Elective Access to Treatment Policy

​​​​​​​​​ ​​​​​​​​​​​​Introduction

​Ration​ale​

Health and Care Jersey (HCJ) is committed​ to the delivery of high quality and timely care to patients. 

This policy is issued and maintained by the Chief Operating Officer. It supersedes and replaces all previous versions.

The policy has been developed following consultation with:

• staff
  
• General Practitioners (GPs)
• clinical leads
• patients​
  

It will be reviewed and ratified at least every year. 

Over the course of the next year the policy will be underpinned by a comprehensive suite of detailed Standard Operating Procedures (SOPs) and training. All clinical and non-clinical staff have a responsibility to ensure they understand the intent in delivering elective care and comply with the specific instructions published.

HCJ is committed to promoting and providing services which meet the needs of individuals and does not discriminate against any employee, patient, or visitor.

While HCJ remains committed to the achievement of timely access to treatment.

Waiting list sizes and waiting times, in some specialties, remain greater than those achieved pre-COVID and the access standards to be delivered in the year ahead reflect the challenges the organisation faces whilst stability is gained. Find more details below in our agreed recovery standards .

Agreed Health and Care Jersey standard and the recovery standards for 2025 (table 1)​

The management of patients on elective care pathways is complex. The flow charts below provide a summary of the key stages of the Referral to Treatment (RTT) pathway and the cancer  pathway which are not yet fully implemented. ​

Key stages of referral to treatment​ (RTT) patient pathway (diagram 1)

​Key stages of cancer waiting times (CWT) patient pathway (diagram 2)​

Scope

This policy is relevant for all clinical and administrative staff, who have a role in the management, booking and scheduling of patients referred to for elective or cancer care.

This includes staff for whom this may be a part of their role and those for whom it is their full time role.

This policy covers 3 principal areas of scope:

• the transparent, fair, and equitable management of patient access to elective and cancer services in accordance with clinical priority
• the clarification of the rules and principles under which HCJ manages access to outpatient appointments, diagnostics and elective inpatient or day case care
• HCJ work towards full implementation of this policy over 18 to 24 months as systems mature and develop

While training will be provided to staff and guidance is available corporately, it is also the responsibility of the individual member of staff to remain updated in all aspects of guidance and best practice in relation to patient management.

HCJ is committed to developing a programme of training and development of all staff involved in the management of elective and cancer patients.

The scope of this policy includes all patients requiring access to planned care. It does, however, exclude: 

• screening 
• mental health services that are not medical or surgical consultant-led, including multi-disciplinary teams (MDTs) and community teams, irrespective of setting
• obstetrics and midwifery 
• emergency pathway non-planned follow-up clinic activity
• private patients

Core principles of the policy

Health and Care Jersey promotes diversity and inclusion, as an employer and service provider. As such we seek to ensure that all have staff involved in patient pathway management have access to the most up to date information to provide equitable access for patients through effective tracking and oversight of pathways.

Health and Care Jersey staff will: 

Seek to provide the best possible quality of care to patients, and to treat patients, carers, and relatives with dignity and respect, considering issues, interpretations and where possible, the specific needs of people of different: 

• race
• faiths
• cultures
• genders
• abilities

Take personal responsibility to keep themselves aware of policies to promote equality and of the legislative requirements affecting patient groups.

Review practices and procedures to ensure that services are accessible.

Make reasonable adjustments where necessary to accommodate the needs of people of different: 

• race
• faiths
• cultures
• genders
• abilities

Ensure the management of patients on waiting lists is equitable and transparent.

Ensure patients:

• are treated in relation to their clinical need and in accordance with their rights to timely treatment
• of the same clinical priority will be offered dates for treatment in chronological order

Only add patients to an inpatient waiting list if they are deemed clinically fit, willing, and able to commence treatment.

Offer patients choice of appointment and admission dates that are ‘reasonable’ as determined by this policy.

Ensure that communication with patients at all stages is 

• informative
• timely
• unambiguous
• concise
• documented on core systems

Request a second opinion from their specialty linked UK hospital. Should the linked UK hospital be unable to provide this, the linked UK hospital will advise Jersey from whom a second opinion can be sourced. The second opinion will be final with no other option for further opinion provided by HCJ.

Patient eligibility

Health and Care Jersey will check every patient’s eligibility for treatment. Therefore, at the first point of entry, patients will be asked questions to assess their residential status. 

Hospital treatment is free to people who are resident in Jersey as described in the Resident and Non-Resident Charging Policy.

Resident and Non-Resident Charging Policy

All staff have a responsibility to identify patients who are overseas visitors and to refer them to the Overseas Visitor’s Office for clarification of status regarding entitlement to treatment before their first appointment is booked or date To Come In (TCI) agreed. 

Patients requiring criteria based clinical treatments

Patients referred for specific treatments where there is limited evidence of clinical effectiveness, or which might be considered cosmetic, can only be accepted with prior approval.

Therefore, the referrer must seek prior approval before referring the patient and the approval must accompany the referral. 

In some instances, it will not be apparent until the outpatient consultation or on completion of diagnostic testing, that the patient requires an excluded procedure. Should this occur, approval to continue with the patient’s care is required at this stage.

Approval will be made by the Individual Funding Patient Request Panel (IFPR) on completion of the relevant paperwork.

Patients moving between HCJ and private care

If a patient chooses, they can transfer to self-funded private care at any stage during their pathway without prejudice. Patients will not be permitted to switch from private to public during a course of treatment or select which elements of their treatment are private or public.

Conversely, patients may also transfer from self-funded private care to HCJ. Patients referred to HCJ in this manner will join the waiting list and be treated chronologically based on clinical priority

Patients that have come from self-funded private care will not be given priority over other patients unless clinically relevant.

A Change of Status (Private to Public) form must be completed and signed by the patient, with a copy held on their medical record, and their EPR updated.

All patients who change status are still liable for charges they incur for treatment while they are still categorised as a private patient. Any patient changing their status after using private services should not be treated differently from other public patients.

Healthcare for military veterans

In line with the Armed Forces Covenant, published in 2015, all veterans and war pensioners should receive priority access to care for any conditions related to their service. Military veterans should not need first to have applied and become eligible for a war pension before receiving priority treatment.

