Referrals to Treatment Access Policy
Care UK Health Care Division
Controlled document
Copyright © Care UK 2011. All rights reserved.
Reference number / Southampton OP03
Version / V5
Key updates
Onward referral process
Updates in keeping with current 18 week and 6 week diagnostic waiting times targets
Authors / Kathryn Dunning, Administration Manager
Francesca Cortvriend, Operational Manager
Date ratified / January 2016
Committee/individual responsible / Administration Leads
Senior Management
Issue date / May2017
Review date / May 2018
Target audience / Administration Teams
Clinical Managers
Clinicians
External interested parties – Clinical Commissioning Groups, Patients, Referrers
CONTENTS
Policy Statement...... 3
Southampton NHS Treatment Centre Exclusions Criteria...... 4
Minimum Data Set......
18 Week Referral to Treatment (RTT) Guidance...... 5
Referral for Direct Access Diagnostic Procedures...... 7
Summary of STC Referral, diagnostic and Admission Procedures...... 7
GLOSSARY OF TERMS...... 11
References...... 13
Policy Statement
This policy will reflect the overall expectations of the Southampton NHS Treatment Centre (STC) and the Sponsor CCGs of the current contract on the management and admissions into and within the STC and defines the principles on which the policy is based.
This policy is intended to be of interest to and used by all those individuals who are responsible for referring patients to the STC and those responsible for managing referrals. It will also be used by all those individuals within the STC, including clinicians and administrative staff who have responsibility for the patients’ progress along the care pathway.
This policy has been introduced to enable the STC to focus on delivery of the contractual 18 week patient pathway and ultimately to enable all patients to access treatment in a timely manner.
Principles of the Policy
This policy highlights the key principles that govern effective and reliable referral and admission management throughout the local health community.
- Referral for patients should be made when the patient is fit, ready and willing to be able to undertake assessment and any necessary treatment in a timely manner
- The process of referral, diagnostic and admission management will be transparent to the public and external organisations.
- The STC will use their Patient Administration System (PAS) to monitor patients through their pathway against the 18 week contracted RTT pathway.
- Accuracy and reliability of waiting list and diagnostic information produced by the STC is the responsibility of all staff in the STC who is involved in referral for outpatients and diagnostics and admission management, or have access to the administration and upkeep of patient access systems.
- Consultant to Consultant Referrals – Referrals can be made internally or to another provider within the same specialty or directly relating to the original reason for referral. Referrals will be managed as a continuation of previous wait. Additionally a referral can be made to aid the treatment of a patient that is an inpatient at the time of referral.
Urgent cases such as cancer however will be referred directly to University Hospital Southampton NHS FoundationTrust (UHSFT) by STC. In all cases the patient and their GP will be made aware of the plans for care.
- Onward referrals may be made by STC where it is felt that the patient is best treated in another organisation for any reason. Both the patient and the GP will be made aware of the plans for care. This will include
a)Secondary condition where referral is only loosely associated with the original problem
b)Incidental findings, including those found in the course of pre-operative assessment that do not impede anaesthesia or surgery.
In all the above circumstances case the patient will be offered choice of treatment location and clinician
c)Bilateral procedure – Where the patient has been referred for a bilateral procedure this will be performed when the patient is sufficiently well and recovered from the primary operation in order to safely proceed. Where a decision is taken that a bilateral procedure is required after the first procedure has been completed, the treating clinician will contact the GP to inform them of the decision to proceed. The GP may choose to intervene if they require further information.
Southampton NHS Treatment Centre Exclusions Criteria
Full information regarding inclusion/exclusion criteria may be found at:
The majority of cases can be treated at the centre. However, there are a number of exclusion criteria to ensure the safety of patients. Key areas where patients are not suitable for treatment are:
• Under 16 years of age
• High suspicion of cancer
• Clinical emergencies
• Patients with poorly controlled co-morbidities (further details on the referral criteria on the website)
• Pregnancy (unless procedure under local anaesthesia only)
• BMI greater than 40 for patients undergoing procedures under general or regional anaesthesia only: many procedures can be performed under local anaesthesia (dental, gynaecological, minor general, urology and orthopaedic). Please contact the treatment centre if you are unsure as to an individual patient’s suitability
In addition reference must be made to the Clinical Commissioning Procedures of Limited Clinical Value guidance. Some procedures have specific inclusion criteria stated.
