BICPOL04 Provide Referral Management and RTT Policy by Provide Community

Version: V10

Ratified by:

Quality Reference Group

Date ratified: 18/07/2023

Name of author:

Reviewed by Committee or Expert Group

Equality Impact Assessed by:

1. Introduction

1.1 This policy asserts PROVIDE’s intent to manage access to appointment-based patient services, in line with current Government quality standards.

1.2 The policy includes:

• The Standards which patients can expect with respect to access to services

• The Processes for managing waiting lists and appointments

• The Responsibilities of staff groups and patients to participate in these processes

1.3 The policy will be reviewed by the BI Team and all amendments authorised by the PROVIDE Board every two years to enable the inclusion of updated processes to be captured as the programme of work to improve access develops and matures.

2. Purpose

This policy strives to ensure that all patients receiving care from an RTT-applicable service are treated within the maximum target waiting time for their service.

3. Definitions

3.1 RTT – Referral to Treatment Time

3.2 Reasonable Offer – when offering appointments, a reasonable offer is considered to be an offer of an appointment which is 2 weeks or more in advance of the date of the offer being made. There should also be a choice of 2 different days and 2 different times offered to the patient. Appointments for the purpose of ‘reasonable offer’ appointments are those whereby the first definitive treatment can be provided, unless the appointment is DNA'd or cancelled by patient. See Section 10 for more information

3.3 DNA – Did Not Attend. The patient has not attended an appointment at a time of which they have previously agreed, but have not given prior notice. See section 11 for more information.

4. Duties

The duties that need to be actioned as a result of this policy are listed in the table below:

Action

Responsible party

Submission of referral letter/form to PROVIDE GP

Other referring clinician Patient

Identification of definitive treatments

Establishment and maintenance of waiting list

Prioritisation of waiting list

Communication with patients about waiting list and appointments

Communication with specialist clinicians and GPs about patients’ treatment pathways

Establishment and maintenance of a monitoring and reporting system for waiting times

5. Consultation and Communication

Leads and Clinical managers

Designated service staff under the supervision of the service manager

Lead Clinician

Designated service staff under the supervision of the service manager

Designated service staff under the supervision of the service manager, specialist clinicians, GPs

Service Leads with Assistant Directors in conjunction with the PROVIDE Business Intelligence and Contracts Team

5.1 This policy has been developed through consultation with: Assistant Directors of applicable services; the Business Intelligence and Contracts Team and the SystmOne Team

5.2 Communication processes are as follows:

• This policy is available on MyCompliance

• Knowledge of policy to be included in staff induction programme

• Line managers to ensure that all staff are aware of policy and apply contents appropriately

• Line managers to monitor and report on compliance with policy as required

• This local policy is clearly defined and specifically protects the clinical interests of vulnerable patients (e.g. children) and is agreed with clinicians, commissioners, patients and other relevant stakeholders

6. Monitoring

Monitoring of waiting times and breaches will be an on-going process. Mechanisms will include:

• Daily/weekly reviews by Leads and Clinical Managers

• Weekly/monthly reviews by Assistant Directors

• Monthly performance reports and PROVIDE Board reports

• Co-ordination by members of the PROVIDE Business Intelligence and Contracts Team

7.

Standard for Access to Appointment-based Services

7.1 As per the NHS Constitution, patients referred after 1st April 2010 have the legal right to start consultant-led treatment within 18 weeks from referral and to be seen by a specialist within 2 weeks of GP referral via an urgent referral for suspected cancer for diagnosis or treatment of cancer. In addition, PROVIDE is contracted to deliver nonconsultant–led services which adhere to the Referral to Treatment (RTT) standards set out in this policy. A list of all services that PROVIDE delivers which are subject to this standard is included in Appendix 1.

7.2 Patients with suspected or confirmed cancer will follow the Cancer Treatment Pathway. Provide will triage referrals and any query cancer patients will be returned to Primary Care requesting that they refer to the Acute Cancer Pathway. If after seeing a patient within Provide a cancer is suspected, Provide will immediately refer to the Acute Cancer Pathway.

7.3 In some cases, the maximum RTT wait listed in Appendix 1 for a service may be inconvenient or clinically inappropriate; for example, where patients:

• Require a period of active monitoring before the treatment is delivered

• Require treatment for another condition before the treatment is delivered

• Are temporarily unfit for treatment.