GPs will notify HCJ of the patient’s condition and its relation to military service when they refer the patient, to ensure 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 priority.

Healthcare for prisoners

All patient access standards and rules are applicable to prisoners. Delays to treatment due to difficulties with prison staff escorting patients to appointments or for treatment do not affect the recorded waiting time for the patient.

Health and Care Jersey will work with staff in the prison services to minimise delays through clear and regular communication channels and by offering a choice of appointments or admission dates in line with reasonableness criteria.

Communication

All communications with a patient and anyone else involved in the patient’s care pathway, for example G.Ps, whether verbal or written, must be informative, clear, and concise. 

Copies of all relevant correspondence with the patient must be kept in the patient’s medical record or stored electronically for auditing purposes in the patient’s EPR.

Referrers must be kept informed of the patient’s progress in writing. When clinical responsibility is being transferred back to the GP or referrer, this must be made clear in any communication.

Confidentiality

Staff should always comply with the law of confidentiality, the requirement of the Data Protection (Jersey) Law 2018 and Human Rights (Jersey) Law 2000.

When contacting patients to book appointments and TCIs staff should be aware not to leave messages on answer phones and should always confirm a patient’s identity prior to commencing the conversation.

Vulnerable patients and safeguarding

It is essential that all staff within their roles ensure that patients who are in vulnerable groups are identified as early as possible in the referral pathway. 

Staff should ensure that patients are provided with whatever additional help and support is required. 

This includes: 

• communications in the appropriate format to access services
• liaison with carers where there is a concern over understanding or capacity
• offering available services to those whose first language is not English

The referrer should make clear what needs have been identified and record them in the patient’s electronic and paper medical records. This should be reviewed and updated on subsequent visits.

When safeguarding issues are identified, HCJ protocols should be followed in the normal way. Staff should be aware of what actions to take if they have concerns for a Child, Young Person, or Adult at risk. Staff can contact the Health Safeguarding Team for advice and support.

It is important to recognise patients may lack the capacity to understand. This should be considered when patients do not attend appointments. Equally, if a patient has capacity it does not mean they do not have vulnerabilities or are not at risk. Professional curiosity should be applied in these cases and discussed before discharging them for repeated non-attendance.

Staff are required to familiarise themselves with relevant policy and the Capacity and Self-Determination Law  Code of Practice. Additional resources are also available from the Health Safeguarding team. All staff must attend the relevant Safeguarding training.

Capacity and Self-Determination Law Code of Practice​​

Validation

HCJ will validate patients on open waiting lists who are over the expected waiting time target every 12 weeks through a 3 stage validation process. Validation must be documented. 

It is the responsibility of the service to ensure that patients on their waiting lists are validated. 

The 3 stage validation includes:

• administration validation to ensure the waiting list is accurate and up to date
• patient discussion where patients are contacted by a locally determined competent team to establish their wishes
• clinical validation for patients who wish to discuss their situation in more detail with their clinician using shared decision making

Policy purpo​se​

The purpose of this policy is to ensure that all patients who are referred to HCJ are managed equitably and consistently, in line with the local waiting time standards and set out in this policy.

This policy: 

• is designed to ensure the management of planned patient access to services is transparent, fair, equitable and managed according to clinical priority
• sets out the rules and principles for managing patients through their planned care pathways
  
• applies to all clinical and non-clinical staff and services relating to planned patient access
• will be equally applied to all patients

Agreed speciality pathways will be in place to optimise the use of resources and support effective outcomes.

All reasonable steps will be taken to ensure all patients are treated fairly and equitably regardless of disability, race, gender, religion, or sexual orientation in accordance with the Discrimination (Jersey) Law 2013.

Roles and responsibilities

Timely and safe access to elective and cancer care is possible because of the wide range of individuals involved. It is important that everyone involved, is clear of the role they take and the responsibilities they hold. 

Chief Officer

The Chief Officer has overall responsibility and accountability for delivering access standards as defined by HCJ and the Government of Jersey.

Chief Operating Officer for Acute Services

Responsible for:

• ensuring there are robust systems in place for the monitoring, audit, and management of referral to treatment and cancer access standards against the criteria set out in this policy
• reporting of performance standards. Accountable for the management of patient information and data

Medical Director

Responsible for:

• directing the activities of the clinical leads to ensure compliance with this policy
• assuring delivery of timely access to care to optimise quality and patient safety
• ensuring information governance related to patient healthcare records is in line with legislative requirements

Head of Access

Responsible for:

• ensuring compliance with elective and cancer access standards and reporting to the Chief Operating Officer (COO)
• providing support to the care group teams to improve compliance

Care Group General Managers

Responsible for 

• monitoring performance in the delivery of all standards  
• ensuring the clinical care groups deliver the activity required to meet these standards through adequate capacity and demand management

Lead Cancer Clinician

Responsible for ensuring high standards of cancer clinical care across the Organisation in line with the Cancer strategy.

Lead Cancer Manager

Responsible for: 

• development of the Cancer Services team 
• development and implementation of the Cancer strategy
• line management of the cancer Multi-disciplinary team co-ordinators

Tumour Group Clinical Leads

Responsible for:

• ensuring clinical pathways are designed to deliver treatment within 62 days of referral 
• reviewing the outputs of any breach root cause analysis to develop actions to resolve any delays to patients

Assistant General Managers

Responsible for: 

• the performance of the elective care standards, ensuring specialties deliver the activity required to meet these
• ensuring adequate capacity is available and chairing the weekly Patient Tracking List (PTL) meeting to mitigate any potential issues and plan activity requirements

Business Support Officers

Responsible for: 

• attendance and minute taking at the weekly PTL meetings
• monitoring compliance of administrative staff against this policy
• planning capacity to meet demand, escalating issues as they arise

Waiting List Managers

Responsible for: 

• ensuring patients are booked in line with this policy
• escalating lack of capacity to the relevant operational manager
• ensuring validation of waiting lists is undertaken to accurately maintain patient pathways

Non-Clinical Support Services Outpatient Appointments team

Responsible for: 

• liaison with referring GPs and HCJ medical teams for referral management processes and triage
• building new and amending existing clinic templates within PAS as directed by the operational teams
• liaising directly with patients regarding appointments. entering all data accurately within PAS

Patient Booking Clerks

Responsible for: 

• ensuring their outpatients, diagnostics, and elective inpatients waiting lists are managed to comply with this policy escalating to their team leader and operational manager, as necessary
• ensuring all information is accurately entered onto PAS. Book patient transport, as necessary

This role is carried out by a wide variety of different staff, who do not necessarily have this job title, however the function responsibility remains the same.

