ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST
OPERATION GUIDANCE
2008-09
GENERAL
Management of waiting lists

Patients will be treated in order of their clinical need.

Patients with similar clinical needs will be treated in chronological order.

The Trust will meet/achieve national directives on outpatient, inpatient, day
case and diagnostic waiting times (including cancer standards), adhering
also to targeted volumes for the total number of patients waiting.

iSoft Patient Manager (PAS) or linked systems must be used to administer
all referrals and waiting lists.

Patient information stored on all computer systems must be accurate and
confirmed with patients on each attendance.

All patients added to a waiting list will be either partially or fully booked.

There will be a process of regular audit of waiting list management to
ensure compliance with the policy and guidance

Patients removed from the Trust waiting list in accordance with this policy
may be reinstated where there is a sound clinical reason for doing so.
This will only occur with prior agreement by the responsible consultant,
clinical lead or general manager for the Division within which the specialty
sites, and the service manager responsible for the specific waiting list.

Patients who inform the Trust that they no longer wish to remain on the
waiting list will have their request confirmed in writing.
The GP and consultant will be notified in writing and will be given two
weeks in which to reinstate the patient on the waiting list on clinical
grounds and with the agreement of the patient. Children and known
vulnerable adults will be discussed with the consultant.

Patient records on PAS will be updated in real time.
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Cancellations or changes to appointments

Reasons for cancellations or changes to appointments must be accurately
recorded in PAS using either a drop down menu or free text.

A clear audit trail for all changes must be available from the patient’s
electronic record.
Patient cancellations

Patients who cancel their initial appointment will be given an alternative
date at the time of cancellation. The patient must be informed that the
cancellation is regarded as a self-rejected and will reset the start of the
wait to the date on which the patient would have attended. If a patient
cancels two reasonable offers, the patient is to be informed that this will
result in removal from the waiting list.

With 18 weeks the clock start date does not change if the patients cancel
Cancellation by the Trust

Patients that have been previously cancelled should not be cancelled a
second time except in exceptional circumstances. All such
cancellations must be authorised by the appropriate General Manager,
and a plan for patient care agreed.

If there are changes to patient appointments at short notice, the date of
the rescheduled appointment must take account of clinical urgency

Where patients have to be cancelled within six weeks, the clinical
needs of the patients must be taken into consideration and the
scheduler must discuss this with the clinician.
Cancellation by a clinician

A minimum of six weeks notice is required when a clinician requires a
clinic/ list to be cancelled due to annual leave, study leave or other
planned reasons.

Any clinic/ list cancellations need to be approved and signed of by the
relevant general manager or service manager using the Trust clinic
cancellation pro forma and must be accompanied by a clinic/ theatre
list indicating the timescales in which cancelled patients must be
rebooked, having consulted the doctor/ nurse concerned about the
clinical requirements.

When clinics have to be unavoidably cancelled at short notice,
immediate notification to the relevant general manager or service
manager, nursing staff and outpatient managers/ schedulers (where
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appropriate) is essential. The head of outpatient/ inpatient scheduling
must work with the relevant specialty general manager or service
manager to arrange reprovision of the clinic/ list.
Patients who do not attend their appointment
New appointments
 All adult patients who do not attend their hospital appointment will be
discharged back to GP care. Exclusions to this are: cancer patients and
known vulnerable adults.

All Paediatric patients who do not attend will have their notes reviewed by
their clinician to determine the future care plan.

If a patient disputes a discharge due to not attending their appointment,
then the manager or supervisor for that area may, at their discretion, book
a further appointment/ procedure for the patient.
Follow Up appointments
 Patients are discharged unless the clinician requires otherwise.
Transfers into/ out of Trust

Patients who have had a private outpatient appointment, but have elected
to have NHS inpatient treatment will be treated in the same way as
patients who have had a NHS consultation. Former private patients must
be referred via their GP or their private patient consultant.

Patients can be transferred to another provider by local arrangement.
These patients must remain on the Trust waiting list until treated.
Selection of patients is in accordance with the prevailing criteria.
Waiting list monitoring

Management of the waiting list will be routinely monitored as outlined in
the appropriate procedure.
Communication

Communication with patients will be informative, clear and concise.

