Outpatient good practice guide by keralaguest

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									Portsmouth Hospitals NHS Trust
Outpatient Waiting List Good Practice Guide




     Portsmouth Hospitals NHS Trust




                           Outpatient
                          Waiting List
                       Good Practice Guide



      Originator:                   Project Manager Outpatients
                                    Outpatient Waiting List Manager
                                    Lead 18 Weeks

      Approved Route:               Associate Director Patient Pathways
                                    Head of Business Intelligence Department
                                    DGM Outpatients

      Issue No:                     2 - Draft 1

      Date of issue:                June 2010

      Review Date:                  June 2011




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Outpatient Waiting List Good Practice Guide


1      Introduction .................................................................................................................... 5
    1.1        OUTPATIENT WAIT TIMES AND 18 WEEKS............................................................................................. 5
    1.2        ACCESS TO HEALTH SERVICES FOR MILITARY VETERANS ..................................................................... 5
    1.3        OUTPATIENT WAIT TIMES AND PATIENT CHOICE .................................................................................. 5
    1.4        THE OUTPATIENT BOOKING CENTRE (OBC) ......................................................................................... 5
    1.5        POLICY STATEMENTS ............................................................................................................................. 6
    1.6        GOOD PRACTICE GUIDE ......................................................................................................................... 6
2      Policy Statements .......................................................................................................... 8
3      The NHS Plan & National Waiting List Targets ............................................................ 12
    3.1        NATIONAL WAIT TIME TARGETS ......................................................................................................... 12
    3.2        NATIONAL & LOCAL TARGETS SPECIFIC TO OUTPATIENT BOOKING & SCHEDULING STAFF ............... 13
    3.3        ACCESS FOR MILITARY VETERANS AND WAR PENSIONERS ................................................................. 14
4      Receiving Outpatient Referrals. ................................................................................... 15
    4.1        AIMS OF THIS SECTION ........................................................................................................................ 15
    4.2        OUTPATIENTS REFERRALS AND 18 WEEKS .......................................................................................... 15
    4.3        RECORDING THE NEW REFERRAL (ROUTINE & URGENT) ..................................................................... 16
    4.4        REVIEWING THE REFERRAL ................................................................................................................. 16
    4.5        CHANGING PRIORITY OF A REFERRAL.................................................................................................. 17
    4.6        REDIRECTING REFERRALS ................................................................................................................... 17
    4.7        REJECTING A REFERRAL ...................................................................................................................... 17
    4.8        MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION ............................................... 18
    4.9        PROCEDURES FOR MANAGING & GRADING PAPER REFERRALS ........................................................... 19
5      Appointments. .............................................................................................................. 20
    5.1        AIM OF THIS SECTION .......................................................................................................................... 20
    5.2        MAKING APPOINTMENTS ..................................................................................................................... 20
    5.3        PRIORITISATION OF APPOINTMENTS..................................................................................................... 21
    5.4        BOOKING TYPE .................................................................................................................................... 21
    5.5        MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION ............................................... 21
6      Booking Appointments ................................................................................................. 23
    6.1        RELEVANT POLICY STATEMENTS ......................................................................................................... 23
    6.2        AIM OF THIS SECTION .......................................................................................................................... 23
    6.3        TRADITIONAL BOOKING....................................................................................................................... 23
    6.4        PARTIAL BOOKING ............................................................................................................................... 23
    6.5        FLOW CHART / PROCEDURE FOR BOOKING APPOINTMENTS USING THE PARTIAL BOOKING SYSTEM .. 25
    6.6        FULL BOOKING – INC CHOOSE AND BOOK SYSTEM ............................................................................. 27
    6.7        SLOT UNAVAILABILITY........................................................................................................................ 27
    6.8        MAKING AND RECORDING OFFERS ....................................................................................................... 28
7      Consultant to Consultant Referrals – within Portsmouth Hospitals NHS Trust .............. 29
    7.1        RELEVANT POLICY STATEMENTS ......................................................................................................... 29
    7.2        AIM OF THIS SECTION .......................................................................................................................... 29
    7.3        CONSULTANT – TO CONSULTANT REFERRALS AND 18 WEEKS ............................................................ 29
    7.4        INFORMING GP’S AND PATIENTS REGARDING CONSULTANT TO CONSULTANT REFERRALS................. 30
    7.5        MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION ............................................... 30
8      Referrals from Consultants in other Trusts - Inter Provider Referrals ........................... 32
    8.1    POLICY STATEMENTS ........................................................................................................................... 32
    8.2    18 WEEKS RULES ON CLOCK STARTS APPLICABLE TO INTER PROVIDER TRANSFERS .......................... 32
    8.3    THE MINIMUM DATA SET .................................................................................................................... 32
    8.4    PROCEDURE FOR THOSE INTER PROVIDER TRANSFERS INTO PORTSMOUTH HOSPITALS NHS TRUST ... 33
    8.5    PROCEDURES FOR THOSE INTER PROVIDER TRANSFERS FROM PORTSMOUTH HOSPITALS NHS TRUST
    TO OTHER PROVIDER ORGANISATIONS .............................................................................................................. 33
9      Cancer Referrals .......................................................................................................... 35
    9.1   RELEVANT POLICY STATEMENTS ......................................................................................................... 35
    9.2   AIM OF THIS SECTION .......................................................................................................................... 35
    9.3   NEW CANCER REFORM STRATEGY AND STANDARDS ........................................................................... 35
    9.4   RECEIVING CANCER FAST TRACK REFERRALS .................................................................................... 36
    9.5   BOOKING OF SUSPECTED CANCER PATIENTS ...................................................................................... 37
    9.6   SUSPECTED CANCER PATIENTS BOOKED BY THE SPECIALTIES ............................................................ 37
    9.7   ESCALATION PROCESS TO ENSURE SUSPECTED CANCER AND UPGRADE / URGENT PATIENTS ARE
    BOOKED WITHIN THE 14 DAY PERIOD ............................................................................................................... 38




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  9.8         MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION ............................................... 38
10        Patient & Hospital Initiated Postponements (cancellations) ...................................... 40
  10.1        RELEVANT POLICY STATEMENTS ......................................................................................................... 40
  10.2        AIM OF THIS SECTION .......................................................................................................................... 40
  10.3        PATIENT INITIATED POSTPONEMENTS / CANCELLATIONS AND 18 WEEK CLOCK RULES ...................... 40
  10.4        2ND OR SUBSEQUENT APPOINTMENTS POSTPONED / CANCELLED BY THE PATIENT ............................... 41
  10.5        HOSPITAL POSTPONEMENTS................................................................................................................. 41
  10.6        CLINIC CANCELLATIONS ...................................................................................................................... 42
  10.7        MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION ............................................... 42
  10.8        PROCEDURE FOR DEALING WITH PATIENT INITIATED POSTPONEMENTS (FOR NEW PATIENTS) ............. 43
11        Patients who do not attend their Appointment (DNA) ................................................ 44
  11.1   RELEVANT POLICY STATEMENTS ......................................................................................................... 44
  11.2   AIM OF THIS SECTION .......................................................................................................................... 44
  11.3   PATIENTS WHO DO NOT ATTEND THEIR APPOINTMENTS (DNA) AND 18 WEEKS .................................. 44
  11.4   CHECKING DETAILS & NOTICE PERIODS FOR APPOINTMENTS ............................................................. 44
  11.5   DECIDING ON OUTCOME OF DNA – CLINICAL DECISION TO DISCHARGE THE PATIENT ....................... 45
  11.6   DECIDING THE OUTCOME – CLINICAL DECISION TO NOT DISCHARGE THE PATIENT............................ 45
  11.7   SUSPECTED CANCER PATIENTS AND DNA ........................................................................................... 46
  11.8 DISCHARGE OF VULNERABLE / CANCER PATIENTS WHO DNA .................................................................. 46
  11.9 MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION .................................................... 46
12        Re-Instatement onto the Outpatient Waiting List ....................................................... 47
  12.1        RELEVANT POLICY STATEMENTS ......................................................................................................... 47
  12.2        AIM OF THIS SECTION .......................................................................................................................... 47
  12.3        RE-INSTATEMENT FOR CLINICAL REASONS ......................................................................................... 47
  12.4        RE-INSTATEMENT FOLLOWING AN INAPPROPRIATE REMOVAL ............................................................ 47
  12.5        MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION ............................................... 47
13        Ministry of Defence Patients ..................................................................................... 48
  13.1        PROCEDURES ....................................................................................................................................... 48
14        Follow-up Appointments ........................................................................................... 49
  14.1    RELEVANT POLICY STATEMENTS ......................................................................................................... 49
  14.2    AIM OF THIS SECTION .......................................................................................................................... 49
  14.3    GUIDANCE FOR BOOKING OF FOLLOW UP APPOINTMENTS ................................................................... 49
  14.4    BOOKING FOLLOW UP APPOINTMENTS ................................................................................................ 49
  14.5    FOLLOW-UP APPOINTMENTS DECLINED BY THE PATIENT..................................................................... 50
  14.6    DNA FOLLOW-UP APPOINTMENT ........................................................................................................ 50
    The Healthcare Professional for the clinic must be informed of patients who have DNA’d as soon as the
    clinic has finished. The decision to discharge or not to re-appointment a follow-up patient can then be
    made. The GP and patient must be kept informed of the decision not to re-appoint the patient due to the
    DNA. ............................................................................................................................................................ 50
  14.7    TELEPHONE / VIRTUAL FOLLOW UP’S ................................................................................................. 50
  14.8    MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION ............................................... 50
15        Pre-operative Assessment and TCI Scheduling within Outpatients........................... 51
  15.1   RELEVANT POLICY STATEMENTS ......................................................................................................... 51
  15.2   AIM OF SECTION ................................................................................................................................... 51
  15.3   WAIT TIME TARGETS FOR INPATIENTS AND DAY CASES ..................................................................... 51
  15.4   WHEN TO ADD PATIENTS TO THE WAITING LIST ................................................................................. 52
  15.5   WHEN NOT TO ADD PATIENTS TO THE WAITING LIST ........................................................................ 52
  15.6   DETERMINING PRIORITY ...................................................................................................................... 52
  15.7   TIMELINESS OF ADDING PATIENTS TO THE WAITING LIST ................................................................... 52
  15.10LINKING 18 WEEK OUTPATIENT AND INPATIENT EPISODES ON RTT PAS ................................................ 53
  15.11 REASONABLE NOTICE AND PATIENT CHOICE .......................................................................................... 54
  15.12NEW AND SUBSEQUENT TREATMENT 18 WEEK CLOCK STARTS .............................................................. 54
  15.13CATEGORISING PATIENTS ON THE WAITING LIST..................................................................................... 54
        Active Waiting List: ............................................................................................................................. 54
        Planned Waiting List: ......................................................................................................................... 54
  15.14 CATEGORISING PATIENTS REQUIRING MULTIPLE PROCEDURES .............................................................. 55
  15.15 CATEGORISING PATIENTS REQUIRING BILATERAL PROCEDURES ............................................................ 55
  15.16 ADJUSTMENTS TO 18 WEEKS FOR ADMITTED PATIENTS- CLOCK PAUSES FOR PATIENT CHOICE ........... 56
  15.17 DEALING WITH PATIENTS WHO ARE UNFIT FOR SURGERY - MEDICAL SUSPENSIONS ............................... 56
  15.18 REMOVING PATIENTS FROM THE ACTIVE WAITING LIST – WHEN THEY ARE UNFIT ................................ 56


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  15.19 ADDING PATIENTS SEEN PRIVATELY FOR OUTPATIENT CONSULTATION................................................. 57
  15.20 CATEGORISING THE BOOKING TYPE ........................................................................................................ 57
  15.21 SCHEDULING OF PATIENTS FOR INPATIENT / DAY CASE SURGERY FROM OUTPATIENTS ......................... 57
  15.22 PRE-ASSESSMENT – INTRODUCTION........................................................................................................ 58
  15.23 MANAGING THE OUTCOME OF PREOPERATIVE ASSESSMENT .................................................................. 58
16       Managing Planned Clinic Capacity ........................................................................... 60
  16.1      AIM OF THIS SECTION .......................................................................................................................... 60
  16.2      PROCEDURES ....................................................................................................................................... 60
  16.3      MONITORING OF THIS SECTION ............................................................................................................ 60
17       Clinic Outcome Forms .............................................................................................. 61
  17.1      AIM OF THIS SECTION .......................................................................................................................... 61
  17.2      THE CLINIC OUTCOME FORM............................................................................................................... 61
  17.3      USING THE CLINIC OUTCOME FORM .................................................................................................... 61
  17.4      CLOSING DOWN CLINICS – ................................................................................................................... 61
  17.5      MONITORING ....................................................................................................................................... 62
18       Validation and the use of Primary Targeting Lists ..................................................... 63
  18.1      AIM OF THIS SECTION .......................................................................................................................... 63
  18.2      THE NON ADMITTED PATIENT TRACKING LIST (PTL) ......................................................................... 63
  18.3      LISTS FOR ONGOING / PLANNED FOLLOW UP PATIENTS ...................................................................... 63
  18.4      18 WEEK CLINIC OUTCOME STATUS REPORTS ..................................................................................... 64
  18.5      ACCURACY OF THE PTL....................................................................................................................... 64
  18.6      VALIDATION OF THE NON ADMITTED PTL / WAITING LIST.................................................................. 64
  18.7      INTERNAL QUALITY VALIDATION OF ALL OUTPATIENT INFORMATION................................................ 65
  18.8      VALIDATION OF PATIENTS WITH STAGE OF TREATMENT WAITS OVER 11 WEEKS ............................... 66
  18.9      MANAGING AND VALIDATION OF CHOOSE AND BOOK AND CLINIC TEMPLATES ................................. 66
  18.10        MANAGEMENT OF THE DIRECTORY OF SERVICES (DOS) ................................................................. 66
  18.11        MANAGEMENT OF CLINIC TEMPLATES ............................................................................................ 66
  18.12        MONITORING OF ACHIEVEMENT OF THE STANDARDS IN THIS SECTION........................................... 67
  18.13        FLOW CHART & PROCESS FOR VALIDATING OUTPATIENT WAITING LIST ....................................... 68
19       Roles and Responsibilities in Managing Outpatient Waiting Lists ............................. 69
20       Appendix 1 – Glossary of Terms .............................................................................. 73
21       Appendix 2 - List of DoH Guidance Documents ........................................................ 74
22       Appendix 3 – Clinic Outcome Form – example (see attachment) ............................. 74
23       Appendix 4 - Inter Provider Transfer Form................................................................ 74




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     1 Introduction
     The length of time a patient needs to wait for hospital treatment is an important quality
     issue and is a visible and public indicator of the efficiency of the hospital services
     provided by the Trust. The successful management of patients who are waiting for
     elective treatment is the responsibility of all staff working within the NHS. This Good
     Practice Guide is designed to support the achievement of the new 18-week standard
     and other waiting time targets applicable to outpatients. The guidance is also intended
     to support the transition from traditional booking systems, and to provide guidance to
     staff operating within all outpatient-booking areas within the Trust.


                   1.1    Outpatient Wait Times and 18 Weeks
       18 weeks is the waiting time target for all elective / routine referrals into the Trust.
       From December 2008 the 18 week target will mean that all new routine referrals into
       the Trust (from all sources) must receive the start of their first treatment within 18
       weeks of the receipt of the referral. To achieve this overarching target there will need
       to be additional stage of treatment targets along the patient pathway to ensure that the
       patient‟s journey is achieved within the 18-week period where appropriate.

       The start of the patient‟s journey, normally the first outpatient appointment, is an
       important event and sets the timescale for the patient‟s perception of the quality and
       the timeliness of care. It is important that this first visit is carried out as quickly as
       possible to allow for other events in the patients journey to occur in a similar timely
       fashion so that the overall treatment is achieved for the majority of patients within 18
       Weeks. Strict targets applying to outpatients are therefore important and it is the Trusts
       intention to ensure that all routine outpatient appointments are conducted within 6
       weeks of referral. Key details of the various sub targets affecting 18 weeks are
       included in Section 3 of this document

                   1.2    Access to Health Services for Military Veterans
        In line with December 2007 guidance from the Department of Health all veterans and
        war pensioners should receive priority access to NHS care for any conditions which
        are related to their service subject to the clinical needs of all patients. Military
        Veterans should not need first to have applied and become eligible for a war pension
        before receiving priority treatment. GP‟s should notify the Trust of the patients
        condition and its relation to military service when they refer the patient so that the
        Trust can ensure that it meets the current guidance for priority service over other
        patients with the same level of clinical need. In line with clinical policy patients with
        more urgent clinical needs will continue to receive clinical priority.

                   1.3    Outpatient Wait Times and Patient Choice
       Built into the NHS Constitution is a legal right for patients to Choice. Choice is defined
       as a Choice of provider for treatment. Portsmouth Hospitals NHS Trust is required to
       offer this legal right to Choice via the Choose & Book system.

                   1.4    The Outpatient Booking Centre (OBC)
       From January 2008 onwards the Trust has been working with individual specialties to
       centralise the booking of all new elective and cancer outpatient appointments whether
       received via a GP, a consultant, a military office or another Trust. In order to achieve
       this, the outpatient booking centre was opened at St Mary‟s Hospital. The outpatient
       booking and scheduling functions has been centralised into the Outpatients Booking


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       Centre. The Outpatients Booking Centre is responsible for booking all new
       appointments. The specialty outpatient departments are responsible for booking any
       subsequent follow up appointments.

       The reason for the split of this function is for a number of reasons:
        o Firstly 18 weeks and the rules applicable to the booking of all new referrals have
            changed dramatically, It is important that new patients are booked within the
            national guidance and this can be better achieved and monitored with a
            standardised central approach.
        o Secondly there are new changes to the rules and appointment targets applying to
            cancer patients. Arranging for these referrals to be received into a central and
            dedicated point with dedicated staff able to ensure that patients are booked into
            fast track clinics supports these requirements.
        o Thirdly it is important that the Trust moves away from traditional and partial
            booking and ensures that patient choice is offered via Choose and Book.

       The booking of second and subsequent appointments (follow ups) is not included
       within the Outpatients Booking Centre because these bookings are best completed
       whilst the patient is still in the outpatient department after their first appointment.

       It is the intention of the Trust that all patients attending their first outpatient
       appointment should receive the booking for their second and subsequent follow up
       visits prior to leaving the clinic. This is essential if the Trust is to make the achievement
       of 18 weeks sustainable for the future and is best achieved by booking the next
       appointment in a timely fashion.