Reception teams

Responsible for: 

• providing a friendly patient-focused service
• responding positively to patient queries, escalating where necessary
• ensuring all clinic outcomes are completed within 72 hours of clinic finishing

Medical Records

Responsible for: 

• ensuring all clinic administration is in place prior to the start of the clinic
• ensuring all health records are accurately filed in line with  policy

Hospital Consultants

Shared responsibility and ownership with their operational managers for: 

• managing their patients’ waiting times in accordance with this policy
• ensuring timely; triage of referrals, response to Advice and Guidance (AG) requests, review of patients who DNA, completion of clinic outcome forms and undertaking clinical validation of waiting lists
• working with the operational management teams to ensure capacity meets demand, escalating to General Managers and Clinical Leads when risks are identified
  
• supporting the implementation of improvement processes across the specialties

Clinical Nurse Specialists

Shared responsibility and ownership with their consultants and operational managers for managing their patients’ waiting times in accordance with the policy.

Head of Business Intelligence

Responsible for: 

• administering data required for managing and reporting waiting times including cancer, activity, and outcomes
• delegating attendance and reporting at the weekly Patient Tracking List (PTL) meetings
• ensuring there is a robust standard operating procedure for the reporting of performance
  

Cancer Management Team

Responsible for: 

• monitoring delivery of key tasks by the Multi-disciplinary team (MDT) co-ordinators and running weekly audits of cancer referrals
• producing weekly reports showing compliance with cancer standards in preceding week for discussion at weekly PTL meeting
  

Multi-Disciplinary Team Co-ordinators

Responsible for:

• monitoring the cancer pathway for patients from receipt of referral, ensuring it is managed in line with this policy
• assisting in the proactive management of patient pathways on PAS and the Somerset Cancer Register (SCR)

Medical Secretaries

Responsible for: 

• sending out DNA letters to reschedule their appointment as directed by the consultant
• ensuring clinic letters are typed and sent to the referrer in compliance with this policy
• discharging patients from PAS as directed by the consultant and in line with their pathway

General Practitioners (GPs) and other referrers

Responsible for: 

• ensuring patients are fully informed during their consultation of the waiting times for a new outpatient consultation as published on the Government of Jersey website and of the need to be contactable and available when referred
• submitting quality referrals

Patients

Patients are responsible for: 

• making a significant contribution to their own, and their families, good health, and wellbeing, and taking personal responsibility for it
• providing accurate information about their health, condition, and status
• ensure that  has the correct contact details to ensure correspondence reaches them. 
• keeping appointments or cancelling them within a reasonable timeframe
• ensuring that the Hospital is aware of any periods of unavailability
• informing the hospital as soon as possible should their condition improve and not require treatment
• asking questions and giving feedback to the hospital teams regarding any aspect of their care, condition, or treatment
• being available in line with the reasonableness criteria as set out in this policy, unless previously advised

Corporate​ procedur​e

Referral m​anagement

To standardise the referral process, in the future HCJ will implement a central referral point.

Once the referrer has considered the appropriateness of the referral against the procedures with restrictions and thresholds policy, the referral can be sent in.

Patients must only be referred to HCJ when they are fit, willing and able to proceed to treatment.

Definition of terms in relation to referrals:

Fit

No obviously apparent pre-existing conditions are going to prevent likely required treatment.

Willing

Clinically the patient is willing to commence to treatment.

Able

The patient has no pre-existing commitments that would prevent attendance for example, a 3-month cruise booked and paid for.

The Patient Advice and Liaison Service (PALS) will help patients with any concerns about length of wait. The Secondary Scheduled Care Waiting times can also be found on the Government of Jersey website which is updated monthly Secondary Scheduled Care Waiting Lists.

To expedite pathways for patients, the principle of shorter waits and sustained improvement for all patients will be implemented by operating a pooled patient practice. Initial referral information provided to the service by referrers will be used to direct patients into the appropriate clinic.

Service sta​​ndards for referral management

All specialties will aim to offer patient care within the internal operating standards and time periods as described below. A process of audit against the internal standards will be undertaken on an annual basis to inform the outpatient department annual report.

Refer​rals

Currently there is a mixture of referral methods. Referrals will be sent to a central point of referral, either the central administration team or a local specialty booking team. 

Where clinically appropriate, referrals will be made to a service rather than a named clinician. Clinical criteria to support triage and vetting through a local system must be in place, and patients will then be allocated to the most appropriate clinician, considering waiting times. 

Referring to services is in the best interests of patients as pooling referrals promotes equity of waiting times and allows greater flexibility in booking appointments.

Referrers must include in the referral the Minimum Data Set (MDS) as set out in Appendix 1. 

Straight to test diagnostics​

For patients who are referred for a diagnostic test a six-week diagnostic clock will start. These are defined as straight-to-test diagnostic referrals.

Direct access diagnostics

Patients who are referred directly for a diagnostic test, but not consultant-led treatment, by their GP for example, clinical responsibility remains with the GP, will have a six-week diagnostic clock running only. These referrals are defined as direct access diagnostic referrals .

Triage

All referrals must be reviewed and accepted or rejected by clinical teams within 5 working days. 

Where there is a delay in reviewing referrals this will be escalated to the relevant clinical or management team and actions agreed to address. 

The triaging consultant may reprioritise a referral from urgent to routine and vice versa as clinically appropriate.

If the triaging clinician deems a referral to be clinically inappropriate, this should be returned to the referrer with an explanation of the rejection.

Additionally, referrals can be rejected on the following grounds:

• referral pathway, as defined by the clinical specialty or  policy, has not been followed
• diagnostics prior to referral have not been undertaken where specified in a pathway
• the patient does not require secondary care input and written advice is provided by a specialty clinician
• if a patient will be off the island for a period of longer than 3 months such as university students 
• non-eligible patients who do not wish to pay for their treatment or care

The referrer must be notified in all circumstances of the rejection reason.

