18 Week Access Policy
This document outlines the policy to be followed by Fairfield Independent Hospital in the management of NHS Choose and Book patients.
The purpose of this document is to ensure that all patients are managed consistently and according to national and local policies.
This document is for use with NHS patients only and must be used in line with the Hospital’s PAS system.
2. KEY PRINCIPLES
Patients should not leave the Hospital without knowing their outcome i.e. what the next stage of their pathway will be and when it is booked or intended to be booked.
The Hospital will agree with patients a convenient date and time for appointments and admissions.
The patient’s pathway will be tracked according to the 18 weeks rules and definitions. See Referral to Treatment consultant – led waiting times for April 2014 on the Hospital’s shared drive in the 18 weeks folder.
Any potential breaches of waiting times must be notified to the Admin Manager.
3. ACCESS FOR MILITARY VETERANS AND WAR PENSIONERS
The Hospital is committed to ensuring that all veterans/war pensioners receive priority access to treatment within the NHS when compared to patients with a similar clinical need.
Veterans need not have first applied for a war pension for this prioritisation to apply. Veterans will be identified by the GP referral.
4. REJECTING A REFERRAL
Following a review, referrals will be rejected if:
- The patient has been directed to the wrong speciality, for example, a Gastroenterology patient to an Orthopaedic Consultant.
- The referral is clinically incorrect or falls into one of the Hospital’s exempted categories, i.e. if they are under 18 or if their BMI is 40 or over, or if they have an incapacitating disease that is a constant threat to life.
Patients and their GP’s should be informed why referrals are rejected.
4.1. Bilateral Referrals
When a patient is referred for a bilateral procedure, they are first listed for one side with a clock start and clock finish following completion of the first procedure. Once the patient is fit and able to have the second procedure then a new clock should be started and the second procedure completed within 18 weeks of the new clock start.
4.2 Procedures of Limited Clinical Priority
Following referral to the hospital, guidance from the relevant CCG must be followed with regards to PLCP. Authorisation must be sought where applicable from the referring CCG. If there are issues then advice must be sought from the OPD manager.
5. NEW 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 patient’s 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.
6. 18 WEEKS RULES ON CLOCK STARTS APPLICABLE TO INTER PROVIDER TRANSFERS
18 Week’s national guidance regarding inter-provider transfers is as follows:
- For those inter-provider transfers where the patient’s condition is the same as the original GP referral and where treatment 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, the 18 Week clock start date will be the date of receipt of the consultant referral from the referring Hospital/Trust.
Inter-provider referrals into Fairfield Independent Hospital will be very rare and the OPD / Admissions Manager must be contacted.
For all inter-provider transfers from Fairfield Independent Hospital the appropriate documentation, FHC 449 MUST be completed to be sent to the accepting Hospital / Trust.
7. 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 speciality i.e. for a second opinion on the same condition.
- Where the referral is to another consultant/specialty within the Hospital 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 different 18-week pathways for two / more different specialities; all appointments should be booked within 6 weeks for routine and 2 weeks for urgent referrals.
8. CATEGORISING PATIENTS REQUIRING MULTIPLE PROCEDURES
There are instances where patients are listed for more than one procedure either in the same or different specialities. 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 speciality 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.
If following the first surgery the patient is deemed unfit for the second procedure then the clock stops.
9. OUTPATIENT APPOINTMENTS
9.1 Reasonable Notice – New and Follow-up Outpatient Appointments
For a verbal offer to be deemed reasonable, the patient must be offered a minimum of two appointment dates on different days, with a minimum of two calendar weeks’ notice.
For a written offer to be deemed reasonable, the patient must be offered an appointment date with a minimum two calendar weeks’ notice.
Earlier dates can be offered if the patient is available and they are acceptable.
Appointments made directly via Choose and Book will be deemed to be reasonable due to patient choice at the time of booking.
Where patients are not given reasonable notice, they should not be discharged back to their GP.
9.2 DNA Appointment Non-Attendance
A DNA is strictly defined as a patient failing to give notice that they will not be attending their appointment. Patients who give prior notice no matter how small are not classed as DNA’s Providing reasonable notice of the appointment was communicated to the patient/carer, DNA’s will be managed as follows:
- New patients – will be returned to the referrer (usually GP) if they DNA their first new outpatient appointment. (As long as clear communication can be evidenced).
- Follow-up patients – Routine patients should be returned to the referrer (usually GP). A further appointment will only be made if the treating clinician requires the patient to be seen. The consultant must decide whether a further appointment needs to be booked.
Should the patient DNA a second time they will be discharged by the Consultant and referred back to the GP.
9.3 Patient Cancellations
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. Patients should not be discharged back to their GP simply because they have cancelled referral back to the GP should be a clinical decision.
However, patients can choose to delay their treatment in order to plan around their personal circumstances. These are referred to as Patient Initiated Delays. The 18-week clock continues to tick during such delays. There is no blanket rule regarding PID however for those patients requesting a delay longer than 12 weeks should have a clinical review to decide if this delay is appropriate. If the clinician is satisfied that the proposed delay is appropriate then the Hospital should allow the delay, regardless of the length of wait reported.