• Choose to delay their care.

Section 13 lists the various scenarios in which the clock may be stopped or where it is appropriate to discharge the patient and wait for the GP to re-refer them when the patient is fit and ready for treatment. Though this list is not exhaustive, services will refer to this list in the first instance when changing the RTT clock on a referral, or else will seek guidance from the Business Intelligence and Contracts Team.

8. Accepting Referrals and managing Waiting Lists

8.1 All referrals should meet the service eligibility criteria before being accepted by the service for treatment. The service eligibility criteria is set out for most services in the commissioning MSE ICB Service Restriction Policy (For most services this is Mid Essex, See Intranet for the MSE ICB SRP), but is also formed by local triage criteria by each service. If a patient does not meet this criteria, it is expected that services send the referral back to the referrer (e.g. the patient’s GP or the patient themselves) at which point they can be re-referred once the criteria is met.

8.2 In addition, a patient cannot be admitted to a waiting list without a referral letter, an agreed referral form from their GP or another authorised clinician. Services accepting self-referrals should obtain the minimum data set information (see 8.4 below) and if appropriate, should have authorisation from the patient’s General Practitioner before seeking treatment.

8.3 Any and all referral letters or referral forms received by a service should be recorded and date stamped on arrival. Electronic referrals received through SystmOne or another clinical system should be correctly acknowledged and accepted without delay as per IGPOL63 Health Record Keeping Policy. If the referral is for a SystmOne patient, they

should be added to the appropriate waiting list(s) without delay, assuming they meet the minimum dataset listed in 8.4 below.

8.4 The minimum data set that is required on all referrals prior to patient contact/acceptance onto a waiting list is below:

• The patient’s NHS number (if known), demographic data, contact information (including name, address, postcode and telephone number)

• Relevant details of their condition, including fitness for treatment being requested and a summary of the reason for referral.

• An indication as to whether the patient is aware of the treatment for which they are being referred.

• Funding approval if required for specialist services

• Where concern over fitness for treatment is indicated, a health screening questionnaire must be completed – if they are assessed as unfit for treatment, they must be discharged back to the referrer.

8.5 Once a referral has been accepted and the patient put on a waiting list(s), it is the responsibility of the services to monitor the referral and ensure the following occur:

• If indicated in Appendix 1, services are to ensure an RTT clock is added to the referral for the appropriate length of time (6, 18 weeks, 2 days, 2 hours etc.), as well as an indication of whether the referral is Urgent or Routine

• All patients on waiting lists are offered appointments in a reasonable amount of time. See Sections 9 and 10 for more information.

• All patients on waiting lists are prioritized according to clinical priority and /or time waiting. Urgent referrals should be prioritised over Routine referrals and appropriately managed by the lead clinician for the service. Routine referrals should be offered appointments in date order of when they were added to the waiting list.

• Patients who refuse offers of treatment or who default appointments without explanation and fail to rebook will be permanently removed from the waiting list and discharged back to referrer with an explanation for removal. See section 11 for more information.

• Patients on a waiting list are be given an adequate information (e.g. an information sheet) with details of procedures to be followed in the event of a change in their personal data, their condition or their availability for treatment.

• Patients requiring more than one referral at the same time should be reviewed and have their treatments prioritised. This may involve a temporary removal from the waiting list for the lower priority treatment(s).

• The referrer must always be informed when a patient is discharged. In relation to vulnerable patients, including children and young people see SGPRO10 Safeguarding/Child Protection Guidance: Management of Children and Young People who Fail to Attend Appointments.

8.6 The waiting list will be validated at monthly intervals as part of a continuous process of validation. This will involve a review of waiting times and clinical priorities and confirmation by letter or telephone of a patient’s continued intention to pursue treatment.

9. Appointment Offers and Setting RTT Clocks

9.1 When offering an appointment, patients will be contacted by the most appropriate manner to include telephone or letter within a maximum of ten working days from date of referral (the date on which the referral is received by the service) and offered an appointment. The approach taken will depend on whether a service is operating a full or partial booking service, and the appointment will take into account the notice period set out in Section 10.

9.2 As far as possible (in accordance with our table of scenarios in Section 13 regarding patient choice and reasonable offers in section 10 below), services will endeavour to accommodate patient choice with regard to the selection of specialist clinician, the timing of appointments and the scheduling of treatment.