All specialties will offer advice and guidance to referrers as a way of reducing the requirement for unnecessary referrals into the Organisation.

Advice and Guidance (AG)

Response to AG requests should be within 48 hours of receipt with management arrangements, monitoring and reporting undertaken by the Care Group leads, once systems have been developed.

Consultant to consultant referrals

Consultant to consultant referrals is acceptable if the referral is regarding the condition that was originally referred to secondary care. ​If a condition can be managed in primary care, then the patient should be discharged back to the GP Practice.

Consultant to consultant referrals must not be made by junior medical staff without the approval of the consultant.

Internal speciality to specialty referrals should be done electronically with acknowledgment of receipt provided by the recipient to the referrer.

If the event that the electronic referral is not available then the consultant-to-consultant referrals are dictated, typed, and printed for receiving speciality team to triage.

Inter-provider Transfers (IPT) and tertiary referrals

A process is being designed for appropriate staff to complete and send an Inter Provider Transfer Administrative Minimum Data Set (IPTAMSD) form containing all key patient information which transfers with them.

The principal requirement for using the form is to ensure all service providers involved in a patient’s pathway have adequate information to enable the patient’s management to be conducted within appropriate time frames.

HCJ are working towards the following booking processes:

• all new referrals will be fully booked
• all follow-up appointments required at 6 weeks or less from previous appointment will be fully booked
• all follow-up appointments required over 6 weeks from previous appointment will be booked from a worklist or waiting list

Full booking systems will apply to agreed subspecialties and/or other urgent criteria, such as cancer or where a service has the capacity immediately available and is able to comply with clinical prioritisation and routine booking in chronological order. These principles apply to all outpatient activity regardless of profession.

Booking from a worklist/waiting list will be used for any patient who requires a follow-up appointment over six weeks from previous appointment. The ‘due by date’ for follow up must be recorded in PAS to allow for the mitigation of any potential patient harm resulting from delays in access times.

Full booking will be used when patients require an appointment within 6 weeks of the last appointment and the capacity is available to directly book the patient appointment.

All cancer pathways will use the full booking model.

Full booking process for new non-cancer appointments

Once triaged: 

• patients will be contacted to agree a suitable date and time for their first outpatient appointment
• this contact will be by telephone initially
• should the patient not be contactable after 3 attempts, on different days and times, the referrer will be contacted to check patient contact details are correct
• once correct contact details are confirmed, a letter will be sent requesting the patient contact the booking team to make an appointment
• a second letter will be sent 3 weeks later if patient still does not respond
• should patient still not respond, the patient will be sent back to the referrer for further management

If there are no appointments available following triage, the patient referral will be added to a new patient waiting list AFB (appointments for booking) pending capacity. Once capacity becomes available, the process above is followed.

Full cancer and non-cancer booking process for follow-up appointments 

If the clinician has requested a follow-up appointment with the patient within 6 weeks, including week 6, the clinic desk reception clerk will fully book the patient into a date and time slot as dictated on the outcome form.

If there are no available appointments, the receptionist will add the patient to an escalation list to be actioned at the end of clinic. 

The receptionist will either confirm the appointment with the patient at the time of booking or inform the patient they will be contacted to arrange a convenient date. 

Partial booking process for non-cancer follow-up appointments

If the clinician has requested a follow-up appointment over 6 weeks, the clinic desk reception clerk inform the patient that they will be contacted shortly before their appointment due date to agree a convenient appointment.

Consultation media type

HCJ will offer a choice of consultation media based on clinical appropriateness.

The main consultation types are:

• face-to-face
• phone

The majority of new referrals will require face-to-face consultation, it is the responsibility of the triaging clinician to identify if a different consultation type is appropriate.

For follow-up appointments, the clinician must identify on the clinic outcome what the next appointment media type is required to ensure the patient is booked into the post appropriate clinic.

Monitoring of media type activity will form part of  performance measurement.

Capacity and demand planning

Care Groups will regularly and continuously monitor levels of capacity to ensure any shortfalls are addressed in advance. This will avoid long waits from referral to treatment. 

Reasonableness

Reasonableness is a term applicable to all stages of the planned pathway. It refers to specific criteria which should be adhered to when offering routine appointments and admission dates to patients to demonstrate that they have been given sufficient notice. 

For HCJ, a reasonable offer is defined as:

• patients being given at least 3 weeks’ notice of appointments, unless clinical urgency requires the patient to be seen sooner
• patients being given a choice of 2 separate dates for surgical admissions
  

For an urgent appointment or upgraded referrals to be deemed reasonable patients must be verbally offered 2 appointments within 28 days of receipt of the referral and with a minimum of 24 hours’ notice.

All offers of appointments must be recorded in the PAS for audit purposes and to ensure maintenance of the rules of the Access Policy.

Special consideration should be made for patients with access issues and those in vulnerable patient groups. The clock will not be paused for patients who choose to spend protracted durations off island, the compliance standard allows tolerance in these cases.

If the patient has been offered a choice of 2 or more appointments, each with over 3 weeks’ notice, and they wish to defer again, the clinician will be informed to ensure any delay caused to the patient’s pathway is safe. 

If the clinician confirms it is safe for the patient to delay their care a further appointment will be made and communicated to the patient.

The clinician may decide it is in the patient’s best interest to be discharged from secondary care and return to the care of their GP until they are ready to attend. If the clinician decides to discharge the patient back to Primary Care, a new referral will need to be made if a further appointment is required.

Where available, patients can be offered short notice earlier dates, but this offer is not classed as reasonable.

The inpatient waiting list should only contain patients who are fit, willing and able to have their procedure.

Appointment reschedule requests

If patients request to reschedule their appointment, they will be limited to a maximum of 2 rebooking requests and their case should be reviewed by medical staff to ensure there is no clinical risk in not treating the patient and it is agreed that the patient is not considered to be vulnerable. 

All offers of appointments must be recorded in the PAS for audit purposes and to ensure maintenance of the rules of the Access Policy.

Chronological booking

Patients will be selected for booking appointments or admission dates according to clinical priority, with the appropriate clinician. Patients of the same clinical priority should be appointed and treated in chronological order, for example, the patients who have been waiting longest will be seen first using the HCJ Patient Tracking Lists (PTLs) only. They will not be selected from any paper-based systems. 