The process of waiting list management will be transparent to the public,
staff and commissioners of the service. This will include the patient being
made aware of their responsibility to attend for treatment and to inform the
Trust of any changes in their condition or social circumstances.
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
When a patient attends the hospital the following information will be
confirmed:
o Confirmation of the patient’s address (including postcode) and referring
general practitioner;
o Patient’s telephone number (home, work and mobile) or a number
through which they can be contacted;
o Availability to come in at short notice (e.g. less than 72 hours) if an
unexpected vacancy arises and if the patient has not been given an
admission date;
o Any special circumstances requiring longer notice than usual for
admission (e.g. caring for elderly relative, transport arrangement);
o Any dates when a patient will not be available for admission (e.g.
booked holiday).
o Ethnicity, if not already recorded.
This information is expected to be provided by the GP or referring
consultant for the first outpatient appointments.

Patients will be given a date which is considered robust and unlikely to
change.

For written and verbal offers of an appointment or admission offer to be
reasonable (with the exception of patients with suspected cancer), the
following waiting time guidance will be followed:
i)
“For a written appointment or admission offer to a patient to be
deemed reasonable, the patient is to be offered an appointment
or admission date with a minimum of three weeks notice (21
days).
ii)
“In addition to the 3 weeks notice, for a verbal appointment or
admission offer to a patient to be deemed reasonable, the
patient is to be offered:
 for inpatient admission - a minimum of two admission dates
 for an outpatient appointment - an appointment on a
minimum of two different dates.
Where patients are offered dates with less than 21 days notice, the
patient’s decision to decline the date must not be recorded as a self
rejection.

GPs and consultants must refer in line with specialty protocols where they
exist.
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OUTPATIENTS
Referrals
Choose and Book

Patients can be booked into outpatient clinics using the direct booking
Choose & Book system (DBS). Directly booked patients will agree
their appointment slot during, or immediately after, their GP
appointment. A letter confirming their time and date of appointment is
automatically generated by the national Choose and Book system.
Paper referrals

All paper referrals must be date-stamped on day of receipt into Trust, in
order to indicate start of the outpatient wait.

For the 18 week target, the start of journey is



the date of referral from the GP whether that referral is directly
to the Trust or via an external organisation
the date of a consultant’s decision to commence a patient on a
pathway
when the patient converts their Choose and Book unique
booking reference number (UBRN).

Most referrals are made to a specific consultant. Where there is
pooling, referrals are registered to the consultant with appropriate
specialty/ subspecialty interest and the shortest wait. Where more than
one clinician partakes in the same specialty/ subspecialty the referrals
will be pooled and allocated to the clinician with the shortest wait.

If a referral has been made and the special interest of the consultant
does not match the needs of the patient, the consultant must transfer
the referral to an appropriate colleague where such a service is
provided by the Trust, and a letter to this effect sent to the GP or
referring consultant. The 18 week clock start remains unaffected.

If the referral is for a service that is not provided by the Trust, then the
referral letter will be returned to the referring GP or consultant advising
that patient needs to be referred elsewhere.
Cancer Referrals

To meet required NHS standards, suspected cancer referrals must be
seen by a specialist within 14 days of their GP deciding that they need
to be seen urgently and requesting an appointment.

Referrals from GPs will comply with the referral guidelines for
suspected cancers as agreed by the North London Cancer Network in
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January 2008. Referrals will be by referral protocol or must clearly
identify the two-week rule/ cancer/ tumour.
Appointments

Outpatient appointments are classified into three groupings:
o See within 2 weeks (Cancer 2 week rule referrals)
o See within 4 weeks (Urgent referrals)
o See within the maximum allowable time limit (all other patients)
In all cases, patients are to be allocated outpatient slots in a chronological
order.
During 2008-9, the Urgent referral category will disappear as the maximum
waiting time decreases to 5 weeks.
Clinic management

Clinic templates will be reviewed annually by the general manager and
lead clinician.

Templates should reflect expected performance as laid out in the
Service Level Agreement with the lead PCT and good clinical practice;
in line with National agreements and guidelines.