9.3 Patients should be advised that preferably seven days’ notice is required for a cancellation and patient information leaflets should reflect this standard. In the event that the service needs to cancel a booked appointment, then the patient offered an alternative appointment within four weeks (28 days) or within the RTT standard for that service, whichever is sooner.

9.4 Services listed in Appendix 1 will set clocks appropriately for each referral. See the guide in Section 13 for more information, but a rough guide is below:

RTT Status

First Activity (10)

Not Applicable to RTT (98)

Subsequent Activity (20)

First Definitive Treatment (30)

Activity after RTT Period (90)

Reason for use

Referral In

Patient cancels their first appointment (refer to Section 12 for more information

Activities that are not first definitive (see below) and where further clinical interventions are anticipated (e.g. a preassessment appointment for surgery)

The first clinical intervention intended to manage a patient's disease, condition or injury and avoid further clinical interventions, e.g. Surgery or assessment/advice as the start of treatment

Activities after the RTT period has ended (e.g. follow up appointments, dressing changing etc.)

9.5 Should a patient fail to attend an appointment, services should follow the guidance set out in Section 11 regarding Did Not Attends. In relation to vulnerable patients, including children and young people see SGPRO10 – Safeguarding/Child Protection Guidance: Management of Children and Young People who Fail to Attend Appointments.

9.6 RTT clock pauses should not be used by services, with the exception of Podiatric Surgery. These can be used only in cases where patients choose to delay their surgery (e.g. by going on holiday), and should be used in place of Patient Led Active Monitoring.

10.Reasonable Offers and Decision Time about Treatment

10.1 Patients should be given sufficient time to accept an appointment or to make a decision to proceed with treatment. Patients should be given at least 14 days to decide whether to go ahead with planned treatment. If no decision is received within this timescale they should be removed from the waiting list as having declined treatment and the clock stopped. They may self-refer back to the service but a new clock will start.

10.2 Patients should be given reasonable notice and reasonable choice of appointments. A reasonable offer is an offer of a time and date two or more weeks from the time that the offer was made.

10.3 Patients should expect to receive 2 reasonable offers of appointments within 18 weeks before breaching the Referral to Treatment time set out in Appendix 1 Reasonable offers of appointments are those whereby the first definitive treatment can be provided, unless they are DNA'd or cancelled by patient. E.g. if a service offers 2 appointments within 18 weeks before the First Definitive Treatment can take place and the patient cancels one or both of these appointments, then these can both be counted as reasonable offers. If a service offers 2 appointments within 18 weeks before the First Definitive Treatment can take place, both appointments are attended and then the First Definitive Treatment falls outside the 18 weeks, this will still be counted as breaching the 18 week RTT pathway.

10.4 The exception to the above is if the referral is urgent, in which case the appointment can be at any point.

10.5 Any reasonable offers must be clearly documented in the SystmOne or other clinical patient record. This has been adopted by PROVIDE in order to help ensure that patients are able to have some patient choice over their appointments, without severely affecting the efficiency of the service which may negatively affect other patients.

10.6 Should a patient decline two reasonable offers, the service should set the RTT clock status as Patient Led Active Monitoring and allow the patient time to come back to the service with dates of when they are free. See Section 13 for more information.

10.7 RTT and direction to self-help materials.

For certain low risk conditions, clinicians will identify where a directed self-help intervention is deemed a suitable response to the referral. A decision is made whether the intervention is;

• A definitive treatment, or

• Is patient led active monitoring

In the case of definitive treatment. The decision is being made that the direction to self-help is the definitive treatment itself i.e. there is no other alternative treatment. The clock will be stopped and the referral ended.

For patient led active monitoring, the patient’s clock is stopped whilst the patient reviews the material and then the service will contact the patient to confirm that that

the treatment has finished (and to end the referral) or if further treatment is required –to end the original referral and start a new referral for the next treatment. This latter option is used where there is a potential for the for the direction to self-help does not resolve the matter and then patient requires some further intervention.

Services will maintain local SOPs to define their service approach.

11.Did Not Attends (DNAs)

11.1 A DNA is defined as where a patient fails to attend an appointment/admission without prior notice. Patients who cancel their appointments in advance should not be classed as a DNA and therefore should not have their clocks nullified.