Elective pathway management and recording

Clinic outcome

A clinic outcome must be completed correctly, and in a timely manner, to indicate how the patient’s pathway or care plan is to continue.

As the care plan is a clinical decision made and agreed with the patient, the outcome must be completed by the clinician at the end of clinic and the clinic must be administered immediately.

Decision to admit: reasonable offer

The decision to add a patient to the waiting list must be made by a consultant or representative.

A To Come In (TCI) form is completed and submitted to the Elective Admissions Team who will add the patient to the surgery waiting list within 48 hours of decision to admit. 

A reasonable offer for admission is at least 2 dates with 3 weeks’ notice and must be documented in the PAS.

When documenting the offer, it must be noted that the following details were given to the patient:

• date the patient is to be admitted
• the team or the person performing the treatment

If a patient chooses to delay their treatment for a period, the patient should continue to be managed in accordance with their indicated period of ‘choice’ in mind. Wherever possible, a future date for treatment should be agreed and recorded.

Clinically urgent patients

Where a patient is deemed clinically urgent, but wishes to postpone their procedure, the clinician, or a nominated member of their team, must contact the patient to discuss the risks and benefits of attending for admission. If the patient is still not willing to accept a date for their procedure, a clinical decision must be made to either place the patient into Active Monitoring or discharge back to the care of the referrer for continuation of care.

If either of these decisions is made, a letter must be sent to the patient and the GP advising them of the decision and confirming any next steps.

If the patient is to remain on the waiting list, the patient must be reviewed every twelve weeks by the relevant clinical team, until a date can be mutually agreed and the information must be recorded in PAS for audit purposes.

Clinically non-urgent patients

Following a clinical review, if the patient is deemed as not clinically urgent, agreement will be sought from the clinician to agree whether it would be in the best clinical interests of the patient for them to remain on the worklist or waiting list. The information must be recorded for audit purposes.

If the patient is going to be discharged back to the care of their GP this must be reviewed by a clinician who will discuss with the patient to ensure they understand the implications for them. The communication with the patient and the GP be documented in PAS for audit purposes. 

Multiple treatments

Patients can only be on a waiting list for treatment for 1 condition. Patients could be on multiple pathways with multiple co-morbidities. However, they can only be fit, willing and able to commence treatment for 1 procedure at any 1 time. If the patient requires treatment for more than 1 condition, clinicians must decide which condition takes precedence and the patient should be added to the waiting list for that condition.

Bilateral and 2 stage procedures

Where bilateral or 2 stage procedures are to be undertaken the patient should be added to the elective waiting list for the second procedure at the point, they are clinically deemed fit, willing, and able to proceed after the first.

Pre-operative assessment

Pre-operative assessment (POA) ensures that the patient is fit for their procedure or surgery and anaesthesia or sedation and wishes to proceed. Only patients who are fit will then be offered a date to proceed. This is key to hospital efficiency as this will both significantly reduce the number of ‘short notice’ cancellations for medical reasons and increase the likelihood of patient satisfaction with outcomes.

If determined fit after assessment, the patient will be offered a date for their procedure or surgery in clinical priority order or chronological order if the clinical priority is the same.

If the patient has a ‘transient condition’ for example, a cold, the patient should still be offered a date for their procedure or surgery as the patient should be booked for 2 to 3 weeks later. 

If, however, the patient is determined not fit to proceed and they will not be fit within 3 months the patient should either be placed into Active Monitoring, discharged to primary care for optimisation or discharged with a decision not to treat. This must be a clinical decision, in discussion with the patient.

Patient consent

Patient consent should be sought as part of the pre-assessment process for both LA, Sedation and GA cases and should not occur on the day of surgery or treatment. 

Patients must be given enough time to make an informed decision about their treatment. The Royal College of Surgeons in 2018 released Consent: Supported Decision-Making - A Guide to Good Practice this explains the change in case law and the impact this has on gaining consent from patients. 

It offers a set of principles to help surgeons support patients to make decisions about their care and gives a step-by-step overview of how the consent process should happen.

Planned and surveillance patients

Planned care means an appointment or procedure, or a series of appointments or procedures as part of an agreed programme of care which is required for clinical reasons to be carried out at a specific time or repeated at a specific frequency. Planned care is also sometimes called ‘surveillance’

Patients should only be placed on a planned list for a planned procedure or operation that is to take place at a specific time, such as a repeat colonoscopy, or where they are receiving repeated therapeutic procedures.

Patients on planned lists should be booked in for an appointment at the clinically appropriate time and they should not have to wait further. All patients placed on the planned waiting list must have an expected treatment date.

When patients on planned lists are clinically ready for their care to commence and reach the date for their planned appointment, they should either receive that appointment. The appropriate care group managers are responsible for reviewing their planned lists on a regular basis to ensure full compliance. 

Examples of procedures which could be on a planned waiting list are:

• check procedures such as cystoscopies, colonoscopies and similar
• patients proceeding to the next stage of treatment after first definitive treatment

Follow-up appointments

Follow-up appointments are only appropriate when a patient’s condition requires the continued intervention of specialist clinical expertise.

In situations where there is no evidence that a further specialist clinical intervention is required, for example: the patient no longer has symptoms, patient has been treated and is beyond a clinically appropriate period, or primary healthcare support is considered more appropriate, the patient should be discharged to the care of their GP. The clinic outcome form must be completed to reflect this decision.

To ensure time to process test results, follow-up appointments should be booked at an appropriate interval following the test in line with diagnostic waiting times with allowance for results to be readily available for view.

If the results of tests are negative, consideration should be given to the need for the subsequent outpatient appointment. A suitable letter to the patient and GP may be sufficient, and the patient must be discharged on PAS.

Patient compliance, outpatient and inpatient pathways, cancellations, and non-attendance

If a patient gives any prior notice that they cannot attend their appointment (even if this is on the day of clinic), this should be recorded as a cancellation and not a DNA.

Patients can choose to postpone or amend their appointment or treatment if they wish, regardless of the resulting waiting time. However, clinicians must be informed of patient-initiated delays to ensure that no harm is likely to result from the patient making the decision to wait longer for diagnosis or treatment.

It is not in the patient’s best interest to be left on a waiting list for an extended period.