       Ongoing service developments to improve the booking and scheduling of patients will
       be undertaken and this policy will be amended in line with those changes

                   1.5    Policy Statements
       This document begins by listing the policy statements that this Trust has in relation to
       elective outpatient‟s access issues and waiting list management. These policies are
       consistent with both national rules and regulations regarding waiting list management
       and accepted good practice.

                   1.6    Good Practice Guide
       The remainder of the document is an operational guide for staff working within
       Portsmouth Hospitals. The aim of this part of the document is to outline the good
       practice that is expected in all departments and specialties within the Trust. This will
       help achieve consistency of practice and ensure that all practice is in keeping with the
       associated waiting list policies.

       The guidance works through the key stages of the waiting list dynamic, from receiving
       and accepting the referral, to the clinic outcome and scheduling of any further care
       required.

       Each section outlines:

        The aim and rationale for the procedures in the section,
        The key procedures to be followed (with reference to additional information in an
           appendix if relevant)
        How achievement of the standards will be monitored.



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       As implementation of this policy culminates in improved access to elective services for
       patients, elements of this policy will be monitored to ensure adherence and therefore
       protect patients‟ access to such services. It is crucial that hospitals begin to monitor
       systems rather than purely the outputs of such systems to ensure improved access for
       patients.

       Some sections of the good practice guide make reference to different rules or
       procedures to be followed for military patients. Some sections will also give an
       overview of roles and responsibilities but these are outlined in more detail in Section
       17. There is a glossary of terms used in the document in Appendix 1

       There will be occasions when situations arise which are not covered by this document.
       In such circumstances the appropriate Operational Manager should be contacted who
       will raise the issues with appropriate management staff and forums within the Trust.

       All staff involved in outpatient‟s appointment management should be provided with a
       copy of this policy at commencement of employment. Copies should be made
       available to patients on request. Local patient and primary care organisations should
       be provided with copies




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     2 Policy Statements
     The following statements are a list of the standards and philosophies that Portsmouth
     Hospitals NHS Trust has adopted in managing Outpatient Appointment Booking. These
     statements are consistent with Department of Health guidance on waiting list
     management and guidance for 18 weeks. They also reflect current best practice such as
     the recommendations of the „Getting the Patients Treated Handbook‟ (National Patient
     Access Team 1999). A list of DoH guidance documents can be found in the Appendix 2
     for further information

     The aim is to have standardised procedures across the Trust. However, there maybe
     occasions when there will be a need for exceptions for a set of patients, e.g. some
     groups of children. These variations must be agreed within the Directorate with the
     Chief Operating Officer and Divisional General Managers

    1. The overall aim of the policy is to ensure patients are seen and treated in a timely
       and effective manner.

    2. The process of outpatient appointment booking will be fair and transparent to the
       public.

    3. Communication with patients will be clear, informative, concise and timely.

    4. Fast track (GP Links/Faxed Proforma) cancer patients must be seen within two
       weeks (14 Days) from the date the GP referral letter / fax is received by the Trust

    5. Other cancer patients referred form the national cancer screening programmes such
       as bowel, breast and cervical screening programmes should receive their first
       assessment or contact within 2 weeks of the screening programme identifying a
       suspicion of cancer

    6. Those patient referrals identified by consultants as having a suspicion of cancer, and
       who have not yet attended their first outpatient visit must be identified as a
       “consultant upgrade” urgent patient and should receive their appointment booking
       within 14 days – similar to the current fast track GP referrals, this is a new aspect of
       the cancer reform strategy. The time starts from the date the consultant upgraded the
       referral letter.

    7. Fast track patients for cardiac conditions should be seen within two weeks (14 days)
       from the date of the GP fast Track referral letter

    8. Clinically urgent patients will be treated as a priority and within the shortest waiting
       times possible, this is normally indicated to be within two weeks (14 days)

    9. Routine patients will be treated in turn based on their length of time since referral, the
       Trust will endeavour wherever possible to meet the locally agreed wait time targets of
       a 6 week wait for all first outpatient appointments. Where this wait time is exceeded
       no routine patient will wait longer than the nationally agreed wait time target of 13
       weeks for the first outpatient appointment.

    10. All war pensioners and military veterans should receive priority access to NHS care
        and wait times for any condition which are likely to be related to their service subject
        to clinical needs and urgency of all patients. Where the clinical need is similar to
        other patients the Trust is committed to ensure that war pensioners and military


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        veterans receive priority of access against other patients of similar clinical need.
        Military veterans should not need to first have applied and become eligible for a war
        pension before receiving priority care.

    11. In accordance with the 18-week targets all elective patients referred from GP‟s and
        other primary care professionals will be managed in accordance with 18 weeks
        principles and should have a 18-week pathway initiated when the referral is received
        by the Trust. In line with this all new patients should be admitted onto an 18 week
        pathway on the 18 week RTT PAS system (referral to treatment RTT)

    12. In the past consultant to consultant referrals have been excluded from most waiting
       list targets. From March 2008, all consultant to consultant referrals will form part of
       the 18 week standard and as such should be seen within outpatient waiting times
       targets of 6 weeks for routine referrals and 2 weeks for urgent referrals

     13. In the past patients who require a follow up 2nd or subsequent outpatient visit, have
        not been included in previous government wait targets. As part of the 18 week
        referral to treatment targets there will be a number of patients who require a follow up
        appointment prior to their decision to treat being made. These patients should be
        seen as quickly as possible following their diagnosis and receive the start of their first
        treatment within 18 weeks.

    14. Those patients returning for their ward or post operative follow up should be seen in
        line with the clinician‟s recommendation and as early as appropriate. Appointments
        should be booked by the ward staff prior to the patient leaving the hospital post
        surgery

    15. For those other patients who may have received the start of their first treatment
        already but who require longer term ongoing follow up visits – all efforts must be
        made to ensure that the appointment is booked for the follow up in line with the
        clinical recommendation. Operational staff should ensure that there will be enough
        capacity and clinic space available to ensure that follow up patients are seen within
        the timescales indicated by their clinicians. Issues associated with capacity and long
        waits for follow ups should be escalated to the appropriate operational and divisional
        general manager. Information relating to wait times for follow up appointments will
        be provided by the Business Intelligence Unit.

    16. All new routine patients, whose appointments are booked verbally or by letter, should
        be given wherever possible a 10 day notice period of an appointment and a minimum
        choice of two dates within the nationally agreed wait time targets. Where there are
        difficulty contacting patients either by phone then a letter should be sent asking them
        to contact the Trust for appointment. Where there is not response to this within 7
        days – the patient‟s details should be checked and a second letter sent to the patient
        asking them to contact the trust within 5 days. Where there is no contact from the 2nd
        letter within 5 days then the patient should be removed from the waiting list and
        discharged to the GP, detailing the reasons for discharge. A copy of this letter should
        be sent to the patient informing them of the decision. Should the patient require a
        further appointment a new referral can be made by the GP.

    17. The Trust will move away from traditional and partial booking systems to full booking
        systems so that patients have a choice of a mutually convenient date for treatment.
        The Choose & Book system enables this choice to be provided to the patient at the
        time of booking.




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    18. The Trust will maintain accurate and up to date electronic records of all patients on
        the waiting list. All outpatient activity will be recorded and monitored on the Patient
        Administration System (PAS) and its associated 18-week RTT module. This
        information will be shared with primary care and the Strategic Health Authority where
        appropriate and where required. Data held should be timely, accurate, and complete
        and subject to regular audit and validation.

    19. All routine elective patient referrals should be entered onto the 18 Week PAS and
       Outpatient PAS system within 2 working days of receipt of the referral into the Trust.

    20. Fast Track referrals for suspected cancer patients should be included on the 18-week
        pathway as well as the current system for monitoring wait times for cancer patients.
        These referrals should be entered onto the PAS 18 Week and outpatient system
        within 24 hours and the patients booked within a 48 hour period of the Trust having
        received the Fast Track referral.

    21. In order to meet the 18-week referral to treatment targets, there is a requirement to
        record the patient‟s status on the 18-week pathway. Recording of decisions made in
        the clinic should be completed by the clinical staff utilising the clinic outcome form,
        which has been designed in collaboration with the various clinical specialties. The
        clinic outcome form should be completed for all elective outpatient appointments and
        the form should be collected by the clinic reception staff who in turn should record the
        clinic outcome decisions onto the 18 Week RTT PAS system. The clinic outcome
        form contains information on follow up appointments and time of these, requests for
        diagnosis and the 18 week status of the patient. An example of a generic clinic
        outcome form and its instructions for use can be found in Appendix 3. Clinic
        outcomes and information pertinent to the patient‟s status should be entered onto the
        RTT PAS system as part of the current clinic closedown procedures for each
        specialty. Clinic closedown procedures should be complete within 48 hours of the
        clinic being held

    22. The list of patients awaiting outpatient appointments will be validated at regular
        intervals to ensure that only patients who want an appointment form part of the list.

    23. The Trust will try to find a convenient date for patients who postpone the first date
        that is offered to them so that they are seen as quickly as possible. Patients who
        postpone more than one reasonable offer will be removed from the outpatient waiting
        list and returned to the care of their GP, where this is clinically appropriate to do so.
        This decision will be communicated by letter to both the patients GP and the patient.

    24. Patients whose appointment is postponed by the Trust will be offered another
        appointment as soon as possible after the postponed date and within trust target
        date. Wherever possible, a patient who has been postponed once will not be
        postponed a second time.

    25. All Healthcare Professionals must give at least six weeks notice when a clinic is to be
        cancelled or reduced.

    26. Patients who fail to attend (DNA) their appointment without providing any notification
        will be reviewed by the consultant or a member of the team, removed from the list
        and returned to the care of their GP. The exception to this will be if there are
        compelling medical or social reasons why the patient should remain on the list or if
        the patient is a paediatric or vulnerable patient. This decision should be
        communicated to the patients GP and the patient.



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    27. A patient who DNA‟s their first appointment following the initial referral that started
        their 18 Week clock will have their 18 week pathway closed (nullified) provided that
        the provider can demonstrate that the appointment was clearly communicated to the
        patient and that a choice of dates and sufficient notice was given. Where it has been
        agreed with the clinical staff that it is not clinically appropriate to discharge the
        patient, a letter should be written to the patient asking them to contact the outpatient
        department for a new appointment to be made. A new 18-week clock will start when
        the patient contacts the department to set the new appointment date. Similar rules
        apply for those patients who DNA any other appointment and are subsequently
        discharged back to the care of their GP.

    28. The Trust will work in partnership with other NHS Trusts and independent providers
        of healthcare to create additional capacity to treat patients from its waiting list where
        this is required or appropriate. This will help ensure shorter waiting times for
        treatment but should be agreed with the Divisional General Manager and operational
        managers for the specialty

    29. The Trust will implement systems and processes that ensure a balance between the
        demand for elective care and the Trust‟s ability to provide the capacity to meet that
        demand. Regular reviews of the specialty and the Divisions capacity and demand
        requirements should be conducted by the specialty operational managers and the
        Divisional General Manager

    30. Staff will be trained to undertake their role and will be made aware of their
        responsibilities with regard to Outpatient Appointment Booking / Scheduling. Staff will
        be supported if they are adhering to the principles of the policy but equally, staff
        operating outside of the policy may be subject to disciplinary action




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     3 The NHS Plan & National Waiting List Targets
     This section outlines the national and local targets associated with wait times involved in
     a patient‟s journey. The first part indicates wait time standards applicable to the whole of
     a patient‟s journey whilst the second section indicates the wait time targets pertinent to
     outpatient booking and scheduling staff.

                   3.1    National Wait Time Targets
       The following are a list of the national targets, which are applicable to all elective
       patients referred to the Trust. 18 Weeks is the overarching target applicable to all
       routine and cancer patients referred into the Trust, however to achieve this overall
       target and to ensure that the patients treatment pathway is conducted within 18 weeks,
       a number of locally agreed sub targets along the patients pathway also apply, these
       are indicated below.

              18 Weeks - From December 2008 the majority of routine patients being
               referred into the NHS should receive the start of their first treatment within 18
               weeks of the GP, Primary Care Professional or Consultant referral. The target
               is measured in two parts as follows:
                   o 90% of those patients who are admitted for treatment as a hospital
                       inpatient or day case must receive the start of this treatment within 18
                       Weeks of the receipt of their referral
                   o 95% of those patients who receive treatment in an outpatient or non
                       admitted setting should receive this within 18 Weeks of the receipt of
                       their referral

              Outpatient Targets 6 Weeks – All routine elective referrals into the Trust must
               receive their first outpatient appointment within 13 weeks as part of the national
               target. The local target for this first outpatient appointment is 6 weeks

              Outpatient Appointments for Cancer Fast Track Referrals 2 Weeks – All
               cancer fast track referrals received from GP‟s, the national cancer screening
               programmes, and consultant upgrades should receive their first outpatient
               appointment within 2 weeks (14 days) of receipt of referral or from the
               screening centre notifying us of the suspicion of cancer

              Outpatient Appointments for Cardiology Fast Track Referrals 2 Weeks –
               All fast track cardiology patients should receive their first outpatient
               appointment within 2 weeks of receipt of the fast track referral

              Diagnostic targets 6 Weeks – All patients being referred for a diagnostic
               procedure, as part of their overall care pathway should receive their diagnostic
               appointment within 6 Weeks of the referral into the diagnostic specialty. Locally
               the Trust has agreed a 2 week wait for all key diagnostic tests such as MRI,
               CT, non Obstetric ultrasound and gastro intestinal endoscopic procedures

              Inpatient Treatment Targets – 90% of patients should receive the start of their
               treatment within 18 Weeks – however to ensure that this occurs within this
               period the Trust has set a local wait time target for the inpatient part of a
               patients journey of 8 -15 Weeks from the point where the Decision to Treat is
               made to the point where the treatment is carried out. For those patients who do
               not receive their treatment within the 18 Week period the national wait time for
               the inpatient stage of treatment is 26 Weeks. In other words no patient should


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               exceed the national target of a 26 week wait from the point the decision to treat
               has been made to the point that actual treatment is carried out

              Cancer 62 Days – All patients referred as a suspected cancer fast track
               referral should in addition to receiving their first outpatient assessment within 2
               weeks, receive the start of their first treatment within 62 days from the point of
               receipt of the referral to the start of the treatment whether this be surgery,
               chemotherapy or radiotherapy

              Cancer 31 days – For those cancer patients who have not been referred as a
               fast track patient or not identified as having cancer at the point of referral or
               where a second or third episode of cancer has been diagnosed there is a
               requirement to ensure that treatment is carried out as quickly as possible. The
               national target for this is that these patients should receive their treatment
               (either surgery or chemotherapy) within 31 days of the Decision to Treat. The
               decision to treat is the date when the patient and the Doctor agree the
               treatment plan
              Cancer patients, whilst having their own fast track pathways, are also included
               on the 18 week pathway

                   3.2    National & Local Targets Specific to Outpatient Booking &
                          Scheduling Staff
     The following national Targets are specific to outpatient booking staff

       No patient must wait more than 2 weeks (14 days) from urgent GP/GDP referral to
        outpatient appointment for suspected cancer, this includes referrals received from the
        3 national screening programmes and referrals made by consultants who have
        upgraded routine referrals as suspicious of cancer
       No fast track cardiology patient must wait longer than 2 weeks for their first outpatient
        appointment
       From March 2008, no routine patients must wait longer than 13 weeks for an
        outpatient appointment from the point that the referral is received to the point of the
        appointment. Locally this target has been agreed as 6 weeks
       From December 2008 – all routine elective referrals into the Trust (including those
        from GP‟s, other primary care professionals and consultant to consultant referrals
        form part of the 18 Week pathway and should receive their first outpatient
        appointment within 6 weeks of receipt of the referral

       The table below gives details of the local targets and national targets for outpatient
        appointments


         Target                                    TRUST TARGET                NATIONAL TARGET


         Cancer Fast Track Referrals               14 days                     2 weeks


         Cardiology Fast Track Referrals           14 days                     2 Weeks


         Routine Outpatient Referrals              42 days                     13 weeks




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        Managers within the trust will be working with key staff to develop standards per
        specialty for follow up appointments. Where treatment is provided, these will be
        distinguished from follow up appointments which are planned and which follow on
        once treatment has been started – normally known as planned follow ups. New
        standards developed will be added into this document as these are developed.

                   3.3    Access for Military Veterans and War Pensioners
        The Trust is committed to ensuring that all veterans / war pensioners receive priority
        access to treatment within the NHS, when compared to patients of a similar clinical
        need. Veterans need not have first applied for a war pension for this prioritisation to
        apply.




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       4 Receiving Outpatient Referrals.
                   4.1    Aims of This Section
        It is important that the receipt of the referral is recorded on PAS so that it can be
        processed speedily and efficiently. It is also important to ensure that all new routine
        referrals including consultant-to-consultant referrals form part of the 18-week
        pathway and as such should have a new 18-week pathway opened on PAS on
        receipt of the referral. Recording in this way ensures that there is a permanent record
        of the referral arriving in the Trust so that even if the referral letter is mislaid, the
        Trust knows that there is a patient waiting to be seen.

        It is good practice to use the prioritisation indicated by the GP, however with
        consultants reviewing the referrals letters and grading in clinical priority, the Trust
        ensures that only those patients who need to see a secondary care clinician receive
        an appointment and that those patients with the greatest clinical need are seen
        quickly. The GP prioritisation will take precedence unless consultant review of the
        referral is judged to require expediting.

        By encouraging generic referrals, routine patients can be allocated to the clinician
        with the shortest waiting time, ensuring timely access to care and equitable waiting
        times.

        The preferred referral route for all new patients is via Choose & Book. The Trust and
        Primary Care will work together to ensure that the location where the patient is seen
        and treated is in the most appropriate setting

        This section sets the procedures and guidance for ensuring that referrals are
        received, recorded and appointments set quickly for patients

                   4.2    Outpatients Referrals and 18 Weeks
        All new referrals from all health care professionals will initiate an 18 week pathway
        for patients; this includes all referrals received from GP, opticians, nurses, GPSI‟s
        and other professionals in primary care.

        All consultant to consultant referrals between consultants within Portsmouth
        Hospitals NHS Trust will also be included within the 18 week targets. Specific rules
        relating to clock starts and stops for consultant to consultant referrals are included in
        more detail in Section 7 of this document.

