patient access policy · 2020-06-24 · constitution, have been included at the beginning of the...

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Patient Access Policy

Version No.: 3.1

Effective From: 12 October 2018

Expiry Date: 12 October 2021

Date Ratified: 24 September 2018

Ratified By: Audit Committee

1 Introduction

This Policy details how patients accessing non-emergency clinical services from The Newcastle upon Tyne Hospitals NHS Foundation Trust will be managed at all points of contact with the Trust. It also sets out the responsibilities of Newcastle Hospital’s staff in relation to patient access. This policy should be read in conjunction with the more detailed Operational Policies included in the appendices. Within this updated Policy the legal rights for patients, as outlined in the NHS Constitution, have been included at the beginning of the document. Trust targets and timescales have been more clearly defined, and include information in respect to their performance management. 18 Week Referral to Treatment and cancer waiting times have been referenced within this policy as appendices. The policy no longer has separate sections relating to outpatients, inpatients and diagnostics as much of this information was duplicated or irrelevant to the public.

2 Scope

This policy applies to all patients on a planned pathway of care regardless of site or point of delivery (e.g. diagnostics, outpatients, planned inpatients or day cases, community, non-face to face contacts and pre-assessment) and all staff involved in their management. The principles of the policy apply to both clinical and administrative waiting list management. The policy has been developed to ensure that Newcastle Hospitals provides consistent, fair and equitable access for all patients in line with clinical need, the requirements of the Five Year Forward View, the commitments made to (and expectations of) patients under the NHS Constitution and any obligations towards people who have had, or have disabilities under the Equality Act (2010).

3 Aims

This policy aims to reflect national and local expectations in relation to patient access to diagnostic, community, outpatient and elective admission services for the benefit of patients, staff and commissioners. The policy includes information on DNAs (Did Not Attends) and cancellations.

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4 Duties (Roles and Responsibilities)

4.1 Trust Board The Trust Board is responsible for implementing a robust system of corporate governance within the organisation. This includes having a systematic process for the development, management and authorisation of strategies, policies and procedures including this policy. 4.2 Chief Executive The Chief Executive is ultimately responsible for ensuring effective corporate governance within the organisation and for overall compliance with this policy. 4.3 Executive Group The Executive Group is responsible for approving all new strategies, policies and procedures that cover Human Resource issues, and approving all major revisions to such policies and procedures. 4.4 Clinical Policy Group The Clinical Policy Group is responsible for approving all new strategies, policies and procedures that do not cover Human Resource issues and approving all major revisions to such policies and procedures. 4.5 Directorate Managers/Clinical Directors Directorate Managers and Clinical Directors will be responsible for implementing this policy and ensuring compliance. 4.6 Clinicians Individual clinicians will be expected to comply with this policy including:

Providing clinical judgement as to clinical priority where applicable

Reviewing referrals within 7 days

Complying with annual leave and study leave policies to ensure that patients can be given reasonable notice and that resources are used efficiently and effectively

Effectively managing their waiting lists and waiting times in accordance with clinical need, national and local requirements to ensure excellent patient experience and outcomes.

Ensuring patients listed for procedures are medically fit (excluding cancer), willing and able.

4.7 18 Week Team The 18 Week Team are responsible for collecting, validating, monitoring and reporting data around 18 week waiting times including expediting patients or specific

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cohorts of patients (e.g. long waiters) through their pathways. They are also responsible for training staff in awareness of the 18 week rules and their application (including eRecord documentation) to patient pathways. The team will work closely with high risk Directorates and specialties to develop robust action plans and will escalate any compliance risks to the Trust Board. 4.8 Cancer Services Team The Cancer Services Team are responsible for collecting, monitoring and reporting of data around cancer waiting times including expediting patients through their pathways. They are also responsible for training staff in awareness of the cancer waiting time rules and their application (including eRecord documentation) to patient pathways. The team will work closely with high risk Directorates and specialties to develop robust action plans and will escalate any compliance risks to the Trust Board. 4.9 Information Services Information Services are responsible for:

The storing, extraction and reporting of a wide range of waiting time information.

Working with end users and colleagues in IM&T to ensure that eRecord and other key systems are updated in line with changes in national requirements and are enhanced to improve the quality and efficiency of recording and reporting of data.

Developing reporting tools to support the operational and performance management of waiting times.

Monitoring data quality and identifying those areas where training and guidance are required.

Providing modelling and analytical support to departments to assist in the management of services.

Submission of waiting times reports and datasets in line with statutory and contractual timetables.

4.10 Performance Team The Performance Team will provide expertise on internal and external performance indicators, and will report performance against those indicators (and highlight any concerns/issues) to the Trust Board, NHS Improvement (NHSI), Commissioners and other groups as agreed. They will also assess and report the impact of non-compliance with this policy. 4.11 Wards and Departments As above, Directorate Managers and Clinical Directors are responsible for implementing and complying with this policy within their own Directorate arrangements.

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All ward and departmental staff should ensure that patients and carers are dealt with in accordance with the patient access policy; providing efficient, effective care for all patients without unnecessary delay. All staff are responsible for the accurate and timely recording of data in relation to the patient encounter within the Trust e.g. registration of referrals, recording of attendances in outpatients or admissions on inpatient wards. 4.12 Waiting List Officers and Secretaries Waiting List Officers and Secretaries are expected to support clinicians to record and manage patient pathways in accordance with this policy. 4.13 All Staff All staff within Newcastle Hospitals are responsible for ensuring that they are familiar with all strategies, policies and procedures relevant to their area of work and that they act in accordance with these at all times. 4.14 Commissioners Commissioners should advise the Trust of any required national and local access criteria as well as liaising with GPs as referrers. 4.15 Referrers All referrers are responsible for ensuring that referrals are appropriate, clear and contain the minimum data set required to process patients effectively and efficiently. Referrers should ensure patients are made aware during their consultation of the choices/options available to them (including what is provided by each service provider where applicable), likely waiting times for a new outpatient consultation and of the need to be contactable and available when referred. Patients should be clearly advised when they have been referred on a 2 week cancer pathway, although clinical urgency will ultimately be determined by hospital specialists.

5 Content

Improved access to hospital services, alongside increased patient choice, has been a major priority for the NHS since the publication of the NHS Plan1 in 2000. This is now enshrined in the NHS Constitution2.

1 The NHS Plan: A plan for investment, a plan for reform. Department of Health. July 2000 2 The NHS Constitution. Department of Health. First published 2010. Updated August 2014. https://www.gov.uk/government/news/nhs-constitution-and-handbook-updated

https://www.gov.uk/government/news/nhs-constitution-and-handbook-updated

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6 The NHS Constitution

One of the primary aims of the Constitution is to set out clearly what patients, the public and staff can expect from the NHS and what the NHS expects from them in return. The Constitution distinguishes between: a. Rights. A right is a legal entitlement protected by law. b. Pledges. The Constitution also contains a number of pledges which the NHS is

committed to achieve, supported by management and regulatory systems. The pledges are not legally binding and cannot be guaranteed for everyone all of the time, because they express an ambition to improve, going above and beyond legal rights.

c. Responsibilities. The Constitution sets out expectations of how patients, the

public and staff can help the NHS work efficiently and effectively to ensure that finite resources are used fairly.

6.1 Patient’s Rights under the NHS Constitution Patient’s rights are legal entitlements protected by law. The NHS Constitution outlines a number of patient’s rights in relation to access:

1) “You have the right to receive NHS Services free of charge, apart from certain limited exceptions sanctioned by Parliament”.

Exceptions are legally defined and include prescription charges, charges for Dental Services and charges for overseas visitors.

2) “You have the right to access NHS Services. You will not be refused access on unreasonable grounds”.

Access cannot be denied because of age, disability, race, gender or gender reassignment, sexual orientation, pregnancy and maternity, religion or belief, or marital or civil partnership status. Nor can access be denied in situations where patients pay for additional private care separately. If patients are in the Armed Forces, the Ministry of Defence is responsible for their medical care. Primary care will generally be provided by Defence Medical Services and secondary care by the NHS.

3) “You have the right to expect your NHS to assess the health requirements of your community and to commission and put in place the services to meet those needs as considered necessary and, in the case of public health services commissioned by local authorities, to take steps to improve the health of the local community”.

This is the responsibility of NHS Commissioners. Commissioners buy services for their local population from organisations such as NHS Foundation Trusts. A

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number of commissioners buy services from The Newcastle upon Tyne Hospitals NHS Foundation Trust and a full list is included in Appendix 1.

4) “You have the right, in certain circumstances, to go to other European

Economic Area countries or Switzerland for treatment which would be available to you through your NHS Commissioner”.

Access to this right is at the discretion of NHS England on behalf of the

Secretary of State for Health, unless the NHS cannot provide the treatment without ‘undue delay’.

5) “You have the right not to be unlawfully discriminated against in the provision of

NHS services including on grounds of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity of marital or civil partnership status”

In addition, where patients’ human rights are engaged (e.g. Article 2 of the

European Convention on Human Rights (ECHR) right to life)), discrimination may be contrary to Article 14 of the ECHR.

Individual health professionals are also governed by the standards set under

the professional regulatory regime that applies to their profession. 6) “You have the right to access certain services commissioned by NHS bodies

within maximum waiting times, or for the NHS to take all reasonable steps to offer you a range of suitable alternative providers if this is not possible. “

Patients have the right to:

Start their consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions and;

Be seen by a cancer specialist within a maximum of two weeks from GP referral for urgent referrals where cancer is suspected

If this is not possible, the clinical commissioning group or NHS England, whichever commissions and funds their treatment, must take all reasonable steps to offer a suitable alternative provider, or if there is more than one, a range of suitable alternative providers, that would be able to see or treat them more quickly than the provider to which they were referred.

There are a number of exceptions where the right to treatment within maximum waiting times will cease to apply, in particular in relation to 18 week targets, including where:

Patients choose to wait longer;

Delaying the start of treatment is in patients’ best clinical interests, for example where smoking cessation or weight management is likely to improve the outcome of the treatment;

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It is clinically appropriate for their condition to be actively monitored in secondary care without clinical intervention or diagnostic procedures at that stage;

They fail to attend appointments which they had chosen from a set of reasonable options; or

The treatment is no longer necessary. The following services are not covered by the right:

Non-medical consultant-led mental health services;

Maternity services; and

Public health services provided or commissioned by local authorities.

18 weeks and Cancer “rules” are complex and the subject of separate guidance and policies with regards to implementation, recording and monitoring (See Appendices 2 and 3).