After 1 instance of the same pathway event occurring, that is 1 DNA, 2 consecutive cancellations, a clinical review of the case must be triggered. This will determine the appropriate next steps which could include a return to the referring clinician through a clinical letter being generated, providing the following guidance is adhered to:

• it can be demonstrated that the appointment was clearly communicated to the patient
• discharging the patient is not contrary to their best clinical interests, which may only be determined by a clinician
• discharging the patient is carried out according to local, publicly available, policies on DNAs on the  website
• these policies are clearly defined and specifically protect the clinical interests of vulnerable patients and are agreed with clinicians, patients, and other relevant stakeholders

If the patient has never been seen and advises they do not wish to progress their pathway, they will be removed from the relevant worklist or waiting list. The patient will be informed that their consultant and GP will be advised of this.

Patients who cancel their first new appointment should be given an alternative date at the time of cancellation. It is HCJ’s responsibility to respond to letters or phone cancellations to rebook appointments.

If a new or follow-up patient informs the Hospital that they cannot attend as they have been admitted as an inpatient to a hospital, the administrator taking the call will inform the relevant consultant of the circumstances and seek advice as to further action required. Locally agreed process within the specialities and departments should be in place.

Staff need to consider whether are any potential safeguarding concerns and seek advice. Staff can contact the Health Safeguarding Team and discuss their concerns with the Named Nurse Adult Safeguarding or the Named Nurse Safeguarding Children. Where abuse or neglect is suspected staff must make the appropriate referral to Children and Family Hub for Children and Safeguarding Adults Team for adults. Appropriate referral forms can be accessed via the safeguarding intranet.

Paediatric Was Not Brought (WNB) appointment management plan​

A detailed process has been established for the management of paediatrics. Appendix 2 provides a detailed table. It details the process for the prevention and management of 

• Was Not Brought
• Could Not Attend
• No Access Episodes
  

There are a number of reasons children are not bought to their appointments to have their health needs met. The most vulnerable group are usually children and young people due to them being dependent on adults, parents, or carers bringing them to their appointments. Staff need to be vigilant to patterns of important appointments not being attended or cancelled. Staff who identify children not being bought to appointments or suspect neglect or abuse must seek advice and make appropriate referrals to Children and Families Hub.

It should be noted that some children and young people aged 16 to 18 may decide not to attend an appointment. Staff need to determine if the young person is Gillick Competent, which means they can demonstrate they have the emotional and intellectual maturity and ability to understand the proposed treatment. However, if staff have safeguarding concerns, they should seek advice and contact the Health Safeguarding Team to discuss the concerns.

Hospital initiated cancellations

Hospital initiated changes to appointments will be avoided as far as possible as they are poor practice and cause inconvenience to patients.

Clinicians are actively encouraged to book annual leave and study leave as early as possible.

Care group managers and clinical leads will try to prevent short notice cancellations and where possible will look to provide cover.

Cancellations for admitted patients on the day of treatment

Where a patient’s procedure or surgery is cancelled on the day for non-medical reasons, arrangements must be made to re-admit the patient within 28 days. The patient must be given reasonable notice of the rearranged date. If this is not possible the patient will be offered further dates. 

Cancer pathway management and recording 

Clock starts, suspected cancer

For a patient referred on a GP suspected cancer referral, their treatment pathway clock starts on the date the referral is received by the provider who will first see the patient and is classed as day 0.

Clock starts, cancer screening programme 

The clock start is when a referral is received by a provider after the screening pathway for further investigation after an initial screening test.

Incidental findings 

Some patients may be diagnosed with cancer during routine investigations where cancer has not been suspected, or whilst being treated for another condition, these are classed as incidental findings.

These patients should be monitored on the 31-day decision to treat (DTT) standard.

Reasonable offer inpatient or day care 

A patient requiring inpatient or day-case admission should be given at least 2 reasonable offers of an admission date. Reasonable is defined as any offered appointment between the start and end of the 31 or 62-day standard.

First Definitive Treatment (FDT) 

FDT is normally the first intervention which is intended to remove, debulk or shrink the tumour.

Where no definitive anti-cancer treatment is planned almost all patients will be offered a palliative intervention, or palliative care, which should be recorded as FDT.

A 31-day and 62-day standard cancer pathway clock will stop when patients receive FDT.

There are enabling treatments that can be classed as FDT, please consult the CWT guidance.

Anti-cancer drug FDT

Where patients are prescribed an anti-cancer drug in clinic for patients to take at home or have administered by the GP, the treatment start date is the day the oncologist agrees the treatment with the patient.

Diagnostic procedures

A diagnostic procedure, undertaken as therapeutic in intent, will count as FDT irrespective of whether the margins were clear.

28-day FDS clock stop

The 28-day FDS clock stop is at the point of communication with the patient, whether this is to inform them of a diagnosis of cancer, a ruling out, or if they are going to have treatment before a clinical diagnosis of cancer can be made.

All diagnosis of cancers should be made through direct face-to-face communication with the patient, unless otherwise agreed with the patient.

Reasonable forms of communication with patients to confirm that cancer has been ruled out include:

• direct communication with the patient, face-to-face or virtual
• written communication, by letter or by email

​​​​Interval scans or tests

In a case where a patient requires an interval scan or test, the 28-day FDS clock will stop when cancer has been ruled out. It is important that patients having interval scans are tracked and monitored to ensure the scan or test is completed when planned.

Active monitoring

Active monitoring may be used where a cancer diagnosis has been reached, but it is not appropriate to give any anti-cancer treatment at that point in time. An active treatment is still intended or may be required at a future date. The FDS clock will stop on the date that the diagnosis is communicated to the patient.

Whilst being actively monitored, the patient may receive symptomatic support.

If a patient has active anti-cancer treatment planned, but has other co-morbidities, because of the cancer, which need to be addressed before the active cancer treatment can commence, then active monitoring can be used. 

Examples include:

• dietetics support for malnourished patients
• respiratory support for those with breathing difficulties
• haematology input where patients are anaemic

Active monitoring is not to be used for patient thinking time, apart from low and low-intermediate risk prostate cancer patients. 

Patient died before communication of diagnosis

Where a patient dies before a communication of cancer diagnosis or exclusion of cancer, the end date is the date the patient died.