        Consultant to consultant referrals within Portsmouth Hospitals NHS Trust must meet
        the criteria outlined and agreed with the local PCT‟s. a summary of this is included
        within Section 7 and the actual policy statement is included within Appendix 5

        In line with 18 weeks guidance all inter trust / provider referrals, i.e. those coming
        from another secondary care provider (consultant in another Trust) are part of 18
        weeks. Rules on Clock start dates and relevant procedures to be followed are
        available in Section 8 of this document. All referrals from and to consultants in other
        Trusts will have to be accompanied by a minimum dataset. This will apply to those
        received by the trust and those which our own consultants will refer onwards to other
        specialist centres. An example of the minimum dataset form to be completed can be
        found in Appendix 4




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        This process will be developed for all trusts, and is currently coordinated at
        Portsmouth Hospitals NHS Trust by the Outpatient Booking Centre. Details of
        referrals from other Trusts received in this way should form part of the booking
        policies and targets already outlined.

                   4.3    Recording the New Referral (routine & urgent)
        All referrals should include full demographic details, including telephone/mobile
        numbers (day and evening if possible). Relevant clinical details must also be
        provided, including highlighting any special needs. This will reduce administrative
        time in contacting the patient and ensuring the patient is seen in the best setting.

        All paper referrals should be date stamped with the date of receipt into the Trust.

        All new referrals (including inter trust / provider referrals) should be received and
        recorded on the Patient Administration System (PAS) and 18 Week RTT module of
        PAS within two working days of receipt by the Outpatient Booking Centre (OBC) at
        QAH. All new referrals received through Choose & Book will automatically be
        recorded at the point of the appointment being booked.

        On receipt of referral, patient demographic details on PAS must be checked that they
        match the patient demographic details on the referral letter. It is good practice to
        check that there is not already a referral on the Pas system for the same condition for
        the same specialty, where there are duplicate referrals these should be amended,
        utilising the earliest start date

        The “date of referral” on PAS is the date of receipt of the referral into the Trust. This
        includes cancer 2-week (TWW) fast track referrals that have their own procedure as
        described later in this document

        It is good practice to use the prioritisation indicated by the GP on the referral letter
        although it is recognised that this may be changed by the Consultant in the grading
        procedure described later

        Generic "Dear Doctor" referrals will be allocated to the consultant with the shortest
        waiting time. GPs are encouraged to address referrals to the hospital speciality rather
        than named individual consultants.

        If a referral is to a specific consultant because of a specialist interest, this consultant
        should see the patient.

        Following all referral information being recorded on the PAS system, the subsequent
        booking will take place in accordance with the national and local targets outlined in
        Section 3 and subsequent local booking rules defined by the specialities and
        implemented by the Outpatient Booking Centre at SMH. (See Section 5 for making
        an appointment).



                   4.4    Reviewing the Referral
        Once booking has taken place, the referral letters will be sent to the consultant for
        review within 48 hours,– (2 working days. )

        Bookings made via Choose & Book are immediately available to the consultant for
        review on their work list.


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        For paper referrals, the grading process is best conducted electronically or by fax to
        a set point within the specialty.

        The clinician, or a nominee, will decide if the referral and booking is clinically
        appropriate. Should the referral not be received back within 48 hours – 2 working
        days the Outpatient Booking Centre should go ahead and book the patient‟s
        appointment within the local standards.

        Consultant annual leave, study leave or sickness delaying the review of referral
        letters must not disadvantage the patient, Directorates and specialties must work with
        the consultants to ensure that there are contingency arrangements to cover periods
        of leave to ensure all referrals are reviewed within 48 hours – 2 working days.

        The Outpatient Booking Centre should ensure that where referrals are not received
        back within 48 hours – 2 working days this is escalated to the specialty operational
        managers for review of the policy.

        Referral letters should be tracked on PAS when they are sent for review and
        recorded when returned. Any referral letters not returned back to the Outpatient
        Booking Centre within 7 working days must be accounted for, and any action
        required on PAS must be taken.

                   4.5    Changing Priority of a Referral
        Following the review of the referral if the patient has been graded as more urgent,
        then the patient is to be rebooked in accordance with the new grading instructions.
        Those patients regarded as „urgent‟ should be booked into the earliest appointment
        possible. As a guide, this should be within a two week period.

                   4.6     Redirecting Referrals
        Where a patient has been referred to the correct specialty and requires an
        appointment elsewhere within the department or with another consultant, the original
        appointment is to be cancelled and rebooked as quickly as possible. The 18-week
        wait time still applies to these redirections and all attempts should be made to
        minimise delays in the patient‟s pathway.

        Where the referral is through Choose and Book, redirections and rebooking are to
        be made within the Choose & Book system as per the Trust training manual.

        Where a routine referral is received and then deemed to be a suspected cancer
        following clinical grading (consultant upgrade) the referral must be rebooked and/or
        redirected as a matter of urgency in accordance with the Cancer Fast Track referral
        guidelines. The specialty Multi disciplinary coordinators – MDTC‟s should be notified
        to enable them to adequately track patients according to cancer wait time standards

                   4.7    Rejecting a Referral
        Following the review by the Consultant, referrals will be rejected if

            The patient has been directed to the wrong specialty for example a
             Gastroenterology to Orthopaedics




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               The referral is to a clinically incorrect / inappropriate location, for example a
                paediatric patient referred to an adult clinic.

        Where referrals are rejected, the patient‟s appointment is to be cancelled either
        within PAS or Choose & Book depending on the referral route. A clear precise
        comment is to be entered which guides the referrer as to the next steps to be taken.
        The comment should not include names or acronyms.

        Patients and GP‟s should be informed by letter or through the CAB system of the
        decisions taken with regard to rejected referrals and the reasons why.

                     4.8    Monitoring of Achievement of the Standards in This Section
       A number of reports will be generated on a weekly and monthly basis to allow
       operational and business intelligence staff to monitor the 18-week and other
       outpatient‟s targets indicated within this section. Reports include:

                 Reports that show the difference between the referral date and the date of the
                  transaction on PAS
                 Details of outpatient wait times
                 Details of cancer fast track and two week wait times
                 Inter provider transfers in and out of the Trust
                 Details of clinic outcome status and disposal codes entered onto PAS

       Business Intelligence Managers will discuss any variation from the target of recording
       all referrals with the relevant Operational Manager and Outpatient Supervisor who will
       work with their clerical staff to improve performance against the target.

       Business Intelligence Managers will also carry out an audit once a month, on a rolling
       programme, to ensure that referral letters are being stamped appropriately and that
       the correct date of referral is being used on PAS.

       Weekly and monthly information pertaining to 18 weeks and the development of an 18-
       week PTL will be produced and discussed at weekly and monthly PTL meetings at
       various levels within the organisation from outpatient supervisors and operational
       managers to weekly meetings between operational managers and divisional general
       managers

       Exceptions to the targets should be reported to the Divisional General Managers and
       the Chief Operating Officer

        Information on both referrals received into the Trust and referrals sent out of the
        Trust are kept on an inter provider Database within the Outpatient Booking Centre.
        This is maintained by the inter provider coordinators and a copy of this database and
        information is submitted to the Trusts business intelligence department, who are
        responsible for reporting to the SHA on a regular basis.




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                   4.9     Procedures for Managing & Grading Paper Referrals



                         Referral containing all relevant demographic information
                      (including telephone/mobile numbers) received into the Trust



                       Referral letter (or fax) date stamped with the date of receipt.



                     Referral registered on PAS within two working days of receipt,
                     irrespective of point of entry into the Trust. 18 Week pathways
                                   initiated for all new routine referrals
                         Patient demographic details on PAS must match patient
                                demographic details on the referral letter
                    The date of referral is the date the referral was received into
                                                  the Trust

                         Patient booked‟ pending clinical review‟ using GP priority –
                                              urgent/routine




                            Letters sent to consultants for clinical review.
                    „Dear Doctor‟ letters to be allocated to specialty consultant with
                                        the shortest waiting times



                    Record the movement of the letter on PAS for tracking purposes




  Consultant decides that the                 Consultant decides that the      Consultant decides that the
   patient does not need OP                      patient should see a            referral is appropriate
          appointment                                 colleague



   Consultant writes to GP                    Letter passed to colleague,      Consultant grades the letter
  with advice and informs the                    appointments made as           as „urgent‟ or „routine‟ and
   GP that the patient does                    rapidly as possible and in      decides on the site that the
        not need an OP                          line with local outpatient       patient should be seen
         appointment                                      targets


       Consultant informs                       PAS records updated                Letter returned to
    appointments office and                                                    appointments office within 3
    referral is discharged on                                                      days of receipt by
                PAS                                                                    consultant

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      5 Appointments.
                   5.1    Aim of This Section
       All patients must be seen within the maximum waiting times determined by the
       Trust/Government. However, clinically urgent & cancer patients must be given priority,
       routine patients should be given the first available appointment and war pensioners
       and military veterans should be given priority against patients with similar clinical
       needs

       Clinicians and managers need to design the clinic templates and the directory of
       services so that the number of slots available meets the demand from all sources of
       referral and ensure the maximum waiting time is met.

       The aim of this section is to highlight the rules and processes pertaining to making
       appointments for patients

                   5.2    Making Appointments
        Updating of patient demographic and GP details (name, address etc) on PAS takes
        place within 2 days of receipt of the referral. When making the appointment these
        details should be checked on PAS again. If the details are found to be different than
        those identified on the referral letter then PAS must be updated.

        Once the referral for the new patient has been prioritised and graded by the
        consultant, the referral should be returned to the Outpatient Booking Centre QAH
        within 2 days for an appointment to be made.

        Divisions, Consultants and Primary Care should agree and define the outpatient
        clinic templates to ensure demand and capacity is managed. These templates should
        be reviewed regularly to ensure changes in demand are accounted for.

        Patients must not be given new appointments beyond the local Trust target waiting
        time. Where capacity is limited and prevents an appointment from being granted
        within the wait time outlined in Section 3, this should be escalated to the Supervisor /
        Manager of the Outpatient Booking Centre and the relevant Specialty Operational
        Managers so that appointments can be allocated within the wait times appropriate.

        Cancelled slots should be used to bring forward long waiting patients identified on
        either the Primary Targeting List (PTL), or Outpatient Waiting List (OWL).

        Patients should be discharged if they do not have a future appointment and there is
        no intention to provide them with one.

        To ensure patients do not breach the local trust waiting times determined by the
        Government SOS (Open Appointment) discharges must not be used for referrals that
        have not had a “new” first appointment. Patients must be referred under a new
        episode of care.

        SOS (Open Appointment) discharges can only be used for follow-up patients.



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        When making an appointment the 18 Week RTT status of referrals should be
        checked and if patients do not have an 18 week pathway this should be initiated

                    5.3   Prioritisation of Appointments
        Fast track (GP Links/Faxed Proforma) cancer patients must be seen within two
        weeks from the date the referral is received within the Trust

        Urgent referrals must be given priority, as a rule this should normally be within 2
        weeks unless stated otherwise by the clinician.

        All other patients should be given appointments on a “first come, first served” basis,
        to ensure equity of access. An exception to this is Military / War Veterans who should
        receive priority treatment but only if the condition is directly attributable to injuries
        sustained during war periods.

        As part of 18 Weeks all referrals from GP‟s, other primary care professionals and
        consultant to consultant referrals will start an 18 week pathway. All referrals into the
        Trust should therefore be seen within the 6 week period outlined in Section 3 if
        routine or in line with the urgent / cancer 2 week waits period if this is the clinical
        designation

                    5.4   Booking Type
        On arranging an appointment for either a new or follow-up patient the appointment
        booking type must be entered on PAS: -

                 0 = Traditional booking (applies to military patients only)
                 1 = Partial booking
                 2 = Full booking

        The definitions of these different booking types are detailed later in the document.

                    5.5   Monitoring of Achievement of the Standards in This Section
            The Business Intelligence Department will produce information that shows the
            length of time all outpatient patients have waited, by clinic, over a period of time.
            Operational Managers will use this to determine whether routine patients are
            being seen in turn.

            Information on the following performance information, will be produced by the
            business intelligence department on a weekly and monthly basis to enable
            operational managers and outpatient staff to manage the wait list and booking
            schedule

                    Weekly 18 Week Non admitted PTL indicating all new and follow up
                     patients
                    Weekly 18 week non-admitted PTL indicating all new OP lists and time of
                     wait
                    Information on specialties where wait times exceed national targets
                    Weekly information on Choose and Book
                    Weekly information on cancer two week wait times
                    Detailed information on new, follow up and non GP referrals
                    Number new referrals per month


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                    New outpatient to Follow up ratios per specialty
                    Other information as requested by operational and specialty managers

        Operational and specialty managers and outpatient supervisors should use the
        abovementioned information to actively manage all outpatients in line with the
        national and local targets agreed




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      6 Booking Appointments
                   6.1    Relevant Policy Statements
       Statements outlined in Section 2 are relevant to this section:

                   6.2    Aim of This Section
       The Trust intends for all first new appointments to be booked via Choose & Book. This
       moves away from traditional and partial booking systems to full booking systems,
       which allows the patient to choose a mutually convenient date for their appointment.

       In line with local guidance patients should be provided with at least 10 days notice and
       a choice of 2 dates. Experience has shown that these patients are more likely to
       attend their appointment thus avoiding the need for rescheduling, minimising DNA
       rates and maximising the use of clinics.

       Should the patient not respond to the first letter within 7 working days of asking them
       to contact the Trust for an appointment, demographic details should be checked using
       the NHS Tracing Service, or GP practice. Should the patient details be incorrect, these
       should be amended and a second letter sent asking them to ring in within 5 working
       days to arrange their appointment. If the patient fails to respond to the second letter
       they can be removed from the waiting list with a letter sent to their GP, copied to the
       patient, informing them of this. Any deviation from this must be agreed at
       departmental management level with the clinical lead

       The aim of this section is to outline the Trusts intention and key procedures applicable
       to the various aspects of booking

                   6.3    Traditional Booking
     Traditional booking should only be used for military patients in communication with
     MPAC, for further details please see Section 17.

     Once the referral has been graded using abovementioned procedures, the department
     must send the appointment to MPAC within one week of receipt of the referral into the
     Trust.

                   6.4    Partial Booking
     This is where an invitation letter is sent to the patient inviting them to telephone the
     department to arrange their appointment date and time. In line with local guidance we
     should offer a 10 day notice period as a minimum and a choice of 2 dates when the
     appointment is arranged are required.

     A letter is sent to the patient asking them to contact the specific specialty to agree a
     convenient date and time to see a consultant. The letter must state the date the patient
     needs to reply by. The letter must include the telephone number of a contact person
     who the patient can call with any questions. It must also request that the patient informs
     the specific specialty if they no longer require their appointment. The letter must inform
     the patient of the booking process and the consequence if they fail to respond to the
     letter, this may include removal from the outpatient waiting list and discharge where
     appropriate.




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     When making the appointment, the patient should be given a minimum of 10 days
     notice of their appointment and offered a choice of two appointments on different days.
     Appointments offered but declined by the patient should be added to PAS and reported
     as cancelled / declined by the patient.

     On agreeing the appointment date, an appointment confirmation letter is sent to the
     patient. This letter should clearly state the consequences of postponing or not attending
     the clinic appointment.

     Should the patient not respond to the first letter within 7 working days of asking them to
     contact the Trust for an appointment, demographic details should be checked using the
     NHS Tracing Service, or GP practice. Should the patient details be incorrect, these
     should be amended and a second letter sent asking them to ring in within 5 working
     days to arrange their appointment. If the patient fails to respond to the second letter
     they can be removed from the waiting list with a letter sent to their GP, copied to the
     patient, informing them of this. Any deviation from this must be agreed at departmental
     management level with the clinical lead.

     Once booking has taken place the referral letters will be sent to the consultant for
     review within 3 working days. The consultant or a nominee will decide if the referral and
     booking is clinically appropriate.

     Referral letters should be tracked on PAS when they are sent for review and recorded
     when returned. Any referral letters not returned back to the specific specialty within 7
     working days must be accounted for, and any action required on PAS must be taken.




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                   6.5    Flow Chart / Procedure for Booking Appointments Using
                          the Partial Booking System

    Enter referral on PAS ensuring patient details on PAS match patient details on
    referral letter. Forward referral to Consultant for grading

                         Referral letter received back from consultant



                                                   Enter details onto the PAS outpatient waiting list (OWL)


                                                    Generate and send acknowledgement letter to patient
        If patient needs to be seen                ensuring the letter is clear and informative and contains
            urgently, using either                   the name or job title and the telephone number of a
      Traditional of Partial Booking                   person to contact if the patient has any queries
     processes, make appointment
       and ensure it is linked to the
          referral on PAS to avoid
        duplicate entries and send                   Also ensure the letter contains information about the
     appointment letter ensuring the                 approximate waiting time for the clinic, details of the
      letter is clear and informative                partial booking system and the consequences of not
     and contains information about                            responding to subsequent letters
     the potential consequences of
      postponing their appointment
          more than once or of not
       attending their appointment                 About 6 – 8 weeks before the clinics are due to run, use
                                                    the outpatient waiting list reports to generate letters to
                                                     send to patients inviting them to ring in and make an
                                                                         appointment.
     Patient phones within 3 weeks
             of initial letter.

                                                  Patient does not respond to initial letter within 3 weeks of
                                                                    asking them to ring in.

      Agree a mutually convenient
         date with the patient.
                                                     Check patient demographic details with GP or NHS
                                                                     Tracing service.

      Generate appointment letter
        and send to patient as
      confirmation of appointment                 If incorrect, update PAS           If correct, discuss with
                  date                             and send letter-inviting        consultant. If patient is to
                                                   patient to ring in again.       be removed from waiting
                                                                                    list, ensure patient and
                                                                                         GP are informed
                                                   Patient responds to 2nd
                                                            letter

                                               If patient doesn‟t respond to 2nd letter within 2 weeks,
                                             discuss with consultant. If patient is to be removed from
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                   6.6    Full Booking – inc Choose and Book System
     This booking system is used by the Choose & Book application and the Outpatient
     Booking Centre. This booking system requires the patient to have the opportunity to
     book their appointment as soon as possible following the decision to refer.

     The system can be used for all categories of patients including new and follow up
     appointments

     This booking system also applies to any department that contacts the patient within one
     working day of their referral from the GP / health care professional or the consultant‟s
     decision to refer.

     The new referral from the GP/GDP or Consultant can be via fax, paper referral or
     Choose and Book. The patient must be registered onto PAS within two working days of
     receipt of referral regardless of who receives the referral.

