Elective Access Policy
Originator:
Lead Director:
Version No:
Implementation Date:
Ratified By:
Date of Review:
Date of Next Review:
Patient Access and Waiting List Manager
Director of Operations
V1.2
September 2014
Outpatients Steering Group
March 2015
March 2016
Section
Number
Contents
Page
1.
Introduction
6
1.1
Guiding principles
6
1.2
Scope of the policy
6
1.3
Purpose of the Policy
6
1.4
Responsibilities
7
2.
General Access Rules
8
2.1
Patients entitlement to NHS Treatment
8
2.2
Patients not eligible to NHS Treatment
8
2.3
Patients transferring from the Private sector to the NHS
9
2.4
Patients transferring from the NHS to private
9
2.5
NHS Provider Commissioning Private Sector Service
9
2.6
Patients requiring commissioner approval
9
2.7
Access to Health Services for Military Veterans
10
2.8
Interpreter Requirements
10
2.9
Disabilities or Special Needs
10
2.10
Patient Transport
10
2.11
Religion and Ethnicity
10
3.
National Operating Standards
11
3.1
Key Waiting Time Standards
11
3.2
RTT Monitoring Systems
12
3.3
RTT Rules Guidance
12
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4.
The Patient Pathway
13
4.1
The Referral Process
13
4.1.1
Choose and Book
13
4.1.2
Specialty Level Referrals
13
4.1.3
Advice and Guidance
13
4.1.4
Direct Access Diagnostics Referrals
13
4.1.5
Urgent GP Referrals
14
4.1.6
Emergency Outpatient Appointments Referrals
14
4.1.7
Consultant to Consultant Referrals
14
4.1.8
Interprovider Transfers (IPT’s)
14
4.1.9
Self-Referrals
15
4.1.10
Fertility Pathways
15
4.1.11
The Trust’s responsibility
15
4.1.12
The Healthcare Professionals responsibility
15
4.1.13
Referral Triage (Grading Process)
16
4.2
Outpatient Booking Processes (Non Admitted Pathways)
16
4.2.1
New Outpatient Appointments
16
4.2.2
Offer of Appointment (New and Follow-up Appointments)
17
4.2.3
Full Booking
17
4.2.4
Partial Booking of Outpatient or Outpatient Diagnostic Appointment
17
4.2.5
Booking of Follow-up Appointments and Partial Booking of Follow-up
Appointments
17
4.2.6
Patient Cancellations
18
4.2.7
Hospital Cancellations
18
4.2.8
Clinic Cancellation – Notice period greater than 6 weeks
18
4.2.9
Clinic Cancellation – Notice period less than 6 weeks
18
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4.2.10
Clinic templates
19
4.2.11
Failure to Attend an Outpatient Appointment (DNA’S)
19
4.2.12
Late arrival for an appointment
20
4.2.13
Failure to Attend a Paediatric Outpatient Appointment (DNA’s)
20
4.2.14
Failure to Attend suspected cancer, vulnerable adults, and patients
with notifiable diseases
20
4.2.15
Unable to contact patients
20
4.2.16
Outpatient Clinic Processes
21
4.2.17
Data Quality
21
4.2.18
Recording Clinical Outcomes
21
4.2.19
Clinical outcome – Open Appointment
22
4.2.20
Clinical outcome – Discharge
22
4.2.21
Clinical Outcome – Added to Elective Waiting List
22
4.3
Diagnostic and Pre-Operative Assessment Appointments
22
4.3.1
Direct Access Referrals (Imaging)
23
4.3.2
Appointments for Endoscopy Diagnostic Tests
23
4.3.3
Appointments for Outpatient Imaging
23
4.3.4
Pre-operative Assessment Appointments
23
4.4
Elective Admissions and Admitted Pathway Processes
24
4.4.1
Procedures of Limited Clinical Values (PLCV)
24
4.4.2
Patient Order for Elective Admission
24
4.4.3
Arranging Elective Admission & Patient Non-response to Contact
Attempts
24
4.4.4
Reasonable Offer for Elective Admission and Patient Pauses
25
4.4.5
Patient Requested Review of Treatment Decision
25
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4.4.6
Patient Cancellations of an Agreed Date for Admission
25
4.4.7
Removals from the Waiting List for Reasons Other Than Treatment
26
4.4.8
Patients Failing to Attend Elective Admission Date (DNA)
26
5.
Appendices
Appendix 1
Referral to Treatment (RTT) rules
27
Appendix 2
Outpatient: Cancellation Process
29
Appendix 3
Outpatient: DNA Process
30
Appendix 4
Outpatient: Unable to Contact Process
31
Appendix 5
Inpatient: Cancellation Process
32
Appendix 6
Inpatient: DNA Process
33
Appendix 7
Inpatient: Unable to Contact Process
34
Appendix 8
Endoscopy: Cancellation Process
35
Appendix 9
Endoscopy: DNA Process
36
Appendix 10 Endoscopy: Unable to Contact Process
37
Appendix 11 Glossary of terms
38
Appendix 12 Cancer Services Access Policy
42
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1. Introduction
Frimley Park Hospital NHS Foundation Trust (hereafter referred to as ‘the Trust’) is committed
to providing an exemplary standard of care to patients and an important component part of this
is patient access to services. The Trust is committed to provide a service that is fair and
accessible to all, providing patient choice and delivering a positive patient experience.
This policy outlines the scope and standards which must be followed explicitly for:
• Referring patients into the Trust
• Pathway management of all patients referred into the Trust
• Current national standards and data definitions
All clinical and non-clinical staff involved in patient pathway management must ensure that their
processes and procedures are consistent with this policy
1.1 Guiding Principles
The delivery of patient care will be patient focused, clinically led and consistent with the values
of the Trust.
Clear communication and transparency between all stakeholders, including referrers, hospital
staff and patients, will underpin the delivery of services in the elective pathway.
The Trust is committed to provide sufficient levels of resources to provide the best care for our
patients and treat them within national waiting time standards.
Patients are seen and treated based on their clinical need, providing fair and consistent access
for all.
Patients have a personal responsibility for their own health.
1.2 Scope of the Policy
This policy applies to all patients referred electively into the Trust for investigation and
treatment, and for all members of staff employed by the Trust. In particular it applies to those
staff involved in delivering or supporting direct clinical care.
1.3 Purpose of the Policy
The Purpose of this policy is to guarantee that the best interests of our patients are served by
ensuring that the Trust’s services are managed in line with national waiting time standards and
the NHS Constitution (April 2010). This document outlines the Trust and Commissioner
Requirements and Standard Operating Procedures (SOP) for managing timely patient access to
secondary care services from referral to treatment, as well as discharge to primary care.
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This policy gives guidance to staff within the Trust on providing access to services for patients.
This will be achieved by ensuring that all staff understand their role in managing patient access
and the delivery of waiting time standards.
1.4 Responsibilities
The Director of Operations has Board level responsibility for the Elective Access Policy and
will ensure that all clinical managerial and administrative members of staff adhere to the policy.
The Clinical Directors are responsible for ensuring that there is sufficient clinical capacity to
meet elective demand.
The Associate Directors within the Clinical Directorates are responsible for ensuring that their
staff understand fully the principles and requirements of the policy and for ensuring that
Standard Operating Procedures are in place and that staff fully comply with them.
All Trust Managers and Team Leaders within the Clinical Directorates are responsible for
ensuring that their individual teams are fully trained and understand the processes and
procedures that must be followed explicitly to ensure that the requirements of the policy are met.
All clinical staff are responsible for adhering to the policy, and for completing the required
outcome documentation for each patient they see.
All Staff are responsible for adhering to National guidelines and the principals outlined in this
policy when organising and scheduling clinical care for patients.
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2. General Access Rules
2.1 Patients Entitlement to NHS Treatment
The NHS constitution clearly sets out a series of pledges and rights for what patients, the public
and staff can expect from the NHS. A patient has the right to the following:



The choice of hospital and consultant
A referral from their GP for treatment into a consultant-led service, with a maximum
waiting time of 18 weeks from referral for elective conditions
To be seen by a cancer specialist within a maximum of two weeks from a GP referral for
urgent referrals where cancer is suspected
If this is not possible, the Trust has to take all reasonable steps to offer a range of alternatives.
The right to be seen within the maximum waiting times does not apply:





If the patient chooses to wait longer
If delaying the start of the treatment is in the best clinical interests of the patient, for
example where stopping smoking or losing weight is likely to improve the outcome of the
treatment
If it is clinically appropriate for the patient’s condition to be actively monitored in
secondary care without clinical intervention or diagnostic procedures at that stage
If the patient fails to attend appointments that they had chosen from a set of reasonable
options, or
If the treatment is no longer necessary
The following services are not covered by this constitution:


Maternity services
Obstetric services
Patients registered with a GP in either Northern Ireland, Scotland or Wales are also eligible for
elective treatment, subject to prior approval from their local health board.
Patients must be treated within the national waiting time standards. Failure to achieve these
targets and thresholds will put the Trust at risk of breaching its terms of authorisation as a
Foundation Trust and may lead to financial penalties within the NHS standard acute trust
contract.
2.2 Patients not eligible to NHS treatment
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The Trust has a legal obligation to identify patients who are not eligible for free NHS treatment.
The NHS provides health care for people who live in the United Kingdom. People who do not
normally live in this country are not automatically entitled to use the NHS free of charge –
regardless of their nationality or whether they hold a British passport or have lived in and paid
National Insurance contributions and taxes in this country in the past.
All NHS Trust’s have a legal obligation to:



Ensure patients who are not ordinarily resident in the UK are identified
Assess liability for charges in accordance with Department of Health Overseas Visitors
Regulations
Charge those liable to pay in accordance with Department of Health Overseas Visitors
Regulations
The Human Rights Act 1998 prohibits discrimination against a person on any ground such as
race, colour, language or religion. The way to avoid accusations of discrimination is to ensure
everybody is treated equitably.
The Trust needs to check every patient’s eligibility for treatment. An NHS number does not give
automatic entitlement to free NHS treatment. Therefore, at first point of entry, patients may be
asked questions which will assist the Trust in assessing ‘ordinarily resident status’.
2.3 Patients transferring from the Private sector to the NHS
Patients can choose to convert between an NHS and Private status at any point during their
treatment without prejudice. All patients wishing to transfer from the private service to the NHS
must be offered choice and onwards referral to an NHS provider and their GP should be
notified.
Patients who are referred from a private service can be added direct to the NHS waiting list on
the referral received date. They do not need an NHS appointment prior to the addition.
2.4 Patients transferring from the NHS to private
Patients already on an NHS pathway opting to move to private care must have the relevant
episodes cancelled from the NHS system. A new NHS to private referral must be created on
the Patient Administration System (PAS) when care is transferred within the Trust.
2.5 NHS Provider Commissioning Private Sector Service
There may be circumstances where the Trust chooses to commission services provided by the
private sector to enable waiting time standards to be met. In this situation the RTT Pathway
waiting time would continue with the Trust remaining accountable for the delivery of the RTT
pathway standards.
2.6 Patients requiring commissioner approval
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No referral for an excluded procedure should be accepted without prior approval from the
relevant CCG. If the referral does not have the relevant approval the referral should be returned
to the GP for them to request treatment funding approval via the relevant CCG panel.
In some instances it will not be apparent until the outpatient consultation that the patient
requires an excluded procedure. When it is identified at the outpatient consultation, the relevant
clinician should request the GP to progress the funding application to the relevant CCG.
All patients should be offered an outpatient appointment or other investigations as per the
standard pathway. If they require an excluded procedure the GP should apply for approval.
There may be instances however where it is more appropriate for the hospital clinician to seek
commissioner approval. The contracts department can support clinicians in seeking
commissioner approval.
The Clinical Guidelines document which details all excluded procedures is available to view at
http://www.frimleypark.nhs.uk/gps/clinical-guidelines, accessible in conjunction with a valid
username and password. There are details via this link should you not possess valid login
details.
2.7 Access to Health Services for Military Veterans
It is the Healthcare Professionals responsibility to inform the Trust that the patient being referred
is a Military veteran and that the condition they are being referred for is service related. Military
veterans should be prioritised over other patients with the same level of clinical need if their
condition is service related. An alert must be added to PAS and the patients case notes to
identify the patient’s status.
2.8 Interpreter Requirements
Where a patient requires an interpreter for an appointment or admission, this must be
highlighted at the top of the referral or request, and also must clearly state the type of interpreter
required.
2.9 Disabilities or Special Needs
The Trust is committed to providing, wherever possible, a booking system to support the
requirements of individuals with disabilities; this may involve for example booking an
appointment time that is more suitable to the patient’s needs.
We will continually work towards ensuring that individuals with disabilities are not disadvantaged
by this policy; we will, through the impact assessment process and involvement with local
disability groups, identify areas of concern and work to eliminate these issues wherever
possible.
2.10 Patient Transport
For initial appointments, patients will be required to contact their referring Healthcare
Professional to arrange transport with the Central Booking Centre.
Transport required for follow-up appointments can be made by the clinic receptionist at the end
of the initial appointment.
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2.11 Religion and Ethnicity
The Trust is committed to providing, wherever possible, a flexible booking system to support the
ethnic or religious requirements of the service user, for example, more suitable appointment
times or female interpreter for female service users.
We will continually work towards ensuring that individuals due to their ethnic or religious
requirements are not disadvantaged by this policy; we will, through the equality assessment
process identify areas of concern and work to eliminate these issues wherever possible.
3. National Operating Standards
3.1 Key Waiting Time Standards

95% of non-admitted patients will not wait longer than 18 Weeks (126 days) for their
clock to stop. Non-admitted pathways are those that end in treatment that does not
require an elective admission to hospital or where no treatment is required.

90% of admitted patients will not wait longer than 18 Weeks (126 days) for their clock to
stop. Admitted pathways are those that end in an elective admission to hospital either as
an elective inpatient or day-case for treatment.

92% of patients on an incomplete pathway will be within 18 weeks (126 days) of the
referral.

99% of patients will wait no longer than 6 weeks for a diagnostic test, investigation or
image.

Patients referred on a suspected cancer pathway will be managed as per the Trust
Cancer Access Policy (Appendix 9, page 38). The RTT pathway does not replace the
Cancer waiting time target.
The RTT pathway does not replace other waiting time targets or standards where these are
shorter than 18 weeks. This includes waiting times for patients with suspected cancer or waiting
times for Rapid Access Chest Pain clinics.
Patients may have more than one RTT waiting time running simultaneously if they have been
referred to and are under the care of more than one clinician at any one time. Each RTT
pathway has to be measured and monitored separately and will have a unique patient pathway
identifier in PAS.
It should be noted that referral of any of the following patients are not applicable to the RTT
waiting time, unless a new decision to treat or significant new plan of care is commenced where
a new RTT clock would start:



An obstetric or midwifery service
The fracture clinic following an Emergency Admission or Emergency Department
attendance
All patients seen in the Outpatient Department following an emergency admission
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3.2 RTT Monitoring Systems
The Trust needs to know the clock start date, clock stop date and clock pauses for all RTT
patient pathways. An RTT status should be recorded at each stage of the patient journey at the
time of the patient appointment, contact or intervention. The Trust’s primary system for
administrating patients and their pathways is PAS with other systems providing supporting
information.
All waiting lists must be held and managed on the PAS system, except for some specific
services whereby another agreed Trust system is in place.
The Trust will utilise patient tracking and booking lists (PTLs) for the management of patient
pathways; these will include non-admitted, admitted, diagnostic and cancer. The PTLs are
created from RTT entries made on the PAS system. All activities such as referrals, requests for
admission and clinic outcome forms must be entered onto PAS in a timely manner and in
accordance with this policy and standard operating action card procedures. Failure to add
patient activities to the waiting lists and in a timely manner is a serious matter that can delay
patient care unnecessarily and non-compliance with this policy may result in action being taken.
The PTLs will be the central list of patients being seen at the Trust including those who are no
longer on an active RTT pathway, which will be subjected to an audit cycle. The PTLs are
distributed by the Information Department through the agreed mechanism and are the
responsibility of the appropriate operational management and booking teams to access the
information they require to book and schedule patients.
The Trust will provide the necessary training to staff in the use of PAS and specific functions
within the system relating to each individual member of staff’s job role ensuring a clear
understanding of expectations is communicated. RTT training will be available for all staff to
ensure accurate and timely data collection is performed which enables the Trust to meet
reporting requirements both internally and externally.
Standard letters of invitation, such as removal from the list, should be generated from PAS or
another Trust system, when this is in place. This provides a uniform approach and an audit trail.
The Trust standard letters should be used where appropriate.
3.3 RTT Rules Guidance
The RTT pathway applies to elective pathways that involve consultant-led care. The RTT Rules
Suite provides further definition of the RTT maximum waiting time standard and should be read
in conjunction with this document. The RTT Rules Suite can be located within the following web
address http://www.england.nhs.uk/statistics/rtt-waiting-times/rtt-guidance/
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4. The Patient Pathway
4.1 The Referral Process
A referral is a decision made by a Healthcare Professional to refer a patient to a particular
Healthcare Provider and to a particular service.
It is the referring Healthcare Professional’s responsibility to inform the patient of the intention to
refer into secondary care and ensure that the patient is ready, willing, and able to immediately
start their pathway by booking an appointment. The responsibility lies with the referring
healthcare Professional to ensure patients understand this before beginning an elective
pathway.
Where the referring Healthcare Professional knows that the patient is unavailable, for example
on a tour of duty, extended holiday or has work or study commitments, the referral should not be
made until a more appropriate time.
4.1.1 Choose and Book (CaB)
Ultimately, the Trust expects that all referrals will be made via the Choose and Book (CaB)
System where possible. CaB is the nationally recommended referral route allowing the patient
choice over Provider, date and time of their appointment.
All clinical information to support choice is contained within the Directory of Services (DoS).
Healthcare Professionals can use the CaB system to search the DoS for clinically appropriate
services or request advice and guidance about the most suitable care path for their patient.
4.1.2 Specialty Level Referrals
Routine practice will see referrals made to a generic service rather than an individual. This will
lead to improved waiting times across consultants and services to ensure patients are seen in a
timely manner. As set out within the NHS Constitution, the Trust will work to ensure patients
see the consultant of choice where a preference is expressed.
4.1.3 Advice and Guidance
The Trust also accepts requests for Advice and Guidance (AaG). To provide a robust audit trail,
these are encouraged through the CaB system.
The Trust aims to respond to routine requests within 7 days, and urgent requests within 4 days.
4.1.4 Direct Access Diagnostics Referrals
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The Trust operates a Direct Access Diagnostic Service where the GP can refer the patient for a
diagnostic procedure only, with the intention that the responsibility for the patient remains with
the GP and there is no intention for the patient to go on to see a consultant or enter a consultant
led service at that stage. This does not start a RTT clock. However, if the GP chooses to refer
the patient on into secondary care to a consultant led service on the basis of the test results the
receipt of the new referral would start a RTT pathway.
4.1.5 Urgent GP Referrals
Some patients will present at their GP and will require an urgent referral into a consultant led
clinic. This referral is subject to Consultant triage, and once approved will be booked into the
relevant slot on PAS. This referral will not be classed as an emergency attendance and
therefore will generate a RTT start on the date of the GP telephone referral. A referral letter
must also accompany the telephone referral prior to the patient being seen.
4.1.6 Emergency Outpatient Appointments Referrals
The Trust accepts emergency referrals from Healthcare Professionals for patients needing to be
seen the same day in the Eye Treatment Centre (ETC) and for Ear, Nose and Throat (ENT).
These referrals will be made by telephone to the Senior House Officer (SHO) and will be
supported by a paper referral accompanying the patient when they attend. These patients are
classed as genuine emergencies and are therefore not applicable to a RTT Pathway.
4.1.7 Consultant to Consultant Referrals
This type of internal referral should only occur where it is for the same condition as the original
referral from the Healthcare Professional. Exceptions to this include any urgent or cancer
related onward referrals. Any patient referred consultant to consultant will be managed in line
with their RTT waiting time. All other unrelated conditions must be returned to the referring
Healthcare Professional for the patient to be offered choice of provider.
Where the referral is for the same condition as the original referral, the pathway must be linked.
Where the referral is for a new condition, this would result in the generation of a separate RTT
pathway and a clock start. These referrals must be prioritised alongside external referrals.
4.1.8 Interprovider Transfers (IPTs)
Patients may be referred into the Trust from another provider. This is classed as an IPT and the
referring Trust is mandated to accompany the referral letter with a minimum dataset containing
the relevant 18 week information if applicable. Any patient transferred from another provider will
be managed in line with their RTT waiting time. If the referral into the Trust is for a new condition
this would result in the generation of a new RTT pathway and clock start at the receiving Trust.
If the referral into the Trust is for a condition that the patient is already being seen for at the
referring provider then the referring Hospital must provide the RTT clock position.
The minimum dataset must include patient:



Name
Date of Birth
NHS No
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




Address
Patient Pathway Identifier (PPI)
Current 18 week position
Current RTT start date
Date of decision to refer
Incomplete RTT data is not an acceptable reason for delaying the acceptance of an appropriate
referral; however this information must be obtained from the referring provider and the Trust
PAS system updated.
4.1.9 Self-Referrals
The Trust will only accept a patient self-referral into clinical pathways that have been agreed
between the Trust and the relevant CCG.
4.1.10 Fertility Pathways
There are specific arrangements for the application of RTT principles and rules to fertility
patients and their families which can be found within the DoH website.
4.1.11 It is the Trust’s responsibility to:



Ensure accurate, clear and up to date information about Outpatient, Advice and
Guidance and Direct Access services provided by the Trust will be included on the CaB
DoS and/or Trust Website, to ensure patients are referred into the most appropriate
service reducing the need to redirect referrals.
Monitor slot availability and forward plan for any identified capacity constraints.
Accept and treat all referrals made to them that are clinically appropriate, and in
accordance with the patient’s wishes
4.1.12 It is the Referring Healthcare Professionals responsibility to:








Ensure that patients are only referred when they are ready, willing, and able to attend an
appointment.
Use the Choose & Book system wherever possible. Refer and book the patient into the
most appropriate clinical service by utilising the information contained within the DoS
Ensure that all elective referral letters or forms are clear and concise, stating the clinical
priority and reason for the referral request.
Generate and send urgent referral letter or form within one working day, and a routine
referral letter within three working days of the date of decision to refer.
Order any investigations which have been indicated within the CaB DoS as essential,
with this referral.
Book patient transport if required and they are eligible. In these circumstances, a late
morning or early afternoon appointment are more appropriate.
State if the patient has any special needs or a learning disability. Do they require an
interpreter or signer, and what language is required.
To ensure a minimum set of patient information is contained within the referral;
I. The GP’s name, and practice details
II. NHS Number
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III. Name, Gender, and Address
IV. Date of birth
V. Date of the referral
VI. Contact details, including evening or daytime and/or mobile telephone
number
VII. Ethnicity
VIII. Current drug regime and significant past medical history (to include drug
allergies)


Is the patient a military veteran, and are they being referred for a condition which has
been caused as a result of their military service.
Ensure a Unique Booking Reference Number (UBRN) is generated for all CaB referrals,
and where possible an appointment booked before the patient leaves the GP surgery.
At the point the UBRN is converted into an appointment date and time this will electronically
generate a RTT clock start.
4.1.13 Referral Triage (Grading Process)
All referrals must be graded by a Trust clinician prior to acceptance and will be sent to the
required department within 24 working hours of the date request received. The triage process is
to ensure the patient is allocated to the correct clinic within the correct time frame and that any
pre-existing referral criteria agreed with the commissioning CCGs are met.
Clinicians should review referrals within 72 working hours of receipt to ensure the patient is
booked to the appropriate specialty and with the correct urgency.
Any inappropriate referrals will be returned to the referrer by the rejected referral option within
CaB or paper referrals manually returned with an explanation as to why they were inappropriate.
It is the referring Healthcare Professional’s responsibility to notify the patient of any rejected
referrals to ensure the patient does not attend a previously booked appointment.
The duty of care rests with the referrer until such time as the referral is accepted by the Trust.
4.2 Outpatient Booking Processes (Non Admitted Pathways)
This outpatient section applies to all patients awaiting an outpatient consultation both new and
follow-up with the Trust.
4.2.1 New Outpatient Appointments
The Trust is committed to ensure that all patients entitled to NHS treatment that are referred to
the organisation, will be seen within a maximum of 6 weeks from the start of their RTT clock.
This is irrespective of referral source. Consideration must be given to the overall RTT clock for
those patients that are Inter-consultant referrals or Inter-provider referrals. This timescale is
subject to appropriateness, diagnosis, and patient choice.
If the patient is unable to agree a first appointment at the Trust within 6 weeks of receipt of
referral the patient will be discharged back to the GP or other Healthcare Professional until such
time that they are able to accept an offer of an appointment. This decision must be clearly
communicated to the patient and not contrary to their clinical urgency. Patient exceptions that
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apply to this rule include paediatric patients, those with suspected cancer, vulnerable adults and
patients with notifiable diseases.
Where patients are discharged back to their GP the RTT clock would stop, and any subsequent
re-referral would start a new clock. It must be emphasised to patients by their referring
Healthcare Professional the importance of being ready, willing, and able to be seen and treated
by the Trust. Responsibility for ensuring that there is sufficient outpatient capacity to meet these
waiting times lies with the Service Managers.
4.2.2 Offer of Appointment (New and Follow-up Appointments)
The Trust will offer all patients a reasonable choice of appointment. For New Appointments,
some patients will have chosen their own appointment on CaB at a date and time most
convenient to their needs.
For outpatient appointments (excluding diagnostic) both New and Follow-up, the Trust
deems a reasonable offer for an outpatient appointment is an offer of a date and time at least
two weeks from the date that the offer is made.
For a diagnostic outpatient appointment a reasonable offer of appointment is at least three
weeks from the date the appointment is being offered as per the national diagnostic guidance.
However patients will be encouraged to accept a date within 2 weeks. Further details are
covered within the diagnostic section of this policy.
The following criteria will determine if the appointment booking was made with reasonable
notice or not, utilising the ‘Booking Type’ data field on PAS.
4.2.3 Full Booking - to be classed as a ‘fully booked’ appointment a face to face or telephone
communication with the patient, or the patient’s proxy, to mutually agree the outpatient or
outpatient diagnostic appointment must have taken place. This booking type would be classed
as reasonable for any time frame of offer of appointment.
4.2.4 Partial Booking of Outpatient or Outpatient diagnostic appointment – to be classed
as a ‘partially booked’ appointment the Trust invites the patient to telephone the Trust to book a
mutually agreeable appointment date and time. . This booking type would be classed as
reasonable if the offer of appointment is 2 or more weeks from the date that the offer is made or
the patient agrees to an appointment less than 2 weeks’ notice verbally.
4.2.5 Booking
Appointments
of
Follow-up
Appointments
and
Partial
Booking
of
Follow-up
Where possible, follow-up appointments required within four months will be booked for the
patient in the Outpatient Department immediately following their initial outpatient consultation.
Where this is not possible, or the appointment is required more than four months ahead, a
partial booking system will be used.
These patients will be added to a waiting list, and given a reminder slip advising them to phone
us to make an appointment four months before it is due. A reminder letter will be sent to any
patient remaining on the waiting list eight weeks prior to when their follow-up is due.
Page 17 of 54
4.2.6 Patient Cancellations (See Appendix 2, page 28)
A patient cancellation is where a patient contacts the Trust in advance of their appointment,
including on the day, stating that they are unable to attend. Patients who attend but are unable
to wait for their appointment are included in this category.
There will be occasions where the patient will need to rearrange a previously agreed
appointment. The Trust will make every effort to book a mutually agreeable date and time with
the patient, providing they delay their appointment by no more than two weeks.
Should a patient cancel two sequential appointments within a pathway they will be discharged
back to their GP. A letter explaining this will be sent to the patient, their GP, and responsible
clinician. The Referral to Treatment (RTT) clock will be nullified and a new clock will start on the
subsequent patient contact or should the patient be re-referred. If the responsible clinician
wishes to reinstate the patient on a clinical need, a further appointment will be made.
Should a patient require a delay of greater than two weeks at their first cancellation, they will be
able to self-refer back (SRB) within three months. A letter explaining this will be sent to both the
patient, their GP, and the responsible clinician. The delay may be reduced or advised against if
the clinical need warrants this.
4.2.7 Hospital Cancellations
Every effort will be made to avoid cancelling patient appointments. As a key principle the Trust
will endeavour never to change a patient’s appointment more than once in any 6 month episode
of care.
4.2.8 Clinic Cancellation – Notice period greater than 6 weeks
All requests for clinic cancellation or reduction must be submitted in accordance with medical
staff leave policy giving a minimum of 6 weeks’ notice and including the relevant authorisation
from their Associate Director or Clinical Director.
4.2.9 Clinic Cancellation – Notice period less than 6 weeks
A short notice cancellation is defined as any cancellation or reduction of any clinic session with
less than 6 weeks’ notice. Cancellations of clinics with less than 6 weeks’ notice will be made
only in exceptional circumstances, such as unforeseen sickness or clinician unavailability due to
personal circumstances. If the cancellation is due to a clinician’s unavailability, approval must be
given by the Associate Director or Clinical Director before any action is taken.
The Service Managers, on receipt of this information, will exhaust all options to ensure the clinic
session can still go ahead by arranging appropriate cover without either cancellation or
reduction taking place.
In circumstances where this is not feasible the Service Manager must immediately contact the
appropriate appointments Team Leader to progress the cancellation of the session and to
organise the rearranged appointments with patients.
Page 18 of 54
Should the clinic need to be rearranged then the clinical risk and the potential effect on waiting
time targets must be taken into consideration by the Service Manager, and the appointments
rearranged appropriately.
4.2.10 Clinic templates
The Trust will endeavour to provide accurate clinic templates which allow all theoretical activity
to be included. This will assist in making the operational management more effective, and the
service development process more informed.
Services should adhere to some key principles when reviewing clinic templates:
1. There should be a regular review of clinic templates across all services (at least on an
annual basis to coincide with capacity and demand planning for the year ahead).
2. The Trust has set out that each clinic will run for a minimum of 3.5 hours of patient facing
time
3. The start and finish time of the clinic should reflect the actual time the clinician is expected
to be in the clinic, face to face.
4. The clinician is expected to arrive in clinic on time, allowing for any preparation required for
the first appointment. An allowance of 30 minutes administration time is provided within the
four hour session.
The lead clinician should be involved in any discussions around changing clinic templates.
Other departments, such as the outpatient nursing team, phlebotomy, radiology and other
diagnostic teams should be consulted in relation to resource availability, to support any changes
to clinic templates.
4.2.11 Failure to Attend an Outpatient Appointment (DNA) (See Appendix 3, page 29)
The Trust will make every effort to offer the patient a choice of date and time for all Outpatient
Appointments. We will confirm all appointments in writing and, where patients have provided a
mobile phone number, will send an SMS text message reminder before the majority of clinic
appointments. The onus is therefore on the patient to attend their appointment.
The following rules apply to the management of DNAs for both New and Follow-up
appointments. Patient exceptions apply to this rule covering paediatric patients, those with
suspected cancer, vulnerable adults, and patients with notifiable diseases.

A DNA of the first appointment following a Healthcare Professional’s referral will result in
the RTT clock being stopped, and the patient will be discharged back to the care of the
referrer. The receptionist will make the responsible clinician aware of any DNA’s before
the end of the clinic. If discharged the patient can be re-referred at the Healthcare
Professional’s discretion, in which instance a new RTT pathway will start on the date the
new request is received.