Clinics should not be overbooked, except in exceptional circumstances
and with the agreement of the general manager and consultant.

Blocked clinics will be created in PAS to allow rescheduling of
patients who have had to be cancelled at short notice. It is anticipated
that as waiting times decrease these should only be used infrequently.
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DAY CASES AND IN-PATIENTS

Patients will only be added to the ‘live’ waiting list if they are medically
fit for surgery and can attend (with reasonable notice – see below) for
surgery within the maximum waiting time specified within the national
guidance and annual SLA agreed with the Lead PCT.
Additions to waiting lists
Summary of criteria for addition to waiting lists






Only add patients to a Waiting List when they have accepted
consultant advice for elective treatment.
Only add patients who are ready to come in on the date the decision to
add to the list is made.
Do not add patients if they have weight to lose or gain.
Do not add patients if they are unfit.
Do not add patients if they are not ready for the surgical phase of
treatment, unless they fit the criteria of an addition to the planned
waiting list.
Do not add patients where there is no serious intention to admit them:
o because they are not ready to be treated, for example, because
they are pregnant at the time that the decision to add to the list
is made
o because of the rules of this policy
o because of procedural restrictions, e.g. clinically prohibited
procedures
o Second opinion
Patients Listed for more than one procedure

Where more than one procedure will be performed at one time by the
same surgeon, the first procedure will be added to the waiting list with
additional procedures noted.

Where different surgeons working together will perform more than one
procedure at one time, the patient will be added to the waiting list of the
consultant surgeon for the priority procedure with additional procedures
noted.

Where a patient requires more than one procedure performed on
separate occasions by different (or the same) surgeons the scheduler
will seek guidance from the relevant consultants as to the order in
which the patient will be treated.

If the later Decision To Admit (DTA) is the highest priority procedure to
be undertaken, then the waiting list episode relating to the earlier DTA
will be suspended - NB no suspensions with 18 weeks immediately
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with a review date allowing enough time for the patient to be treated
and recover from the procedure (the maximum 60 day suspension rule
will not apply in this case, but a note will be made on the patient’s
record to review within 6 months)

If the earlier DTA is the highest priority procedure to be undertaken,
then the waiting list episode relating to the later DTA will be suspended
NB no suspensions with 18 weeks from the date of the TCI for the
highest priority procedure with a review date allowing enough time for
the patient to recover from this procedure (the maximum 60 day
suspension rule will not apply in this case, but a note will be made on
the patient’s record to review within 6 months).

If the DTA for both procedures are made at the same time, then the
lowest priority procedure to be undertaken will be treated as a
“planned” procedure and so will go onto the planned waiting list.

Bilateral procedures - initial surgery on one side at first admission and
subsequent admission for a second side. The patient will be added to
the waiting list for the first side and put on a planned list for the second
procedure.
Structure of Inpatient/ Day Case Waiting Lists

To aid both the clinical and administrative management of the waiting
list, the lists are sub-divided into the following:
o Active Waiting Lists - consists of patients awaiting admission
who are available to come in.
o Suspended/Deferred Waiting Lists – patients who are already on
the waiting list but become unsuitable for admission for clinical
or social reasons.
o Planned Waiting Lists - patients who are waiting to be recalled
to hospital for a further stage in their course of treatment or
investigation. Examples include:
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‘Check’ endoscopic procedures
The second procedure for bilateral operations
Removal of screws/metal work
Age/growth related surgery
Investigation/treatment sequences.
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Suspended Waiting List

Suspended patients will not count as waiting for statistical purposes.
Any periods of suspension will be subtracted from the patient’s total
time on the waiting list for Körner returns.

No single suspension period may exceed 60 days.