7) “You have the right to make choices about the services commissioned by NHS

bodies and to have information to support these choices. The options available to you will develop over time and depend on your individual needs.”

This means patients have the right to choose the organisation that provides their NHS care when they are referred for their first outpatient appointment with a service led by a consultant. There are certain exceptions including: Persons excluded

Persons detained under the Mental Health Act 1983;

Serving members of the Armed Forces; and

Prisoners (including those on temporary release).

And Services excluded

Where speed of access to diagnosis and treatment is particularly important, e.g. emergency attendances/admissions;

Attendances at a Rapid Access Chest Pain Clinic under the two-week maximum waiting time; and

Attendance at cancer services under the two-week maximum waiting time.

Maternity services;

Mental health services; and

Public health services commissioned by local authorities. 8) “You also have a right to information where there is a legal right to choice e.g.

the right to information to support you in choosing your provider when you are referred for your first outpatient appointment with a service led by a consultant”.

Information to help patients make their choice can be found on the NHS Choices website3. CCGs are expected to promote this information and make it more accessible to patients.

3 NHS Choices Website (www.nhs.uk)

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6.2 NHS Pledges to Patients under the NHS Constitution The NHS Constitution also contains a number of pledges which the NHS is committed to achieve, supported by management and regulatory systems. The pledges are not legally binding and cannot be guaranteed for everyone all of the time, because they express an ambition to improve, going above and beyond legal rights. 1) “The NHS commits to provide convenient, easy access to services within the

waiting times set out in the Handbook to the NHS Constitution”.

All patients should receive high-quality care without any unnecessary delay.

Patients can expect to be treated at the right time and according to their clinical priority.

Patients with urgent conditions, such as cancer, will be able to be seen and receive treatment more quickly.

An organisation’s performance is monitored across all waiting time pledges (See Section 14).

There are a number of government pledges on waiting times, including: Diagnostics

A patient waiting for a diagnostic test should have been waiting less than 6 weeks from the date of referral for that test;

Cancer4

Maximum two week wait for an urgent GP referral for suspected cancer to date first seen for all suspected cancers.

Maximum two week wait from referral for general breast symptoms (where cancer is not initially suspected) to date first seen.

Maximum one month wait from urgent GP referral for suspected cancer to first treatment (start date) for children’s, testicular cancers and acute leukaemia.

Maximum one month wait from diagnosis (date of decision to treat) to first

treatment for all cancers.

Maximum two month wait from urgent GP referral for suspected cancer to first

treatment (start date) for all cancers.

Maximum two month wait from referral from a cancer screening service to first

treatment for all cancers.

Maximum one month wait for all subsequent treatments for new cases of

primary and recurrent cancer where an anti-cancer drug regimen or surgery is

the chosen treatment modality.

4 DSCN 20/2008 22/2002

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Maximum one month wait for all subsequent treatments for new cases of

primary and recurrent cancer where radiotherapy is the chosen treatment

modality.

Accident and Emergency (Emergency Department)

A maximum four-hour wait in A&E from arrival to admission, transfer or discharge;

Hospital Cancellations

All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice;

Other

A maximum 7 day wait for follow-up after discharge from psychiatric inpatient care for people under adult mental illness specialties on Care Programme Approach.

All ambulance Trusts to respond to 75 per cent of Category A calls within eight minutes and to respond to 95 per cent of Category A calls within 19 minutes of a request being made for a fully equipped ambulance vehicle (car or ambulance) able to transport the patient in a clinically safe manner.

Local authorities with public health responsibilities should bear in mind that it is best practice for the care of patients and their sexual partners to offer genito-urinary medicine appointments as soon as possible, and that the clinical evidence indicates a maximum of 48 hours.

2) “The NHS commits to make decisions in a clear and transparent way, so that

patients and the public can understand how services are planned and delivered”.

NHS England and clinical commissioning groups (CCGs) are responsible for involving their patients, carers and the public in decisions about the services they commission. Furthermore, CCGs must consult on their annual commissioning plans and any changes that may affect patient services. In addition to the legal duty on NHS organisations to involve people and their representatives about services, patients and the public are placed at the heart of local decision-making through Health and Wellbeing boards and Healthwatch:

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3) “The NHS commits to make the transition as smooth as possible when you are referred between services and to put you, your family and carers at the centre of decisions that affect you or them”.

This includes transition between care settings and organisations (including local authority social care) as well as a requirement to centre care on the person as a whole, rather than on specific conditions.

6.3 NHS Constitution Patient and Public Responsibilities The NHS Constitution also outlines a number of responsibilities for patients and the public in relation to their health and access to healthcare: 1) “Please recognise that you can make a significant contribution to your own, and

your family’s good health and wellbeing, and take personal responsibility for it.” This includes self-care and lifestyle choices”.

2) “Please register with a GP practice – the main point of access to NHS care as

commissioned by NHS bodies” 3) “Please treat NHS staff and other patients with respect and recognise that

violence or the causing of nuisance or disturbance on NHS premises could result in prosecution. You should recognise that abusive and violent behaviour could result in you being refused access to NHS services.”5

4) “Please provide accurate information about your health, condition and status.”

5) “Please keep appointments, or cancel within reasonable time. Receiving treatment within the maximum waiting times may be compromised unless you do.”

6) “Please follow the course of treatment which you have agreed, and talk to your

clinician if you find this difficult.” 7) “Please participate in important public health programmes such as vaccination.” 8) “Please ensure that those closest to you are aware of your wishes about organ

donation.” 9) “Please give feedback – both positive and negative – about your experiences

and the treatment and care you have received, including any adverse reactions you may have had. You can often provide feedback anonymously and giving feedback will not affect adversely your care or how you are treated. If a family member or someone you are a carer for is a patient and unable to provide feedback, you are encouraged to give feedback about their experiences on their behalf. Feedback will help to improve NHS services for all.”

5 http://nuth-intranet/apps/policies/healthsafety/ExclusionFromTreatment201609.pdf

http://nuth-intranet/apps/policies/healthsafety/ExclusionFromTreatment201609.pdf

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7 Overarching Principles

This policy has been developed to ensure that Newcastle Hospitals provides consistent, fair and equitable access for all patients in line with clinical need, the requirements of the Five Year Forward View, the commitments made to (and responsibilities of) patients under the NHS Constitution and any obligations towards people who have had, or have disabilities under the Equality Act (2010). All processes in the management of patients who are waiting for appointments/treatments must be clear and transparent to patients, staff and commissioning organisations and must be open to inspection, monitoring and audit. The separate Operational Policies reflect the processes by which the Policy expectations are activated. Fair access to services must take account of: 7.1 Clinical Priority The Trust will give priority to clinically urgent patients and treat everyone else in turn. 7.2 Patient Choice A patient’s right to choose where they are treated, and to be involved in their care, is enshrined in the NHS constitution. However, any non-Newcastle GP referrals for Newcastle Hospital’s Community Services and Community Therapy Services should be referred to local Community Teams in line with each CCG’s commissioning policies. 7.3 National Waiting Time Requirements The Trust will work to meet and improve on the maximum waiting times outlined by the NHS Constitution for Diagnostics, 18 Weeks or Cancer as detailed above. 7.4 Veterans of the Armed Forces6 Veterans of the armed forces whose condition relates directly to their military service will be prioritised over other patients with the same level of clinical need. However, veterans will not be given priority over patients with more urgent clinical needs. This also applies to Veterans accessing Community Services. 7.5 Serving Armed Forces Personnel Medical services are delivered to servicemen and women by the MoD, the NHS, charities and welfare organisations. Armed forces personnel currently undertaking a

6 Healthcare for the armed forces community - NHS Choices

https://www.nhs.uk/nhsengland/militaryhealthcare/pages/militaryhealthcare.aspx

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pathway of care who are relocated into the local area may require a transfer of care to Newcastle Hospitals as appropriate. Their waiting times would be identified on referral and the “Referral to Treatment” waiting time would continue. The Trust will give priority to clinically urgent patients and treat everyone else in turn. This also applies to servicemen and women accessing Community Services. 7.6 Disabilities under the Equality Act (2010) This places a legal obligation on organisations to make reasonable adjustments to facilitate the care of people with disabilities. The decision as to what adjustments to make is not prescriptive, and must be agreed with the patient, their carer and the team caring for the person. By Law, if the adjustment is reasonable, then it should be made. 7.7 Notices to Patients The Trust will aim to give patients “reasonable notice”. This is a minimum of 3 weeks’ notice of OP appointments/admission dates unless referrals are deemed to be clinically more urgent than this. Under the Statutory Accessible Information Standard, if patients have a disability, the Trust must send the appointment information in an accessible format. Where possible, patients should be able to negotiate convenient appointment and admission dates and times with the Trust. For outpatient appointments this is available via the eReferral system. It is possible, due to cancellations or the availability of alternative clinicians/locations, that appointments or admissions may become available at shorter notice. Where this is likely, services should maintain a list of patients who can attend at short notice. In these circumstances contact should be made by telephone in the first instance. 7.8 Communication with Patients There should be proactive communication with patients to plan their attendance/admission around their needs. The “Coming to Hospital Booklets”7

should be sent to all patients being admitted or attending outpatients for the first time. The booklet states “If you have any individual needs such as mobility, communication, hearing or visual difficulties or religious or cultural needs, please tell the staff and we will do our best to meet them. The Trust has an interpreter services policy in place for all our hospitals and is committed to ensuring that everyone whose first language is not spoken English receives the support and information they need to communicate with health care staff and to use health services” 7.9 Annual Leave

7 Intranet > Support Services > Patient Information > Patient Information leaflets > General

Information

http://nuth-intranet/cms/SupportServices/PatientInformation/PatientInformationleaflets/GeneralInformation.aspx

http://nuth-intranet/cms/SupportServices/PatientInformation/PatientInformationleaflets/GeneralInformation.aspx