Patient declined all diagnostic appointments or all appointment

This only applies where a patient declines all diagnostics or all appointments and is therefore discharged back to the GP after a clinical decision has been made.

Patient opted for private diagnostics 

This only applies where a patient has opted to have their diagnostics through private funding.

First seen adjustments

An adjustment to the cancer pathway is acceptable if a patient DNAs the allocated appointment time without giving prior notice, for their initial outpatient appointment or diagnostic clinic that would have been recorded as Date First Seen.

If the patient arrives for their appointment in a condition where it is not possible to carry out the required procedure, for example, not taking a preparation they need to take prior to the appointment, it should be recorded as a Rebook.

If the patient arrives after the scheduled appointment time and it is not possible to fit them in, for example, the clinic is fully booked, or there is not enough time to carry out the planned procedure or tests in the remainder of the session, this is classed as a DNA.

Cancel and D​NA 

If a patient cancels their first outpatient appointment and then DNAs the re-arranged appointment, the clock can be reset to the date the appointment is rebooked.

DNA consultant upgrade

If a patient is upgraded by a consultant onto a 62-day standard and they DNA the first outpatient appointment an adjustment can be made, for example, a consultant upgrades a patient after reading a referral letter but then the patient DNAs. 

The adjustment only applies if the patient has not been seen. The clock can be reset to the date the appointment is rebooked; however, this adjustment is rare.

DNA a diagnostic appointment

An adjustment is only possible if the diagnostic appointment is also the first attendance.

The clock can be reset to the date the appointment is re-booked.

First seen adjustment from screening 

Although there is no screening first seen standard, a first seen adjustment can be applied using the same rules as a first appointment. The adjustment would then be applied to the 28-day FDS.

Patient choice treatment adjustment

If a patient declines a reasonable offer of admission for treatment, an adjustment can be applied. This applies to both admitted and non-admitted pathways.

For cancer patients who are being monitored on the 31-day or 62-day standard, the adjustment would be the time between the date of the declined appointment, to the point where the patient could make themselves available.

Patient DNAs or cancels an offer of treatment

If a patient has agreed to a reasonable offer, which they subsequently cancel or DNA, pathway adjustments are not applicable. 

As part of the re-booking process the patient should be offered alternative dates for treatment. If at the re-booking stage the patient declines a reasonable offer of treatment, then an adjustment to the pathway is applicable. The clock is paused from the date of the earliest reasonable offer given. The end of the pause will be the new date that the patient states from which they are available.

First appointment DNAs

If a patient DNAs a face-to-face or virtual first appointment, the operational team must establish why the patient did not attend and how to facilitate attendance. Where there is straightforward evidence of a barrier to attendance, that is known, consideration should be given to communication of appointment by different means, for example, by using telephone interpreter services.

If a patient DNAs a first appointment this will trigger a clinical review and referral back to GP to determine next steps.

A letter must be written to the GP after each failure to attend, to include the next steps applicable to facilitate attendance. GP letters must be kept and uploaded onto clinical systems.

Cancer patient declares unavailability

If a patient makes themselves unavailable for treatment for a set period, offering reasonable dates would be inappropriate. In these instances, an adjustment applies. The clock can be adjusted from the date of the earliest reasonable offer that would have been offered, to the date that the patient makes themselves available.

Specific cancer treatment option

If a patient is offered a choice of treatments and the patient enquires about another treatment, that they are aware of, if it is deemed that the treatment is appropriate the patient is declining a reasonable offer of treatment initially. An adjustment to the pathway applies. The adjustment would be from the date that would have been offered, to the date that the patient makes themselves available for a further appointment.

Cancer patient wishes to wait for a specific consultant or provider

If a patient is given a reasonable offer of treatment with a consultant or location but requests a different consultant or location and an appointment cannot be offered within the standard time, an adjustment can be applied if treatment with consultant or location was not offered originally as an option.

Religious event

If a patient makes themselves unavailable due to attending a religious event, pathway adjustments are not applicable. The time delay caused by patients attending religious events is considered in the set operational standards.

Clinically urgent treatment of another condition

A pathway adjustment can be applied if it is deemed clinically essential to treat another medical condition before treatment for cancer can be given, after a decision to treat the cancer has been made. The adjustment would apply from the point at which it is confirmed that a patient needs treatment for the other medical condition, to the point at which the patient is deemed clinically fit to commence their cancer treatment. 

Patient declined all diagnostic appointments or all appointment

This only applies where a patient declines all diagnostics or all appointments and is therefore discharged back to the GP after a clinical decision has been made.

Patient who cancels their first appointment

Patients who cancel their first new appointment should be given an alternative date at the time of cancellation. Patients originally referred on a suspected cancer referral must be given a further appointment within 14 days of receipt of the original referral where possible.

Repeat cancer DNA

This only applies following more than 2 DNAs and patient cancellations where a clinical decision is made to discharge the patient back to the care of their GP. 

The following protocol applies:

• do not discharge a patient after a single DNA or cancellation
• if a patient has rescheduled an appointment, this shows that the patient has engaged and still requires follow up. A clinical decision must be made before a patient can be discharged

Cancer tracking pathways​

The tracking team will locate information by interrogation of multiple systems and multi-disciplinary sources such as cancer MDT outcomes or Cancer Nurse Specialists (CNS) to retrieve information or data relevant to the cancer pathways. 

As a minimum, the information system used for cancer patients collects data on key milestones such as:

• date referral received
• date first seen appointment
• key diagnostic test or tests
• diagnosis
• decision to treat
• MDT discussion 
• transfer to another provider
• treatment, or decision not to treat
  

Governance

The application and implementation of this policy is the responsibility of all staff and services relating to patient access managed. All staff involved in the management of patients’ access to services within the organisation are expected to follow this policy and associated operating procedures.

Competency

As a key part of their local induction programme, which is being developed all new starters will undergo training and system training applicable to their role in line with departmental protocols.

All existing staff will undergo training when updates are made.

All staff will carry out local competency assessments that are clearly documented to provide evidence that they have the required level of knowledge and ability.

This policy, along with the supporting suite of SOPs and systems user guides will form the basis of the required local training programmes.

Monitoring

Operational teams will regularly monitor levels of capacity for each pathway milestone to address any shortfalls in advance as much as is practicable. If any shortfalls are identified, additional capacity will be arranged to avoid poor patient experience, resource intensive workarounds and breaches of the access standards. In addition, demand and capacity and job plans, will be reviewed annually to ensure they reflect the needs of the service.