9.3.1 First New Appointment Cancellation
The patient may have their consultation re-booked i.e. offered and agreed on a reasonable date and evidenced that this has been communicated to the patient within the 18 week period.
9.3.2 Second New Appointment Cancellation
Patient discharged and care returned to GP. Both the patient and the GP should be advised of this.
9.3.3 Follow Up Cancellation
If a patient cancels their second scheduled follow-up outpatient attendance they will be referred to the Consultant and discharged the patient back to the care of the GP.
9.3.4 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.
9.3.5 Hospital Cancellations
Where possible no Hospital-imposed cancellations should occur. However, if the patient’s appointment is cancelled by the Hospital the patient’s appointment should be re-booked for the earliest date, which is agreed with the patient. The clock still ticks with regard to 18 weeks.
10. PRE- OP ASSESSMENT APPOINTMENTS
10.1 Not Attend (DNA)
A DNA is strictly defined as a patient failing to give notice that they will not be attending their appointment. Patients who give prior notice no matter how small are not classed as DNAs.
Patients who DNA a pre-op assessment will be removed from the waiting list and referred back to their GP.
10.2 Patient Cancellation
Patients, who cancel two consecutive appointments, having had reasonable notice of the appointment or agreed on the date, will be returned to their GP.
If patients do not re-appoint on the day of the cancellation, they will be returned to their GP.
10.3 Hospital Cancellations
Where possible no Hospital-imposed cancellations should occur. However, if the patient’s appointment is cancelled by the Hospital the patient’s appointment should be re-booked for the earliest date, which is agreed with the patient.
11. ACTIVE MONITORING
An 18-week clock may be stopped when it is clinically appropriate to start a period of monitoring without clinical intervention or treatment or diagnostic procedures. If a patient who is being actively monitored decides within a 6-week period to proceed with their proposed treatment, a new 18-week clock would start from the date of the patients’ decision to go ahead. After 6 months the patient would need to be re-referred.
12. DIAGNOSTIC WAITING TIMES
The target waiting time for all diagnostic tests is a maximum of 6 weeks.
By “diagnostic”, this means a test or procedure used to identify a person’s disease or condition and which allows a medical diagnosis to be made.
In contrast, a “therapeutic procedure” is defined as a procedure, which involves actual treatment of a person’s disease, condition or injury. Therapeutic procedures should be excluded.
Patient waiting times for the following groups of tests and procedures should be reported:
- Imaging – Magnetic Resonance Imaging.
- Imaging – Computed Tomography.
- Imaging – Non-obstetric ultrasound.
- Imaging – Barium Enema.
- Imaging – DEXA Scan.
- Physiological Measurement – Audiology – Audiology Assessments.
- Physiological Measurement – Cardiology – echocardiography.
- Physiological Measurement – Cardiology – electrophysiology.
- Physiological Measurement – Neurophysiology – peripheral neurophysiology.
- Physiological Measurement – Respiratory physiology – sleep studies.
- Physiological Measurement – Urodynamics – pressures & flows.
- Endoscopy – Colonoscopy.
- Endoscopy – Flexi sigmoidoscopy.
- Endoscopy – Cystoscopy.
- Endoscopy – Gastroscopy.
Who to include
Include all patients waiting for a diagnostic test/procedure funded by the NHS at any location This includes all referral routes (i.e. whether the patient was referred by a GP or by a Hospital-based clinician or another route). It is recognised that there will be some overlap between patients reported on this return and patients reported in the inpatient and outpatient waiting times returns.
Who to exclude
Do not include waits for diagnostic tests/procedures where:
- The patient is waiting for a planned (or surveillance) diagnostic test/procedure, i.e. a procedure or series of procedures as part of a treatment plan which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency, e.g. 6-month check cystoscopy;
- The patient is waiting for a procedure as part of a screening programme (e.g. routine repeat smear test etc.).
- The patient is currently admitted to a Hospital bed and is waiting for an emergency or unscheduled diagnostic/test procedure as part of their inpatient treatment.
Only include patients waiting where the prime purpose of the wait is for a diagnostic test/procedure, i.e. do not include patients waiting for a therapeutic operation on the inpatient waiting list who may require routine diagnostic tests/procedures following their admission.
DNA – diagnostic appointments
Contact the patient and offer a further appointment. If the patient DNA’s again pass the request back to the referring Consultant who will if appropriate discharge the patient back to the care of the GP.
Cancellation of diagnostic appointments
Rebook a further appointment, if the patient then cancels for a second time the request should then be passed back to the referring Consultant who will if appropriate discharge the patient back to the care of the GP.
If a patient cancels or misses an appointment for a diagnostic test/procedure, then the diagnostic waiting time for that test/procedure is set to zero and the waiting time starts again from the date of the appointment that the patient cancelled/missed. Where this presents a significant technical challenge and doing so does not adversely affect wait times the same clock can continue if there is still an intention to carry out a diagnostic.