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All requests for annual and study leave must be approved by the lead clinician a minimum of six weeks before leave is to be taken in accordance with the services’ annual leave policy. Requests for leave at less than 6 weeks’ notice should be addressed to, and signed off by, the Clinical Director and Directorate Manager for that service to allow the leave request to be considered against service requirements and the ability to re-arrange clinics/admissions if necessary. If the request is made at less than 6 weeks’ notice, and there is a need to re-arrange appointments or clinics and it is not possible to offer patients alternatives within 2 weeks of their original appointment, then this must be authorised by the Medical Director as part of the reschedule process. 7.10 Training Staff will be expected to undertake any training identified as part of the Training Needs Analysis in this policy, including any regular updates. 7.11 Capacity and Demand Directorates, with support from the Trust, should work towards capacity planning rather than queuing of demand. 7.12 Information Systems The Trust will ensure that management information on all waiting lists and activity is recorded on an appropriate Trust system. Appropriate Trust systems are those authorised by the Senior Information Risk Owner (SIRO). For The Newcastle upon Tyne Hospitals NHS Foundation Trust this is the Trust Secretary. Information should be linked into the Trust’s Electronic Patient Record. Stand alone or paper based systems must not be used unless authorised by the Trust’s Chief Information Officer. 7.13 Data All systems that collect patient data and associated waiting time, patient access, local and national reporting data have been procured and implemented locally to ensure compliance with Caldicott Guidance, the Data Protection Act and GDPR. The Data Protection Act (1998) requires, amongst other things, that information held by organisations is stored securely, is accurate and up to date. All staff should be appropriately trained to perform their roles and responsibilities. There should be a particular emphasis on data integrity and accuracy of all information. All data recorded should be in line with national data standards as defined in the NHS Data Dictionary. It is the responsibility of each department to ensure that data is recorded in a complete, accurate and timely fashion Responsibility for the regular day-to-day compliance with all policies and procedures for applications rests with the line manager who must ensure that staff are

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adequately trained before access to systems is enabled, and that any training needs are identified and addressed as part of the annual appraisal process. 7.14 Collection of Patient Sensitive Information In order to comply with the Equality Act 2010, it is necessary to collect some sensitive demographic data on patients who attend the Trust. This process will be handled sensitively and in recognition that some patients may not wish to disclose this personal information, patients may choose to complete a ‘prefer not to say’ option. Data in relation to a patient’s vulnerability (See section 8.14 below) must be recorded on the appropriate information system in line with the Statutory Accessible Information Standard to ensure that when selecting a patient for admission, their needs are identified and appropriate arrangements made. This information should also be included in the GP Referral where relevant.

8 Referral Management

8.1 Referrers

Any agreed referral guidelines/criteria should be met before the referral is made, including seeking funding or Prior Approval Tickets (PATs) where necessary for specific conditions.

Referrals should be made to a service rather than a named clinician. Where patients are referred to a named consultant they may be offered appointments with a different consultant. Where the change of consultant is due to ill health, retirement or is clinically inappropriate, this offer does not affect the patient’s waiting time.

Referrals should only be sent to the Trust if the patient is fit (excluding cancer), willing and able to be treated within the maximum access times targets and should not be sent if the referrer knows the patient is unavailable (e.g. on a tour of duty; extended holiday or work/study commitments).

Referrers should ensure that referrals are appropriate, clear and contain the appropriate minimum data set required to process patients effectively and efficiently. As a minimum this should include the patient’s full name, date of birth, current address, telephone number and NHS number.

Referrals should contain information on communication needs and any specific needs of patients including a patient’s vulnerability (see Section 8.7) or the patient’s entitlement to priority treatment in the case of veterans of the armed forces (see section 8.6).

E-Referral is the Trust’s only method of referral by GP for most services (where it is appropriate for the given service, for example it is not currently possible to process same-day appointments or non-GP referrals through e-Referral). In

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these circumstances, manual written referral from GPs or other referrers will be accepted and processed without delay.

8.2 NHS e-Referral The NHS e-Referral Service became the successor to Choose and Book in June 2015. NHS England has directed that 100% of appropriate referrals from GPs to consultant-led first outpatient appointments should be made via e-Referral by October 2018. Referrals made through e-Referral are safer and quicker than paper referrals. They promote good data quality because they obviate the need to register referrals manually on Trust Systems (Cerner and SystmOne) and automatically provide a validated NHS number. For these reasons, e-Referral is the Trust’s preferred mechanism to receive referrals from GPs. The e-Referral Policy can be viewed at E-Referral Service Policy and is included as Appendix 4 to this policy. When no clinic appointment is available for patients to book in the NHS e-Referral Service, the referral can be forwarded (via the Patient Web Application) or deferred (via the professional application) to the provider to enable the provider to book the patient an appointment. 8.3 Appointment Slot Issues

When a referral is forwarded or deferred, it will appear on the provider’s ‘Appointment Slot Issues’ (ASI) worklist. Appointment Slot Issues compound waits by creating a backlog of patients whose waiting time has already started, create a significant amount of avoidable administrative work and can cause patient safety issues. Therefore Directorate Managers should regularly review coverage and capacity in their services to ensure that patients have equitable access to all clinical services via e-Referral. Capacity should be reviewed to ensure ASIs are kept to a minimum. Directorate Managers must also ensure that all staff managing the ASI worklists are appropriately trained, are in the correct workgroups, and have the necessary skills and authority to manage these referrals effectively, within the required timescales. 8.4 Diagnostic Referrals All Access Policy rules apply equally to diagnostic appointments and admissions. Further information can be found in Appendix 5. 8.5 Cancer Referrals GPs are encouraged to refer patients with a suspected cancer under the 2 week wait

rule in line with NICE guidelines8 by use of the standard cancer specific proformas.

8 Suspected cancer: recognition and referral | Guidance and guidelines | NICE

http://policies.app/launchit.asp?launchit=1764


https://www.nice.org.uk/guidance/ng12

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Rapid access facilities exist for receiving cancer referrals to dedicated fax machines.

E-Referral is currently being implemented across the Trust for cancer referrals but is

not yet available for all cancer groups, it will run alongside the fax system. The Trust

aim is for fax machines to become obsolete and for referrals to be received via

secure email or e-Referral.

The process for recording Cancer Referrals is set out below:

Patients who are referred for an outpatient appointment should be recorded on eRecord with a priority type of “Cancer 2ww”.

Patients who are at the outset referred direct to test/investigation (e.g. Endoscopy), must be identified on eRecord by adding the patient to the inpatient/day case waiting list with a priority type of “Cancer Target”. No patient waiting for a diagnostic appointment or admission can be suspended or paused.

If an appointment is not available within 14 days then this must be escalated to the relevant Directorate Manager in order to prevent the patient breaching. Details of all Cancer Waiting Time standards are listed in Appendix 3. 8.6 Veterans of the Armed Forces When referring a patient who is known to be an armed forces veteran, GPs have been asked to consider if the condition may be related to the patient’s military service. If the GP decides that a condition is related to service, any referral for treatment should make this clear. It is for the hospital clinician to determine whether a condition is related to service and to allocate priority. Where hospital clinicians agree that a veteran’s condition is likely to be service related, they have been asked to prioritise veterans over other patients with the same level of clinical need. However, veterans will not be given priority over patients with more urgent clinical needs. 8.7 Vulnerable Patients

It is essential that patients, who are vulnerable, for whatever reason, have their needs identified at the point of referral. This group of patients includes:

Patients with learning difficulties or psychiatric problems

Patients with physical disabilities or mobility problems

Patient who require an interpreter or have communication needs

Patients who pose an increased anaesthetic risk (e.g. uncontrolled epilepsy, diabetes, congenital heart disease.)

Elderly patients who require community care.

All the relevant information must be recorded on the appropriate system to ensure that when selecting a patient for admission, their needs are identified and appropriate arrangements made.

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8.8 Chest Pain Referrals All patients with new exertional chest pain must be seen in outpatients within 14 days of receipt of the GP referral. 8.9 Named Referrals/Transfer of Consultant

Referrals should be made to a service rather than a named clinician. The Trust may make a decision about the appropriate lead healthcare professional for a patient based on the clinical detail provided within the referral letter. This will usually be the clinician with the relevant specialism and the shortest waiting time. Where patients are referred to a named consultant they may be offered appointments with a different consultant in the same specialty to reduce their waiting time. Patients may prefer to remain with a named consultant however this may result in a delay to their treatment. This should be fully explained to the patient. 8.10 Direct Access A number of the Trust’s services are available via Direct Access e.g. endoscopy and some MRI scans. Direct Access means that the services can be requested by a GP without the need to see a hospital consultant first. Results are sent back to the GP. Usually these requests are for investigations or assessment prior to a referral to a hospital clinician where appropriate. 8.11 Receipt of Referrals into the Trust Timeliness in handling and managing referrals into the Trust is important for patient’s health/experience as well as impacting on NHS Constitution targets. Waiting times will be calculated from the date that the referral was received or the date that the Unique Booking Reference Number (UBRN) was converted on eRecord. The Trust aspires to review referrals within 2 days but recognises that this is not always possible and therefore clinical review of referrals should take place within a maximum of 7 days. If the information received is insufficient to allow this then referrals should be returned to the referrer.

Tertiary referrals9 (not from a GP) and services not available on e-Referral: Letters will be opened and stamped on the date of receipt. All referrals received will be registered on the Patient Administration System (PAS) and either booked or added to a waiting list on the relevant system within 24 hours of receipt.

GP Referrals through e-Referral (ERS): GP referrals for all relevant services should be sent electronically via the e-Referral system.

Deferred letters (ERS): In line with national requirements, GP referrals received that were not (but could have been) sent via ERS will be deferred back

9 This will include referrals from practitioners outside of the domain of e-Referral such as dentists and

GPs outside of England.

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to the GP. Appendix 13 contains the associated Standard Operating Procedure (SOP) for this process.

8.12 Incorrect or Inappropriate Referrals

Where referrals are considered inappropriate by the receiving clinician, not in line with local guidelines (including a paper referral into a service available through e-Referral) or they do not include the complete minimum data set they will be sent back to the referrer clearly stating the reason for the return. The referral should be recorded on the PAS along with the request for re-referral. Patients should not be added to the outpatient or admitted waiting list.

Referrals that are clinically very urgent or for suspected cancers, which are deemed inappropriate, will be discussed with the referring GP rather than delay treatment further.

Where a referral is clinically appropriate but has been made to the wrong clinician, the Trust may re-direct the referral to the correct clinician; however this will not affect the patient’s breach date. The GP will be advised as to the most appropriate management of the patient.

8.13 Referrals back to GPs or other Referrers. Referrals back to GPs or other referrers, for whatever reason, should be in the best interests of patients. This policy should also not adversely impact on those patients deemed vulnerable or at risk e.g. children, cancer patients and vulnerable adults. Decisions to refer back to the patient’s GP must therefore be agreed on an individual basis with the consultant responsible for the patient. 8.14 Patients who are not willing, ready and available

When a patient cannot agree an appointment within a reasonable (defined)

timeframe, or repeatedly cancels their planned appointment, in accordance with the

principle of the patient being willing, ready and able, the GP must re-refer the

patient. The original referral must be closed accordingly.

8.15 Patients requiring Commissioner Approval (Value Based Commissioning

Policy etc.)