        Choose & Book referral

                The referral is created in Choose & Book either as „urgent‟ or „routine‟ as
                 determined by the GP
                The patient uses Choose & Book to make their appointment
                The appointment is booked „pending clinical review‟
                The appointment is either accepted or rejected by the clinician

        Paper referral

                The Outpatients Booking Centre receives the referral and registers it on PAS
                The referral is registered either as „urgent‟ or „routine‟ as determined by the
                 GP
                The Outpatients Booking Centre telephones the patient and books an
                 appointment for a mutually convenient time
                The appointment is booked „pending clinical review‟
                The appointment is either accepted or rejected by the clinician

        Follow up appointments should be fully booked by mutually agreeing the next
        appointment with the patient at the first outpatient appointment. This should be at the
        reception desk in the department where the outpatient clinic is held or at outpatient
        departments in community. At the time of booking the follow up the appointment
        must be linked to the correct specialty referral episode on PAS.

                   6.7    Slot Unavailability
        In the event that there are no appointments available within Portsmouth Hospitals for
        a patient to book directly into the following procedure should be adhered to:

           An appointment request will be forwarded by the Telephone Appointments Line
            (TAL) to the Outpatient Booking Centre QAH notifying them of an Appointment
            Slot Issue (ASI).

           The Outpatients Booking Centre must liaise directly with the patient and must
            offer the patient an appointment within a four day window in accordance with
            national guidelines.




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           The waiting time – 18 week clock start begins from when the patient first tries to
            convert their unique booking reference number (UBRN) i.e. the date of the
            notification from the TAL.

           There should be at least three attempts to contact the patient; if it has not been
            possible to contact the patient by the end of the second working day a letter is to
            be sent by 2nd class post asking the patient to contact the organisation in order to
            book their appointment.



                   6.8    Making and Recording offers
        Where a patient is offered two appointments with at least 10 days reasonable notice
        and the patient refuses both appointments, this should be recorded onto the PAS
        system. The patient should then be discharged back to the care of their GP.

        Clock start dates for 18 weeks cannot be adjusted even though the patient has
        declined a reasonable offer of two dates with sufficient notice. For 18 weeks the clock
        start date will remain the original referral date.




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`

      7 Consultant to Consultant Referrals – within Portsmouth
                    Hospitals NHS Trust
                   7.1    Relevant Policy Statements
       Statements outlined in Section 2 are relevant to this section:

                   7.2    Aim of This Section
    The aim of this section is to ensure that staff working within outpatient services are
    aware that from March 2008 all consultant to consultant referrals from Dr‟s within the
    Trust are part of the 18 Week Pathway and as such all consultant to consultant referrals
    should meet the national wait time periods for new outpatient appointments – 6 weeks
    for routine appointments and 2 weeks for urgent appointments.

    Consultants within the Trust should also be aware that PCT‟s have a local policy in
    relation to consultant-to-consultant referrals, which the Trust should adhere to. The
    original policy is included in Appendix 5 for information. The following information details
    the key aspects of the PCT policy relating to consultant-to-consultant referrals

    Consultant to consultant referrals, are only supported when the condition for which the
    patient has been referred requires a further consultant opinion and this meets the
    following criteria:

In the case of urgent referrals (within 2 weeks), including suspected cancers where referral
back to the GP would cause unnecessary delay and potential harm to the patient

For suspected fractures (including referrals to fracture clinic from A&E and to orthopaedics
from the fracture clinic)

Urgent pre-operative assessment

HIV referrals (children and adults)

There is an expectation that all consultant to consultant referrals will be initiated by or agreed
with the original consultant and not a more junior doctor.

                   7.3    Consultant – to Consultant Referrals and 18 Weeks
    National guidance on consultant-to-consultant referrals and 18-week clock start dates
    indicate the following:

            Where the referral is for the same condition as the original GP referral and where
             the patient has not yet received treatment then the clock start date remains the
             original GP referral even though the referral is passed onto a new consultant.
             This would apply mainly to referrals within the same specialty i.e. for a second
             opinion on the same condition, these appointments should be booked in line with
             the outpatient booking targets outlined in Section 3
            Where the referral is to another consultant / specialty within the Trust for a new
             condition (i.e. a condition other than what the patient was referred for by the GP)
             then a new 18 week pathway should be initiated. A patient can have two or more




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             different 18 week pathways for two / more different specialties all appointments
             should be booked within 6 weeks for routine and 2 weeks for urgent referrals
            Consultant to consultant referrals letters should be typed as quickly as possible
             and Faxed / Scanned / Emailed to the appropriate booking centre as quickly as
             possible to ensure the patient is not disadvantaged by any delays. Use of the
             internal mail for ensuring referrals reach the booking centre are discouraged as
             these can cause delays
            All clinical and managerial /outpatient staff should ensure that consultant to
             consultant referrals are treated with the same priority as new or urgent outpatient
             referrals and should be booked in line with outpatient booking targets outlined in
             Section 3
                   7.4    Informing GP’s and Patients regarding Consultant to
                          Consultant Referrals
    Where a hospital consultant thinks that a referral to another consultant may be
    necessary for a patient, a letter should be sent back to the G.P providing the patient‟s
    details and explaining fully why the referral is recommended. This procedure also applies
    to all tertiary referrals and outpatient referrals from Accident and Emergency (unless the
    above exclusion criteria apply).

    This will enable the patient‟s G.P to review the appropriateness of the referral taking into
    account:

            The conditions for which the patient has already been investigated and received
             treatment

            The expertise and services available within primary care and the community to
             assess and manage the patient‟s condition

    It will also ensure that the patient is offered a choice of provider for their assessment and
    treatment in line with national requirements on Free Choice.

    The consultant should advise the patient of the local policy in such a way as to not raise
    expectations that a further referral will be made e.g. „I will write and let your GP know
    about this problem and your GP will contact you to confirm how this will be managed.‟

    The patient‟s GP will review the information from the consultant and decide whether the
    condition can be managed within primary care or if a referral is required (this may be to a
    locality service or secondary care). The GP is responsible for ensuring the patient is fully
    engaged in this process and for offering Choice at the point of referral. Choice is offered
    by making a referral using the Choose & Book application.



                   7.5    Monitoring of Achievement of the Standards in This Section
    Monthly information on all consultant-to-consultant referrals per specialty should be
    made available by the performance department

    Consultant to consultant referrals should be included within the non admitted 18 week
    PTL which is produced weekly

    The Primary Care Trust will monitor consultant-to-consultant activity on a monthly basis.
    Information will be available for each provider on a specialty basis by Practice.




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    The Trust (through Practice Based Commissioning Clusters) will audit these referrals to
    ensure they are appropriate and adhere to the exclusion criteria.




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      8 Referrals from Consultants in other Trusts - Inter Provider
                     Referrals
                   8.1    Policy Statements
     Statements outlined in Section 2 are relevant to this section

                   8.2    18 Weeks Rules on Clock Starts Applicable to Inter
                          Provider Transfers
       18 Weeks national guidance regarding inter provider and consultant to consultant
       referrals is as follows:

              For those inter provider transfers where the patient‟s condition is the same as
               the original GP referral and where treatment in the referring Trust has not yet
               started, the 18 Week clock start date will be the date of the original GP referral.

              For those inter provider transfers where the patient‟s condition is different or
               new to the original GP referral or where treatment has already commenced in
               the referring Trust, the 18 Week clock start date will be the date of receipt of
               the consultant referral from the referring Trust.

               In other words referrals from other Trusts to Portsmouth Hospitals NHS Trust,
               where treatment has already started or where the patient‟s condition is new /
               different to that on the original GP referral, the start date for the 18 week and
               outpatient targets will be the date the Trust receives the referral.

              A national minimum dataset of information regarding the patients status on the
               18 week pathway should accompany the clinical referral letter to allow Trusts to
               accurately determine the correct clock start dates for patients care and to
               encourage Trusts to develop joint care pathways that allow patients to be
               treated within 18 Weeks across differing organisations

       In the past referrals from other provider Trusts have been made via clinical letters from
       the referring consultant to the consultant in the receiving Trust and the date of the
       receipt of the consultant referral in the receiving Trust has been used as the date for
       the start time of previous outpatient targets.

       Application of the rules indicated above has meant that additional information
       regarding GP referral dates and the patient‟s treatment 18 Week status should be sent
       with the clinical letters. To enable this to happen most Trusts have developed new
       processes and centralised points for the receipt and recording of inter provider referral
       letters

                   8.3    The Minimum Data Set
        A national minimum dataset has been developed specifically for inter provider
        transfers which enables all trusts to accurately record clock start and 18 week status
        on clinical pathways. An example of the Trusts inter provider transfer form and the
        minimum dataset required is available in Appendix 4

        Details of the processes developed to manage inter provider transfers can be sub
        divided into those Inter Provider transfers received into Portsmouth Hospitals NHS




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        Trust and those inter provider Transfers where Portsmouth Hospitals NHS Trust
        refers patients to other provider Trusts

                   8.4    Procedure for those Inter Provider Transfers into
                          Portsmouth Hospitals NHS Trust
        All referrals from consultants in other Trusts should be accompanied by a minimum
        dataset in the form of the Inter Provider Transfer form, (Appendix 4) which
        accompanies the clinical referral letter.

        Referrals should be made to a dedicated fax line / NHS number indicated below
        which is located within the Outpatient Booking Centre at QAH.

The Outpatient Booking Centre - 18 Week Safe Haven Fax Number is 023 9286 6844

                 18 week Inter provider transfer dedicated NHS net email address is as
                                                 follows
                                   pho-tr.18weeksITRPHT@nhs.net

        Referrals are logged onto the PAS 18 Weeks system by the Inter Provider
        Coordinators who are based in the Outpatient Booking Centre within 2 days of
        receipt of the referral with the relevant 18-week clock start dates.

        Where the referral details indicate that the patient has not yet received treatment
        from the referring Trust the clock start date will be the date of the original GP referral,
        where the referral reason is new and the patient has received the start of the first
        treatment from the referring trust the clock start date for 18 weeks will be the date the
        outpatient booking centre receives the referral details

        Clinical referrals received from other Trusts to specialties without the minimum
        dataset or without the GP referral letter, should be faxed/ emailed to the above
        addresses in the outpatient booking centre so that the inter provider coordinators can
        ensure that the correct details are sought from the referring Trust and entered onto
        the PAS system in line with procedures for normal referrals.

        All appointments for inter provider transfers should be in line with wait time targets for
        all new outpatient patients, new routine appointments should be made within 6
        weeks, urgent referrals within 2 weeks and cancer inter trust referrals made within 2
        weeks

        Information on all inter provider referrals received into the Trust or transferred out of
        the Trust should be kept on the inter provider database and reported weekly to the
        business intelligence department. This information is shared with local PCT
        organisations and the SHA

                   8.5    Procedures for those inter Provider Transfers from
                          Portsmouth Hospitals NHS Trust to other Provider
                          Organisations
        All referrals from Portsmouth hospitals consultants to consultants in other Trusts
        should follow the abovementioned 18 week rules for inter provider transfers. Details
        of the minimum dataset and the inter provider form should accompany the clinical
        letter and be forwarded via dedicated fax / electronic NHS Mail to the receiving
        Trusts Inter Provider office



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        In order to facilitate the above process the following procedure should be followed by
        consultants, medical secretaries and typists within the various specialties within the
        Trust where the original referrals will originate

                 Consultants should dictate referral letters as current practice and include
                  details of treatment status where appropriate to do so.

                 Medical secretaries and audio typists should type letters as current practice
                  ensuring no unnecessary delays for typing and post the clinical letter to the
                  consultant / address of referrals in the other Trust as is current practice


                 A second copy of the referral letter should be forwarded to the inter provider
                  coordinators in the outpatient booking office at the following addresses

Outpatient Booking Centre - 18 Week Safe Haven Fax Number 02392 86 68 44

                 18 week Inter Provider Transfer dedicated NHS net email address is
                                  pho-tr.18weeksITRPHT@nhs.net

                 The inter provider coordinators will then complete the minimum dataset for
                  the patients details checking on PAS the 18 week status recorded and the GP
                  referral date

                 The Inter provider transfers form containing the minimum dataset and the
                  clinical referral letter are then faxed / emailed to the receiving Trusts 18 week
                  address ensuring that clock start details are accurate

          Information on all inter provider referrals received into the Trust or transferred out of
          the Trust should be kept on the inter provider database and reported weekly to the
          information / performance department. This information is shared with local PCT
          organisations and the SHA




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     9 Cancer Referrals
                   9.1    Relevant Policy Statements
       Statements from Section 3 are applicable to this section:

                   9.2    Aim of This Section
       In line with HSC 1999/205 all patients referred by the GP via the fast track process for
       suspected cancer must be appointed within two weeks of the GP referral date. This
       forms part of the cancer pathways and standards implemented by the DoH in 2005.

       The existing standards and targets for cancer have recently been extended to include
       a wider range of patients and ensure that those patients who have secondary cancers
       or what require subsequent treatments are not disadvantaged

       The aim of this section is to ensure that all staff are aware of the new cancer standards
       and the procedures and policies for the booking of all cancer patients

                   9.3    New Cancer Reform strategy and Standards
       The aim of this section is to ensure that all staff are aware of the new cancer standards
       and the procedures and policies for the booking of all cancer patients

       Existing Standards

                        All patients referred by their GP with an urgent suspicion of cancer –
                         should receive their first appointment within 14 days of the date of the
                         referral being received

                        All of the above patients referred by their GP as an urgent Cancer
                         referral (Two week Wait) must receive their first treatment within 62
                         days from the date of the original GP referral being received

                        Not all patients diagnosed with cancer would have been referred as part
                         of the TWW fast track system, those patients diagnosed with cancer
                         through routine or other appointments, should receive their first
                         treatment 31 days from the point that they have agreed their treatment
                         plan with their doctor, this is known as the decision to treat date (DTT)

        New Standards

             o    The current cancer GP fast track system is extended to include those
                  patients identified as having a suspicion of cancer through the 3 national
                  screening programmes or though routine referrals being identified as being
                  urgent suspicious of cancer called “consultant upgrades”

             o    All of the above fast track GP referrals, national screening programme
                  patients and consultant upgrades for suspected cancer should receive their
                  first outpatient appointment / contact within two weeks (14 days). The time
                  starts from the date the GP referral is received, the date the consultant
                  decides on the upgrade or the date that the screening programme identifies
                  a suspicion of cancer




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             o    All of the above cancer patients should receive the start of their first
                  treatment within 62 days of their original GP referral or consultant upgrade
                  or screening programme identification
             o    All cancer patients should receive the start of their first treatment within 31
                  days of their decision to treat, this is determined as the time the Doctor and
                  the patient decide on the most appropriate course of treatment

             o    All patients identified as having a recurrence or requiring subsequent –
                  second and third treatments for cancer which require either surgery or
                  chemotherapy should receive this treatment within 31 days of the Decision
                  to treat having been made


             o    From December 2009 – all breast referrals for cancer and non cancer must
                  receive their first outpatient appointment within 14 days of receipt of the
                  referral. This includes all routine breast referrals

             o    From December 2010 - all patients identified as having a recurrence or
                  requiring subsequent – second and third treatments for cancer which require
                  radiotherapy should receive this treatment within 31 days of the Decision to
                  treat having been made




                   9.4    Receiving Cancer Fast Track Referrals
       All patient referrals for suspected cancer this includes GP fast track referrals and those
       where the consultant has graded a routine referral, as a Consultant Upgrade must be
       recorded in PAS using the 'Fast Track' options and fully booked within 14 days for their
       first outpatient appointment.

       Each of the above entries must be coded on PAS as fast track in the in line with the
       national guidance.

       Cancer Fast Track Referrals are faxed to a central point in each of the outpatient
       (specialty) centres or the outpatient booking centre and coordinated and logged onto
       the PAS system immediately so that the patients journey and pathway can be
       monitored and tracked through the system as quickly as possible, in order to facilitate
       their treatment being provided within 62 days.

       The dedicated Fax Line for cancer fast track Referrals within the Outpatient booking
       Centre is

                                              023 9228 3385


       It is the GP who decides whether a patient needs to be seen urgently and requires a
       specialist outpatient appointment within the two-week period. Therefore the referral
       should not be sent to the consultant for grading. The referral is sent and received
       within the Trust within 24 hours of a cancer urgent 2 week wait fast track proforma and
       should be booked for the first appointment within 2 weeks of the date the referral is
       received

       Those routine referrals where the consultant has graded the referral and identified this
       as being suspicious of cancer “Consultant Upgrade” must be booked within 14 days


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       following the same procedure as is followed for the GP Fast Track patients. The date
       starts form the date the consultant upgraded the referral. MDT coordinators must be
       informed of any consultant upgrades.

       The patient is not to be disadvantaged by consultant annual leave, study leave,
       sickness, or national bank holidays. Therefore contingency arrangements must be put
       in place during these periods.

       New referrals can arrive by fax or electronically from GP‟s, or the GP can book on-line
       directly into PAS if they have the capacity to do so. Future developments will include
       the facility to utilise the choose and book system. Although this functionality is
       available on Choose & Book nationally, is not available at this stage for suspected
       cancer referrals made to Portsmouth Hospitals NHS Trust.

                   9.5    Booking Of Suspected Cancer Patients
        Currently the booking of the first outpatient appointment for suspected cancer
        patients is decentralised across the Trust with some specialties booking their own
        suspected cancer patients and other specialties being booked by the Outpatient-
        Booking Centre.

        Some referrals are received in the Outpatient Booking Centre – the dedicated Fax
        Line for this is as follows:

                                                023 9282 3385

        The Outpatient Booking Centre is currently responsible for making the first outpatient
        appointment for the following specialties:

                                     General Surgery
                                     Colorectal Surgery
                                     Upper Gastrointestinal Surgery
                                     Vascular Surgery
                                     Gastroenterology
                                     Gynaecology

        The Outpatient Booking Centre receives these referrals and books the appointments
        immediately without grading using the full booking system.

        Patients must receive their appointment within 14 days maximum as they must
        receive the start of their first treatment within 62 days.

        All suspected cancer referrals should also be part of an 18-week pathway and should
        have an 18-week pathway opened upon receipt of referral

                   9.6    Suspected Cancer Patients Booked by the Specialties
        There remain a few specialties where cancer referrals are booked direct to specialty
        based dedicated fax lines. All rules and regulations applicable to the Outpatient
        Booking Centre must be adhered to by these individual specialties.




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                   9.7    Escalation Process to Ensure Suspected Cancer and
                          Upgrade / Urgent Patients are booked within the 14 Day
                          Period
        Whilst the Outpatient Booking Centre is responsible for booking the first appointment
        within 14 days of receipt of the GP fast track referral or identification of a consultant
        upgrade, it is the divisions and specialties that are responsible for managing the
        capacity availability to allow this to happen.