Similarly, if a patient turns down reasonable appointments, i.e. 2 separate dates and 3 weeks notice, then the diagnostic waiting time for that test/procedure can be set to zero from the first date offered.
13. HOSPITAL (ELECTIVE) ADMISSIONS
13.1 Reasonable Notice
A minimum of three weeks notice and one date should be applied to constitute a reasonable offer. Earlier dates can be offered if available and acceptable.
Where patients do not agree on dates within the reasonable timescale they should be discharged back to their GP.
Where patients have not been given reasonable notice, they should not be discharged back to their GP.
13.2 Patient Initiated Cancellations
If a patient cancels, postpones or rearranges their appointment this has no effect on the clock which continues to tick.
Patients should not be discharged back to their GP just because they have cancelled or rearranged their appointment; referral back to the GP should always be based on a clinical decision, based on the patients’ best clinical interests.
If a patient cancels two admission dates, the clinician must review the patient and decide if they are to be removed from the waiting list and discharged to the care of their GP.
Patients should not be allowed to self-defer their admission on more than one occasion. The consultant will decide if any proposed delay is appropriate. The clinical risks as a result of such a delay should be clearly communicated to the patient and evidenced as such.
The patient should be advised that if they defer again they will be removed from the waiting list and returned to the care of their GP, at this stage the clock will stop. However, the patient can be re-referred by their GP within 3 months if it is still clinically appropriate.
If the patient is removed from the waiting list the patient and GP should be informed in writing by the Hospital.
The current definition of a “reasonable offer” is that it gives the patient a minimum of 2 weeks notice for outpatient and diagnostic appointments and 3 weeks for inpatient and day case procedures with a choice of 2 dates if the offer is made verbally.
13.3 Hospital Cancellation
The patient’s admission should not be cancelled for non-clinical reasons on more than one occasion.
Patients that have their surgery cancelled by the Hospital for non-clinical reasons must have their TCI date rescheduled within their 18-week pathway. Hospital cancellations do not stop the clock.
13.4 Did Not Attend
A DNA is strictly defined as a patient failing to give notice that they will not be attending their appointment. Patients who give prior notice no matter how small are not classed as DNAs.
Patients must have received reasonable notification of their TCI date or accepted at short notice.
If a patient DNA’s a routine admission they can only be removed from the waiting list if it is not contrary to their best clinical interests i.e. – the Consultant must make the decision and refer the patient back to the GP.
If however the patient was booked at short notice they may be re-referred within 3 months
13.5 Unfit For Surgery
Patients who are not clinically fit for surgery and will not be so within 3 months will be discharged back to the care of their GP. The GP will be advised as to why the patient is not fit for surgery.
If the patient becomes clinically fit after 3 months their GP will need to re-referring the patient for a new clinical assessment and a new 18 weeks clock will commence.
If the patient is unfit for surgery due to for example a cold or minor illness the clock continues to run and the patient will be progressed as appropriate up to a maximum of 4 weeks. If they remain unfit after the 4 week period they will be referred back to their GP detailing the reasons why they are not fit for surgery.
In some cases treatment within 18 weeks may prove not to be possible for clinical reasons. For instance, if a series of tests must be done in sequence for clinical reasons; when a second condition presents itself that needs to be treated before the first; where the patient and consultant have agreed that the patient should receive a second opinion, which despite best efforts, adds a critical delay; where the patient is medically unfit to be treated; any patients for whom there is genuine clinical uncertainty about the diagnosis but where watchful waiting (and clock stop) is inappropriate.
13.6 Patients Who Choose To Delay Their Surgery
With effect from October 2015, the RTT Rules Suite has been updated to reflect the removal of the provision to apply adjustments to RTT pathways for patient-initiated delays. There is no longer any provision to report pauses or suspensions in RTT waiting time clocks in monthly RTT returns.
The Hospital will, however, wish to maintain a local record of all patients initiated delays, to aid good waiting list management and to ensure patients are treated in order of clinical priority.
The Hospital will identify those patients who chose to start treatment after 18 weeks that is those who were offered a reasonable appointment within 18 weeks of referral but chose to wait longer, for personal or social reasons. A reasonable offer of an appointment is one for a time and date three or more weeks from the time that the offer was made.
There is now no blanket rule that applies a maximum length to patient-initiated delay. Patients requesting a delay longer than 12 weeks should have a clinical review to decide if this delay is appropriate. If the clinician is satisfied that the proposed delay is appropriate then the Hospital should allow the delay, regardless of the length of wait reported.
If the clinician is not satisfied that the proposed delay is appropriate then the clinical risks should be clearly communicated to the patient and a clinically appropriate TCI date agreed.
If the patient refuses to accept the advice of the clinician then the responsible clinician must act in the best interest of the patient. If the clinician feels that it is in the best clinical interest of the patient to discharge the patient back to the care of their GP and inform them that treatment is not progressing then this must be made clear to the patient. This must be a clinical decision and documented as such.