Certain activity commissioned via CCGs (i.e. non specialised activity) is subject to Value Based Clinical Commissioning (VBC) Policies. These policies cover treatments of limited clinical value, such as cosmetic procedures. When referring into the Trust for one of the VBC procedures, GPs are required to seek prior approval via an online portal, or CCG panel, and refer with evidence of the approval. Where patients require one of the procedures but were not referred for that purpose (e.g. referral was for clinical opinion or diagnosis), it is the Trust’s responsibility to ensure that the patient meets the criteria stated in the VBC policy (which may or may not include prior approval being sought), or commissioners reserve the right not to pay for the treatment.

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Treatment for certain conditions will always require approval or adherence to commissioner’s funding policies, which are amended from time to time. Some commissioners have instigated Referral Management Services (RMS). These act as a point of triage/approval before the referral reaches the Trust. Referrals from these CCGs that circumvent the RMS cannot be accepted (e.g. by faxing a referral), although there are pre-agreed exceptions (such as Cancer) that are excluded from RMS. NHS England routinely publishes commissioning policies for specialised services, some of which will require prior approval. Activity relating to non-specialised services for Scottish patients always requires an Individual Funding Request (IFR) via the Trust’s Finance Department. Policies and links to websites with such policies can be found on the Contracting and Performance intranet page, within the Business and Development section10.

Every effort should be made to seek relevant approval and ensure the patient meets relevant requirements as early in the patient’s pathway as possible. Should services experience delays in the approval process, this should be escalated via the Trust’s Finance Department to chase a commissioning decision. These processes are subject to review and external audit at any time and information will be cascaded should commissioning rules change. 8.16 Overseas Visitors/Migrants The Trust has a legal obligation to establish whether a person is an overseas visitor to whom charges apply or whether they are exempt from charges by virtue of the Charging Regulations for the NHS services provided. The NHS provides healthcare for people who are classed as ordinarily resident in the United Kingdom (UK); that is those people who live in the UK on a lawful, voluntary and properly settled basis. People who are not ordinary residents are not automatically entitled to use the NHS free of charge. A person does not become ordinarily resident in the UK simply by: having British nationality; holding a British passport; being registered with a GP; having an NHS number; owning a property in the UK; or having paid (or currently paying) national insurance contributions or taxes in this country. This includes British Citizens who no longer live in the United Kingdom. Staff who have any reason to believe that a patient may not be eligible to NHS treatment free at source, should contact the Overseas Visitors Coordinator. For details please refer to the Trust Overseas Visitor Policy including guidance on health

10

Intranet > Support Services > Business & Development > Performance & Contracting >

Useful Publications & Guidance

http://nuth-intranet/cms/SupportServices/BusinessDevelopment/PerformanceContracting/UsefulPublicationsGuidance.aspx

http://nuth-intranet/cms/SupportServices/BusinessDevelopment/PerformanceContracting/UsefulPublicationsGuidance.aspx

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tourists, failed asylum seekers and ex-patriots which can be found at Overseas Visitors Policy There are some limited exceptions to the above for emergency situations. However, these are beyond the scope of this policy. Staff must refrain from giving advice on eligibility for treatment free at source, unless the Overseas Visitors Coordinator has advised them accordingly. 8.17 Patients transferring between private and NHS care Only patients eligible for NHS treatment free at source may opt to convert to NHS status and receive treatment free at source (see Section 8.15 above re: Overseas Visitors). Subject to the above, a patient may at any time in their patient pathway request to revert to NHS status. Key principles include:

A patient who chooses to be treated privately, is entitled to NHS services on exactly the same basis of clinical need as any other patient;

A patient seen privately, providing they are entitled to those services as defined by the Department of Health Overseas Visitors Charging Regulations, is entitled to change his or her status subsequently and to seek treatment as an NHS patient;

Any patient changing their status after using private services should not be treated differently from other NHS patients;

Any patients referred to a NHS service following a private consultation or private treatment should join an NHS waiting list at the same point as if the consultation or treatment had been an NHS service. Their priority on the waiting list should be determined by the same criteria applied to other NHS patients and in consultation with the Directorate Manager. It is essential that Directorates ensure the correct status is recorded against each patient encounter to ensure that the Trust recovers the cost of the NHS portion of the patient’s care;

If a patient admitted to an NHS hospital as a private inpatient subsequently decides to change to NHS status before receiving treatment, there should be an assessment to determine that patient’s priority for NHS care. This should be undertaken by the Head of Department or Clinical Director. If the patient’s clinical priority is judged lower than NHS patients on the Department’s waiting list, consideration should be given to discharging the patient and placing them on an appropriate NHS waiting list.

There will be very rare occurrences when private treatment undertaken within the Trust results in unforeseen adverse events, which necessitate the transfer of a private patient to NHS care for emergency or specialised care. In all cases, the clinical priority will be the wellbeing of the patient.



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This transfer may not happen simply by authorisation from the patient’s consultant but must be authorised by the Medical Director or the on call member of the Medical Director’s team in advance of that transfer of care taking place. In clinical emergencies, the Medical Director or on call treating clinician must inform a member of the Medical Directors team as soon as practically possible. The consultant must complete a transfer of care status form and a completed copy must be sent by the consultant to the Private and International Patient Business Office to ensure no further private charges are incurred. The consultant must ensure the patient’s status is changed to NHS in eRecord so that income is recovered appropriately.

Once a patient has transferred from private care to NHS care, they must remain an NHS patient for the duration of that episode of treatment. It is not acceptable for patients initially to be seen privately, to transfer to NHS care for treatment or investigations and then, subsequently, to be seen for follow up in the private sector.

More detail can be found in Section 7 of the Trust policy “Code of Business Conduct for “non-NHS patients” including Private Patients and those NHS patients initially seen in the independent sector” at: Private Patients: Code of Business Conduct 8.18 Internal Referrals (Primarily Consultant to Consultant)

Consultants will only refer to consultant colleagues for patients that require further advice/consultation for the condition that they were originally referred for. These referrals will follow the same pathway as external referrals using the internal MDS form generated through eRecord. Further information can be found in the Trust’s Consultant to Consultant Out Patient Referrals Policy

Onward referrals necessary for treatment or diagnosis of the condition in question

should be booked accordingly.

If the patient requires treatment for a different condition (with the exception of

emergencies and suspected cancer) than originally referred, the patient should be

referred back to the GP for further referral as required.

It is important that services record activity correctly and that the referral source entered onto PAS reflects the true nature of the referral. For example, if the patient’s referral request is as a result of an emergency admission, this is a referral source in its own right and should not be recorded as a straightforward “referral from a consultant”. 8.19 Referrals through intermediate services Referrals which are required to go through other primary care based services (e.g.

IMATT, triage centres, physiotherapy) prior to coming to one of the Trust’s clinicians,

should be clearly marked as having done so on the referral letter or form. Failure to

do so could result in the Trust returning the referral.



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Inter Provider Transfer Administrative Minimum Data Set (MDS – Department of

Health DSC Notice: 30/2007) need to accompany these referrals. The treatment

status, pathway ID and, if treatment has not yet been given, the clock start date

should be recorded as a minimum.

webarchive.nationalarchives.gov.uk/+/http://www.isb.nhs.uk/library_old/dscn//dscn20

07/302007.pdf

8.20 Tertiary Referrals/Inter Provider Transfers/Inter Trust Referrals

(Commonly known as External Referrals) The above terms are used interchangeably to describe referrals between Trusts. Referrals between Trusts can occur for those patients who are inpatients, and also those on an outpatient pathway. There are a number of scenarios where the transfer of care for a patient is needed between Hospitals:

A consultant may refer a patient to a consultant in another hospital for an opinion or to further their treatment in a more specialised or different area.

Where a patient is seen as an outpatient in one hospital or facility, they may then be treated as an inpatient in another, under the care of the same or different consultant.

Patients may be transferred to their local hospital to aid their recovery after an acute condition has been treated in a specialist area.

Referrals can be made into the Trust from other secondary care providers and out of the Trust to continue the patient’s care pathway. All tertiary referrals will be tracked in and out of the Trust using the national

mandatory minimum data set (as above). Transfers to and from other providers must

be managed with the consent of the patient and consultant. This information should

be sought on receipt of the referral including the patient’s treatment status and, if

treatment has not yet been given, the clock start date and pathway ID as a minimum.

8.21 Results Reporting Reporting of results must be made available in time to allow progress through all stages of the referral to treatment (RTT) pathway. 8.22 Second Opinions Patients requiring second opinions should request this from their consultant who can then refer onwards if appropriate. If a patient is not comfortable to do this then requests can be made via PALs or the patient’s own GP. Further useful information on second opinions is available from NHS Choices http://www.nhs.uk/chq/Pages/910.aspx?CategoryID=68

../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/EBEN7IMR/webarchive.nationalarchives.gov.uk/+/http:/www.isb.nhs.uk/library_old/dscn/dscn2007/302007.pdf

../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/EBEN7IMR/webarchive.nationalarchives.gov.uk/+/http:/www.isb.nhs.uk/library_old/dscn/dscn2007/302007.pdf

http://www.nhs.uk/chq/Pages/910.aspx?CategoryID=68

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8.23 Management/Administration of prisoner attendances Please see Appendix 6.

9 Cancellations/Did Not Attends (DNAs)

9.1 Hospital Cancellations The Trust aims to avoid cancelling patients wherever possible, however it is inevitable that, for a variety of reasons, this may occur. Ideally, patients should not be cancelled more than once. Where cancellations of new outpatient appointments are initiated by the Trust, patients should be contacted and offered an alternative appointment at their convenience, acknowledging the maximum access times targets and clinical need. Admissions should not be cancelled without approval by the Directorate Manager or delegated authority. All patients who have their operations cancelled for non-clinical reasons on the day of admission will be offered a binding date within 28 days and within the maximum waiting time guarantee as per the NHS Constitution. 9.2 Theatre Cancellations

Theatre cancellations should be avoided if at all possible. All theatre cancellations (less than 6 weeks) must be authorised by the appropriate Clinical Director.

9.3 Patient Cancellations

This section applies to both paper based and NHS e-Referral cancellations.