Compliance​

Operational teams, specialties and staff will be performance managed against key performance indicators (KPIs) applicable to their role. Role-specific KPIs are based on the principles in this policy and specific aspects of the SOPs.

In the event of non-compliance, a resolution should initially be sought by the team, specialty, or individual’s line manager. 

Performance reporting

The Business Intelligence team will be responsible to produce reports via the Power BI reporting system that have been determined to be critical to the day-to-day management and performance management of elective and cancer services. 

These reports will inform weekly PTL meetings for elective and cancer care and will provide a single version of the truth.

Performance management

Weekly PTL meetings are central to patient management and oversee the delivery of timely access to safe care for all our patients.

The attendance at weekly PTL meetings must include but not limited to:

• Assistant General Manager who will act as Chair
• Clinical Lead
• Operational Managers
• Waiting List Manager 
• Business Support Officer for specialty
• Business Intelligence or data analyst for specific specialty

Each speciality can nominate any other clinical or non-clinical representatives as required for their own service to enable effective management of the PTL and thus performance of the service.

Escalation process​

Following each weekly PTL meeting, escalations will be formally communicated to the Care Group General Manager with actions agreed to rectify.

Monitoring of actions and resolutions will be maintained by the General Manager until compliance is achieved. 

Should further escalation be required, this will be formally reported to the Chief Operating Officer.

Glossary

Definitions of technical or specialised terminology used within your document.

A

Advice and Guidance (AG)

Allows 1 clinician to seek advice from another without referring the patient into consultant-led service.

Accident and Emergency (AE)

The department also known as Emergency Department or casualty, deals with genuine life-threatening emergencies.

Active monitoring

Where a decision is made and agreed with the patient, that it is clinically appropriate to start a period of monitoring whilst the patient received symptomatic support, without any specific or significant clinical intervention.

B

Bilateral

Condition affecting both sides of the body.

C​

Chronological Booking

Refers to the process of booking patients for appointments, diagnostic procedures, and admission in date order of their addition to the waiting list referral date.

Consult​​​​​ant-Le​d Service

​D

A service where a consultant retains overall responsibility for the care of the patient. Patients seen in nurse-led clinics which come under the umbrella of the consultant-led service.

Day Cas​​​e (DC)

Patients who require admission to hospital for treatment and will need the use of a hospital bed but who are not required to stay in hospital overnight.

Decision to ​​​​Admit (DTA)

Where a clinical decision is made to admit the patients for either day case or inpatient treatment.

Did Not Att​​​end (DNA)

Patient did not attend their agreed appointment.

F

First Definitive Treat​​​ment (FDT)

The first clinical intervention intended to manage a patient’s disease, condition or injury and avoid further clinical interventions.

G

General Practitio​​​ner (GP)

General Practitioners treat all common medical conditions and refer patients to hospitals and other medical services for urgent and specialist care.

H

Health and Care Je​​​rsey Advisory Board

The HCJ Advisory Board play a key role in shaping the strategy, vision, and purpose. For further assurance and transparency, the organisations elective performance is scrutinised as part of their local audit programme.

I

Incomp​​​lete Pathways

Patients who are waiting treatment on an open pathway.

Indep​​​​endent sector (IS)

A private sector healthcare company that is contracted for additional healthcare capacity.

Inpatien​​​​​ts (IP)

Patients who require admission to the hospital for treatment and are intended to remain in hospital for at least 1 night.

Inter Provider​​​ Transfer (IPT)

When a patient follows a pathway of care that involves a referral between providers.

M

Minimum Data​​​​ Set (MDS)

The minimum data set of information needed.

N

National​​​​ Health Service (NHS)

The National Health Service is the UK Government funded medical and health care service that eligible people living in the UK can use without being asked to pay the full cost of the service.

Nullifie​​​d

The patient pathway is stopped and removed from PAS as if the referral has never been received.

P

Patient Advis​​​ory and Liaison Service (PALS)

Patient Advisory and Liaison Service, offering confidential advice, support, and information on health-related matters.

Patient Admini​​​​​stration System (PAS)

Patient administration system, the system used to record patient pathways.

Patient Initi​ated Delay

Where a patient cancels, declines offer or does not attend appointments or admission on an open pathway.

Patient Path​​​​way

The process the patient follows for the management of their condition once referred into secondary care.

Patient Trackin​​​g List (PTL)

A list of patients who are awaiting an appointment at various stages of a pathway.

Pla​​​nned patients

An appointment or procedure, or a series of appointments or procedures as part of an agreed programme of care which is required for clinical reasons to be carried out at a specific time.

Pooled patie​​​​nts

Patients are listed on a single specialty list enabling true chronological booking and efficient use of operational capacity.

Pre-op Assessme​​​nt (POA)

Prior to certain procedures, patients require clinical assessment to ensure suitability for procedure to be undertaken.

Provi​​​der

Hospital organisation.

R

Referral to Trea​​​tment (RTT)

Referral to Treatment is the measure of the waiting time experienced by patients who are referred to a consultant-led service from receipt of referral until they are treated or discharged.

Reasonable ​​​​Offer

A choice of 2 appointments or admission dates with 3 weeks’ notice.

S

Standard Opera​​​​​ting Procedure (SOP)

Standard Operating Procedures are the procedures that underpin the Patient Access Policy and inform staff of the documented processes that should be undertaken to deliver the policy.

Straight to ​​​​Test

Arrangements where a patient can be referred straight for diagnostics as the first appointment part of the pathway.

Study leav​​​e

Relates to the educational needs of an individual clinician for example, attending courses, conferences, teaching, exams and similar.

Subsequen​​t activity

Once the RTT clock has started, any appointment that takes place whilst waiting for treatment or discharge for example, diagnostic, pre-op.

T

To Come​​​ in TCI

The date that the patient has agreed to be admitted as an inpatient or day case.

W

Was N​​​​​ot Brought WNB

A child who was not brought to a scheduled appointment.

Appendices​

Appendix 1: Minimum Data Set (MDS)

Appendix 2: Missed appoi​ntment management plan

Ask what the impact of this missed health appointment is for every child.