When the responsible trust clinician requests a second appointment, the clock will start
from the booking date of the new appointment. These will be exceptional circumstances
(e.g. paediatric patients, vulnerable adults, patients with suspected cancer) and based
on clinical concern.
Page 19 of 54



In the event of a second DNA the patient will be discharged back to their Healthcare
Professional. A letter will be sent to the patient, their Healthcare Professional, and the
responsible clinician confirming this. If the patient is referred back to the Trust, a new
clock will start on the date of receipt of the re-referral.
Follow-up patients who DNA their appointment should be discharged back to their GP. A
letter will be sent to the patient, their Healthcare Professional, and the responsible
clinician confirming this.
When the responsible trust clinician requests a second appointment for a follow-up
patient, it will be due to exceptional circumstances (e.g. paediatric patients, vulnerable
adults, patients with suspected cancer) and based on clinical concern.
4.2.12 Late arrival for an appointment
Where a patient arrives late for their appointment and the clinic is still running, the Trust will
endeavour to see them wherever possible. If this is possible they will need to be informed that
they may have to wait until the end of the clinic session. If the patient chooses not to wait they
will be recorded as “arrived late, not seen” on PAS, and a new appointment will be made before
they leave.
4.2.13 Failure to Attend a Paediatric Outpatient Appointment (DNA)
As per the Trust’s Safeguarding Children Policy, two or more Paediatric DNA’s should be
notified to the Safeguarding Team to investigate. Any decision to discharge the patient must be
made in consultation with the Paediatric Clinic.
If the appointment is rebooked the RTT pathway will continue. If the patient is discharged back
to their Healthcare Professional the RTT clock will stop. If the patient is re-referred by their
Healthcare Professional, then a new RTT pathway will start.
4.2.14 Failure to Attend: Suspected Cancer, Vulnerable Adults, and Patients with
Notifiable Diseases
It is at the responsible clinician’s discretion whether to request further appointments following a
DNA for the above set of patients. In most instances patients will be sent a further appointment
after the first DNA; however the Trust must make every reasonable effort to ensure that the
patient attends for their appointment. This process is explained in Appendix 3, page 29.
If the appointment is rebooked the RTT pathway will continue where applicable. If the patient is
discharged back to the referring Healthcare Professional, the RTT clock will stop where
applicable. If the patient is re-referred by the Healthcare Professional, then a new RTT pathway
will start.
4.2.15 Unable to contact patients (See Appendix 4, page 30)
Where contact cannot be made by telephone with a patient to arrange an appointment, a letter
will be sent asking them to contact us within seven days. If no response is gained from this letter
within 14 days, the bookings team will check the patient’s details with their Healthcare
Professional and attempt contact by telephone again.
Page 20 of 54
If this is still unsuccessful, a further letter will be sent stating that we will make no further
attempts to contact them if they do not respond within seven days. No contact after this final
time period will result in the patient being removed from the waiting list, and care being
discharged back to the Healthcare Professional.
A letter explaining this will be sent to the patient, their Healthcare Professional and the
responsible clinician. All attempts at contact must be recorded on the appropriate clinical
booking system.
4.2.16 Outpatient Clinic Processes
Each clinic MUST be fully prepped by the very latest the day prior to the clinic taking place for
all but emergency patients. This will include ensuring that:
 The patient medical notes are available for each consultation
 The patient medical notes are prepared adequately to record the consultation in
accordance with the prepping SOP
 Any referral letters are available for all new appointments
 Any tests and investigation reports are completed and available for the clinician to view
wherever applicable
 Every patient has a relevant yellow bookmark with the current RTT status and Breach
Date (where applicable) recorded, to enable the RTT pathway to be managed
appropriately
4.2.17 Data Quality
It is essential that accurate patient demographic data is held on PAS at all times, therefore it is
paramount that at every opportunity this information is confirmed with the patient. This will take
place either by the clinic receptionist, or at the self-check-in terminal.
This will include:









Patient Name
Date of Birth
Patient Address and postcode
GP details
Telephone contact details
Next of Kin
Religion
Ethnicity
Any special requirements
If any patient details have changed since the patients last attendance this information must be
amended by the receptionist on PAS. New medical notes front sheet and labels will be
produced, and any old front sheets will be removed from the notes and placed in the confidential
waste.
4.2.18 Recording Clinical Outcomes
To be able to record a clinical outcome, a yellow bookmark must be completed by the clinician
for every patient. This needs to be completed whether the appointment is a New or Follow-Up. It
Page 21 of 54
is the responsibility of the clinician to complete all relevant information including any outpatient
procedures or diagnostic tests. In every instance a primary diagnosis code should also be
recorded. The patient should ensure the yellow bookmark is returned to the clinic receptionist on
the Outpatient reception desk at the end of the consultation. This will also be used to provide
the information for the booking of the next appointment, if applicable.
Every outpatient attendance must have a defined clinical outcome and RTT status. Outpatient
receptionists must ensure that all patients have a clinical outcome and RTT status recorded
accurately on PAS, at the end of every clinical session. All clinic outcomes MUST be completed
fully within 24 working hours of the clinic taking place. A daily un-reconciled clinic report will be
sent to the Outpatient Clinic Supervisor for immediate action. This will be monitored through
internal audit processes.
4.2.19 Clinical Outcome – Open Appointment
There is a clinical option to offer a patient an open appointment for a period of 6 months
following their last outpatient attendance.
If a patient does not book an appointment within these 6 months, they will be classed as
discharged back to their Healthcare Professional. A letter will be sent to the patient, their GP,
and the responsible clinician confirming this. If they require further consultation, a new referral
must be sought which will start a new RTT pathway and clock.
4.2.20 Clinical Outcome – Discharge
The patient has been discharged from the Trust back to the care of the referring Healthcare
Professional and no further consultation is required. A letter will be sent to the patient and their
GP confirming this, as part of the clinic letter from the responsible clinician. If further
consultation is required a new referral must be sought from the Healthcare Professional which
will start a new RTT pathway and clock.
4.2.21 Clinical Outcome – Added to Elective Waiting List
Patients can be added to a diagnostic, therapeutic or planned waiting list as a Day-case or
Inpatient Admission. Please refer to the Elective Admissions section for further guidance.
4.3 DIAGNOSTIC AND PRE-OPERATIVE ASSESSMENT APPOINTMENTS
Many patients require diagnostic tests to determine the appropriate diagnosis and their
subsequent treatment. Diagnostic tests must be performed within a maximum of 6 weeks of
request for the test to ensure delivery of the national waiting time target. In many instances they
will also form part of the patients RTT 18 week journey.
The importance of timely access to diagnostics and their reporting is a key element to ensuring
that patients are not made to wait unnecessarily for treatment within 18 weeks. Diagnostic
patients cannot have their RTT clock paused. The diagnostic phase of treatment has a
maximum waiting time of 6 weeks.
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4.3.1 Direct Access Referrals (Imaging)
The rules of booking and administering patient appointments equally apply to appointments for
GP direct access services (plain film x-rays and ultrasound). Patients who DNA these
appointments will be returned to their GP and discharged. Patient cancellations and failure to
contact will follow the same process as outlined for outpatient appointments.
4.3.2 Appointments for Endoscopy Diagnostic Tests
The rules of booking and administering patient appointments equally apply to appointments for
endoscopy diagnostic procedures. Patients who DNA their appointment will be returned to their
GP and discharged. Patient cancellations and failure to contact follow the same principles as
daycase/inpatient procedures. Endoscopy specific booking flowcharts have been developed by
the endoscopy booking team which can be found in appendix 8, 9 and 10.
4.3.3 Appointments for Outpatient Diagnostics
The rules for booking and administering outpatient diagnostics are the same as for outpatient
clinic appointments; however patients will be encouraged to accept dates within three weeks of
referral due to the total patient journey timeframes required. Patient cancellations and failure to
contact will follow the same process as outlined for outpatient appointments.
4.3.4 Pre-operative Assessment Appointments
The rules for booking and administering patient appointments equally apply to pre-operative
assessment appointments; however patients will need to be available for dates that are
sufficiently in advance (normally 2-3 weeks) of their operation date. This is due to the total
patient journey timeframes required. Patient cancellations and failure to contact will follow the
same process as outlined for outpatient appointments.
Where a patient fails to attend an agreed date for their Pre-Operative Assessment Appointment
the relevant secretary or booking clerk will be informed and will contact the patient to ascertain
the reason for the non-attendance. Where a genuine reason is given and the patient wishes to
proceed, and where the agreed admission date will not be affected, the patient will be offered a
further date for Pre-Operative Assessment. It will be explained to the patient that a further failure
to attend will result in them being removed from the elective waiting list.
All decisions to remove from the waiting list must be agreed and made by the responsible
clinician, who must inform the GP in writing with a copy to the patient. The consultants Medical
Secretary is responsible for removing the patient from the waiting list and appropriately stopping
the waiting time clock.
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4.4 ELECTIVE ADMISSIONS AND ADMITTED PATHWAY PROCESSES
4.4.1 Procedures of Limited Clinical Value
Local commissioners have identified a range of procedures and treatments which are classified
as Procedures of Limited Clinical Value (PLCV). These procedures are available to view at
http://www.frimleypark.nhs.uk/gps/clinical-guidelines, accessible in conjunction with a valid
username and password. There are details via this link should you not possess valid login
details.
Together with our local CCGs, we have developed Trust specific guidelines regarding PLCV.
These guidelines apply to all patients who are treated at the Trust, regardless of which CCG
they belong to.
4.4.2 Patient Order for Elective Admission
Patients will be selected for elective admission chronologically on their RTT breach date. Priority
will only be given to patients highlighted as clinically urgent by the responsible clinician or
highlighted as war pensioners and service personnel injured in conflict (DH 2007).
4.4.3 Arranging Elective Admission and Patient Non-response to Contact Attempts
(see appendix 7, page 33).
In order to arrange a date for elective admission, the patient should be contacted twice within 5
working days of addition to the waiting list by telephone. These attempts should be made at
varying times on separate days, and should be recorded on the appropriate clinical booking
system.
Where the attempt to contact the patient has been unsuccessful, a letter should be sent out to
the patient asking them to contact the appropriate Secretary within 7 days.
Where the patient has not made contact at the end of the 7 day period, a further attempt to
contact the patient by telephone will be made. If this is unsuccessful, another letter will be sent
to the patient explaining that no further attempts will be made to contact them and after a further
7 working days they will be removed from the waiting list.
If still no response from the patient the Secretary will check the patient’s contact details with the
GP. If they are found to be incorrect the process will be restarted, if correct the patient will be
highlighted to the responsible clinician with a view to removal from the waiting list and discharge
back to their GP. The responsible clinician will ensure a letter is sent to the patient and GP
explaining this. The RTT clock will be stopped and a new clock will start should the patient be
re-referred.
The responsible clinician can request a further contact attempt is made; this is offered only in
exceptional circumstances based on clinical concern.
Some consultants or clinical departments within the Trust may wish to set up blanket
arrangements whereby the waiting list staff do not need to seek individual permission to remove
a patient from the waiting list. This may include all patients for which they are responsible or
those meeting specific criteria such as day surgery patients.
Page 24 of 54
4.4.4 Reasonable Offer for Elective Admission and Patient Pauses
Patients should be offered two dates a minimum of two weeks apart for surgery with at least
three weeks’ notice. Should the patient not wish to accept either of these dates but do wish for a
later date, this later date should be agreed with the patient and a pause recorded from the
earlier of the two dates offered until the patient is available.
Where a patient makes it known immediately that they are unavailable until / during a certain
period and this clashes with actual, potential, indicative or likely TCI dates, the waiting time will
be paused from the first of these until the date they wish to accept. It is not necessary to discuss
these dates with the patient in this instance.
Patient initiated pauses of up to 3 months will be made before the advice of the responsible
clinician is sought with regard to further delay. Delays of up to 6 months can be accommodated,
after which consultant discharge of the patient back to the care of their GP will be considered.
In some cases when discussing pauses with a patient it may be obvious they wish to be
‘paused’ or deferred until a certain period. In this case the pause should be applied from the first
date they were or could have been offered to the date they wish to accept. This discussion
needs to be recorded and dated on PAS, and the responsible clinician must be informed, to
ensure that this is clinically appropriate.
Should a patient subsequently wish to delay a TCI date and their clock is already paused, this
pause should be left in place and extended until the newly agreed TCI date. Note: If the patient
is listed for a diagnostic procedure they cannot be paused.
All admission offers (actual, potential, indicative or likely) should be recorded on PAS to show
dates that the patient could have attended to provide an audit trail.
4.4.5 Patient Requested Review of Treatment Decision
Where a patient already on a waiting list for surgery subsequently decides they wish to review
or further discuss the treatment, they will be offered the opportunity to discuss with the clinician
or member of their team over the telephone, or in clinic with pre-operative assessment staff.
Alternatively they will be encouraged to discuss matters with their referring Healthcare
Professional.
If the patient still wishes to discuss matters with the responsible clinician in person in an
outpatient clinic they will be removed from the elective waiting list and their waiting time clock
stopped. A new waiting time clock will start should the patient decide to proceed with the
procedure following discussion with the responsible clinician. This process and the likely impact
on waiting time must be made clear to the patient before it is enacted.
4.4.6 Patient Cancellations of an Agreed Date for Admission
A patient cancellation is where a patient contacts the Trust in advance of their appointment,
including on the day, stating that they are unable to attend. Patients who attend but are unable
to wait for their appointment are included in this category.
Should a patient cancel two sequential appointments within a pathway they will be discharged
back to their GP. A letter explaining this will be sent to the patient, their GP, and responsible
clinician. The Referral to Treatment (RTT) clock will be nullified and a new clock will start on the
Page 25 of 54
subsequent patient contact or should the patient be re-referred. If the responsible clinician
wishes to reinstate the patient on a clinical need, or if the cancellation is at short-notice for
medical reasons, a further appointment will be made.
This process is demonstrated in Appendix 5, on page 31
4.4.7 Removals from the Waiting List for Reasons Other Than Treatment
There are a number of scenarios where a patient may need to be removed from an elective
waiting list without initially identified treatment taking place. This may include the procedure no
longer being required, the patient no longer wanting procedure or the patient has chosen to
seek treatment privately. In any event of a patient being removed from the elective waiting list
they must only be removed from the waiting list on PAS and not deleted. This is to ensure a
robust audit trail exists.
4.4.8 Patients Failing to Attend Elective Admission Date (DNA)
Should the patient not attend on the agreed date for surgery, the facility (ward or theatre
admission lounge) will notify the appropriate Medical Secretary.
Patients who DNA their operation admission will be removed from the waiting list and
discharged to the care of their GP following clinical review. A letter will be sent to the patient and
GP confirming this and their RTT clock will stop.
The responsible clinician can request a second date for elective admission; this is offered only
in exceptional circumstances based on clinical concern, for example paediatric patients,
vulnerable adults and patients with suspected cancer.
This process is demonstrated in Appendix 6, on page 32
5. Appendices
Page 26 of 54
Appendix 1 – Referral to Treatment (RTT) rules
RTT Pathway Start
A RTT pathway commences under the following circumstances when any Healthcare
Professional or service permitted by an English NHS commissioner to make such referrals,
refers to:



A consultant led service, regardless of setting, with the intention that the patient will be
assessed and, if appropriate, treated before responsibility is transferred back to the
referring health professional or general practitioner
An interface or referral management or assessment service, which may result in an
onward referral to a consultant led service before responsibility is transferred back to the
referring health professional or general practitioner
A waiting time clock also starts upon a self-referral by a patient to the above services,
where these pathways have been agreed locally by commissioners and providers and
once the referral is ratified by a Healthcare Professional permitted to do so
Upon completion of a consultant-led referral to treatment period an RTT pathway recommences
under the following circumstances:





When a patient becomes fit and ready for the second of a consultant-led bilateral
procedure
Upon the decision to start a substantively new or different treatment that does not
already form part of that patient’s agreed care plan
Upon a patient being re-referred in to a consultant-led; interface; or referral management
or assessment service as a new referral
When a decision to treat is made following a period of active monitoring
When a patient rebooks their appointment following a first appointment DNA that
stopped and nullified their earlier clock
RTT Pathway Stop
A RTT pathway stops under the following circumstances for treatment or non-treatment where a
clinical decision is made and has been communicated to the patient, and subsequently their
Healthcare Professional without undue delay.
Clock stops for treatment

First definitive treatment is defined as being an intervention intended to manage a
patient’s disease, condition or injury and avoid further intervention. The date where first
definitive treatment starts will be the date that stops the clock - this may be either in an
interface service or a consultant-led service.
Clock stops for ‘non-treatment’


It is clinically appropriate to return the patient to primary care for any non-consultant led
treatment in primary care
A clinical decision is made to start a period of active monitoring
Page 27 of 54