Newcastle Hospitals encourages patients who need to cancel their appointment to do so giving as much notice as possible to ensure a slot is not wasted i.e. so that it is able to be offered to another patient. The Trust also recognises that cancellation at short notice is sometimes unavoidable. In such circumstances patients are able to cancel their admission/appointment by contacting the appropriate department up to 24 hours before their agreed appointment time without being discharged back to their referrer. However patients who have cancelled their appointments numerous times will be referred back to their GP to confirm patient details and to ensure patients still require treatment. Referrers should also identify whether they consider a patient to be vulnerable as per section 8.7 above. 9.3.1 Patient Cancellations Not Requiring Further Appointments

When patients cancel their admission/appointment and do not wish to have

another admission/appointment, a letter indicating the reason for the

cancellation will be sent to the referring GP by the relevant clinician’s

secretary, following discussion with the clinician to ensure the cancellation is

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clinically appropriate. Individuals receiving cancellations that do not require

further appointments need to ensure that the relevant clinician/clinician’s

secretary is aware of this. Should the patient's GP deem that the appointment

is necessary then a second re-referral from the GP will be required. 9.3.2 Patient Cancellations Requiring Further Appointments

Ultimately it is an individual clinician’s responsibility to determine if a further appointment should be offered or the patient be discharged back to the GP and this will depend on a number of factors including number of cancellations/DNAs, clinical urgency and/or perceived vulnerability. Any decision should always be made in the best interests of the patient. The following may be used as a guideline in addition to this:

a) For patients who have already received first definitive treatment:

Patients who cancel their appointment, who have already received their first definitive treatment may be rebooked according to their clinical need.

b) For patients who have not yet received their first definitive treatment:

First Cancellation

Patients who DNA a first appointment (if received in line with the Statutory Accessible Information Standard) will receive a letter from the Trust (copied to their GP) advising them to contact the relevant department to re-book their appointment if it is still required. Patients will be advised that this should be within one month of the date of the letter (to ensure that national waiting time commitments are met) or they will be discharged back to their GP.

9.3.3 Multiple Cancellations

When a patient cancels an admission/appointment for the second time, and

the patient has not yet received first definitive treatment, the patient should

be informed that we are unable to book a subsequent appointment, (with the

exception of cancer referrals). A letter indicating the reason for the

cancellation and discharge should be sent to the referring GP and the referral

must be closed on PAS.

If a GP then contacts the Trust for another appointment, this should be treated as a new referral as per the date of the telephone call/letter.

9.4 NHS e-Referral Cancellation

When patients using the e-Referral system cancel their own appointments, they

need to be mindful of the above criteria. Following repetitive cancellation via e-

Referral, a letter indicating the reason for the cancellation and discharge should be

sent to the referring GP and the referral must be closed on PAS.

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9.5 Did Not Attend (DNAs) As above, although the Trust encourages patients to give the Trust as much notice as possible when cancelling their appointment/admission, where circumstances cannot be anticipated, patients can cancel up to 24 hours before their agreed appointment time without being discharged back to their referrer. A patient is recorded as Did Not Attend (DNA) if they do not arrive at their allocated appointment/TCI or pre-admission slot and no prior notice is given of this intention. Patients who were unable to attend an appointment or give prior notice because of exceptional circumstances should inform the department as soon as reasonably possible as to the reasons for the DNA. As before, ultimately it is an individual clinician’s responsibility to determine if a further appointment should be offered or the patient be discharged back to the GP and this will depend on a number of factors including number of cancellations/DNAs, clinical urgency and/or perceived vulnerability. Any decision should always be made in the best interests of the patient. Patients with a priority of 2WW who DNA their 1st appointment will be re-booked within the next 14 day period. Any further DNAs should be referred back to the patient’s GP to ensure they are aware of the patient’s DNA and the likely impact on their treatment/outcome. If a patient attends their appointment but subsequently leaves due to an unacceptable delay, this should be recorded as a patient cancellation, providing they inform reception staff of their intention.

10 Diagnostics

Many patients require diagnostic tests to determine a diagnosis in relation to the subsequent treatment of their condition. In line with the NHS Constitution, diagnostic tests must be performed within 6 weeks of the date requested and can be in the form of a blood test, biopsy, MRI, or an endoscopy procedure or x-ray. Patients who DNA a first diagnostic appointment can have a second appointment booked. Following a 2nd DNA, the clinician is to decide if it is clinically appropriate to discharge the patient back to the GP/referrer or re-appoint. The referrer and patient will be notified of this in writing. Further information on diagnostics is included in Appendix 5.

11 Community

Services provided in the community can include those delivered in community clinics, GP practices and those delivered in the patient’s own home. Further information can be found via the following information links: http://www.newcastle-hospitals.org.uk/services/NHCH.aspx

http://www.newcastle-hospitals.org.uk/services/NHCH.aspx

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http://www.newcastle-hospitals.org.uk/services/sexual-health.aspx

12 Outpatients

Information in respect to outpatient services can be found via the following information link:

Newcastle Hospitals - Outpatient Departments

13 Elective Admissions (including reference to Waiting List Policy)

A separate Waiting List Policy is available at Appendix 8. 14 Performance Targets/Monitoring

14.1 Internal Performance Monitoring The Trust Board is responsible for monitoring performance against the agreed strategic objectives, reviewing waiting times performance and ensuring remedial actions are taken where necessary. The Executive Team is the executive management committee for the Trust and is accountable for reviewing, approving and monitoring performance against national targets, high quality patient experience and outcomes, service transformation and cost improvement plans.

The Directorate Management Teams are responsible for delivering high quality, safe, efficient and financially viable services. All managers are responsible for the delivery of performance targets and objectives, and they will be expected to proactively escalate any risks to delivery in a timely manner. Clinical Directors and Directorate Managers will align their business unit, team and individual performance measures to the corporate performance objectives. The Information Department will be responsible for providing timely, consistent and relevant information to manage effective waiting lists and highlight any concerns about waiting times directly with the nominated contact for each service. Directorates are expected to review and act upon the information provided to ensure that patients are treated in order of clinical priority and then in chronological order. In order to manage Key Performance Indicators, the Information Department, 18 Week Team or Cancer Team will provide Directorates with weekly and monthly reports including:

Patient Tracking Lists

Outpatient Waiting List

Incomplete Pathways

Cancer waiters

http://www.newcastle-hospitals.org.uk/services/sexual-health.aspx

http://www.newcastle-hospitals.org.uk/services/outpatients.aspx

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Diagnostic long waiters

Potential duplicate referrals

Outpatients waiting without an appointment date

Data Quality Reports

Nulls and 99 report of un-outcomed appointments

IPM for RTT performance.

Weekly validation of incomplete pathways, i.e. where a clock has started and the patient has not yet received treatment, will be undertaken by the Directorates and the 18 Week Team. The accurate recording of data within a pathway will support this and enable the Trust to provide assurance that, where clinically appropriate, all patients receive treatment within national waiting time standards. Furthermore, data quality reports, i.e. missing clinic outcomes (“Nulls” report) are provided to Directorates on a weekly basis to assist them in achieving the required standards of this policy.

The Corporate Waiting List Group oversees the development of reporting mechanisms to support monitoring and compliance against access targets.

14.2 External Performance Monitoring The Trust’s performance in these areas is monitored externally as follows: 14.3 Diagnostic Targets Diagnostic tests or procedures are a critical element in the care of most patients. Shorter wait times are of benefit to patients, as they help people to get quicker access to the treatments they need. The Department of Health introduced a 6 week diagnostic wait target (for 15 key diagnostic tests) in March 2008 to ensure people would not be waiting longer than 6 weeks following referral for a diagnostic test. The 6 week diagnostic standard ultimately supports achievement of the 18 week referral to treatment target. A diagnostic waiting times & activity submission is uploaded monthly to the Strategic Data Collections Service (SDCS) (the online collection system used for collating, sharing and reporting NHS and social care data). The data collection covers tests/procedures where the primary purpose of the admission or appointment is diagnostic, irrespective of referral route or setting. 14.4 18 Weeks In line with the NHS Constitution, the maximum waiting time for patients to receive their first definitive treatment is 18 weeks. This is measured for individual patient pathways from referral to treatment or other clock stop where no treatment is required. There are also some exceptions to these rules e.g. maternity pathways, private patients etc. However, the right to start treatment within 18 weeks does not apply: if patients choose to wait longer;

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if delaying the start of treatment is in the patient’s best clinical interests, for example where stopping smoking or losing weight is likely to improve the outcome of the treatment;

if it is clinically appropriate for their condition to be actively monitored in secondary care, without clinical intervention or diagnostic procedures at that stage;

if they fail 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 the right: mental health services that are not consultant-led; maternity services; public health services commissioned by local authorities.

Individual patient pathways are monitored against 3 key measures:

92% of incomplete pathways will be within 18 weeks. These are pathways for patients not yet treated.

95% of non-admitted clock stops will be within 18 weeks i.e. those patients who receive their treatment or decision not to treat in outpatients.

90% of admitted clock stops will be within 18 weeks i.e. those patients who received their treatment as a day case or in patient admission.

National standards require each specialty within the Trust to be compliant against the first of these targets, as this is the main measurement of patients currently on the waiting list. Non-compliance can result in a significant financial penalty for the Trust. In addition to this, local commissioners set targets within the contract and non-compliance against these targets may also incur a financial penalty. The Trust compliance against the RTT target is reported on a monthly basis to the Department of Health. This information is published and reported to NHSI on a quarterly basis. 14.5 Cancer Targets The National Cancer Plan was published in September 2000 and within the plan there are a number of commitments and targets relating to waiting times for treatment (Appendix 3). Data for Cancer Waiting Times is uploaded monthly to the Department of Health’s National Cancer Waiting Times Database (CWT-Db) in line with a national timetable. This data is published on a quarterly basis and monitored by the Department of Health and NHSI. 15 Monitoring Compliance

The Trust will maintain effective performance monitoring systems to ensure implementation of the policy.

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In order to monitor compliance with this policy, the auditable standards will be as follows:

Standard/ process / issue

Monitoring and audit

Method By Committee Frequency RTT waiting times Daily pathway validation

and production of monthly RTT performance report

RTT Operational Lead

Business Delivery and Trust Board

Monthly

Cancer waiting times Daily pathway validation and production of monthly RTT Cancer performance report

Cancer Services Manager


Monthly

Diagnostic waiting times Daily pathway validation and production of monthly diagnostic performance report

RTT Operational Lead


Monthly

Hospital cancellations rebooked <28 days

Weekly report produced using the Cancelled Operations Database. The report is circulated to designated key staff within Directorates for updating/validating. The results are reported to the Board as part of Performance Meeting on a monthly basis and reported Nationally on a quarterly basis.

