms Development Branch - Payment by
Results
3W52 Quarry House, Quarry Hill, Leeds LS2 7UE
Tel: 0113 25 45402, Fax: 011325 45534, Mob: 07789 653501
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Appendix E
Implementation evaluation summary report
In excess of 20 organisations were involved in the early implementation of the refreshed 18 week clock
rules – these included foundation trust, acute trusts, PCTs and Independent Healthcare Providers. The
trial was a short pilot prior to the refreshed clock rules being released to the service for full
implementation by March 2008.
The following report provides a summary of the key issues identified by the Early Achievers, Audiology
pilot sites and the IPT Reference group which were identified when implementing the changes outlined in
the refreshed 18 week clock rules submissions:
Organisational:
•
Implementation of the 18 week agenda constituted a significant time commitment for
organisations. Gaining commitment, identifying individuals, establishing roles and responsibilities,
working with different IT systems and management structures all provided challenges. The
implementation of the refreshed clock rules builds on the work previously undertaken to
implement 18 week, supporting through further clarification the consistent application of the 18
week rules.
•
The majority of the pilot sites used the definitions and clarity provided by the refreshed rules to
review and rewrite existing access policies. The revised access policies were developed in
consultation with clinicians, patients, service providers and the PCT across the local health
community. Implementation of the revised policies was generally incremental with an initial focus
on managing the appropriateness of referrals into the organisation.
•
Existing established systems were utilised to implement the refreshed clock rules. This reduced
the need for further resources.
•
Organisational awareness was critical in ensuring consistent implementation, acceptable data
completeness and quality. Clinical engagement was critical as was ongoing support and training
for administrative and clerical staff.
•
Knowledge and expertise needed to be shared in a structured manner across all service
providers within the local health community possibly facilitated by the SHA.
•
Implementation of the refreshed rules could not be undertaken in isolation, instead, they form an
integral part of the organisations implementation of the 18 week agenda.
•
The refreshed rules are designed to be locally responsive – local health communities need to
work together to the benefit of the patient. Since the measure of success of 18 week delivery will
be a combination of the delivery of the RTT target in combination with the patients perspective on
their treatment.
Behavioural
•
Implementation plans should include time scales for additional education and training.
•
Pilot sites did not identify the need for additional staffing resources however the additional data
collection of adjusted admitted patients did create an additional burden. The burden of this
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additional workload varied depending upon the number and percentage of adjusted submissions.
This percentage varied between specialities within an organisation and between organisations.
•
Pilot organisations identified further work was required to ensure acceptable data quality and
consistent application of the refreshed rules – this would be primarily through further education,
training and audit of adjusted or breach patients.
•
Pilot sites accepted the value of submitting adjusted and unadjusted admitted returns to allow
identification of organisational outliers. They were also supportive of the patient survey
complimenting the RTT data collection in assessing achievement of the target.
•
Pilot organisations recognised that the potential cost of submitting adjusted admitted data would
need to be balanced against the implications that the adjustment might support achievement of
the target.
•
Training of all staff groups on the changes within the refreshed rules and in particular the
recording of patient choice was identified as essential. A range of training techniques were
adopted from developing small ‘expert’ teams through to training all staff.
•
Access policies crucial – education and training on implementing these revisions.
•
Clinical engagement was essential particularly when recording active monitoring and clock starts;
however, a balance between clinical ownership and appropriate use of clinical time was
identified.
•
Patient information need to be updated to explain the patients role and responsibility but also to
clarify their option to express choice and how their perception of their treatment wouldl be a
significant part of the delivery of 18 week
•
Local systems should be implemented to ensure data quality and data completeness. Several
pilot sites identified data quality as a significant issue due to the previous focus on Korner waits
being embedded in the organisation. Pilot sites had introduced validation of breaches + reviewing
patient suspensions to address these concerns.
Technical
•
Several of the pilot sites were unable to implement EROD as a result of which the following work
around was developed:
When reporting inpatient stages of treatment waits, there are two types of adjustment that may be
applied - clock resets and suspensions. Suspensions will be either clinical suspensions or social
suspensions. Clinical suspensions and clock resets are not applicable to RTT. A social suspension
identifies the period a patient makes themselves unavailable for an admission and so is being used
by the early achievers to adjust admitted pathways. This requires the provider to be able to
separately identify social suspensions from other adjustments. This method should only be used in
the short term and providers should move to recording the pause due to a patient turning down two
reasonable offers as soon as possible. Adjustments to local IT systems although were not essential
in order to submit adjusted admitted RTT data.
To enable the reporting of adjusted waits in the short term:
i)
ii)
Identify those patients who had a period of suspension during their admitted pathway
Differentiate between those patients who had had a clinical suspension and those who
had had a social suspension. For those patients who had both a clinical suspension
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iii)
iv)
v)
vi)
and a social suspension, it is only the social suspension that is relevant in the context
of adjustments.
For those patients with a period of social suspension during their pathway, identify the
length of adjustments in reporting a Korner inpatient stage of treatment wait.
Identify the length of social suspensions during each pathway where a social
suspension has occurred.
Deduct the length of the social suspension from the reported unadjusted pathway
wait.
Report the adjusted wait for those patients with an adjustment and the unadjusted wait
for those where no adjustment is applicable.
Conclusion
Implementation of the refreshed clock rules and the ability to record both target and non-target RTT
patients was supported by the pilot organisations. The pilots successfully implemented the refreshed
rules submitting both adjusted and unadjusted data, however the variations in the percentages of patient
pauses indicated further work was needed to ensure consistent application.
It remains essential to embed knowledge and understanding of 18 week principles; definitions clock
starts and stops within organisations to improve both data quality and data completeness. The
submission of adjusted and unadjusted data combined with the benchmark from the original pilot
exercise in Summer 2007 will identify outliers that will be investigated further.
There will undoubted be further pressure on IT departments to provide the additional adjusted admitted
data returns – however the experience of the pilot sites was that there were relatively few patients that
opted to pause their clock when offered an admission date. This reduced the burden of the additional
data collection.
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