In the event that a patient will remain either clinically or socially
unavailable for a period of greater than 60 days the patient must be
removed from the waiting list and returned to the referring general
practitioner. This terminates the patient’s period of wait, with any
subsequent referral regarded as a new episode of care (therefore
constituting a new decision to admit).
Types of suspension
Suspension for Social Reasons (always linked to a clock pause)

Some patients may not be available for admission due to
social/personal reasons, e.g. holidays, work commitments.
In order for a social suspension to be considered, notification of
unavailability must be made in advance of any offer of admission. Any
other circumstance will be considered a self-deferral.
Suspension for Clinical Reasons

Patients who, following a clinical assessment, are deemed medically
unfit to be admitted will be clinically suspended or removed from the
waiting list if this period of unavailability will be more than 60 days.
Offer Rejections & Patient Cancellations

Patients who cancel their admission date or decline a reasonable offer
(i.e., within 21 days notice as per national guidance) of an admission
date will be considered to have self rejected.

In this event the patient's current date on waiting list (CDOL) will be
adjusted to the date of self rejection (national guidance allows the
CDOL to be adjusted to the admission date or the offer date, but the
Trust has adopted a practice that ensures that patients do not wait
longer than is necessary). The patient must be given a re-arranged
date at the time of deferral.

If a patient self rejects more than once then they should be removed
from the waiting list.

In the case of children and known vulnerable adults, the consultant
must be consulted with, it is their decision whether the patient is
removed from the waiting list or not. (anyone - does this read okay)
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Clock Pauses
A clock may be paused only where a decision to admit has been made, and
the patient has declined at least two reasonable appointment offers for
admission. The clock is paused for the duration of the time between the
earliest reasonable offer and the date from which the patient makes
themselves available again for admission.
Patients Admitted and Discharged with Treatment Cancelled

If the patient is admitted to hospital but their treatment is cancelled for
non-clinical reasons and discharge to their place of residence, a new
TCI date must be agreed within 28 days of the cancelled
appointment/ operation date. If the patient rejects this offer, then
every reasonable attempt should be made to admit the patient at their
convenience.
Escalation

In the event that emergency pressures compromise planned
admissions, each clinical team must, on a daily basis, review its
admission list and only prioritise patients:
o Whose care meets NCEPOD category 3 (urgent); this includes
cancer patients;
o Who will exceed the maximum waiting time permitted;
o Who have been cancelled on the day of admission and need to
be treated within 28 days.
If, after prioritisation the number of patients across all specialties exceeds
capacity, the Clinical Director: Clinical Support Services will agree which
patients will be admitted after discussion with the consultants or specialist
registrar.
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DIAGNOSTIC PROCEDURES

To ensure a procedure is accurately recorded and coded as Diagnostic,
and reported in the diagnostic return, the referral form must be accurately
completed to identify whether the procedure to be performed is diagnostic
or therapeutic.