Patient Flow Manager

Trust Board Monthly & Quarterly Nationally

Ensure 100% of appropriate referrals from GPs to consultant-led first outpatient appointments are made via eReferral

Production of monthly report, distributed to Directorate Managers and discussed at Out-patient User Group

Information Services

Out-patient User Group

Monthly

Length of time taken by clinician to triage referral letters on NHS e-Referral Service

Daily monitoring on e-Referral

Office Manager within Directorate

Corporate Waiting List Meeting

Daily

Inpatient admissions resulting in DNAs




Outpatient pathways with a ‘null’ or ‘99’ outcome

Production and distribution of ‘99’ and Null Report to all key managers within Trust

Senior Information Analyst, Information Services Department

Reviewed at Directorate Manager Level

Weekly

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Outpatient hospital cancellations Outpatient patient cancellations Consultant/Clinician 6 week compliance

Production of Quarterly Performance Reviews via the Clinic Utilisation Tool identifying cancellations within RVI. Currently being rolled out across Trust. Manual input by staff required.

Senior Information Analyst

Reviewed at Office Manager Level within Directorates. Quarterly performance report produced by Information Services

Quarterly

Cancelled operations by hospital Cancelled operations by patient




Monthly sample audits of completed RTT pathways, to include accuracy of clock start and stops, pauses and cancellations. This will be timetabled in advance and initially aimed at high priority specialties.

Sample audit of 12 patients carried out by the 18 Week Team

Patient Pathway Navigator, 18 Week Team

Trust Board via Executive Weekly/monthly Dashboard

Monthly

Data Completeness and Timeliness

Data Quality Maturity Index Senior Information Manager

NHS Digital Quarterly

Frequency In each financial year, the Senior Business Development Manager (Performance) and Senior Information will review the measures listed above to ensure that this policy has been adhered to and a formal report will be written and presented at the Corporate Waiting List Group. Any Directorate adherence issues relating to this policy will be escalated through the Performance Review process, with actions agreed and monitored within that forum.

16 Training

Training on eRecord is carried out as part of the Trust induction process. Any further training needs are identified as part of the individual departmental induction process.

17 Impact Assessment/Equality and Diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat staff reflects their individual

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needs and does not discriminate against individuals or groups on any grounds. This policy has been appropriately assessed (see Appendix 15 for Equality Analysis)

18 Consultation and Review

A Previous Access Policy was approved in September 2010. This policy was updated by a group consisting of representatives from Patient Services, Outpatients, 18 Week Team, Cancer Services, Business and Development Team, Information and Performance. Further consultation was undertaken with:

The Trust Waiting List Group

Directorate Managers (and their Directorates)

Business Delivery Group – 15th November 2016

CCG and NHS England Commissioners via the Contract Performance Sub Group

NHSI

Audit Committee – to follow

Clinical Policy Group – to follow

19 Implementation

The Access Policy will be disseminated and made available: Internally - Directorate and Department managers will be expected to

communicate the strategy to relevant staff and it should be integral to the local induction process.

Externally - To NHSI, Commissioners, CQC, Internal and External Auditors, partner organisations and published on the Trust Intranet.

20 Appendices

Appendix 1 - Commissioners of Newcastle up Tyne Hospital Trust Services

All NHS Clinical Commissioning Groups in England

NHS England

Local Authorities: Newcastle, North Tyneside, Northumberland

NHS Scottish Health Boards

National Services Division (Scotland)

Welsh Health Specialised Services Committee

Welsh Health Boards

NHS Blood and Transplant

Health and Social Care Board – Northern Ireland

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Appendix 2 – 18 Weeks

RTT Operational Policy Newcastle upon Tyne Hospitals NHS FT.

Rules Suite (Referral to Treatment consultant-led waiting times rules suite: October 2015; Department of Health) Right to start consultant-led treatment within 18 weeks - GOV.UK

FAQs (Recording and reporting RTT guidance FAQ’s; Department of Health.) https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04/Accompanying-FAQs-v7.2.pdf

Appendix 3 – Cancer Services Operational Policy There are a number of government pledges on Cancer waiting times, including:

a maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the first definitive treatment for all cancers;

a maximum 31-day wait for subsequent treatment where the treatment is surgery;

a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy;

a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen;

a maximum two month (62-day) wait from urgent referral for suspected cancer to the first definitive treatment for all cancers;

a maximum 62-day wait from referral from an NHS cancer screening service to the first definitive treatment for cancer;

a maximum 62-day wait for the first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers);

a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms;

a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, even if cancer is not initially suspected.

Appendix 4 – NHS e-Referral Policy E-Referral Service Policy

Appendix 5 – Diagnostics Policies

Diagnostics Waiting Time and Activity – Monthly Collection

FAQs – Monthly Collection

https://www.gov.uk/government/publications/right-to-start-consultant-led-treatment-within-18-weeks

https://www.gov.uk/government/publications/right-to-start-consultant-led-treatment-within-18-weeks

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04/Accompanying-FAQs-v7.2.pdf

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/04/Accompanying-FAQs-v7.2.pdf


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https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/monthly-diagnostics-waiting-times-and-activity/

Diagnostics Census Definitions – Quarterly Diagnostic Waiting Times https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/diagnostics-census-data/

Appendix 6 – Management/Administration of Prisoner Attendances

1.0 Prisoner Attendances 1.1 All appointments/elective admissions for prison patients should be booked

directly with the Chief Medical Officer at the prison.

1.2 For reasons of security, details of prison service attendances should not be published until the patient has checked out on the day of attendance. This will ensure that all prisoners’ details remain undisclosed for as long as is practical.

1.2 Patient entries on PAS should have the prison as the home address. The home

address would remain on the address history and the main address should be updated on the prisoner’s release.

1.3 The day before a prisoner attendance, the head porter/security manager should

be informed as well as the sister/senior nurses. No patient details need to be given to the porters/security, they will only need to know the time and location.

1.4 Any change of clinic or attendance arrangements should be notified to the Chief

Medical Officer at the prison. Standard paper proformas are held by office managers in all outpatient department areas.

1.5 If the patient is a category A the Security Policy should be followed. 1.6 Prisoner appointment details are not to be disclosed at any time. Staff should

be aware of this when dealing with telephone enquiries wherever a prison address is displayed.

2.0 Outpatient Appointments/Elective Inpatients 2.1 Appointments should be arranged by a Senior Administrator or Outpatient

Manager. 2.2 For outpatient attendances, appointment slots should be reserved on PAS with

a message saying “prison services patient”. Patient details should not be entered at this time. For inpatient elective attendances, a theatre slot should be reserved with the same details.



https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/diagnostics-census-data/

https://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/diagnostics-census-data/

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2.3 The correct date and the patient’s details should be held locally and a confirmation of the appointment should be sent to the Chief Medical Officer of the relevant prison. All appointments are held in paper diaries kept by the office managers in all outpatient departments.

2.4 Any queries regarding any aspect of the appointment must be dealt with in

writing to the Chief Medical Officer and no appointment details should be given to anybody.

2.5 When the patient attends for his/her appointment, the reserved appointment

should be converted into a clinic slot/theatre slot and the patient details entered. For outpatients this should be done once the patient has checked out, for theatre this should be done on admission. Inpatients should be admitted on the day of attendance as normal.

Appendix 7 – Blank

Appendix 8 – Waiting List Policy.

RTT Operational Policy Newcastle upon Tyne Hospitals NHS FT Appendix 9 – Blank

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Appendix 10 - Management of Electives During Winter Pressures

Management of electives during winter Pressures Introduction It is intended that this process is incorporated as an Appendix to the Patient Access Policy. The process below reflects current practice recognising that a number of solutions are being worked on within the Trust’s Transformation programme (Option 2b) to maximise efficient use of beds and simplify this process e.g. implementation of the SAFER bundle, access to real time bed information etc. Bed Management Day to day management of beds is the responsibility of the Patient Services Manager via the Patient Services Co-ordinators and individual Directorates. During times of “normal” pressure i.e. NEEP 1 and NEEP 2 Directorates are able to manage their complement of beds on an individual basis (although PSCs should always be made aware of bed availability). However, at times of pressures i.e. NEEP 3 and above it is important that the Trust manages its beds collectively to ensure clinical safety and ensure that beds are available for those most in need. This inevitably places restrictions on elective activity however the Trust aims to accommodate emergency pressures with the minimum disruption possible to the elective programme. NEEP Levels The Patient Services Manager is responsible for determining and reporting the Trust’s NEEP level on an ongoing basis. Guidelines are:

At NEEP 3 Trust’s should be reviewing their elective inpatient and outpatient programmes and considering reduction or cancellation. This requires a 48hour plan There should also be consideration of a mutual aid request.

At NEEP 4 all electives should be cancelled with the exception of priority 1 Proactive Bed Management 1) Patients should be admitted as “Day of Surgery Arrivals” (DOSA) unless there is a

clinical requirement for earlier admission

2) During known seasonal pressures, such as winter, for routine procedures Directorates should list day cases above IPs (or increase the ratio of day cases to IPs) as IPs are more likely to be cancelled. It is acknowledged that this is subject to available day case capacity.

3) The number of discharges is crucial to optimum bed management. Whilst it may

not be possible to predict discharges with 100% accuracy the earlier a decision to

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discharge is made (and declared) will aid planning for future admissions. If the number of discharges is not known or declared early in the day then electives may be cancelled unnecessarily. Equally, the later in the day a decision is made gives less notice for the patient which is not good patient experience and may result in complaints.

The aim is for decisions to be made about cancellations at, or shortly after, the 1.00 bed meeting. To this end:

i) All patients should have an “Expected date of discharge” (EDD)

ii) Board Rounds/Ward Rounds/Senior Medical Review should take place as

early as possible in the day recognising this is always a balance with other clinical priorities. It is also recognised that the decision to discharge is multifactorial and for some patients can change hour to hour however the aim should be to discharge as many patients as possible before midday and to be aware of the number of discharges likely to take place later in the day and the next day.

High Impact Action 7 states that “Consultant led morning ward rounds should take place 7 days a week so that discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the week. This will support patient flow throughout the week and prevent A&E performance deteriorating on Monday as a result of insufficient discharges over the weekend”.

iii) Equally it is important that Directorates are transparent about the number of discharges that will/are likely to happen and declare the number of beds that will be potentially available for admissions.

iv) It is known that “Boarders”, on average, have longer lengths of stay than other

patients. It is therefore important that these patients receive ongoing and timely medical review in line with ii) above.

Escalation The Patient Services Manager will determine if the Trust is operating “normally” i.e. NEEP 1 or 2 or whether or not pressures should be escalated to NEEP 3 or above. Declaration of NEEP 3 recognises that there is likely to be some impact on the elective programme (although this should be minimised). Once NEEP 3 has been declared priority for beds will be determined on a Trust wide basis by the Patient Services Manager via the PSCs with reference to individual Directorates. The aim is to manage the overall bed complement to ensure that emergency admissions are accommodated alongside the maximum number of electives. This may result in patients being accommodated in the “wrong” specialty bed in order to maximise the overall use of beds.