A patient declines treatment having been offered it
A clinical decision is made not to treat
A patient DNAs their first appointment following the initial referral that started their
waiting time clock, provided that the provider can demonstrate that the appointment was
clearly communicated to the patient
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/published, policies on DNAs; These local policies are clearly defined and
specifically protect the clinical interests of vulnerable patients (e.g. children) and are
agreed with clinicians, commissioners, patients and other relevant stakeholders.
Active Monitoring
The concept of active monitoring stops the clock and caters for periods of care without (new)
clinical intervention e.g. three monthly routine check-ups for diabetic patients. This is where it is
clinically appropriate to monitor the patient in secondary care without clinical intervention or
further diagnostic procedures, or where a patient wishes to continue to be reviewed as an
outpatient without progressing to more invasive treatment. Active monitoring can be initiated by
either the clinician or the patient.
If after a period of active monitoring, the patient or responsible clinician decides treatment is
now appropriate, a new pathway and a new clock starts, where the patient must receive their
first definitive treatment within a maximum of 18 weeks
RTT Pathway Clock Pauses
A clock may be paused only where a decision to admit for treatment has been made, and the
patient has declined at least two reasonable appointment offers for admission. Clocks may not
be paused for patient initiated delays at any other part of the RTT pathway, including all
outpatient and diagnostic stages. Reasonableness is defined as an offer of a day case/inpatient
appointment with at least 3 weeks’ notice.
The 3 weeks’ notice reasonableness for day case and inpatient appointments rule does not
prevent patients from being offered earlier appointments. It just means that if the patient
declines the earlier appointment then this offer date cannot be used in a clock pause
adjustment.
If a patient makes themselves unavailable for a set period of time (e.g. due to school holidays or
other reasons) then this may mean that offering actual dates which meet the reasonableness
criteria would be inappropriate (as the patient would be offered dates that the provider already
knew they couldn’t make). In this case the waiting time clock can be paused from the earliest
reasonable offer date that the provider could have given the patient, had they been available up
until the time that the patient makes themselves available for admission again.
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 for treatment.
Appendix 2 – Outpatient: Cancellation Process
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Outpatient Appointments - ‘Cancellation’ Process
Patient added to the waiting list.
Appointment date booked and
agreed with patient.
Patient contacts and cancels the
appointment date. They are informed that
no further cancellations are permitted.
Offered another appointment within 2 weeks of the original
date. If an appointment is not available, offer earliest
possible date and refer to responsible clinician for review.
Patient is unable to attend
the new appointment date.
Patient agrees to self-refer back (SRB) when
they’re free (within 3 months). Letter sent to
GP (cc’ing patient and responsible clinician).
Patient contacts and
new appointment
booked. New clock
starts.
Patient cancels
appointment date
again.
Patient agrees
to new date.
Patient cancels 2nd
appointment.
No contact for
3 months.
Patient attends on
appointment date.
Patient removed from the waiting
list and letter sent to GP, (cc’ing
patient and responsible clinician),
discharging care back to GP.
Appendix 3 – Outpatient: DNA Process
Page 29 of 54
Outpatient Appointments - ‘DNA’ Process
Patient added to the waiting list
Appointment booked and
confirmed
Patient DNAs; Receptionist provides
responsible clinician with medical notes
Clinician reviews notes before leaving
clinic, and informs receptionist of decision.
Patient is considered
vulnerable, or classed as
clinically urgent.
Unable to contact
patient
Phone call is made to
patient
Follow ‘unable to
contact procedure’
2nd appointment is
booked and confirmed.
Patient attends
appointment
Patient DNAs 2nd
appointment
Appendix 4 – Outpatient: Unable to Contact Process
Page 30 of 54
Patient is not considered
vulnerable, or classed as
clinically urgent.
Patient removed from the
waiting list and letter sent
to GP, (cc’ing patient and
responsible clinician)
discharging care back to GP
Outpatient Appointments - ‘Unable to contact’ Process
Patient added to the waiting list
Booking team rings the patient on two separate days, at different
times, within 5 working days, when an appointment becomes available.
No contact made with patient
Send letter asking for the
patient to contact within 7
days
No contact after a further 14 days
Check patient contact details
with GP and ring again
Contact details
incorrect
Update PAS with
correct details
Contact details
correct
Contact made with patient
Send letter stating that no more
attempts will be made to contact
the patient and if they do not
respond within 7 days, they will
be taken off the waiting list
No contact
Appointment booked.
Patient removed from the waiting list and letter sent to GP, (cc’ing
patient and responsible clinician), discharging care back to GP
Appendix 5 – Inpatient: Cancellation Process
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Daycase/Inpatient Procedures - ‘Cancellation’ Process
Patient added to the waiting list
TCI date booked and agreed with
patient
Patient contacts and
cancels the TCI date
Given another TCI date, but
told that if they cancel
again, they will be removed
from the waiting list
Patient attends on
TCI date
Patient cancels TCI date
again
Patient is removed from the
waiting list and letter sent
to GP, (cc’ing patient and
responsible clinician),
discharging care back to GP
Appendix 6 – Inpatient: DNA Process
Page 32 of 54
Daycase/Inpatient Procedures - ‘DNA’ Process
Patient added to the waiting list
TCI date booked
Patient advises procedure is
no longer required.
DNA pre-op
Unable to contact
patient
Follow ‘unable to
contact procedure’
Patient is removed from the
waiting list and letter sent to
GP, (cc’ing patient and
responsible clinician),
discharging care back to GP
Patient contacted
Given another pre-op date
and informed that if they
DNA again, they will be
taken off the waiting list
Pre-op attended (if
applicable)
DNA again
DNA operation on
TCI date
Patient is removed from the
waiting list and letter sent
to GP, (cc’ing patient and
responsible clinician),
discharging care back to GP
Appendix 7 – Inpatient: Unable to Contact Process
Page 33 of 54
Operating
Consultant reviews
the notes.
Default = discharge
back to GP. One
more date can be
requested if there is
clinical concern
Patient attends
on TCI date
Daycase/Inpatient Procedures - ‘Unable to contact’ Process
Patient added to the waiting list
Secretary rings the patient on two separate days, at different times,
within 5 working days, when an appointment becomes available.
Failed contact with patient
Send letter asking for the
patient to contact within 7
days
No contact after 14 days
Contact made with patient
Check patient contact details
with GP and ring again
Contact details
incorrect
Update PAS with
correct details
Contact details
correct
Send letter stating that no more
attempts will be made to contact
the patient and if they do not
respond within 7 days, they will be
taken off the waiting list
1) Lets them know they’re on the WL
2) States the av. current wait
3) Check contact details
4) Establishes availability
5) Asks if available last minute
6) Asks whether they would be willing to
go with another member of the team
Patient is removed from the waiting list and
letter sent to GP, (cc’ing patient and responsible
clinician), discharging care back to GP
No contact after 7 days
Appendix 8 – Endoscopy: Cancellation Process
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Endoscopy Procedures - ‘Cancellation’ Process
Patient added to the waiting list
TCI date booked and agreed with
patient
Patient contacts and
cancels the TCI date
Given another TCI date, but
told that if they cancel
again, they will be removed
from the waiting list
Patient attends on
TCI date
Patient cancels TCI date
again
Booking officer removes
patient from waiting list
and sends a letter to GP,
discharging the patient,
cc’ing clinician and patient.
Blue card is kept in the
booking office for 1 month
in case clinician wants to
review. Card is filed in the
notes after 1 month.
Appendix 9 – Endoscopy: DNA Process
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Endoscopy Procedures - ‘DNA’ Process
Patient added to the waiting list
TCI date booked and agreed with
patient
Confirmation letter sent out
Patient rung 48 hours before the
TCI date to remind them
Patient DNA’s
Clinician expresses concern
and informs booking office to
offer another date
Default
Booking office contact patient
and offer 1 more date but
inform patient that they will be
removed from the WL if they
DNA again
Booking officer removes patient from waiting
list and sends a letter to GP, discharging the
patient, cc’ing clinician and patient. Blue card is
kept in the booking office for 1 month in case
clinician wants to review. Card is filed in the
notes after 1 month.
DNA again
Appendix 10 – Endoscopy: Unable to Contact Process
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If unable to
contact, follow
the ‘unable to
contact
procedure’
Endoscopy Procedures - ‘Unable to contact’ Process
Clinician refers patient for an endoscopy procedure. Patient informed they
are able to ring the booking office to choose their appointment date
straight away
Booking office ring patient to book if
they do not hear from the patient
Failed contact with patient
Ring the following working day
Failed contact with patient
Send letter asking for the patient
to contact within 7 days
Contact made with patient and
procedure date agreed
No contact after 14 days
Check patient contact details
with GP and ring again
Contact details
incorrect
Contact details
correct
Confirmation letter sent out
No contact
Send letter stating that no more attempts will be made to
contact the patient and if they do not respond within 7
days, they will be taken off the waiting list
No contact
Booking officer removes patient from waiting list and sends a
letter to GP, discharging the patient, cc’ing clinician and patient.
Blue card is kept in the booking office for 1 month in case clinician
wants to review.
Card is filed
in the notes after 1 month.
Appendix
8 - Glossary
of terms
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Adjustment
The length of a patient pathway may be adjusted for admitted patients
only, if they choose to wait longer than the dates they are offered for
admission for treatment for their own convenience.
Advice and
Guidance
AaG – A system which allows one clinician to seek advice from another
without the need to refer
Breach
Patient episode, which would run over the maximum referral to first
definitive treatment time of 18 weeks. This excludes cancer and rapid
access chest pain patients as these have separate shorter access targets
Choose and Book
CaB – National Electronic referral and booking system
Clinical Assessment CAS – Referrals are clinically assessed to determine whether the patient
Service
is first seen in Outpatients or is directed straight to test.
Clinical
Commissioning
Group
CCG – Primary Care Commissioners
Clock Start / Stop
Refers to the start of a period of counting days/weeks in a patient
pathway, until first definitive treatment is given, the time period ends, and
the clock is stopped.
Day Case
Patient who requires admission for treatment but who does not need to
stay overnight
Directly Bookable
Services
DBS: Part of CaB – GP’s are able to use DBS to make appointment in the
hospital clinics from their surgery
Did Not Attend
Patients who have agreed their admission date (inpatients / day cases) or
(DNA) appointment date (outpatients) and who, without notifying the
hospital did not attend for admission / outpatient appointment
Department of
Health
DH - The department of the United Kingdom government responsible for
policy on health and adult social care matters in England
Decision to Admit
DTA - the point at which the clinician and the patient agree that
treatment, as a Day Case or inpatient is required
Fast Track
Special arrangements that are made for a patient who has been unable to
continue on a pathway, as they are medically unfit or unavailable for care.
Fast tracking the patient back into the service starts a new clock but it is
not expected that a patient would have to wait a maximum of 18 weeks
for their first definitive treatment.
Generic referral
A referral to a specialty rather than a named clinician, i.e. Dear Doctor or
Dear Colleague
GRACe
“General Referral Assessment Centre”
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An Administration and triage facility for GP referrals within Primary Care.
A clock is started upon receipt at GRACe for a referral appropriate for a
consultant led service. The pathway is continuous until first definitive
lptreatment is given
Healthcare
Professional
HCP - A trained person who delivers medical care in a systematic way,
following prescribed protocols and procedures. The term “Healthcare
Professional” in this policy covers any person who is authorised to refer a
Patient to secondary care
Indirectly Bookable
Service
IBS - a CaB service that is not mapped to the Trust PAS system. The
Patient telephones the Trust Booking staff to convert their Unique
Booking Reference Number (UBRN) and agrees an appropriate
appointment
Inpatient
Patient who requires admission to the hospital for treatment and who will
stay at least one night
Inter-Provider
Transfers
A patient pathway managed between more than one organisation. Patient
may receive first definitive treatment in a “tertiary centre” – that
specialises in their condition. A specific form and minimum data set
(MDS) must be completed.
Minimum Data Set
MDS – specific information about a patient that should be included in all
referrals between clinicians in any part of the patient’s pathway
Medically Unfit
A patient who has a condition that prevents them from continuing along
their current pathway of care. Special arrangements must be made for
these patients to address their medical condition either in primary or
secondary care and to fast track them back into the service if appropriate
when they are fit and able to restart a pathway of care. (Note a new clock
will start for these patients)
Outpatient
Patient referred by a general practitioner, general practitioner with special
interest (GPSI), general dental practitioner, consultant, optometrist, or
other medical professional for clinical advice or treatment, which does not
require an admission to the hospital
Picture Archiving
PACS - for storage and distribution of computerised images
And Communication
System
Partial Booking
Patients who have had their addition to the schedule (waiting list)
acknowledged, and who are given the opportunity to agree a future date
for their outpatient appointment or admission.
Patient
Administration
System
PAS – electronic system for building maintaining clinic templates
Patient Cancellation A patient who has previously accepted an outpatient time or date
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for an operation and they subsequently notify that they wish to change
or cancel their appointment
Primary Care
Services commissioned by the PCT provided in the community, usually
by a GP, GPSI or other specialists.
Patient Tracking List PTL– a model for collection of prospective waiting times. The report
details patients awaiting elective admission, diagnostic or outpatient
appointment and the starting point of their pathway. The information
team refreshes the list daily. All operational staff will refer to the list to
ensure that patients are treated equitably within a maximum waiting time
of 18 weeks to their first definitive treatment
Procedures of
Limited Clinical
Value
PLCV - The Commissioners have agreed a range of procedures that are
considered outside of the services routinely provided. Prior approval for
referrals of limited clinical value must be gained prior to the referral being
sent to the Trust for treatment.
Rapid Access Chest RACPC – A fast track service for patients with chest pain for referral to a
Pain Clinic
cardiologist – These patients must be seen within 2 weeks from the date
of the GP referral. As they are subject to their own waiting time target
they are not counted within the 18-week rules
Reasonable Offer
Refers to the notice given to a patient by the hospital for a forthcoming
appointment or admission. For an offer to be reasonable two dates with
at least 3-weeks’ notice must be given to a patient undergoing surgery.
For outpatients good practice guidance suggests notice of at least 10
days.
Referral Support
Service
RSS – referral management service used by local primary care
commissioners for triage and onward referral management
Referral To
Treatment
RTT- the measurement of the length of an 18 week pathway
Secondary Care
Services provided in a hospital setting
Self-Deferral
A patient initiated pause in the 18 week pathway. It may involve patient
initiated cancellation for an appointment or admission.
Self-Referral
A patient who contacts the hospital directly. They have usually been
undergoing care but have been either medically unfit or unavailable to
come in for further treatment. Arrangements have been put in place by
the Hospital for the patient to contact a named person directly once they
are fit and ready to continue with treatment.
Sequencing /
Some patients may require more than one procedure but the nature of the
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Sequential
Treatments
procedures means that they need to happen in order – i.e. Right Total
knee replacement followed by the left Total Knee Replacement. A
pathway will start for the first side. When the patient becomes fit to
commence a pathway for the second side a new clock will start.
Standard Operating
Procedures
SOP – A detailed explanation of how a policy is to be implemented. It will
include details of who will perform a task, what materials are necessary,
where the task will take place, when the task shall be performed and how
it will be executed.
To Come In
TCI – a date and time for a patient to come to the hospital for a day case
or inpatient admission.
Tertiary Centre
A third party organisation that usually supplies specialist services to a
regional area
Transient
Ischaemic Attack
TIA - A fast track GP referral system for patients with suspected “stroke”
to see a specialist neurologist
Tolerance
The aim is for all patients to be treated within 18 weeks. However, it is
recognised that there is a proportion that may not be treated in the time
frame due to patient choice or medical reasons where it is “not in the
patient’s best interest to be treated within 18 weeks”
Unique Booking
Reference Number
UBRN – a number given to a patient to progress a Choose and Book
referral. The number is unique to a specific pathway for a patient and is
used to identify a single patient clock or pathway. A patient may have
more than one pathway simultaneously
Urgent 2 week wait
referrals
QMCW Rapid access 2-week referral process for a patient with
suspected cancer. Such referrals are not part of an 18 week pathway
Appendix 9 – Cancer Services Access Policy
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ACCESS POLICY
CANCER SERVICES
AGREEMENT COVER SHEET
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This policy has been agreed by:
Position:
Trust Cancer Lead Manager &
Associate Director, Surgical Services
Name:
Mrs. Elizabeth Howells
Organisation:
Frimley Park Foundation NHS Trust
Date Agreed:
March 2014
Position:
Trust Lead Clinician for Cancer
Name:
Mr. Ian Laidlaw
Organisation:
Frimley Park Foundation NHS Trust
Date Agreed:
March 2014
Policy Author
Position:
Cancer Information Manager
Name:
Simon Gifford
Organisation:
Frimley Park Foundation NHS Trust
Last review date:
March 2014
Review by:
Simon Gifford, Cancer Information Manager
Lauren Lakritz, Cancer Services Manager
Operational Policy Review Date:
March 2016
CONTENTS
Page 43 of 54
SECTION
HEADING
PAGE NO.
1
Introduction
4
2
General Principles
4
3
Waiting Time Targets
5
4
Suspected Cancer (TWR) Referral Process
5
5
Tertiary Referrals
6
6
Registering Referrals & Upgrade Referrals
7
7
Prioritising Patients Requiring Admission
7
8
Hospital Initiated Cancellations
7
9
Patients Who Do Not Attend (DNA)
8
10
Patient Initiated Cancellations
9
11
Patient Initiated Delays
9
12
Patient Tracking Lists (PTL)
10
13
Stopping of Pathway Clocks
10
14
Applications for PCT Funding
11
15
Patients Who Choose the Private Sector
11
16
Communication with GPs
11
17
References
11
18
Glossary
11
Process Maps
13
APPENDIX
A
1.
INTRODUCTION
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The purpose of the procedure is to ensure that all patients referred to the hospital who are
suspected of and/or diagnosed as having cancer (either at the time of referral or at some point
in their pathway) are managed along the appropriate Cancer Pathway in a consistent manner
throughout the Trust. It is essential that, during all stages of the patient’s pathway, information
is given and recorded in a consistent and accurate manner.
The length of time a patient needs to wait for hospital treatment is an important quality issue
and is a visible and public indicator of the efficiency of the hospital services provided by the
Trust. The Trust uses the Somerset Cancer Registry (SCR) to monitor Cancer Waiting Times.
This procedure applies to all staff involved in the process of managing the patients’ cancer
pathways throughout the Trust. The Trust’s medical records, retention and information
Governance policies will also apply to any aspect of the patient’s pathway as appropriate.
2.
GENERAL PRINCIPLES