        Where the Outpatient Booking Centre identifies a shortage of capacity to book the
        patients within 14 days – this should be urgently escalated to the Outpatient Booking
        Centre Supervisor / Operational Manager who should telephone the appropriate
        relevant Specialty Operational Manager and relay the message as urgent. This
        escalation should start ASAP (within 7 days of receipt of the referral) to allow time for
        the Operational Manager to put on the additional capacity required

        Where no response is received within 24 hours or by Day 7- following receipt of the
        referral then the Outpatient Booking Centre Manager should escalate to the
        Divisional GM for outpatients who will liaise with the appropriate Divisional GM for the
        specialty.

        If still no response within 24 hours then the potential breaches should be escalated to
        the Chief Operating Officer

        No patients should breach the 14-day wait time for suspected cancer due to
        unavailability of capacity

        Where Outpatient Booking is carried out within the specialty then the above
        escalation process should continue in the following manner:

        The outpatient booking clerk should contact the specialty operational manager as a
        matter of urgency to relay the message that there is a shortage of capacity – this
        should occur ASAP after receipt of the referral and within 7 days

        If there is no response within 24 hours then the outpatient booking clerk / supervisor
        should escalate to the Divisional GM to resolve

                   9.8    Monitoring of Achievement of the Standards in This Section
       A detailed patient targeting list for cancer is complied weekly by the Business
       Intelligence Department; this is circulated to all outpatient managers, waiting list and
       operational managers and contains details of the following information:

             o    A list of all patients who have been identified as Fast Track referrals on the
                  62-day pathway and the wait time to breach dates

             o    A list of all patients on the 31-day cancer pathway and a list of their wait
                  times and breach dates

             o    Weekly performance against the 14-day target

             o    Weekly performance against the 31 and 62-day targets




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       A weekly waiting list meeting should be held with MDTC coordinators and outpatient
       and waiting list managers within the specialties and attended by operational managers
       and divisional general managers

       A weekly PTL meeting is attended by Divisional GM‟s and Head of Performance and
       Associate Director Performance / Patient Pathways to discuss performance and issues
       associated with the achievement of all weekly targets

       All of the above is reported on weekly and monthly and forms part of the Trust‟s
       monthly performance reports. Cancer Two week fast track referrals forms part of the
       government‟s policy of ensuring that patients diagnosed with cancer are treated as
       quickly as possible

       Information on all cancer waits including the TWW referrals are uploaded onto the
       national cancer database and reported to the Department of Health and Strategic
       Health Authority on a monthly basis. The Trust has its own performance framework,
       which ensures that all cancer standards are monitored and reported on weekly




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      10 Patient & Hospital Initiated Postponements (cancellations)
                   10.1 Relevant Policy Statements
       Statements from Section 3 are relevant to this section

                   10.2 Aim of This Section
       The Trust is committed to seeing all patients referred by their GP within the
       Government‟s maximum waiting time. Furthermore it is committed to the introduction
       of booking systems that offer patients a choice of a mutually convenient date for their
       appointment. In return, patients are asked to keep the date that they agree otherwise
       they will be removed from the waiting list and returned to the care of their GP. This
       approach ensures that clinics are fully utilised and patients who need an appointment
       can be seen as quickly as possible.

       Equally, patients who have agreed a date with the Trust should expect to be seen on
       that date. If healthcare professionals give at least six weeks notice of their absence
       from a clinic then hospital initiated postponements will be kept to a minimum. This will
       minimise the stress caused to patients and reduce the workload of clerical staff. Most
       importantly, the patient retains an appointment that had been mutually agreed with
       them thereby offering a positive patient experience and reducing the likelihood of a
       DNA

       The aim of this section is to outline the procedures applicable for patients who need to
       postpone or cancel appointments which have been made

                   10.3 Patient Initiated Postponements / Cancellations and 18
                        Week Clock Rules
        An accepted principle of 18 week treatment times mean that patients when referred
        should be willing, fit and able to receive their treatment within the 18 week time
        period, the onus is principally on the GP to ensure that this is discussed with the
        patient prior to the referral.

        Within this it is imperative that patients have at least 10 days notice of their
        appointments and a choice of at least two dates convenient to them. On the
        outpatient letter confirming the appointment, it should be made clear that patients
        are part of an 18-week pathway and that as such more than one cancellation will
        result in the referral being discharged back to the GP in line with locally agreed policy

        On some occasions, even though patients have agreed a date suitable to them, they
        may find that this needs to be altered and they may need to postpone their initially
        agreed appointment. Provided this is completed in advance the Trust must
        endeavour to provide a new appointment as quickly as possible.

        Where the patient has to cancel an appointment – the original clock start date
        remains the date the referral was received by the Trust from the GP, there is no
        allowance in the 18 week guidance for any clock / time adjustments for patients who
        have cancelled / postponed their appointment with advance notice. The original 18-
        week clock period remains the date the GP referral was received within the Trust.
        This applies to all cancer fast track referrals as well as all 18 week referrals




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           Where a patient has cancelled an appointment in advance for the second time, it
           should be explained to the patient that they will be discharged in line with local
           policies on 18 weeks and that a letter will be sent to the GP confirming this. Should
           the referral still be required it is acceptable for the GP to re-refer the patient at which
           point a new 18-week pathway will be implemented.

           Where the hospital has cancelled / postponed a patient‟s appointment all attempts
           must be made to ensure that the patient is given another appointment as soon as
           possible within the national targets – the 18 week clock start date remains the date of
           the original GP referral

           Where a patient is discharged due to repeated cancellations of appointments and is
           discharged this should be recorded on the PAS system with details of the reasons
           and number of cancellations. The patient 18-week pathway should also be closed on
           the 18 week RTT system.
       .
                     10.4 2nd or Subsequent Appointments Postponed / Cancelled by
                          the Patient
     If new patients, given 10 days notice of appointment postpone two consecutive
     appointments they should be discharged back to the care of their GP. The GP must be
     informed, with a copy of the notification also being sent to the patient. All offers of
     appointment must be recorded on PAS. The Operational Manager must agree any
     exceptions to this policy.

     The only exceptions to this are:

                   Patients referred under the 2-week wait (suspected cancer referrals).

                   Those patients identified as urgent or as suspected cancer by the consultant

                   Those patients identified as vulnerable where it would be clinically
                    inappropriate to discharge patients without reasonable consultation and
                    discussion

           In these instances the 18 week clock / cancer 62 day pathway continues from the
           point the referral was received by the Trust, all attempts must be made to ensure that
           new appointments are offered within the 14 day period.

                     10.5 Hospital Postponements
     It must be recognised that hospital postponements and rescheduling causes the patient
     confusion and distress. Therefore the only reason to postpone a booked appointment is
     due to the sudden unplanned absence of medical staff. This does not include medical
     absences that identifiable in advance (more than 7 days) any outcome of postponement
     and reason should be recorded on PAS using designated code

     Wherever possible the patient who has previously been postponed must not be
     postponed a second time.

The patient who has been postponed by the hospital must have another appointment
arranged as soon as possible. Any new patient must not wait longer than the maximum
waiting time as according to the NHS Plan and Trust waiting time objectives. The patients‟
wait time still starts from the original referral date.



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     The patient must not be booked after the maximum waiting time set by the Trust. If the
     patient is postponed and the only capacity available for another appointment is beyond
     the maximum waiting time the appropriate Operational Manager must be informed and
     alternative arrangements made.

                   10.6 Clinic Cancellations
     All Healthcare Professionals must give at least 6 weeks notice when a clinic is to be
     cancelled or reduced. Notification should be in writing to the responsible Operational
     Manager. Any clinics cancelled or reduced with less than 6 weeks notice should be
     reported to the Divisional Manager/Clinical Director. Other than sickness or emergency
     cover the Clinical Director of the department must agree any leave requested with less
     than 6 weeks notice. All cancelled or reduced clinics must have the reason clearly
     identified on PAS.

     Divisions should monitor the number of clinics that are cancelled or reduced, as this will
     help them to understand their capacity to accept new referrals. (Details of cancelled
     clinics are published on the Trusts intranet and should be regularly reviewed by the
     division).

     The Operational Manager will inform the Outpatients Supervisor of the cancellation
     immediately. Where possible, cover for the clinic must be arranged by the Healthcare
     Professional. If this has not been possible then the clinic will be cancelled on PAS and
     appointments re-scheduled.

                   10.7 Monitoring of Achievement of the Standards in This Section
       The Performance information department will monitor hospital and patient initiated
       postponements including number of clinics cancelled on a weekly and monthly basis
       and this information will be reviewed at weekly specialty PTL meetings and at the
       weekly PTL meeting for divisions.

       Divisional General Managers will have mechanisms for agreeing the expected level of
       clinic cancellation in a year, set up monitoring arrangements and discuss any variance
       at Divisional meetings. These mechanisms will also monitor the period of notice given.

       Information on the above cancellations will be produced weekly by specialty and by
       consultant and reported at Divisional performance meetings




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                   10.8 Procedure for Dealing with Patient Initiated Postponements
                        (for new patients)



           Patient contacts the hospital to postpone their outpatient appointment


                             Record patient postponement on PAS


     Patient postponing appointment for            Patient postponing a second time
                the first time
       Attempt to contact patient by                 Discuss with consultant and
                telephone                          recommend patient be removed
                                                          from waiting list

     Able to contact           Unable to           Write to patient and GP informing
       patient by            contact patient              them of this decision
       telephone              by telephone

     Negotiate new        Allocate new
        date with        date to patient
     patient for as        for as soon
     soon after the      after the date
       date of the            of the
       postponed           postponed
      appointment         appointment
      as possible          as possible
     Send confirmation letter to patient




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      11 Patients who do not attend their Appointment (DNA)
                    11.1 Relevant Policy Statements
       Statements from Section 3 are relevant to this section

                    11.2 Aim of This Section
               This section aims to outline the local policy for patients who DNA appointments at
               Portsmouth Hospitals NHS Trust

                    11.3 Patients who do not attend their appointments (DNA) and
                         18 Weeks
     In line with 18-week national guidance, a patient‟s 18 Week clock stops for non-
     treatment in the following circumstances:

        A patient DNA‟s their first appointment following the initial referral that started their 18
        week clock, provided that the provider can demonstrate that the appointment was
        clearly communicated to the patient and that at least three weeks notice and a choice
        of two dates have been provided in the first instance

        A patient DNA‟s any other appointment and is subsequently discharged back to the
        care of their GP provided that:

The Trust can demonstrate that the appointment was clearly communicated to the patient
Discharging the patient is not contrary to the patients clinical interests
Discharging the patient is carried out in line with local policies on DNA‟s
Local policies are clearly defined (appendix 6) and specifically protect the clinical interests
of childrend who DNA (WNB, were not brought) for appointments or treatments and are
agreed with clinicians, commissioners and other relevant stakeholders

                    11.4 Checking Details & Notice Periods for Appointments
       As a first step all patients who DNA their first appointment must have their
       demographic details checked to ensure that previous correspondence has gone to the
       correct address, PAS records should be checked for details of the initial appointment
       choice and dates offered. Details should also be checked with the patients GP.

       If the details are correct, then they are to be removed from the outpatient waiting list.
       For vulnerable patients such as the elderly and children a clinical discussion as to the
       suitability of discharge should be made prior to discharge. The necessary changes
       must be made on the PAS system on the outcome of the clinic recorded on PAS and
       the 18-week RTT system

       If the patient details are incorrect both PAS and Patient Library records must be
       amended and another appointment sent or agreed upon as soon as possible.

       For patients` who have made their appointments by using the CAB system, they need
       to refer to the CAB training manual on line via the internet., but the following key
       actions must be carried out at the end of the clinic as part of AAD.
       Within the Service Provider Clinician Admin Section of Choose and Book
        Key actions:-

                Select relevant clinician by show all.


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              Filter by worklist, select appointments for booking.
              Click on the reason heading to sort the worklist.
              Find the DNAs.
              Click on the UBRN, select actions, select record DNA.
              Select options as appropriate.
              For the outcome select no further appointment.
              Use the additional comments box to inform the GP.



       Patients referred under the cancer 2 week rule (fast track referrals) that subsequently
       DNA their appointment must be contacted and given another appointment within 14
       days where possible. The GP must be informed by telephone of this event

                   11.5 Deciding on Outcome of DNA – Clinical Decision to
                        Discharge the Patient
       Within Portsmouth Hospitals NHS Trust it is standard practice in most specialties and
       where patients are deemed vulnerable to discuss any patients who DNA with the
       respective consultant / clinical staff.

       All patients who DNA a clinic should be discussed with the clinical staff at the end of
       the clinic and a clinical decision made as to whether the patient is to be discharged
       back to the GP or not. This will ensure that staff fulfil the requirements outlined in the
       18-week guidance. Specialties may have their own local policies for those patients not
       deemed vulnerable.

       Should the decision be taken to discharge the patient, then the patient and the GP
       must be informed in writing. Prior to this happening the administrative staff should
       ensure that the DNA did not occur as a result of an administrative error and that the
       patient was given reasonable notice of their appointment (three weeks for routine
       referrals) and a choice of at least two dates.

       The consultant must be made aware of this, usually this will occur at the end of the
       clinic. The patient must be informed of this in writing with a copy to their GP.

                   11.6 Deciding the Outcome – Clinical Decision to Not Discharge
                        the Patient
        For those patients where the clinical staff, decide it would be inappropriate to
        discharge the patient, as this is contrary to their clinical interests, a new appointment
        must be offered as soon as possible.

        The administrative staff should contact the patient by phone or letter to inform them
        that they have missed their appointment and that they should contact the department
        as soon as possible to arrange another appointment.

        When the patient contacts the department a new appointment should be offered as
        soon as possible.

        In these circumstances and only these circumstances (where patients are deemed
        vulnerable) the 18-week clock start date may be adjusted to reflect the date that the
        patient contacted the department to make the new appointment




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        Where patients have not attended (DNA) and the above processes have not been
        followed, i.e. the patient has not been discharged or deemed clinical vulnerable then
        the 18 week clock start date remains the date of the original referral

                   11.7 Suspected Cancer Patients and DNA
       The above processes regarding DNA‟s apply to Cancer patients with the following
       exception:

       Suspected cancer patient referrals whether by fast track GP or “Consultant Upgrade”
       should not be discharged for any reason, should such a patient DNA any of their
       appointments all attempts must be made to ensure that the patient books another
       appointment as soon as possible, within the 14 days from the DNA.

       All efforts should be made to contact the patient as speedily as possible (telephone)
       and the patients GP should be informed of the original DNA.

       For suspected cancer patients who DNA their appointment – the start period of the
       referral may be adjusted to the day the patient contacts the department. This will
       ensure that the Trust is not penalised for the patients DNA. Therefore a new clock start
       will begin for the patient‟s 14 day, 62 day and 18 week period.

       In line with the processes above all outcomes and decisions made should be recorded
       on PAS, and the RTT system



                 11.8 Discharge of vulnerable / cancer patients who DNA

       Where a vulnerable or suspected cancer patient DNA a second or third appointment
       the patients GP should be contacted and a decision taken to discharge the patient and
       refer back when the patient is ready to attend. A letter should be written to the patient
       and the GP informing them of the decision and the reason for this decision, with advice
       to refer the patient again when they are able to attend

                   11.9 Monitoring of Achievement of the Standards in This Section
       DNA‟s contribute significantly to reducing capacity ad access for other patients and all
       attempts to reduce DNA‟s must be made, DNA‟s are more common where patients
       have not been given enough notice of their appointments or where choice of
       convenient dates is limited. Use of reminder systems is currently being utilised within
       some specialties with improved results

       Information on the DNA‟s per specialty is produced on a weekly and monthly basis per
       specialty and discussed at all weekly specialty and divisional performance meetings.




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      12 Re-Instatement onto the Outpatient Waiting List
                   12.1 Relevant Policy Statements
    Statements from Section 3 are relevant to this section:

                   12.2 Aim of This Section
       Patients who have been removed from the outpatient waiting list can be re-instated if it
       is in the best interests of their health for this to happen or if they have been removed
       inappropriately.

                   12.3 Re-instatement for Clinical Reasons
     If a patient has been removed inappropriately, they can be re-instated at the request of
     the GP or Consultant as a new episode of care.

     However, it may not be necessary to ask the GP to re-refer if the patient‟s clinical
     circumstances have not changed. In this case, patients will be put on the outpatient
     waiting list as a new episode of care as the result of a telephone request from the GP.

     Patients will only be re-instated as the result of a Consultant or GP decision. Patients
     cannot be reinstated at their own request.

                   12.4 Re-instatement Following an Inappropriate Removal
     If the patient was removed from the outpatient waiting list and the removal was later
     found to be a mistake, then the patient must be re-instated without prejudice, as if he or
     she had never been removed. This is achieved by deleting the incorrect
     remove/discharge on PAS. This then maintains the original referral date.

                   12.5 Monitoring of Achievement of the Standards in This Section
     The outpatient/specialty operational managers will review outpatient templates annually
     to ensure maximum utilisation is established from the various outpatient clinics and
     ensure that these standards of best practice are applied as appropriate.




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     13 Ministry of Defence Patients
                   13.1 Procedures
      All Military of Defence (MOD) patients should be treated according to the maximum
      waiting time specified within the MOD contract with the following exception:

       Fast track outpatient referred patients should be seen by a Consultant within 14 days
       of receipt of the referral letter.

       It is the responsibility of the referring Medical Officer to ensure appropriate details and
       information is provided on the referral.

       The waiting times for MOD patients are as follows: -

          45% of all outpatient referrals should be seen within 4 weeks of receipt of referral.

          90% of all outpatient referrals should be seen within 13 weeks of receipt of referral.

          The outpatient referrals remaining should be seen within 24 weeks of receipt of the
           referral.

          Fast track outpatient referred patients should be seen by a Consultant within 14
           days of receipt of the referral letter.

       Appointments must be made as soon as possible and communicated effectively to the
       patient either directly or through the Medical Centre co-ordinating the patients care. All
       referrals must be recorded on PAS under patient category as MIL (Military) to ensure
       clear identification.

       If the patient does not attend their allocated appointment the referring Medical Officer
       must be notified. The patient must only be given another appointment if instructed to
       do so by the Medical Officer, Medical Centre or the Consultant that the patient is under
       the care of.