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Escalation levels and action are currently being reviewed locally and nationally to ensure appropriate response across the health and social care systems and consistency in reporting. Bed Meetings Once NEEP 3 has been declared the Patient Services Manager will call daily bed meetings at 1.00 following the 12.30 Regional Call. These should be attended (in person or via conference call) by:

All bed holding Directorates via DM or matron

On Call Director, Senior Manager and Associate Medical Director

Representative from Business and Development/18 Weeks team

The call will be chaired by the Patient Services Manager. Information around beds and planned admissions will have been collected prior to the call see Appendix 1 (Declaration of bed state) and Appendix 2 (Prioritisation of Planned Admissions). The bed call will confirm or update this data (including beds closed due to infection) alongside a view of current emergency pressures (e.g. NEEP level, emergency admissions, ED activity, level of Boarders, position of other Trusts within the area etc.) with a view to determining if the full elective programme for the next day(s) should go ahead as planned. On most occasions it should be possible to accommodate the full elective programme however on rare occasions it may be necessary to cancel some or all of the electives. Prioritisation of electives The Patient Access Policy is clear that patients will be prioritised on the basis of clinical need and length of wait. There are a number of other factors that may also determine a patient’s relative priority such as previous cancellations; veteran of the armed forces, changes to drugs regime etc. and more detail in relation to these mitigating factors is given below. All planned procedures will be recorded on e record as either Cancer, Urgent or Routine. As per Appendix 2 Directorates will be asked to review these priorities (with appropriate reference to clinical letters/staff as time allows) and submit each day a list of planned electives prioritised as P1, P2 and P3. These criteria will be used to assess the numbers of planned admissions to be accommodated alongside emergency pressures and the prioritisation for cancellations if necessary (See below). It is proposed that the following criteria, drawn from information used by other Trusts, is used to determine P1, P2 and P3.

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Draft Prioritisation Criteria

Clinical Factors Length of Wait

Previous Cancellations

Mitigating Factors

P1 Life Threatening

Cancer Target

Cancer 2WW

Clinical risk of harm to patient if cancelled

Long Waiters (48 to 52 Weeks)

Previously cancelled (by Hospital) on the day and must be admitted within 28 days

Urgent Operation previously cancelled (by Hospital)

P2 Not life threatening but clinically urgent

Medically complex patient

Complex multi surgeon procedures or cases with high set up costs

Long Waiters (40 to 48 Weeks)

Operation previously cancelled (by Hospital) 2 or more times

P3 Routine with mitigations

Access Target Breaches

Previous cancellation Learning Disability

18 week breach within 2 weeks

Required changes to drug regime

Transfers in/out from other DGHs i.e. admissions swapped for repatriation

Complex social/carer arrangements

Distance e.g.

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undertaken overnight stay locally

Veteran

P3 Routine

Private Patients should be prioritised according to the same criteria. Planned WLIs will be considered alongside other planned admissions, especially at weekends, however it is acknowledged that these are likely to be addressing high priority patients e.g. long waiters, previous cancellations or otherwise trying to maintain the elective stream in the face of emergency pressures. The above list is not intended to be comprehensive and individual cases should be discussed with the Patient Services Manager. Actions from the Bed Meeting The bed call should review and recommend action to reduce the likelihood of cancellations e.g.

Are the level of discharges as expected? Should further medical reviews be undertaken

Is further action/escalation required in relation to Delayed Transfers of Care/Repatriations

Can more discharges be facilitated via Community or Therapy teams

The availability of nursing home/step down beds

Increased staff or movement of staff to enable increased bed capacity

Planned IPs that can be managed as DCs should be encouraged.

Overnight stays that are not medically necessary should be signposted to local hotels.

Consideration of outsourcing (to independent sector) Cancellations The cancelling of any part of the elective programme in times of pressure is the responsibility of the Executive Team via the on call team (i.e. On Call Director, Senior Manager and Associate Medical Director). Recommendations to cancel electives will be made by the on call team with reference to the Patient Services Manager, individual Directorates, Deputy Directors of Nursing and the Business and Development team based on information received on the bed call. It is important that data received on this call, particularly in relation to discharges, is as accurate as possible to avoid unnecessary cancellations. In hours, a recommendation as to the number of cancellations necessary based on the circumstances outlined on the 1.00 bed call will be given to the Executive team for approval. Out of hours where this decision is necessary i.e. in the interests of overall clinical safety the decision lies with the on call Director (taking advice from

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other members of the on call team plus other staff as appropriate) and the Executive Team should be notified as soon as practical the next day. Cancellations should:

Only be made if absolutely necessary as the need to reschedule patients will apply further pressure to the system.

Be made as far ahead as possible. Cancellations on the day must be rescheduled within 28 days

If an urgent operation is cancelled twice this must be notified to the CCG and recorded on the daily sitrep. A penalty of £5k applies to each case.

Role of Directorates in relation to cancellations Whilst the overall decision to cancel will lie with the Executives via the On Call team the final decision as to which individual patients will be cancelled should be taken by Directorate clinical and management teams. Identification of further mitigating circumstances should be discussed on an individual basis with the Patient Services Manager. Individual Directorates will contact patients and update e record. Where appropriate, advice on the resumption of drug regimens should be given. Directorates should maintain records of cancellations and notify the 18 weeks team of patients cancelled so that we can ensure they are rescheduled and identify any other mitigating factors. Patients should be rescheduled within required/reasonable time frames with due regard to the likelihood of further cancellations. Once a patient has been cancelled the “slot” should not be re-booked with emergency or urgent patients (unless life threatening and no alternative) as this takes away a potential bed that will have already been allocated and places further pressure on the system. Slots may be filled by day cases to maximise theatre utilisation. Cancer or Urgent patients should be booked into the next available slot according to normal rules around clinical priority and length of wait. Directorates should not cancel patients due to bed pressures outside of the 1.00 call or without reference to the PSC or the Patient Services Manager as they may be in the process of “creating” a bed where none is available.

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Appendix 1

Declaration of Bed State The intention is for this data collection to become electronic and automated over time however in the interim this is the process for Directorates to follow on a daily basis. A shared drive named “Winter Bed Management” will be available to record the information on a daily template, and should include;

Current unoccupied beds

Predicted discharges for that day

Predicted discharges for the next day

Weekend predictions

Any closed beds

This information should be submitted by the DM or designated deputy by 12 midday Monday through to Friday (Friday submission will include weekend predicted discharges and planned weekend ward closures).

Any queries to: [email protected] [email protected]

mailto:[email protected]


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Appendix 2 Prioritisation of Planned Admissions The intention is for this data collection to become electronic and automated over time however in the interim this is the process for Directorates to follow on a daily basis. Details of planned admissions will be collected prior to the daily bed management call. The following actions will need to be completed on the spreadsheet in the shared drive named “Winter Bed Management”

Daily TCI list will be saved in the shared drive “Winter Bed Management”. This will be taken from infoview

Ultimately Infoview will provide a daily TCI list to access directly, daily.

TCI dates included for next 3 days

Long waiters (over 40 weeks wait) will be highlighted in yellow

To note: changes made in previous 48 hours will not be included in the report

DMs will add o Priority e.g. P1, P2, or P3. o Comments re any individual circumstances to take into consideration

i.e. previous cancellation, long waiter, social package, veteran etc.

To complete by 12 midday each day.

No Day cases will be included on the report as it is expected that these will still go ahead.

This information will be considered in the daily bed meeting and to inform the cancellation process for the following day’s elective programme. If cancellations due to bed pressures are agreed, then please identify the patients who have been cancelled against that patient on the spreadsheet. Queries to: Allison Murray 18 Week Operational Lead [email protected]


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Appendix 11 – Definitions/Glossary of Terms – NHS Organisations

Commissioners - Commissioners are organisations responsible for the planning and purchasing of NHS services to meet the health needs of their responsible population Clinical Commissioning Group (CCG) - CCGs are NHS Organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. CCGs are clinically led groups that include all of the GP groups in their geographical area. The aim of this is to give GPs and other clinicians the power to influence commissioning decisions for their patients. CCGs are overseen by NHS England (including its Regional Offices and Area Teams). NHS England - NHS England is an executive non-departmental public body of the Department of Health. NHS England oversees the budget, planning, delivery and day-to-day operation of the commissioning side of the NHS in England as set out in the Health and Social Care Act 2012. It holds the contracts for GPs and NHS dentists, and is responsible for commissioning specialised services and services for prisoners and serving military personnel from Trusts like NuTH.

Health and Wellbeing Boards - Health and wellbeing boards are statutory bodies introduced in England under the Health and Social Care Act 2012. The aim of the Health and Wellbeing Boards is to improve integration between practitioners in local health care, social care, public health and related public services so that patients and other service-users experience more "joined up" care. The boards are also responsible for leading locally on reducing health inequalities.

HealthWatch - Healthwatch England is the national consumer champion in health and care. Its purpose is to involve patients and the public in the running of the NHS in England. The abolition of its predecessor LINks and the introduction of Local Healthwatch and Healthwatch England was included in the Health and Social Care Act 2012. NHS Improvement - NHS Improvement is responsible for overseeing Foundation Trusts and NHS Trusts, as well as independent providers that provide NHS-funded care. By holding providers to account and, where necessary, intervening, they help the NHS to meet its short-term challenges and secure its future. Formed on 1st April 2016, NHS Improvement is the operational name for an organisation that brings together: Monitor; NHS Trust Development Authority; Patient Safety, including the National Reporting and Learning System; Advancing Change Team; Intensive Support Team.

http://en.wikipedia.org/wiki/Health_and_Social_Care_Act_2012

http://en.wikipedia.org/wiki/National_Health_Service_(England)

http://en.wikipedia.org/wiki/General_practitioner

http://en.wikipedia.org/wiki/NHS_England

http://en.wikipedia.org/wiki/NHS_England

http://en.wikipedia.org/wiki/Non-departmental_public_body

http://en.wikipedia.org/wiki/Department_of_Health_(United_Kingdom)

http://en.wikipedia.org/wiki/National_Health_Service_(England)



http://en.wikipedia.org/wiki/Health_equity



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Appendix 12 – Definitions/Glossary of Terms

The following definitions are provided to ensure a common understanding of the terms used through this document: Admission: The act of admitting a patient for a day case or inpatient procedure. Clinical decision: A decision taken by a clinician or other qualified care professional, in consultation with the patient, and with reference to local access policies and commissioning arrangements. Consultant: A person contracted by a healthcare provider who has been appointed by a consultant appointment committee. He or she must be a member of a Royal College or Faculty. Consultant-led: A consultant retains overall clinical responsibility for the service, team or treatment. The consultant will not necessarily be physically present for each patient’s appointment, but he/she takes overall clinical responsibility for patient care. Convert(s) their Unique Booking Reference Number (UBRN): When an appointment has been booked via the NHS e-Referral Service, the UBRN is converted. (Please see definition of UBRN). Cancer Waiting Times Tracker (CWT): The electronic system used to record data for patients on a cancer or suspected cancer pathway. Day Case: Patients who require admission to hospital for treatment and will require the use of a bed, but are not expected to stay in hospital overnight. DNA – Did Not Attend: Where a patient fails to attend an appointment or admission without prior notice. Decision to treat: Where a clinical decision is taken to treat the patient. This could be treatment as an inpatient or day case, but also includes treatments performed in other settings e.g. as an outpatient. First definitive treatment: An intervention intended to manage a patient’s disease, condition or injury and avoid further intervention. What constitutes first definitive treatment is a matter for clinical judgement, in consultation with others as appropriate, including the patient. Healthcare Professional: A person who is a member of a profession regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002. Incomplete Pathways: Patients on an 18 week RTT pathway who have not yet received the start of treatment for the condition which they were referred.