3.
The policy covers outpatients, inpatients, pre-assessment, diagnostics and treatments.
The Trust will work with primary care colleagues to ensure all referrals are appropriate
and are only made once a patient is physically and psychologically ready to accept
appointments within the National Access Targets Framework.
The Trust will work with primary care colleagues to ensure that the patient is aware of
the reason for referral on a TWR pathway (where appropriate)
Contact with the patient concerning their pathway and its administration, or any
changes should be documented in a timely manner.
Pauses to pathways will only be used for treatments at the decision to treat (add to
waiting list) point in a patient’s pathway and only for non clinical (patient choice)
reasons. Except in the case of the “Earliest Clinically Appropriate Date” for a subsequent
treatment.
Management decisions on patients who cannot proceed with their pathway due to
medical/clinical reasons will be made by a clinician. These patients can no longer be
suspended (paused).
Patients and GP’s will be kept fully informed and have a point of contact at the Trust at
all times in their pathway.
Patients should not leave one hospital attendance without knowing when the next stage
of their pathway is booked or intended to be booked.
Minimum data sets will be completed within 48 hours for all patients requiring referral
to another Trust for advice or treatment. Coordination of this function will be the
responsibility of the relevant MDT coordinator.
WAITING TIMES
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Two Week Rule (TWR)
All patients referred to the Trust with suspected cancer or breast symptoms (including those
not deemed as being suspicious of cancer) should be offered their first appointment within a
maximum of two weeks from receipt of the GP referral by the Trust or the date offered should
be within two weeks. Patients with breast symptoms not suspicious of cancer may be referred
using choose and book, and in such cases the clock will start from the date that the patient
converts their Unique Booking Reference Number (UBRN).
The first appointment will either be a Consultant Outpatient appointment, Radiological
Imaging, Endoscopy or some other form of diagnostic tests (excluding attendance for routine
blood testing).
Patients who are referred due to a family history of breast cancer that are not symptomatic and
those referred for cosmetic reasons are not covered by the two week rule but will be covered
by the 18-week access policy.
62-Day Pathways
Patients referred by their GP with suspected cancer under the two week rule who go on to be
diagnosed with cancer should receive their first treatment within a maximum of two months
(62 days) from receipt of the GP referral.
Patients not referred by their GP under the two week rule but who are later suspected as
having cancer should be upgraded by the Consultant (or a member of their team) who feels
that the patient may have cancer. The patient should then receive their treatment within a
maximum of two months (62 days) from the date that the Consultant upgrades the patient.
The consultant should email the details of the upgrade to the Cancer Unit at the time that the
decision to upgrade is made.
31-Day Pathways
All patients diagnosed with cancer should be treated within one month (31 days) of the
decision to treat (DTT) being made (or the date offered should be within one month (31 days).
All patients who require subsequent treatment following first definitive treatment should be
treated within one month (31 days) of the DTT for subsequent treatment being made or the
Earliest Clinically Appropriate Date (ECAD) (or the date offered should be within one month (31
days).
Any patient who is referred with suspected cancer or who is upgraded and then found not to
have cancer but still requires further investigations and/or treatment will be seen under an 18week pathway and the 18-week access policy will apply.
4. SUSPECTED CANCER (TWR) REFERRAL PROCESS
All patients meeting the criteria for fast track referral under the Two Week Rule (including
those patients with breast symptoms not suspicious of cancer) should be seen within 14 days
Page 46 of 54
of the Trust receiving the referral. If a patient rearranges a fast track appointment the
patient should be offered another appointment within 14 days of the original appointment
date. If the new appointment is then subsequently cancelled by the Trust the patient should
be seen within 14 days of the original referral. If a patient cancels their appointment to be
seen within 14 days they will be rebooked as soon as possible and still within the 14 days
where we can.
All referrals must be faxed to the Two Week Rule Office on 01276 604506. On receipt of the
referral, the TWR administrator will stamp the referral with TWR and the date received. The
referrals will then be processed in accordance with the process at Appendix A.
Due to the time constraints associated with these appointments patients should normally be
telephoned to agree a mutually convenient date and time. If the patient does not have a
telephone contact number, a written offer of appointment will be sent inviting the patient to
attend. If the patient is unable to attend on the date given they are advised to make contact to
enable them to rearrange the appointment.
To help ensure that the Trust achieves the required standards for TWR’s, GP’s will need to
ensure that:
 Relevant conversation will have taken place with the patient by the GP, and the patient
will be aware they will be seen within 2-weeks of referral
 The patient will advised that they are being referred to exclude the diagnosis of cancer
and must therefore make themselves available for the diagnostic pathway.
 Referrals are faxed to the TWR Office in a timely manner
 Referrals are appropriate and are clearly marked as per cancer services’ protocols and
addressed to an appropriate tumour site (e.g. Breast, Skin, etc.)
 Referrals made to the Colorectal, Lung, Gynaecology and Urology (Bladder/Renal) teams
require eGFR blood tests to be taken prior to referral. Failure to provide this information
will result in the referral being returned to the GP.
All patients referred with suspected cancer should be offered an appointment date within 14
days.
If a Consultant feels that a patient does not meet the criteria for a TWR referral, they (or a
designated member of their team) will contact the GP by telephone to discuss the issue and, if
they are in agreement, the GP will revoke the TWR referral and re-refer the patient under an
18-week pathway. This does not apply to breast symptomatic patients as all patients with
breast symptoms should be seen within two weeks.
The Trust must not return TWR referrals to the GP as a result of repeated cancellations by the
patient unless it is agreed with the patient that they no longer require the appointment.
Similarly, patients must not be referred back to their GP if they are unable to attend an
appointment within two weeks, no matter what the reason for non-attendance is. However if
the patient DNAs 2 or more times they will be referred back to the GP for management.
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5.
TERTIARY REFERRALS
It is important that tertiary referrals to or from the Trust include a specific set of details about
the patients pathway to enable the receiving Trust to continue managing the patient’s pathway
in accordance with Cancer Waiting Times. The appropriate MDT Coordinator will ensure that a
copy of the patient’s CWT page from SCR is emailed (using nhs.net) to the tertiary centre with
48 hours of the decision to refer being made. This includes patients who are seen at FPH by a
visiting Consultant and require treatment under the same consultant’s care at the Tertiary
Centre.
A tertiary referral received by the Trust must be accompanied by the relevant cancer pathway
details. It is the responsibility of the MDT Coordinators to ensure that the Trust has all the
pathway information for any referrals received from another Trust. If the details are not sent
automatically by the referring Trust, the MDT Coordinator must contact the referring Trust on
receipt of the referral to obtain the details so that the SCR can be updated appropriately.
6.
REGISTERING REFERRALS & UPGRADE REQUESTS
All paper referral letters and diagnostic requests will be registered within 24 hours of receipt by
the TWR Coordinator on SCR. The TWR Coordinator will then fax the letter to the Pre-Reg
Department or radiology so that it can be logged on the Trust’s PAS (Appendix A). It is essential
that the date of receipt of referral is registered to ensure that maximum waiting times can be
calculated and audited.
All Consultant Upgrade requests must be forwarded to the Cancer Office using the “Cancer
Unit” distribution list on the Trust’s email system. It should clearly state in the email the date
that the consultant (or an authorised member of their team) decided to upgrade the patient
when the decision was made and which tumour site pathway the patient will now be on.
7.
PRIORITISING PATIENTS REQUIRING ADMISSION
All elective inpatient, day case, outpatient and diagnostic waiting lists will be managed so that
patients with an urgent clinical need are seen first. It is the responsibility of the medical
secretaries to add the patients to the waiting lists using the appropriate priority. The MDT
Coordinators must ensure that the patient’s pathway information is provided to the medical
secretaries to enable all additions to be made appropriately.
8.
HOSPITIAL INITIATED CANCELLATIONS
Patients on Cancer Pathways must only be cancelled by the hospital for non-clinical reasons if it
is absolutely necessary.
Outpatient and Diagnostic Test Appointments
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If an agreed appointment needs to be cancelled the patient will be contacted either verbally or
in writing dependant on time constraints. In either instance the patient will be offered an
alternative date within the target period and the opportunity to rearrange this if it is
convenient. This action will be clearly recorded on PAS/Patient Centre as a hospital initiated
cancellation to enable audit to be carried out. The information must also be communicated to
the Cancer Office by the relevant department.
Inpatient & Day Case Admissions
This section covers the circumstances when a patient’s admission may have to be cancelled by
the hospital for non-clinical reasons. Every effort must be made not to cancel patients at the
last minute (e.g. on the day of admission or day of surgery). If it is necessary to cancel an
Inpatient/Day Case Admission, the patient should be contacted by telephone and offered an
alternative date at the earliest opportunity. The new date should still be before the patient’s
Cancer Pathway breach date.
Patients who are clinically urgent are annotated on reports by the clinical category to highlight
the patient’s clinical need to staff. This provides bed managers and ward staff a way or
prioritising the allocation of beds when there are capacity problems.
9.
PATIENTS WHO DO NOT ATTEND (DNA)
If a patient DNAs any hospital appointment, a check should be made that the contact details
held by the Trust are correct; this should include checking the details held at the patient’s GP. If
the contact details were incorrect, the patient should be given another appointment as soon as
possible and within the patient’s pathway timescales. If the patient contact details are correct
and they are booked to another appointment which they subsequently DNA again they will be
referred back to the GP for management.
First Appointment (inc. Diagnostic Appointments)
If a patient DNAs their first appointment following the referral that started their cancer
pathway, the clock will be stopped. A new clock will start on the day contact is made with the
patient and the appointment is rebooked by the patient.
If a patient DNAs for a second time, the managing Consultant (or an authorized member of
their team) should review the referral to decide if they feel it would be clinically appropriate to
refer the patient back to their GP. If it is deemed to be clinically appropriate, a letter should be
sent to the GP advising them that the referral is being returned due to the patient not attending
their appointment without giving notice, so their pathway has been stopped. The letter should
be copied to the patient for information. If the clinician feels that it would be more appropriate
to offer the patient another appointment, contact should be made with the GP to ask them to
speak to the patient about the importance of attending the appointment and another
appointment should be made as soon as possible in conjunction with the patient.
Follow Up Appointments (inc. diagnostic Appointments)
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If a patient DNAs a follow up appointment they should be given a further appointment.
The patient should only be discharged back to the care of their GP, providing that discharge of
the patient is in their best clinical interests. Once the decision has been made to discharge the
patient back to the care of their GP, both the patient and the GP should be informed in writing.
If a patient refuses to have any type of diagnostic test that could potentially diagnose a cancer
then they are removing themselves from a 62 day pathway and will no longer be monitored as
such. They will continue to be investigated on an 18 week pathway and in the event they are
diagnosed with cancer will be monitored on a 31 day target.
10.
PATIENT INITIATED CANCELLATIONS
If a patient repeatedly cancels an appointment relating to their cancer pathway (irrespective of
the nature of the appointment) the relevant Clinical Nurse Specialist (CNS)/Consultant should
be informed so that they can ensure that the patient has fully understood the implications of
their decision (unless the patient has opted for care in the private sector).
If the patient decides they no longer require their appointment/admission, this is deemed to be
a patient cancellation and should be noted as such on SCR and removed from cancer pathway
and noted on PAS/Patient Centre, and the GP informed by letter with a copy filed in the
patient’s notes.
If a patient cancels an appointment on the day, this will be classified as a DNA. It will not be
possible to utilise the appointment slot at short notice, and will effectively be under capacity.
11.
PATIENT INITIATED DELAYS
Outpatients and Diagnostics
A record should be made of all requests from a patient to delay or defer appointments for
investigations as fulfillment of these will protract the pathway. The request should be
annotated on SCR along with the reason for the request if known i.e. patient on holiday. See
section 13 below.
Inpatients and Day Cases
Patients on a cancer pathway need to be offered one date for admission for treatment as an
inpatient (including day case admission) within their 31/62 day period for it to be classed as a
reasonable offer. If a patient chooses to delay their admission for treatment for social reasons,
a clock pause can be applied from the date of the first reasonable offer until the date that the
patient indicates they are ready for admission. If a patient stipulates at their treatment decision
appointment that they are delaying their treatment for whatever reason until a particular date
the hospital does not need to offer them a date in this period to be able to make a patient
Page 50 of 54
pause but must be able to advise that a date could have been offered, this will be well
documented on SCR.
It is essential that staff keep accurate records when handing patient choice delays noting the
date of the first reasonable offer and the date the patient says that they are available for
admission from... If a patient states that they are unavailable for admission between two dates
(e.g. due to holiday) and the earliest date that the Trust could have offered was between these
dates, a clock pause can still be applied without actually making the offer to the patient as they
have already made themselves unavailable. The date that could have been offered should still
be recorded on SCR/in the patient’s notes and the clock pause will start from this date.
If a patient agrees an admission date but then subsequently cancels it, a clock pause can be
applied between the date of the cancelled admission date and the new admission date. Clock
pauses also cannot be applied to outpatient appointments or admissions for diagnostic testing
(unless the test will also be treatment, e.g. excisional biopsies).
12.
PRIMARY TARGET LISTS (PTL)
It is the responsibility of the MDT Coordinator to track the patient’s progress through their
cancer pathway from receipt of referral (or decision to treat to treatment in the case of
subsequent treatments) up to the date of treatment. However, the consultant is responsible
for all clinical aspects and decisions relating to the patient’s pathway, including deciding on
appropriate treatment and ensuring the patient is clinically fit for any treatment.
All patients whose pathway target date falls within 28 days will be discussed at the weekly PTL
meetings, chaired by the Cancer Information Manager (or nominated deputy), in order to
ensure any delays are avoided wherever possible.
13.
STOPPING OF PATHWAY CLOCKS
The 62/31- Day pathway clock stops when the patient has received first definitive treatment
(FDT). Such treatments could be surgery, anti-cancer drugs, Teletherapy, Bracytherapy,
Specialist Palliative Care, active monitoring and non-specialist palliative care.
Enabling treatments are not classed as FDT except for the following:
 Colostomy for bowel obstruction
 Insertion of oesophageal stent
 Non-small cell lung cancer (NSCLC) stent
 Uteric stenting for advanced cervical cancer
 Insertion of pancreatic stent if planned to resolve jaundice before the patient has
resection or commences chemotherapy.
If a patient has an enabling treatment prior to surgery and remains an in-patient between the
enabling treatment and the surgery, this date of admission would stop the pathway clock.
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If a patient undergoes open and close surgery which does not result in the removal of the
tumour, it can be counted as FDT as the procedure is intended to be “anti-cancer” despite the
outcome not being successful.
Active monitoring should only be used if active treatment is not appropriate at that point in
time but may be required at a future date.
It is the responsibility of the MDT Coordinators to ensure that all pathways are stopped
appropriately and that the information recorded on SCR is a true reflection of events. The
information recorded on SCR will be audited periodically by the Cancer Information Manager to
ensure compliance with the relevant guidance.
Patients who are not clinically well enough to undergo diagnostics/treatment within the
relevant pathway timescales must not have their clock stopped.
Patients who are offered a date for treatment of their cancer, but choose to delay this for any
reason including preferential choice of clinician (i.e. Named Surgeon) or treatment (i.e. Robotic)
will effectively pause the pathway from the date of offer treatment until the next preferential
choice is available.
14.
APPLICATIONS FOR PCT FUNDING
When PCT approval of funding is required, the Cancer pathway clock will continue. There are
no adjustments available for this reason. Applications for funding will be made by the clinical
team.
15.
PATIENTS WHO CHOOSE THE PRIVATE SECTOR
If a patient chooses to be seen under the private sector for any diagnostic tests following a
referral to the NHS for the same condition, the patient’s NHS pathway will be closed down and
“No cancer diagnosed” on SCR. If the patient then chooses to return to the NHS for treatment
following a diagnosis being made in the private sector, they will be covered by appropriate 31Day Standard.
If a patient is diagnosed with cancer in the NHS but then chooses to have their treatment in the
private sector, the SCR record will be closed as “Diagnosis of new cancer confirmed – no NHS
treatment planned”.
16.
COMMUNICATION WITH GP’S
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GP’s will be kept fully informed of their patient’s flow through clinical pathways. When a
patient is given a diagnosis of cancer, the clinical team will notify the GP by fax within 24-hours
of the diagnosis being communicated to the patient.
17.
REFERENCES