       All appropriate MOD paperwork must be completed for each patient. –




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     14 Follow-up Appointments
                    14.1 Relevant Policy Statements
       Statements from Section 3 are relevant to this section:

                    14.2 Aim of This Section
The aim of this section is to educate staff in the procedures and policies pertaining to the
management of patients who have received their first appointment but who require follow up
appointments in a planned or ongoing manner

                    14.3 Guidance for Booking of Follow up Appointments
      All follow-up patients must be seen within the clinically appropriate time, indicated by
      the clinician. A guide to the timeliness of booking follow up appointments is as follows:

                   Within 18 weeks for those patients who are having their first follow up and
                    who have not yet received treatment

                   Within 6 weeks or the timescale designated by the clinician for those
                    patients attending for their postoperative follow up / ward appointment

                   Within the time period designated by the consultant for those patients who
                    are attending for ongoing or planned follow ups.

       If everyone is seen in turn it is easier to meet the expected review times.

      Clinicians and managers need to design the clinic templates such that the number of
      slots available meet the demand from all sources of referral and ensure the maximum
      waiting time is met.

      In order to achieve the above timescales patients must receive their 6 week
      appointment (including ward follow-ups) prior to leaving the clinic or the ward. When
      this is not possible this should be escalated to the relevant operational manager and
      clinician to ensure alternative arrangements are made to confirm appointment.

      Appointments required over 6 weeks up to a maximum of 1 year should only be
      booked directly if the clinic capacity is confirmed. Where clinic capacity is not
      confirmed the patient should be informed that they will be contacted nearer the time to
      arrange a mutually convenient appointment date.

      A move away from partial booking systems to full booking systems allows the patient
      to choose a mutually convenient date for their appointment. Experience has shown
      that these patients are more likely to attend their appointment thus avoiding the need
      for rescheduling, minimising DNA rates and maximising the use of clinics.

                    14.4 Booking Follow up Appointments

      Updating of patient demographic details (name, address etc.) on PAS must take place
      at point of contact with the patient

      Follow up appointments (including ward follow ups) should be booked with the patient
      in attendance following on from an inpatient/ outpatient/ day case episode and prior to


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      the patient leaving the hospital. This allows the patient to mutually agree the date,
      without the need for further written or telephone conversations

      All appointments must be linked to the correct specialty referral on PAS

      Patient attendances/DNA‟s/postponements must be recorded on PAS within 48 hours
      of the clinic date

      Patients should be discharged if they do not have a future appointment and there is no
      intention to provide them with one and their Pas details and outcome details updated
      to reflect this

      SOS (open appointment) discharges can only be used for follow-up patients and must
      be for a period of no longer than six months. Following this period the old referral must
      not be opened. Patients must be re-referred under a new episode of care. If the
      patient is re-referred after the six-month time limit a new referral must be received and
      logged onto PAS, the old one must not be reopened.



                   14.5 Follow-up Appointments declined by the Patient
        If follow-up patients decline two reasonable offers of appointment they should be
        discharged back to the care of their referrer. The GP must be informed, with a copy
        to the patient. All offers of appointment must be recorded on PAS. The Operational
        Manager must agree any exceptions to this policy

                   14.6 DNA Follow-up Appointment
        The Healthcare Professional for the clinic must be informed of patients who have
        DNA‟d as soon as the clinic has finished. The decision to discharge or not to re-
        appointment a follow-up patient can then be made. The GP and patient must be kept
        informed of the decision not to re-appoint the patient due to the DNA.

        All patients who DNA (do not attend and do not give notice in advance), and have
        been discharged must be informed of this in writing with a copy to their GP.

        Exceptionally the Healthcare Professional may decide to offer the patient another
        appointment, based upon their clinical or social needs or because they are deemed
        „vulnerable‟.. These exceptions must be agreed at the department level in tandem
        with the Operational Manager.

        Should the patient be discharged all details must be updated on PAS and the RTT 18
        week system

                   14.7 Telephone / Virtual Follow Up’s
        Guidance on this is currently under development

                   14.8 Monitoring of Achievement of the Standards in This Section

        The performance and information department will produce information that indicates
        the different types of follow ups, the length of time follow-up patients have waited, by
        clinic, over a period of time. Operational Managers will use this to determine whether
        follow-up patients are being seen in turn.


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      15 Pre-operative Assessment and TCI Scheduling within
                    Outpatients
                   15.1 Relevant Policy Statements
                Statements from the Section 3 are relevant to this section:

                   15.2 Aim of section
               The purpose of a pre-admission assessment is to make sure that the patient is
               fit and ready for their procedure, and to ensure patients are given a reasonable
               offer of a planned admission dates.

               In some specialties within the Trust Pre Operative assessment clinics and
               scheduling of inpatient appointments are undertaken directly following
               outpatient appointments – it is the intention of this section to provide guidance
               for outpatient staff who will be involved in this scheduling onto inpatient / day
               case lists.

               Where this occurs staff should also be fully familiar with the 18-week rules for
               admitted patients and the inpatient waiting list procedures, which are
               contained, in a separate inpatient good practice guide.


                   15.3 Wait Time Targets for Inpatients and Day Cases
               Patients being added to the waiting list must receive their treatment within 18
               weeks from the original GP referral or the date of a new 18-week clock being
               started, if previous treatment has been provided or a new condition is
               uncovered.

               Within this there are various standalone targets for inpatient and day case wait
               times to ensure that patients progress along the 18 week pathway, these
               include targets for first outpatient appointments of 6 weeks, targets for
               diagnostics – 2-6 weeks and there is a locally agreed inpatient / day case wait
               time target of between 8-15 weeks from the point that the decision to admit
               (TCI) was made.

               For admitted / inpatients wait times should be

                     o    National Target - Within 18 weeks from the original GP referral or new
                          clock start date

                     o    Local Agreed Targets - For the inpatient part of the 18 week pathway
                          all efforts should be made to book patients within 12 – 15 weeks of the
                          Decision to Treat (TCI) date – this may be before or after the 18 week
                          breach date depending on when the decision to treat was made.

               In all cases the 18-week breach date should take precedence, as this is the
               new national target for patients.

               No patient on the inpatient part of the waiting list should exceed a wait time of
               over 15 weeks from the time the decision to treat was made


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                   15.4 When to Add Patients to the Waiting List
               The decision to add a patient to a waiting list must be made by the Consultant,
               or his or her team, in conjunction with the patient.

               Patients who are added must be clinically and socially ready for admission on
               the day the decision to admit is made. In other words, if there were a bed
               available within the wait time period in which to admit a patient, he/she would
               be fit, ready and able to come in.



                   15.5 When NOT to Add Patients to the Waiting List
              Those patients who do not fulfil these criteria on the day the decision to admit is
              made must not be added to the waiting list. This includes patients who do not
              require intervention at this stage of the care pathway.

              Patients not fit for surgery at the point of decision to admit should continue their
              care under their consultant where appropriate or returned to their GP‟s care with
              advice on re-referral when they are fit and ready. Patients are not to be added to
              the waiting list: -

                      If determined by clinician as unfit.

                      If patient are not ready and available for their operation/procedure.

              In addition patients should not be added if the following apply:

                      The procedure is on the agreed list of procedures not normally
                       commissioned by PCT‟s.

                      The procedure is normally performed in a primary care setting

                      The procedure is not recognised as clinically effective.

              The above normally form part of the PCT commissioning and exclusions policies
              based on NICE guidance – details of each policy and a comprehensive list of
              procedures can be found on the Prior Approval and the guide to Excluded
              Procedures Link on the Trusts Intranet page.

                   15.6 Determining Priority
               All patients who are added to the waiting list must be given a clinical priority.
               Patients should be classified as „Urgent‟ or „Routine‟. This priority should be
               adhered to in line with the consultant‟s instructions

                   15.7 Timeliness of Adding Patients to the Waiting List
               Once the decision to admit (DTA) has been made, the patient must be added
               to PAS immediately following their outpatient‟s appointment attendance. The
               date of addition to the waiting list should always be the date the decision was




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               made and the patient agreed that they were ready and available, not the date
               of the PAS transaction.

   15.8 Security and handling of the To Come In Card (TCI)

               Most specialties have developed their own specialty specific TCI cards to
               capture all of the relevant information re the patients planned
               procedure/operation within outpatients prior to adding to the waiting list on PAS.

               These TCI cards must be completed for every planned procedure/operation and
               the information gathered from the clinical teams in outpatients namely the Dr‟s
               and nurse led clinics and returned to the outpatient‟s reception desk to ensure
               accurate clinic close down.

               Speciality Outpatient areas need to ensure there is a documented safe transfer
               process of the TCI cards within the department and onwards to the relevant
               waiting office but this must not be within patient records.

               Peripheral sites need to ensure that the TCI cards are transferred back to
               relevant waiting list offices via secure routes such as yellow bags.


        15.9 Using the TCI card

               Once the information re the patient‟s planned procedure/operation has been
               recorded on the TCI card by the clinician. It remains the only record of the
               patient‟s forthcoming plans for surgical treatment until the patient is added to
               the waiting list and must be treated as an official patient record.

               As part of the clinic close down there is a need to keep the TCI and check
               receipt of cards against the clinic list and record TCI`s appropriately as a clinic
               outcome. Transfer of TCI`s to the relevant surgical information waiting list
               office, should be organised within specific specialties OP departments.
               However it should be borne in mind that information collected on the TCI card
               needs to be entered on to PAS immediately following their outpatient‟s
               appointment attendance.

               ate they were added to Portsmouth‟s waiting list.

     15.10Linking 18 week Outpatient and Inpatient episodes on RTT PAS
               At each outpatient appointment outpatient staff would have updated the
               patient‟s 18-week status by utilising the clinic outcome form. In this way all
               routine patients will have an 18-week pathway opened for their visit.

               Outpatient or Pre-assessment staff involved in the scheduling of inpatient or
               day case episodes of care should check the status of the patient on the 18-
               week RTT system and link both the outpatient and inpatient episodes so that
               the whole pathway is monitored. Detailed guides on the PAS RTT system
               changes are available form the ICT department; Training on the RTT PAS
               system is available from the training department.

               Completing the RTT PAS system with the status of the patient on the 18-week
               pathway is mandatory.



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               When the patient attends as an inpatient or day case admission for surgery –
               ward staff should update the 18-week pathway by indicating on the RTT PAS
               system whether the patient has received their surgery / procedure and whether
               this constitutes treatment. Patients who have received their treatment (surgery)
               will have their 18-week clock closed on the RTT PAS system

       15.11 Reasonable Notice and Patient Choice
              Staff booking patients onto inpatient waiting lists should offer a reasonable
              period of notice which for inpatients is 3 weeks and a choice of a minimum of 2
              separate dates for appointments in line with national guidance.


       15.12New and Subsequent Treatment 18 Week Clock Starts
               In Many circumstances a patient may have received previous treatment in the
               form of surgery, or may have had a clock stopped due to active monitoring of
               their condition. Where this has occurred and where at a follow up or
               subsequent outpatient visit the consultant decides to proceed with another
               treatment a new 18 week clock should be started from the date the decision
               was made by the consultant with the patient

               A new / additional 18 week pathway should be started in the following
               circumstances:

                     When a patient becomes fit and ready for the second of a consultant led
                      bilateral procedure

                     Upon the decision to start a substantially new or different procedure /
                      treatment that does not form part of the patients agreed clinical plan

                     Upon a patient being re referred to a consultant led service as a new
                      referral

                     When a decision to treat is made following a period of active monitoring

                     When a patient rebooks their appointment following a first appointment
                      DNA that stopped and nullified their earlier clock start


       15.13Categorising Patients on the Waiting List
               18-week rules now mean that previous categorisations of the waiting list have
               to be amended to fit with the 18-week rules. The list below describes the
               previous categories and how 18 weeks applies to them

                                   Active Waiting List:
                 Patients who are fit, ready and able to come for treatment within their 18-
                 week target date
   .
                                   Planned Waiting List:
                 In the past patients who have started treatment and there was a plan for the
                 next and subsequent stages. (E.g. removal of metal work) were not counted
                 on the active waiting list.




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                 Under new 18-week rules a new 18-week clock will start at each subsequent
                 where the patient requires a new stage of treatment, these patients should
                 now be regarded as part of the 18 week admitted patient tracking list and
                 managed as part of the active waiting list



     15.14 Categorising Patients Requiring Multiple Procedures
                 There are instances where patients are listed for more than one procedure
                 either in the same or different specialties. In these circumstances an 18 week
                 pathway should be available for both procedures / specialties; this should
                 have been opened at the stage of receipt of the referral. In this manner a
                 patient can be on an active waiting list (18 week pathway) for more than one
                 specialty at a time

                 If the procedures are independent of each other, and the patient could be
                 called in for either, then the patient must be added to the active list for both
                 procedures. An 18-week pathway can be running concurrently for both
                 procedures

                 When one procedure is dependant on the other then the patient should be
                 added to the inpatient 18 week wait list in order of clinical priority, an 18 week
                 pathway wait time can only be running where the patient is fit and able to
                 have their procedure within the 18 weeks. Once the most urgent procedure is
                 undertaken and the patient is fit to resume the second procedure a new 18-
                 week pathway can be initiated for the second procedure

                 If both procedures can be done at the same time by the same surgeon then
                 the patient should be added to the waiting list for the main procedure and the
                 other procedures recorded as secondary procedures as part of the same
                 episode of care.

                 If surgeons from more than one specialty will be needed to carry out a single
                 procedure or if the patient will need more than one procedure done while in
                 theatre and each procedure will be carried out by a surgeon from a different
                 specialty, add the patient to the waiting list of the consultant surgeon for the
                 main procedure, recording the other procedures in the second (and third)
                 place.

     15.15 Categorising Patients Requiring Bilateral Procedures
                 If the patient is listed for bilateral procedures and will have surgery on one
                 side first and the other later:

                    Add to the waiting list for the first side

                    Once the patient is deemed fit and able to continue with the second side a
                     new 18-week pathway should be started from the date that the patient has
                     been certified fit.

                 Waiting List managers and OM‟s must monitor these patients and arrange
                 admission for them as they approach the clinically determined date for the
                 next stage of their treatment.




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     15.16 Adjustments to 18 Weeks for Admitted Patients- Clock Pauses for
     Patient Choice
               Where a patient has received a decision to treat (TCI) and has been added to
               the waiting list and then chooses to decline at least two reasonable dates after
               having received at least 3 weeks notice, the clock may be paused for the
               duration of the time between the earliest reasonable offer and the date from
               which the patient makes themselves available again for admission.

               Local Portsmouth policy states that patients can only choose to pause their
               pathway for a maximum period of 3 months. Any exceptions to this must be
               agreed with the specialty operational manager.

               A clock pause effectively means that if a patient is at week 10 of their pathway
               and they choose to make themselves unavailable for a period of 8 weeks –
               they will resume their wait period at week 10 when they have declared that they
               will be available.

               Clock pauses and the reinstatement of the pathway should be explained to
               patients as they may not understand that the clock will resume where it was
               paused when they have said they are available, it does not mean that surgery
               will be performed at this exact time.

               All clock pauses must be recorded on the PAS system under suspensions for
               social reasons, all dates offered must be recorded and the dates where the
               patient is again available should be recorded



     15.17 Dealing with Patients who are unfit for Surgery - Medical
     Suspensions
               In the past patients have been added to the waiting list who may require
               anaesthetic assessment or who may become unfit for surgery, waiting list
               managers used national rules to take time out of the pathway for these patients
               under the medical suspension guidance. Under 18 weeks taking time out for
               those patients who are not fit for surgery is no longer allowed.

               It is appropriate for patients who are not fit for surgery not to be added to the
               waiting list until they are fit, patients requiring further treatment and monitoring
               under 18 weeks should therefore be managed in outpatients and receive
               treatment for their condition from their consultant or from their GP where
               appropriate. In this instance patients should be removed from the waiting list
               and managed under the appropriate 18 week care pathway

     15.18 Removing Patients from the Active Waiting List – When they are
     Unfit
               Patients who are not fit for surgery should be referred to their consultant for
               advice on future treatment. It is important that medical conditions leading to the
               unfitness should be treated.

               This may mean that patients should be removed / discharged from the waiting
               list and referred to the appropriate medical / clinical team or GP for treatment or
               active monitoring, until fit and ready to be added onto the waiting list again. In




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               this instance the current waiting list episode / 18 week pathway may be closed
               and a new pathway opened in the specialty the patient is referred too.

               A new 18-week clock will start when the patient is again fit and able to have
               surgery within the target period.

               Active monitoring for patients on an active waiting list is very rare – as all
               patients should be fit, willing and able to be treated within 18 weeks. Patients
               who remain on the waiting list but who are unfit for surgery will continue to have
               their 18 week clock ticking from the point of the original GP referral – such
               patients may then breach the 18 week target, as no time out is allowed for
               medical suspensions.

               For clinical record keeping waiting list managers should continue to record in
               PAS under medical suspensions where a patient is unfit but where the patient
               remains on the waiting list – no time out will be allowed as part of the 18 week
               pathway even though this is recorded

               Where patients are unfit for a short period of time – such as they require
               antibiotics for a cold, or require antibiotics for the treatment of MRSA, they
               should not be removed from the waiting list as this is likely to be treated within
               a couple of weeks and it would not be in the patients best interest to remove
               such patients. These patients should remain on the waiting list and their
               condition monitored – the clock start time will remain the original referral date
               and no adjustment will be made for the period that they are unfit. In this
               instance these patients may breach the 18 week target, but may well be within
               the 10% allowance for breaches for complex pathways



     15.19 Adding Patients Seen Privately for Outpatient Consultation
               Patients who have had a private outpatient appointment, but have elected to
               have NHS inpatient treatment should be treated in the same way as patients
               who have had a NHS consultation. That is, they should be added to the list
               without delay from the actual date of the clinical decision to admit. The waiting
               list manager should initiate a new 18-week pathway; from the date the decision
               to admit (TCI) was made. Patients should be managed as part of the 18-week
               pathway as all other inpatients

     15.20 Categorising the Booking Type
               All patients will be given an opportunity to choose the date for their surgery or
               treatment by the fully booked admissions system. It is important to record which
               type of booking system the patient participates in.



     15.21 Scheduling of Patients for Inpatient / Day Case Surgery from
     Outpatients
                 Patients attending one-stop pre-op assessment services must be given a
                 reasonable offer of admission. Using the theatreman System (for more
                 information refer to the Theatreman Operational Procedures view and book
                 patients onto an agreed vacant theatre slot. This should be completed in line
                 with 18 week rules and inpatient / day case wait time targets




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                 The following procedure should be followed:

                         Pre-admit Patient on PAS - Patients must be placed on a waiting list
                          and pre-admitted on PAS whilst at the same time recording the pre-op
                          assessment.