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Inpatient: Patients who require admission to hospital for treatment and are intended to remain in hospital for at least one night. NHS e-Referral System: A national electronic referral service that gives patients a choice of place, date and time for their first consultant appointment in a hospital or clinic. Patient pathway: The route that a patient will take from their first contact with an NHS member of staff (usually their GP), through referral, to the completion of their treatment. It also covers the period from entry into a hospital or a Treatment Centre, until the patient leaves. Planned care: Covers health care services which are planned (scheduled), including all primary care, community and hospital services. This does not include emergency (unscheduled) care. PTL (Patient Treatment List/Patient Tracking List/Primary Targeting List): the PTL is a list of patients (both inpatients and outpatients) whose waiting time is approaching the guarantee date, who should be offered an admission/appointment before the guarantee date is reached. Referral: This is a request for a care service, other than a specific diagnostic investigation or procedure, to be provided for a patient. Referral Management Service: Referral Management Services accept GP (or other) referrals and provide advice on the most appropriate next steps for the treatment of the patient. Depending on the nature of the service they may, or may not, physically see or assess the patient. Referral Management and Assessment Services will have clinical support and will usually follow clear protocols that provide benefits to patients. In the context of 18 weeks, a clock only starts on referral to a Referral Management and Assessment Service where that service may onward-refer the patient to a surgical or medical consultant-led service before responsibility is transferred back to the referring health professional. UBRN (Unique Booking Reference Number): The reference number that a patient receives on their appointment request letter when generated by the referrer through the NHS e-Referral Service. The UBRN is used in conjunction with the patient password to make or change an appointment.

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Appendix 13 – e-Referral Deferral Standard Operating Procedure

Objective:

To ensure that all GP paper referrals received into the Trust via the Secretary are returned to the GP

Scope: This guidance is designed for all Senior Staff to be able to action Responsibility: The Departmental/Outpatient Services Manager or their Deputy

is responsible for ensuring that this procedure is undertaken by members of his/her administrative team

Procedure:

1. Medical Secretary will receive the paper referral directly to their service. They identify that the appointment required can be accessed in eReferral

2. Medical Secretary will then scan the paper referral to [email protected]

3. Assistant Outpatient Services Manager/Clerk will monitor above inbox and will acknowledge receipt of the email to the sender

4. Assistant Outpatient Services Manager/Clerk will telephone the referring GP

within one working day of receipt stating that:

a. The referral should have been made via eReferral, this will be actioned by the Trust for the period 1st April 2018 – 30th April 2018 only

b. The referral will not be actioned and has been returned to the practice to be referred via eReferral from 1st May 2018

5. Assistant Outpatient Services Manager/Clerk to generate a standard letter referring to either 4a or 4b using document store. These letters will go directly back to the GP via ICE or through Synertec

6. Assistant Outpatient Services Manager/Clerk to document receipt of paper referral. This spreadsheet is saved locally: (I) drive – Main Outpatients – eReferral – Deferral spreadsheet

7. Assistant Outpatient Services Manager to run report from document store ensuring referrals have been received back into the Trust


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Appendix 14 – Equality Analysis

The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: _01.08.18_________________ 2. Name of policy / guidance/ strategy / service development / Investment plan/Board Paper:

Patient Access Policy

3. Name and designation of author:

Katharine Simpson, Deputy Director of Business and Development

4. Names & Designations of those involved in the impact analysis screening process:

Allison Murray, 18 Week Operational Lead

5. Is this a: Policy √` Strategy Service Board Paper

Is this: New Revised √

Who is affected: Employees √ Service Users √ Wider Community 6. What are the main aims, objectives of the document you are reviewing and what are the intended outcomes?

(These can be cut and pasted from your policy)

This policy aims to reflect national and local expectations in relation to patient access to diagnostic, community, outpatient

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and elective admission services for the benefit of patients, staff and commissioners.

7. Does this policy, strategy, or service have any equality implications? Yes √ No

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

8. Summary of evidence related to protected characteristics Protected Characteristic

Evidence What evidence do you have that the Trust is meeting the needs of people in all protected Groups related to the document you are reviewing– please refer to the Equality Evidence within the resources section at the link below: http://nuth-vintranet1:8080/cms/SupportServices/EqualityDiversityHumanRights.aspx

Does evidence/engagement highlight areas of direct or indirect discrimination? For example differences in access or outcomes for people with protected characteristics

Are there any opportunities to advance equality of opportunity or foster good relations? If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

Provision of Interpreters Information available in other formats on request Mandatory EDHR Training Trust partnership work with 3rd sector organisations BAME Staff Network

There is evidence of poorer access to services for some minority ethnic groups. Trust partnership work with Public Health and the 3rd sector organisations is ongoing to address some of the issues impacting on this.

Include in related documents that each service should look at the risks in relation to inequality in access and health outcomes and identify any actions required to minimise any risks identified. Review access and DNA

http://nuth-vintranet1:8080/cms/SupportServices/EqualityDiversityHumanRights.aspx

http://nuth-vintranet1:8080/cms/SupportServices/EqualityDiversityHumanRights.aspx

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data by protected characteristic.

Sex (male/ female)

Equality Analysis on Policies and Business plans Structures and staff in place to support the Trust to comply with the Equality Act 2010 Mandatory EDHR Training Single Sex accommodation policy Women’s Health and Sexual Health Services available for advice and support Trust partnership work with 3rd sector organisations

Nationally there is evidence of different health outcomes for men and women in relation to some health conditions. Trust partnership work with Public Health and the 3rd sector organisations is ongoing to address some of the issues impacting on this.

As above. Review access and DNA data by protected characteristic.

Religion and Belief

Equality Analysis on Policies and Business plans, Structures and staff in place to support the Trust to comply with the Equality Act 2010 Chaplaincy Team available for advice and support Religion, Belief and Cultural Practices Policy and Guidance

Race and religion are often intertwined but there is no evidence in relation to religion and access to services.

Include in related documents that each service should look at the risks in relation to inequality in access and health outcomes and identify any actions required to minimise any risks identified

Sexual orientation including lesbian, gay and bisexual people

Equality Analysis on Policies and Business plans Structures and staff in place to support the Trust to comply with the Equality Act 2010 Mandatory EDHR Training Trust partnership work with 3rd sector organisations Trust support of Northern Pride LBGBT Staff Network

Nationally there is evidence of different health outcomes for LGB people in relation to some health needs. Trust partnership work with Public Health and the 3rd sector organisations is ongoing to address some of the issues impacting on this.

As Above

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Age

Equality Analysis on Policies and Business plans Structures and staff in place to support the Trust to comply with the Equality Act 2010 Children and Young People’s Services and Elderly Medicine Services Trust work in relation to Dementia Care Your’e Welcome Accreditation for Children and Young People’s Services Services for teenagers for example Cancer Services Mandatory EDHR Training Trust partnership work with 3rd sector organisations

There is evidence of higher rates of DNAs in the 30-60 age groups. Trust partnership work with Public Health and the 3rd sector organisations is ongoing to address some of the issues impacting on this.

As Above Review access and DNA data by protected characteristic.

Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

Equality Analysis on Policies and Business plans. Structures and staff in place to support the Trust to comply with the Equality act 2010. Psychological and Mental Health Services Rehabilitation Services Professions Allied to Medicine services Accessible Information Standard Provision of BSL Signers and Deaf Blind Guides LD Liaison Nurse, flagging of learning disability and patient passport. Trust work to support Carers Mandatory EDHR Training Trust partnership work with 3rd sector organisations Disability Staff Network

Nationally there is evidence of different access and health outcomes for some disabled people in relation to some health conditions. Trust partnership work with Public Health and the 3rd sector organisations is ongoing to address some of the issues impacting on this.

As above

Gender Re- Equality Analysis on Policies and Business plans Nationally there is evidence of As above

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assignment

Structures and staff in place to support the Trust to comply with the Equality Act 2010 Trust Gender Identity Working Group Mandatory EDHR Training Trust partnership work with 3rd sector organisations

different health outcomes for Trans people in relation to some health needs. Trust partnership work with Public Health and the 3rd sector organisations is ongoing to address some of the issues impacting on this.

Marriage and Civil Partnership

Equality Analysis on Policies and Business plans Structures and staff in place to support the Trust to comply with the Equality Act 2010 Mandatory EDHR Training

No No

Maternity / Pregnancy

Structures and staff in place to support the Trust to comply with the Equality Act 2010 Maternity Services available for advice and support Breast Feeding Policy and signage Mandatory EDHR Training Trust partnership work with 3rd sector organisations

Nationally there is evidence of different health outcomes for mothers and babies who have protected characteristics. Trust partnership work with Public Health and the 3rd sector organisations is ongoing to address some of the issues impacting on this.

Include in related documents that each service should look at the risks in relation to inequality in access and health outcomes and identify any actions required to minimise any risks identified

9. Are there any gaps in the evidence outlined above? If ‘yes’ how will these be rectified?

No

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10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement No, engagement is ongoing and this will be raised through the EDHR working group

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private

and family life, the right to a fair hearing and the right to education?)

There are risks related to health outcomes that can impact on mortality and morbidity. This policy aims to reduce those risks.

PART 2 Name of author:

Katharine Simpson, Deputy Director of Business and Development

Date of completion

01.08.18

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)

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