18.
BCC
CNC
CNS
CUO
CWT
DNA
DTT
ECAS
FDT
FPH
GP
IPT
MDT
NHS
NSCLC
OPA
OPC
PAS
PCT
PTL
SCR
TWR
UBRN
Cancer Waiting Times (CWTs) – A Guide v8.0 (Department of Health)
Frimley Park Hospital 18 weeks RTT Access Policy
GLOSSARY
Basal Cell Carcinoma
Cancelled
Clinical Nurse Specialist
Cancer Unit Office
Cancer Waiting Times
Did Not Attend
Decision to Treat
Earliest Clinically Appropriate Date
First Definitive Treatment
Frimley Park Hospital
General Practitioner
Inter Provider Transfer
Multi-Disciplinary Team
National Health Service
Non-Small Cell Lung Cancer
Outpatient Appointment
Outpatient Clinic
Patient Administration System
Primary Care Trust
Primary Target List
Somerset Cancer Registry
Two Week Rule
Unique Booking Reference Number
Page 53 of 54
Appendix A
Cancer Unit Office - Processing the Referral Letter
TWR
Fax from GP
GP faxes referral
to Cancer Unit
Office
TWR coordinator
stamps letter with
date received
Fax back to GP
Cancer Unit Office
faxes confirmation
to GP
TWR coordinator
reads letter
Does the
patient have a
hospital
number?
No
Contact Pre- reg
for a number
Yes
TWR coordinator
stamps letter with
green TWR stamp
TWR coordinator
notes date patient
must be seen by
on letter above
date stamp
Can TWR
coordinator
identify
specialty ?
Yes
TWR coordinator
processes letter
End stage
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No
TWR coordinator
takes letter to
consultant for
clarification