11.2 For avoidance of doubt, “Without Prior Notice” shall be defined as up to and including the date and time of the appointment. For example, if an appointment was at 12:00, and the patient rang at 11:58 to cancel, this would be still counted as cancelled by patient, not DNA.

11.3 When a patient fails to attend the first appointment after the initial referral (that started their waiting time clock), their clock will be nullified which resets the clock back to 0 week (i.e. it is as if the referral never existed). All Services must then contact the patient to rebook them with the service, following the rules on reasonable offers set out in Section 10. For more information on clock stops, please see Section 13.

11.4 When a patient DNA’s a subsequent appointment, the clock shall stop again, and the patient will be discharged from the service (removed from waiting lists and marked as deducted, etc ) A letter will then be sent to the GP explaining why the patient has been discharged from the service

11.5 For further guidance on clock stops, see section 13.

11.6 When a patient is about to be discharged from the service, the following must be considered:

• Was the appointment clearly communicated to the patient?

• Were they also given two reasonable offers?

• Is discharging the patient not contrary to their best clinical interests? (The final decision will be made by the clinician managing the patient’s care)

• Is the patient a vulnerable adult or child? If yes, PROVIDE’s SGPRO10 Safeguarding/Child Protection Guidance: Management of Children and Young People Who Fail to Attend Appointments will be followed.

11.7 If a patient is kept on for any of the reasons above, services will treat the patient as an urgent appointment and do their best to see the patient as soon as reasonably possible.

12.Cancellations by Patient and Cancellation by Unit

12.1 As identified above, the first time a patient cancels an appointment with prior notice, (As define in Section 11, “With Prior Notice” is inclusive of any time before the patient’s appointment), the clock continues to tick. Services should then try to rebook the patient in for another appointment, following the rules in Section 10 regarding reasonable offers. If a patient does not rebook, the RTT status should be set to Patient Refused Treatment and the clock shall stop.

12.2 The second time a patient cancels an appointment, services should set the RTT status to Patient Led Active Monitoring, discharge the referral, and then refer the patient back to the GP. The clock will then restart from zero once the GP has sent a new referral.

12.3 In the event there is a clinical risk involved with sending the patient back to the GP, the service should make contact with the patient immediately and setup an appointment. The RTT clock will then restart once a patient has confirmed their appointment. If they are still unable to see the patient after this, they should discharge the referral.

12.4 When the appointment is cancelled, the appointment slot is now freed up and will now appear as if it was empty. Services may rebook patients into these slots provided:

• It is clinically appropriate to bring the appointment forward or to offer the slot to another patient

• The patient has been contacted and has agreed to be seen earlier

12.5 If services do bring a patient’s appointment forward, a new appointment with the patient should be booked into the empty slot, and the original appointment should be deleted rather then cancelled. Another patient can then be booked into this slot, and this can continue ad infinitium.

12.6 In the event that the service needs to cancel the appointment due to unforeseen circumstances (sickness, unavailability of venue, unable to travel to site, etc.), the services should mark the appointment as Cancelled by Unit, and the clock should continue to tick. Services should then endeavour to see patients affected within the RTT period.

13.Details of Clock Starts and Stops

Table 1 below lists the common events associated with clock starts and stops:

ClockStops.xlsx

You may view this on the intranet here or here:

14.Appendix 1 – PROVIDE Services Applicable to RTT

Services that are not listed above are not measured against the 18-week RTT pathway.

Please see individual service specifications for services not listed above with regards to waiting times.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Referral to Treatment Time (RTT) Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

The policy’s aim is to ensure that all patients being treated by RTT-applicable services are seen within the target waiting times for their service.

The policy also covers procedures to be followed when the RTT target waiting time cannot be met

The main activities covered by this policy are: the maintenance of waiting lists; reporting of breaches; and offering appointments for services.

Project/Policy Manager:

Date:

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

No, however this initiative is reported on monthly so impact will be informally monitored on a monthly basis, and will be reviewed formally in 2 years.

Guidelines: Things to consider

• Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

• The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

• Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

• Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

• Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

• It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

• It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE:

Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities?Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

• An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

• It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

• The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

• If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.womenandequalityunit.gov.uk – Gender issues in more depth www.opportunitynow.org.uk - Employer member organisation (gender) www.efa.org.uk – Employers forum on age www.agepositive.gov.uk – Age issues in more depth