If the procedure is both Diagnostic and Therapeutic, the diagnostic box on
the form must be ticked as the priority to ensure the procedure is
monitored to meet the diagnostic waiting time and reported in the
diagnostic return. If the box is not ticked, then the form must be returned
to the referring clinician for clarification.
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18 WEEK REFERRAL TO TREATMENT GUIDANCE
By December 2008 all patients will be required to be treated or discharged
within 18 weeks from the time a provider receives notice of the patients
referral or the date of a consultant’s decision to start the clock. Or when the
patient converts their Choose and Book unique booking reference number
(UBRN). Their clock will continue until the patient is given, or admitted for, a
definitive treatment or is discharged. There may be clock stops and starts
along the way. A referral made to the wrong clinic or specialist and has to be
re-referred, will not stop the clock. There are no suspension periods in the 18
week pathway.
Further information about Clock Starts, Clock Pauses and Clock Starts can be
obtained from the 18 week website “The 18 week rules suite - National Clock
Rules”.
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DEFINITIONS
For the purposes of this guidance, the following terms have the meanings
given below:
Attendance & Clinic
Outcomes
This is the process, following an outpatient attendance,
of ensuring that the correct outcome is recorded on
PAS.
Active Waiting List
Patients awaiting elective admission for treatment and
are currently available to be called for admission.
Booked Patients
Patients awaiting elective admission who have been
given an opportunity to negotiate a date. These
patients form part of the active waiting list.
C&B Direct Booking System
Patient booked through Choose & Book at the GP
surgery and given an appointment at that time.
Day Cases
Patients who require admission to the hospital for
treatment and will need the use of bed but who are not
intended to stay in hospital overnight.
Did Not Attend (DNA)
Patients who have been informed of their admission
date (inpatients/day cases) or appointment date
(outpatients) and who without notifying the hospital did
not attend for admission/ OP appointment.
First Appointment
This is the first chronological appointment with a
specific clinician.
Follow up Appointment
The patient has been seen in outpatients by the same
clinical team within the same pathway, then it is a
‘Follow-Up’ appointment
Full Booking
Fully booked patients are those whose admission date
is negotiated at the time of the decision to operate
Inpatients
Patients who require admission to hospital.
New Referral
This is the first outpatient referral at this hospital to a
clinician, even if the consultant has already seen the
patient as an admitted patient
Outpatients
Patients referred by a general medical practitioner,
general dental practitioner, another consultant,
optometrist or other for clinical advice or treatment
provided in an ambulatory setting.
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Partial Booking
Partially booked patients are those who are added to a
waiting list and contacted prior to their expected
admission/attendance date and invited to negotiate a
date.
Planned Admissions
Patients who are to be admitted as part of a planned
sequence of treatment or investigation. They may or
may not have been given a firm date.
Pooled waiting list
Specialties/ subspecialties where more than one
clinician performs the service will be considered as
one waiting list. Referrals will be allocated to the
clinician with the shortest wait.
Self-rejections
Patients who, on receipt of reasonable offer(s) of
admission, notify the hospital that they are unable to
come in.
Suspended Waiting List
A list of patients awaiting elective admission who are
currently unsuitable for admission due to some
underlying medical or social reason.
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WAITING TIME STANDARDS IN 2007/ 08
There will be a maximum wait from GP referral to first treatment (18 RTT) of
18 weeks from December 2008. Within this, there are stage of treatment
maximum targets that state that no patient will wait longer than:
The National stages for 2008/ 09 are that no patient will wait longer than:
o 13 weeks for an outpatient appointment
o 26 weeks for inpatient or day surgery treatment
o 6 weeks for a diagnostic test.
The Trust also has milestones for stage of treatments, which are:
o 5 weeks for first outpatient appointment
o 11 weeks for inpatient or day surgery treatment
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LIST OF PROCEDURES SUPPORTING THIS GUIDANCE

WL(OP)1 – Procedure for Registering and Adding Patients to the Out
Patient Waiting List

WL(OP)2 – Procedure for Booking Routine Paper Based Outpatient
Appointments

WL(OP)3 – Procedure for Booking Urgent Paper Based Outpatient
Appointments

WL(OP)4 – Procedure for Booking Cancer Outpatient Appointments in
the Sarcoma Unit (Stuart)

WL(OP)5 – Procedure for Cancelling Outpatient Appointments and
Clinic: (a) hospital initiated cancellation and (b) Patient initiated
cancellation

WL(OP)6 – Process for limiting number of clinics throughout year/
ensuring less than 52 are booked (Siobhan)

WL(OP)7 – Procedure for Recording Outpatient Outcomes (AADs)
Attendance and Disposal

WL(OP)8 – Checking MDS from third party i.e. tertiary

WL(OP)9 – Sending MDS

WL(IP)9 – Procedure for adding patients to the Trust Waiting List

WL(IP)10 – Procedure for suspending Patients on Inpatients / Day
Case Waiting List

WL(IP)11 – Procedure to record TCI (to come in date)

WL(IP)12 – Procedure for cancelling and rebooking a TCI (to come in)
date

WL(IP)13 – Procedure for dealing with cancellations: (a) Hospital
Initiated Cancellation and (b) Patient Initiated Cancellation

WL(IP)14 – Procedure for dealing with rejections

WL(IP)15 – Procedure for dealing with Theatre Review

WL(IP)16 – 28 Day cancellation and rebooks (Kim)
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
WL(Dx)17 – Procedure for booking OPD Procedures (Pauline)

WL(Dx)18 – Procedure for Ensuring Patients are Correctly Coded for
Diagnostic Procedures (Pauline)

WL(WLM)19 – Procedure for managing and auditing waiting lists

WL(WLM)20 – Escalation of breaches and potential breaches
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