                         Patients unable to attend pre-op assessment at the time of attending
                          their outpatient appointment must be placed on a waiting list and
                          booked a future pre-op assessment appointment.



     15.22 Pre-Assessment – Introduction
                 Pre-operative assessment is the process that ensures a patient is fully
                 prepared, both physically and emotionally for planned surgery and
                 anaesthesia. Risk factors are identified and are eliminated, minimised or
                 accommodated.

                 Patient centred care should result in fully informed patients, who are able to
                 give appropriate consent and be involved in deciding the time and place of
                 surgery. Health care resources can be efficiently utilised with accurate
                 scheduling and fewer cancellations.

                 Patient selection and assessment involves a number of health care
                 professionals, the referring GP, staff, specialist surgical consultants, surgical
                 trainees, specialty nurse practitioners, pre-operative assessment practitioners
                 and surgical house officers. In many areas such as Day Surgery, pre-
                 operative assessment is carried out by non-medically trained staff, usually
                 experienced nurses. By working to locally agreed protocols these staff can
                 identify potential problems and unfit patients, and plan management
                 appropriately.

                 Ultimately the surgeon is responsible for the procedure to be performed and
                 the anaesthetist is responsible for deciding that a patient is fit for anaesthetic.



     15.23 Managing the Outcome of Preoperative Assessment
                 Following completion of pre-op assessment the nurse will review the
                 assessment to identify any major concerns that could impact on the patient‟s
                 forthcoming procedure. Any concerns will be discussed with the referring
                 clinician, as completion of the pre-operative assessment documentation may
                 identify that the patient is unfit to be added to the waiting list.

                 The referring clinician will always have the final decision and may decide to
                 add the patient to the waiting list depending on the patient‟s need for the
                 surgical operation/procedure. All patients who are unfit for surgery will have
                 referrals made directly to relevant specialties either by the healthcare
                 professional or by the POA nurse in liaison with the healthcare professional
                 using the hospital PAS system.

                 Where patients are identified as unfit for surgery, the relevant referring
                 clinician and waiting list manager should be informed so that future
                 treatments options can be discussed with the patient.



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                 Wait list managers in collaboration with clinical staff should make the decision
                 as to where future treatment is best provided – either in an outpatient setting
                 or within primary care. The appropriate decision taken should be recorded on
                 RTT PAS – all of the 18 week rules for inpatient management identified above
                 should be adhered to.

                 Refer to the Inpatient & Day case Waiting List Good Practice Guide for
                 managing patients who are not ready/unavailable for treatment.




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      16 Managing Planned Clinic Capacity
                   16.1 Aim of this Section
     The aim of this section is to inform staff to utilise all planned clinic capacity

                   16.2 Procedures
     Vacant new and follow up slots should be identified by the outpatient booking staff at
     least twice a day using the live utilisation report produced by the business intelligence
     department. This report is available via the corporate information reports on the intranet.

     Vacant slots should be used to bring forward patients with longer waits where
     appropriate.

     Where patients have cancelled their appointments the Patient Cancellation process
     outlined previously should be followed and patients should be appropriately removed
     from the PAS system and their discharge recorded on PAS to ensure that the slot is
     freed for future use

     Similarly any discharge should result in the 18 week pathway being adjusted to reflect
     the change in the patient‟s status

     Escalation for vacant slots and reuse should be developed within the specialties and
     divisions and weekly specialty booking meetings should review any vacant slots for the
     week ahead to ensure maximum utilisation.

                   16.3 Monitoring of this Section
     The business intelligence department will monitor the utilisation of planned clinic
     capacity on a weekly / monthly basis and this information will be reviewed at weekly
     specialty meetings




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      17 Clinic Outcome Forms
                   17.1 Aim of This Section
               The main aim of this section is to explain the clinic outcome form and its use
               with the closedown of outpatient clinics. The aim of the clinic outcome form is to
               collect information pertinent to the measurement of the 18 week pathway to
               ensure that all stages of treatment are recorded at each outpatient visit. An
               example of a clinic outcome form and definitions relating to clinic outcome
               codes are available in Appendix 3

                   17.2 The Clinic Outcome Form
               Most specialties have developed their own specialty specific clinic outcome
               forms for recording the patients 18 week status on RTT PAS. Some specialties
               also utilise the trusts generic clinic outcome form an example of which is in the
               appendix. Both the generic and specialty based clinic outcome forms contain
               the information relating to clinics and follow ups that were part of the old blue
               routing cards, so that one form is utilised to capture all of the relevant outpatient
               information required.

               Once the information contained on the clinic outcome form is input onto the
               RTT & PAS system as part of the clinic close down there is no need to keep the
               clinic outcome form unless specialties wish to do so. This should be organised
               within specific specialties OP departments. However it should be borne in mind
               that information collected on the clinic outcome forms will be entered on PAS as
               part of the clinic close down

                   17.3 Using the Clinic Outcome Form
               One form is completed for every new and follow up outpatient appointment, the
               patient sticker is entered onto the form during the clinic preparation by the
               outpatient staff.

               The form has been designed to have a tick box approach to minimise workload
               and should not take long to complete (see example in appendix 2) the main
               sections of the form (section A & B) should be completed by Health Care
               Professional seeing the patient. On completion of the form, the patient will
               return to the reception desk to schedule any further appointments and hand in
               their clinic outcome form to be processed.

                   17.4 Closing down Clinics –
               It will be the role of the outpatient clerk to enter the information collected from
               the doctor on the clinic outcome form into the RTT PAS system, which contains
               the RTT codes required to stop, start or continue clocks on the 18 week
               pathway.

               Clinics will continue to be closed down as they currently are in one of the
               following ways:

                       Ongoing throughout the clinic as each patient reports back to the
                        reception

                       Forms collected and completed at the end of the clinic


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               Clinics should be closed down within 48 hours of the clinic having occurred,
               clinic outcomes need to be entered on the PAS system within 2 working days
               following the end of the clinic.

               If you are unsure of how to complete the forms, please speak to one of the
               outpatient supervisors / managers within your outpatients or some of the senior
               clinical staff. These forms must be completed for every patient attendance and
               the information gathered from the clinical teams in outpatients namely the Dr‟s
               and nurse led clinics is critical to the Trusts recording of its performance for 18
               weeks

                   17.5 Monitoring
Weekly reports on the status of completion of clinic outcome forms will be produced by the
business intelligence department as part of the 18 week reporting, this information will
indicate which consultants, specialties and categories of codes are using the clinic outcome
forms.

A weekly non admitted patient tracking list will be produced by the performance and
information department indicating patients position per week on the non admitted PTL as
well as the number of patients who have not yet received treatment within and over 18
weeks

Spot checks by outpatient supervisor/managers on accuracy of clinic form completion should
be completed regularly as failure to complete clinic outcome and disposal codes can
influence the Trusts performance against the 18 week target as well as influence income
received into the Trust




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      18 Validation and the use of Primary Targeting Lists
                   18.1 Aim of This Section
               The aim of this section is to ensure that, staff in outpatient departments, are
               familiar with the patient tracking list and the validation processes required to
               ensure that patients receive care in a timely manner.

               Inevitably, some patients will move out of the area, choose to be seen privately,
               get better or for other reasons will no longer need their appointments. It is also
               inevitable that PAS records will contain some inaccuracies. It is therefore
               essential that the accuracy of the data on PAS is checked regularly and that the
               longest waiting patients are contacted regularly to ensure only those patients
               who require an appointment remain on the waiting list.

                   18.2 The Non Admitted Patient Tracking List (PTL)
                 This list contains details of all patients who have been referred for the Trust
                 who have not yet received their Treatment, or who have not yet had their 18
                 week clock closed on the RTT PAS system.

                 Currently this list is subdivided into the following sections:

Total list of all non admitted patients currently on an 18 week pathway who have not yet had
treatment – this is further broken down into
    o A list of all non admitted patients who have not yet received their first appointment
    o A list of all non admitted patients who require a follow up appointment – who have
         not yet received their first treatment – in other words their 18 week clock has not yet
         been stopped on the RTT system. This list is different to the list of ongoing planned
         follow ups (previous OWL lists)
    o A list of all patients on the above lists who are booked over 18 weeks

        The above lists all patients with and without an appointment and can be utilised by
        outpatient staff to book patients to their 6 week targets and to book patients into their
        follow up appointment within 18 weeks (where these patients have not yet received
        treatments).

The non admitted PTL currently contains a number of patients on both the follow up and new
patient sections that are booked over the 6 week target or who exceed the 18 week Target –
part of this will be the due to clocks not have been stopped in the past due to the newness of
the clinic outcome forms or the RTT system earlier in the year – all efforts must be made to
update patients and use the clinic outcome forms to stop clocks where this is required.

                   18.3 Lists for Ongoing / Planned Follow Up Patients
                   The above non admitted 18 week PTL currently only caters for those
                   patients who are new or registered for a follow up appointment – where the
                   patient has not yet received treatment.

                   In addition to this listing there will be a number of planned & ongoing follow
                   up patients whose 18 week pathways have been closed who will require
                   ongoing care and who are booked in advance as follow up patients – these
                   patients currently are not part of an active 18 week pathway but ongoing
                   care should be provided as per the consultants request and capacity should
                   be made available for booking.


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                   There are currently different procedures for managing follow up
                   appointments in different specialties and departments ranging from the use
                   of the OWL function on Pas to direct booking of the follow up appointment.
                   Whatever method is being utilised outpatient supervisors should ensure that
                   capacity is made available for follow up appointments by escalating
                   problems to operational managers

                   18.4 18 week Clinic Outcome Status Reports
               Each week a report indicating the use of the clinic outcome forms and the
               status of patients on the system will be published by the business intelligence
               department, It will be the operational manager and the specialty supervisors
               role to educate staff and clinical staff on the use and importance of the clinic
               outcome forms



                   18.5 Accuracy of the PTL
               To ensure that the non admitted PTL is accurate it is vitally important that all
               patients have an 18 week clock initiated when the referral is received – as
               mentioned previously this includes all referrals and not just GP‟s. All new
               referrals should be booked for their appointment within 6 weeks unless it is
               prioritised an urgent in which case this should be 2 weeks.

               Each time the patient attends an appointment at any site within the Trust it is
               expected that the clinic outcome form will be completed by the clinical staff;
               information must be entered onto the PAS RTT system at the clinic close down
               each week

               The above 2 procedures explained previously in the document must be
               adhered to as they are critical to ensuring that the 18 week non admitted PTL is
               up to date and accurate.

               In addition to the above the 18 week validation team should focus efforts on
               ensuring that all referrals prior to June 2008 – are validated for their 18 week
               status by using patient letters – this should be amended on the PAS RTT
               system so that information on patients prior to the introduction of 18 weeks and
               the RTT system are accurate and updated to reflect the patients current status.

                   18.6 Validation of the Non admitted PTL / Waiting List
            Validation of the non admitted PTL is critical to ensure that patients are now
            booked in a timely manner in line with their 18 week pathway. The following
            paragraph outlines the type of validation that will be expected on an ongoing basis
            on the non admitted pathway and the key staff responsible for this

            Validation of any new referrals booked over 6 weeks
            This is the responsibility of the outpatient booking centre manager in the first
            instance whose department is responsible for the booking of all new
            appointments. Where the over booking is due to capacity not being released
            within the specialty the outpatient booking manager should liaise with the
            appropriate speciality operational manager to look for solutions and ensure all
            booking are made within Trust targets. Escalation policies should be designed to




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            ensure that booking over targets is highlighted to divisional general managers
            where appropriate

            Validation of referrals on the non admitted PTL who are shown as being
            over 18 weeks
            A first stage validation of all patients showing over 18 weeks should be carried out
            by the 18 week validation team who report to the 18 week business intelligence
            performance manager. The majority of these patients are likely to have had
            treatments in the past but their 18 week status code has not been entered onto
            the system. This category of patients should be validated and their correct status
            entered onto the PAS RTT system


            Ongoing Validation of the non admitted PTL showing over 18 weeks
            (Backlog)
            Once the above first step validation is completed any new patient booked over 18
            weeks should be validated for by the specialty outpatient supervisor or their
            delegated persons within the specialty. This information will be supplied weekly
            and will indicate to the outpatient supervisor and staff where clinic outcome forms
            are not being completed correctly. it is the specialty outpatient supervisors
            responsibility to ensure that clinic outcome forms are being completed and the
            RTT system being completed in line with policy.

            Validation of patients reported as breaches on the weekly treatment report
            Each week a report of all non admitted patients treated will be reported to the
            SHA and DoH. This report indicates the number of patients treated within and
            over 18 weeks. Breaches of the 18 weeks should be validated by outpatient
            supervisors to ensure that these are real and that clock start and stop dates have
            been recorded correctly. Information on this must be reported to the business
            intelligence department by each Wednesday before 12 noon. It is the
            responsibility of the specialty operational manager and the specialty outpatient
            supervisor to validate and check all patients who are indicated to be over 18
            weeks and breaches of the 18 week pathway – reasons for breaches should be
            audited and practices changed to manage pathways

        All of the above Validation processes should be carried out on a weekly basis to
        ensure that 18 weeks and the changes required is embedded at a specialty level.

                   18.7 Internal Quality Validation of all Outpatient Information
               In addition to the above validation of the non admitted PTL, there is a
               requirement to ensure that quality validation of all outpatient information is
               performed on a regular basis. The use of the Primary Targeting Lists and PAS
               waiting list reports will enable this to happen through the identification of any
               potential long waiting patients.

               This will include checks for:

                  Duplicate referrals

                  Cases where the patient has been seen in the department by another
                   healthcare professional and the original referral has not been closed down.

                  Inpatient postoperative follow-ups on the system as new GP referrals.



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                 All validation action on PAS must have a clear audit trail and follow the
                 guidance set by ICT Applications and Data Quality departments.

                 The business intelligence department is responsible for producing the relevant
                 reports and the above quality validation remains the responsibility of the
                 outpatient booking centre manager and supervisors

                    18.8 Validation of Patients with Stage of Treatment Waits over
                         11 Weeks
                 Within 18 weeks there remains a stand alone target for the wait times for all
                 new GP referrals; currently all new GP referrals that exceed a 13 week wait for
                 their first appointment will be reported as a national breach of the 13 week
                 target. In order to prevent this business intelligence department will produce a
                 weekly report which identifies all new GP referrals that have exceeded an 10
                 week wait time.

                 All patients indicated as being over this 10 week period must be contacted by
                 telephone or by post to check their demographic details each month, and be
                 offered earlier appointments. New routine appointments must be given 2 weeks
                 notice of a change in appointment.

                 GPs must be kept fully informed of what is happening with their patients if their
                 patient decides to remove him or herself from the waiting list. This can be via
                 copied confirmation letters to the GP or by a report to the GP practice. The GP
                 can always re-refer after discussing the patient‟s decision with the individual.

                 Responsibility for ensuring that new patients do not breach guidelines and
                 targets remains with the specialty outpatient supervisor . a flow chart outlining
                 the process is available in Section 16.13


                    18.9 Managing and Validation of Choose and Book and Clinic
                         Templates
                    18.10          Management of the Directory of Services (DoS)
                 Where services are offered on more than one site and separately bookable,
                 patients should be able to choose which site they attend for their appointment.

                    18.11          Management of Clinic Templates
             o    New and Follow up appointments should be set-up on separate clinic codes;
                     If a clinic is released to choose and Book and the follow up
                        appointments are overbooked, this will prevent the new capacity being
                        released through Choose and Book.

             o    Each clinic should be set up to the period of time which truly reflects the
                  frequency of the clinic. Ad-hoc clinics should only be used for one off
                  occurrences of clinics;

             o    There should be one clinic code for each location that a clinic is held;

             o    Every appointment slots much have a duration of at least 1 minute (i.e. 09:00-
                  09:05);



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             o    Each appointment slot is to be allocated to 1 patient;

             o    The session of the templates should be set up for one hour either side of the
                  predicted start/end time of the clinic;

             o    Appointments should not be allocated to a „soon‟ waiting time;

             o    New Appointments should be allocated to the relevant Choose and Book
                  service as defined in the individual specialty guides

        Each department is responsible for the CAB DoS and clinic templates.
        For any change in service that requires amendments to the DoS, it is the
        responsibility of the department to liaise with the CAB team.
        Annual validation of all clinic templates must take place to ensure all capacity is
        available on CAB.

                    18.12      Monitoring of Achievement of the Standards in This
                         Section
                 A series of new reports will be compiled by the performance / information team
                 to assist operational and divisional managers manage the outpatient‟s capacity
                 and targets required.




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                   18.13      Flow Chart & Process for Validating Outpatient
                        Waiting List
                                     Patients waiting > 10 weeks are identified




                         Check patient demographics comparing referral letter and PAS




   Patient contacted either by letter or telephone and asked if they wish to remain
   on the waiting list




     Patient responds                          Patient responds „Yes‟       Patient does not respond after
           „No‟                                                                        3 weeks




      Remove from list                      Keep patient on waiting
                                          list and make appointment         Check patient details with GP
      and advise GP &
                                                   as normal
        Consultant



                                                PAS details incorrect
                                                                                  PAS details correct



                                               Amend details on PAS
                                                                            Remove from list and advise
                                                                             patient, GP & Consultant


                                              Start process again using
                                               correct contact details




                                              Patient does not respond
                                                after further 3 weeks



                                         Remove from list and advise
                                          patient, GP & Consultant



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        19 Roles and Responsibilities in Managing Outpatient Waiting
                     Lists
     This section outlines the key responsibilities of key groups of staff within the Trust in
     relation to the Outpatient Waiting List Policy and Good Practice Guidance. The list is not
     exhaustive and each group will have other roles and responsibilities that are not listed
     here.

    All Staff
     Adhere to the key rules and regulations outlined in the policy.

        Adhere to the principles of the policy when new scenarios arise.

        Support colleagues in the implementation of the policy

    Consultants
     Take decisions to remove patients from the outpatient waiting list if they postpone
      two or more appointments or if they have DNA‟d

    Chief Operating Officer – or designated lead
     Lead on the development of policy relating to elective waiting list management.

        Support all staff in the implementation of practice that supports the policy of the
         organisation.

        Ensure the Policy and Good Practice Guidance is reviewed annually or as new
         guidance is issued by the Department of Health or Strategic Health Authority

        Ensure the standards within the policy are monitored and that the reports are
         discussed and acted upon at the weekly wait list PTL meeting chaired by the Head of
         the Business Intelligence Department

    Outpatient Booking Centre DGM & Operational Manager
     Ensure that all policies and procedures outlined in this policy are carried out within
       the booking centre for all new appointments , cancer referrals and inter provider
       transfers between Trusts

        Ensure all staff are aware and have been educated on RTT PAS system and 18
         weeks

        Provide specialist knowledge and support to the DGM and OM‟s on issues relating to
         their waiting list & shortages of capacity

        Ensure their is an efficient escalation process in place when capacity is not available

        Ensure outpatient lists are validated for quality validation

        Identify waiting list issues and training requirements for the outpatient booking Staff



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       Lead on the annual review of the outpatient policy for the chief operating officer

    Divisional General Managers
     Ensure posts are funded and that outpatient clerical staff involved in the booking of
       follow ups and other appointments are adequately resourced to carry out their roles.

       Ensure monitoring of achievement of key standards of the Policy and Good Practice
        Guidance is being carried out.
       Ensure that enough capacity is available to manage the booking requirements for all
        patients new and follow up and C&B

       Ensure that the policy on consultant to consultant referrals is communicated within
        their division to the clinical staff

       Ensure that follow up patients are seen in a timely manner in line with the policy and
        the clinical requirements

       Ensure that clinic outcome forms are utilised within the specialties

       Ensure that structures and processes exist for the validation of patients being booked
        over 6 weeks is undertaken within the divisions

    Operational Managers
     Work with outpatient clerical staff when a decision needs to be made to remove a
      patient from the waiting list if they postpone two or more appointments or if they have
      DNA‟d

       Work with consultants to discuss situations where a decision needs to be made to
        remove a patient from the waiting list.

       Ensure that there is regular communication with the outpatient booking centre
        regarding the status of their capacity and booking

       Ensure that there are adequate escalation policies within the specialty to the
        divisional GM‟s where capacity is required and not available

       Ensure that there are adequate procedures in place within the specialty for the
        booking of follow ups in a timely and appropriate manner

       Ensure staff are trained and have adequate resources to perform the role expected
        of them

       Interpret policy when procedure is unclear and direct waiting list staff appropriately.

       Deal with patients who want to challenge the policy and the procedures being
        followed by staff.

       Monitor the achievement of standards within the policy and good practice guidance
        and ensuring action is taken to improve performance against these standards

       Ensure that outpatient supervisors for the specialties are aware that their roles
        extend across the specialty

       Ensure maximum utilisation of all available capacity


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    Outpatient Operational Manager / Supervisor
     Provide specialist knowledge and support to the DGM and Operational Managers on
       issues relating to outpatient waiting list management

       Lead on the management of outpatient services to ensure targets are met and
        standards are achieved

       Work with Operational Managers to ensure all key waiting time and waiting list size
        targets are met

       Support, develop and implement good outpatient waiting list management

       Identify training needs of outpatient clerical staff and ensure all staff are receiving the
        training they need to carry out their roles

       Ensure outpatient waiting lists are validated regularly

    Specialty Outpatient Supervisors –
     Ensure that all staff are aware of the policy and procedures contained within this
       document

       Ensue that adequate procedures exist to provide guidance to outpatient staff for the
        booking of follow up patients

       Ensure that all staff are aware of 18 weeks and have undertaken the 18 week RTT
        PAS system training and understand the use of the clinic outcome forms

       Ensure that use if made of the non admitted PTL to ascertain that validation in line
        with this policy is completed

       Responsible for the validation of the outpatient list for quality issues on a monthly
        basis and for the validation of patients booked over the Trust targets as outlined
        above

       Responsible for ensuring that escalation procedures for the cancellation of clinics
        and the requirement for additional capacity is initiated to the operational manager

    Outpatient Waiting List Staff
     Categorise patients on the waiting list correctly

       Carry out regular validation of outpatient waiting lists

       Book outpatient clinics and select patients for appointments based upon the principle
        that Fast Track Cancer patients will be seen in two weeks, urgent patients will be
        seen in relation to clinical priority and routine patients will be seen in turn.

       Offer patients appointment dates according to these principles and ensure all
        outcomes of offers are recorded appropriately on PAS and on the patient contact log
        if the offer is declined
       Carry out the all other procedures as described in the Good Practice Guidance

       Contact the Operational Manager or Outpatient Supervisor if new scenarios arise
        that are not covered by the Good Practice Guide


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    PAS Trainers
     Ensure all new staff are taught to use PAS & the RTT 18 week PAS Module properly
      and that training is aligned to the outpatient waiting list policy.

       Link refresher training to data quality issues

    Business Intelligence Managers
     Monitor achievements of the standards outlined in the policy

       Produce and distribute PTL‟s in line with the abovementioned policy and aligned to
        the achievement of 18 weeks

       Work with OM‟s to ensure demand and capacity are balanced to enable targets to be
        consistently achieved

    ICT Department
     Ensure PAS functions in such a way as to support the waiting list policy

       Carry out regular audits to ensure all transactions are recorded accurately and in a
        timely way

       Provide information to senior operational staff where compliance with the standards
        in the policy are not being achieved




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      20 Appendix 1 – Glossary of Terms

For the purposes of this policy, the following terms have the meanings given below:


Full Booking in               Patients awaiting an elective appointment who have been given an
Outpatients                   appointment date that they have had the opportunity to arrange and agree
                              after one working day of the GP deciding to refer to the speciality service.

Outpatients                   Patients referred by a General Practitioner (medical or dental) or another
                              Consultant/Health Professional for clinical advice or treatment in an
                              outpatient clinic.

Did Not Attend                Patients who have been informed of their appointment date whom, without
(DNA)                         notifying the hospital, did not attend.

Self- referrals               Patients who refer themselves to a service seeking advice or treatment
                              directly rather than through their GP.

OWL                           Outpatient Waiting List function located on the Torex PAS system.

Partial Booking in            An administrative booking system on PAS where the patient is sent an
outpatients                   acknowledgement letter on receipt of the referral and then invited to
                              contact the Trust and mutually agree an appointment 6-8 weeks prior to
                              the clinic occurring.

Primary Targeting List        This is a list of all the potential long waiting patients in each speciality who
(PTL)                         are at risk of breaching the maximum NHS Plan waiting times targets.

Acknowledge                   An administrative booking system on PAS where the patient is sent an
& Hold                        acknowledgement letter on receipt of the referral and then an appointment
                              is sent to the patient 6-8 weeks prior to the clinic. The patient is not
                              involved in agreeing the appointment date or time.

“Hand- off”                   A process that occurs which is not experienced by the patient, such as
                              paper work in the booking process.

Korner wait                   Calculated waiting time as per the Information Authority guidelines, from
                              the appointment that has been DNA‟d or patient postponed.

Charter wait                  The actual full waiting time for a patient excluding any breaks in calculating
                              the waiting time caused by DNA‟s or patient postponements.




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21 Appendix 2 - List of DoH Guidance Documents


   o    Getting patients treated handbook – National Patient access Team 1999

   o    Portsmouth Hospitals inpatient / day Case Waiting List Guide – Good Practice Guide
           2003

   o    Delivering the 18 Week pathway – 18 week suite – national clock rules – DoH 2008

   o    18 weeks – a how to guide to applying 18 weeks – DoH June 2008

   o    18 weeks – a how to guide to measuring 18 weeks – DoH June 2008

   o    Portsmouth Hospitals NHS Trust – Inter Provider Transfer for 18 weeks Procedure –
           Draft 1 2008

   o    The 18 week Rules – NHS South Central monitoring for Non consultant led services
           – November 2008

   o    Access to health Services for Military Veterans (Gateway 9222) DoH, December
           2007

   o    Priority Treatment for War Pensioners , Health service Guidelines (97) 31 DoH June
            1997




22 Appendix 3 – Clinic Outcome Form – example (see attachment)


23 Appendix 4 - Inter Provider Transfer Form




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                              18 Week - Inter Provider Transfer Form
Referring Organisation
                                                            Treatment
 Organisation Name:
                                                            Function Code
 Organisation Code                                          Contact Name

 Referring Consultant                                       Contact Phone
 and code
 Specialty:                                                 Contact E Mail


Who is to receive the referral?
 Receiving organisation:                                    Receiving Consultant:

 Specialty and treatment code:                              Date MDS sent:


Patient details:
 Patient Surname:                                           Forename

 Patient Title                                              Date of Birth:

 Address:                                                   Email:

 NHS Number:                                                Work Phone:

 Home Phone:                                                Mobile:



GP Details
 Name of GP:                                                GP Practice Post Code:

 PCT Code:                                                  GP Practice Code:



18-Week information - Information must be Completed
 Unique Pathway Identifier:                        Organisational Code: RHU
 Reason for Referral - Please Tick Appropriate Box Below:
 Transfer of Clinical Responsibility – 01 – Specify whether         Opinion Only - 02
 Inpatient or Outpatient:
  Inpatient Procedure Only         Outpatient Appointment           Diagnostic Test Only - 03
 Not Applicable to 18 Weeks –     Not Known - 99                    Other Please Specify
 90
 RTT Status – Please Tick Appropriate Box Below:
      12 - Start of a new pathway? (New condition or change of treatment)

     
                                                  st
         20 - Continuation of an active pathway (1 definitive treatment not yet given)

     90 – First treatment occurred previously (1 definitive treatment given)
                                                       st

 18 Week clock start date        Date of Decision to Refer          Date Referral Received


 Please Fax or Send with Referral Letter or Specialty Referral Criteria to the following
 Fax Number / NHS Address: pho-tr.18weeksITRPHT@nhs.net or 023 9286 6844



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In all other cases, where a hospital consultant thinks that referral to another consultant may
be necessary for a patient registered with a Fareham and Gosport or East Hampshire G.P, a
letter should be sent back to the G.P providing the patient‟s details and explaining fully why
the referral is recommended. This policy also applies to all tertiary referrals and outpatient
referrals from Accident and Emergency (unless the above exclusion criteria apply).

This will enable the patient‟s G.P to review the appropriateness of the referral taking into
account:

        the conditions for which the patient has already been investigated and received
         treatment

        the expertise and services available within primary care and the community to assess
         and manage the patient‟s condition

It will also ensure that the patient is offered a choice of provider for their assessment and
treatment.

The consultant will need to advise the patient but this should be done in such a way as to not
raise expectations that a further referral will be made e.g „I will write and let your GP know
about this problem and your GP will contact you to confirm how this will be managed.‟

The patient‟s GP will review the information from the consultant and decide whether the
condition can be managed within primary care or if a referral is required (this may be to a
locality service or secondary care). The GP is responsible for ensuring the patient is fully
engaged in this process and for offering Choice at the point of referral.


3.     Monitoring and Evaluation
The Primary Care Trust will monitor consultant to consultant activity on a monthly basis.
Information will be available for each provider on a specialty basis by Practice.

The Trust (through Practice Based Commissioning Clusters) will audit these referrals to
ensure they are appropriate and adhere to the exclusion criteria.

It is recognised that unnecessary delays should be avoided, and that over time, more
exception criteria may be added as care pathways are jointly agreed. This work will be
progressed via the Whole Systems Diagnostics Board, and will involve significant clinical
input from primary care.

This policy and its impact on the number of consultant to consultant referrals will be formally
reviewed after 6 months from the date of implementation.


August 2006

25       Appendix 6- Policy for Children who ‘DNAed’ (Were not brought,
WNB) for appointments or treatment at PHT.




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      1. Background

      The issue of children who do not attend (DNA) appointments has been raised nationally
      and locally:

      Confidential Enquiry into Maternal And Child Health – Why Children Die. A Pilot
     Report 2006.
    “Health Services, including primary care and Child and Adolescent Mental Health
   Services (CAMHS) should proactively follow up children who do not attend their
   appointments.”
http://www.cmace.org.uk/getattachment/c77d8563-8795-442e-a998-f4aaef0cfe68/Why-
Children-Die--A-pilot-study-(2006)-Children---.aspx


       NSF for Children 2004, Core Standard 3 (7.6, 7.7)
      Children or young people failing to attend clinic appointments following referral from
      their general practitioner or other professional may trigger concern, given that they are
      reliant on their parent or carer to take them to the appointment. Failure to attend can be
      an indicator of a family’s vulnerability, potentially placing the child’s welfare in jeopardy.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidan
ce/Browsable/DH_4867287

       Serious case review AFE April 2009 – recommendation 17.1
      ‘PHT need to review their procedure for ..writing to the young person/parents if
      child/ren/young people are not brought to appointments, to ensure standard practice
      across the organisation where children are involved.’

This policy has been developed to address these directives and will apply across PHT
wherever children are seen as outpatients or for elective treatment

      2. Key Principles

2.1      Children do not „DNA‟ appointments; rather they „are not brought‟ to appointments.
         Therefore, we would encourage all staff to use the nomenclature of WNB (Was Not
         Brought) rather than DNA (did not attend), although PAS will continue to record as
         DNA. When a child is not brought for appointments, the decision to be made is
         whether this non-engagement has potential to cause harm. This will direct the
         management of the case.
2.2      The health needs of children and the guidance in this policy over-ride any generic
         managerial directives or policies relating to follow-ups.
2.3      Legally, a child is anyone who is less than 18 years of age, regardless of their
         domicile, marital status or any legal order in force. However, from age 16, new
         referrals are made to the adult service and increasing autonomy is expected. In this
         age group, consideration must be given to the young person‟s capacity and
         vulnerability, in deciding whether this guidance applies.
2.4      When appropriate, children should be directly involved in their own medical care.
         This includes offering them (older children) the opportunity to contribute to decisions
         regarding their care.
2.5      Children can be grouped into new referrals and follow-ups, with known safeguarding
         concerns and without, and this is reflected in the policy. Health professionals should
         determine follow-up requirements on an individual patient basis.
2.6      Health visitors (HVs) have a key role in supporting children of pre-school age and
         should be copied in to correspondence about WNB issues by means of a copy letter



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        enclosed with GP letter. HVs collect mail from GP surgeries on a weekly basis and
        this pathway is thus not suitable for urgent requests/information.




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                    CHILDREN WHO ‘DNA’ (WERE NOT BROUGHT,
                    WNB) FOR APPOINTMENTS OR TREATMENT AT
                          PHT – MANAGEMENT PATHWAY
                  New referral, no            New referral,              Follow up, no                     Follow up, known
                  safeguarding                safeguarding               known                             safeguarding concerns
                  concerns                    concerns                   safeguarding
                                                                         concerns

                                                                   Usually 1
                                                                    further
                 Reappointment not                              appointment
                 automatic. Write to                          offered. Repeat
                    parent cc GP                                                                    Discuss with
                                                               WNB – assess
                  outlining options                                                              GP/HV/safeguardin
                                                                 potential for
                   (see full policy)                                                             g team, contribute
                                                                harm, gather
                                                                                                   to a clear plan
                                                                     more
                                                                                                  regarding further
                                                                 information,
                                                                                                    management
                                                               liaise with GP
                   Phone referring GP
                  within 2 working days,.                     (see full policy)


                                                                               Document plan in
                                                                                  notes, inform
                                                                              safeguarding team if
                                                                                 WNB triggers
                                                                                  safeguarding
                                                                                    concerns




                                  Enquiries to: safeguarding team, X 4314 QAH               SAP
                                                                                            04/10




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3.      Guidelines

A.      No known safeguarding concerns

i)      Child WNB to ‘new patient’ PHT appointment following GP referral

3.1     Responsibility remains with the GP as referrer. Letter to be sent from clinic to
        parent/carer, cc referrer, expressing regret that appojntment was not kept, and
        offering departmentally/personally preferred options (eg offer further appointment if
        requested by parents within a defined time frame; or require GP re-referral following
        review of original reasons for referring, and non-attendance)


ii)     Child WNB to follow-up appointment

3.2     It is the responsibility of the consultant involved to assess whether non-attendance at
        appointment(s) has the potential to result in harm to the child, and act accordingly

3.3     First WNB - usual practice is for a further appointment to be offered automatically
        unless the missed appointment was a „back-stop‟/probable discharge to GP‟
        appointment, in which case a „closing letter‟ is sent to parents cc GP.

3.4     2nd WNB - If the appointment was for review of a condition which was expected to
        subside/respond to treatment and be subsequently managed in primary care, PHT
        consultant sends letter to parents cc GP (and health visitor (HV) in pre-schoolers)
        stating presumed reason for non-attendance and advising that further follow-up is
        with GP unless GP contacts PHT otherwise.

3.5     It is not effective to send repeated appointments which are not kept. If the missed
        appointment was for review of more significant health issues than in 3.4 above, PHT
        consultant sends letter to parents cc GP (and HV/school nurse) advising of reasons
        for our concern at WNB, and that we will be discussing with GP. The safeguarding
        team are happy to advise and support in these cases. Information is sought by
        letter from primary care/school health – missed school, frequency of exacerbations,
        adherence to therapy – to inform decision re offering further appointment. The child‟s
        notes should be kept until this decision is made and discussed with/ relayed to the
        GP so that there is agreement on future management. This process must be clearly
        documented in the medical notes.

3.6     If the consultant believes that the child may suffer, or is likely to suffer, significant
        harm as a result of WNB, then the consultant should also discuss this with the PHT
        Child Protection/Safeguarding Children Team.




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       B. Known social concerns or safeguarding issues.


i)        Child WNB to ‘new patient’ PHT appointment following GP referral which
          included safeguarding aspects

     4.1 The PHT consultant telephones the GP within 2 working days to advise of child‟s non
         attendance and discuss most appropriate way forward e.g. sending further
         appointment with HV/GP copy of appointment details. The outcome of this call should
         be documented in a clinic letter.

     4.2 PHT consultant informs Child Protection/Safeguarding Children Office of child‟s
         details, events and plan

ii) Child WNB to follow-up appointment – pre-existing or emerging child protection
        concerns

4.3 These children need to be considered on a case-by-case basis. They may already be
    subject to CPP in which case social care should be informed of WNB and their advice
    sought.

4.4 Persistent non-attendance despite repeated written/telephone contacts and offered
   appointments may reflect „non-engagement‟ and be contributory grounds for referral to
   social care. PHT consultant should discuss with GP/HV/social care, and contribute to a
   clear plan regarding further management. Referral to social care should not happen
   without the parents being informed, unless this is felt to put the child at a greater risk of
   harm – see PHT safeguarding children guidelines.

http://pompi3/sites/safeguarding-children/default.aspx


     4.5 PHT consultant to inform Child Protection/Safeguarding Children Office of child‟s
         details, events and plan . The safeguarding team are happy to advise and support
         in these cases.




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