In summary, the following patients are excluded from Southampton NHS Treatment Centre:
- Unstable Diabetes Mellitus
- Hepatitis C positive
- Patient/family history of Malignant hyperthermia
- Central (neurological) sleep apnoea
- Severe/Critical Aortic stenosis
- Congestive Cardiac Failure- non compensated &/or recent episode
- Severe COPD
- Unstable angina
- Recent myocardial infarction (<3 months)
- Cardiomyopathy with ejection fraction < 30%
- Severe systemic disease with functional limit: e.g. arrhythmias
- Patients fitting American Society of Anaesthesia (ASA) categories 4 & 5 and unstable 3 category
- Patients with suspected allergies/anaphylaxis to routine anaesthetic drugs who have not been formally tested
- Documented failed intubation during previous general anaesthesia
Minimum Data Set
The following is required as the minimum data set (MDS) in order to register a patient with the STC. Further required MDS including religion and ethnicity, etc. will be part of the MDS checked on patient arrival at STC:
Non-Clinical MDS
NHS No
UBRN (unique booking reference number for all e-referral service referrals)
First Name
Surname
Date of Birth
Full postal address including post code
Contact telephone number
Referring GP Name
Practice Name
Practice Code
GP Code
AHP Name (if appropriate)
Referrer’s Address
AHP professional registration code (if appropriate)
Date of referral
Translation service required
Transport service required
Funding code (if applicable ie Procedures of Limited Clinical Value, Individual Funding Requests)
Clinical MDS
- Reason for referral
- Examination finding/investigation results
- Past Medical History
- Current/Recent Medication
- Clinical Warning (e.g. Allergies, blood borne viruses)
- Additional Relevant Information
18 Week Referral to Treatment (RTT) Guidance
It is the responsibility of all members of staff to understand the 18 Week Principles and Definitions. They must be applied to all aspects of individual specialty pathways and referrals. Waits will be managed and measured accordingly.
- Start of the 18 Week Pathway
An 18 week clock starts when any healthcare professional or service permitted by the CCG to make such referrals, refers to:
a)A medical or surgical consultant led service, regardless of setting, with the intention that the patient will be assessed and, if appropriate, treated before responsibility is transferred back to the referring health professional or general practitioner;
b)An interface or referral management or assessment service, which may result in an onward referral to a medical or surgical consultant led service before responsibility is transferred back to the referring health professional or general practitioner.
For referrals through e-Referral System (ERS) the start of the waiting period is at the point of conversion of the Unique Booking Reference Number (UBRN). The STC provides a directly bookable service.
Where ERS is not utilised the 18 week clock starts at the point at which the provider receives the referral letter. If the referral is via an interim service such as a Clinical Assessment Service (CAS) the clock start is from the point the CAS receives the referral. The CAS will make this date available to the STC.
It is the responsibility of the referrer to provide to the STC any additional patient needs such as communication services.
If the patient is being referred for a condition for which the likely surgical procedure is categorised by the CCG as a Procedure of Low Clinical Value (PLCV) or requiring an Individual Funding Request (IFR) the PLCV and IFR policies must be adhered to.
- End of the 18 Week Pathway
Start of first definitive treatment is described as the start of the first treatment that is intended to manage a person’s disease, condition or injury. The clock stops if the treatment that is started is intended to avoid further intervention.
The End of the patients’ 18 week wait would include:
- Treatment as an inpatient or day case
- Treatment/discharge within the outpatient setting, i.e. surgery is not required or the patient is treated as a day case
- First Line Treatment of pain where pain management is defined as the definitive treatment, e.g. medical management of pain.
- Decision not to treat in secondary care and return of patient to primary care.
- Active Monitoring – defined as a situation where a diagnosis has been reached but a period of active monitoring of the patient is deemed clinically appropriate. If a patient subsequently required further treatment after this monitoring period a new 18 week pathway would begin.
- Patient Declines Treatment – if the clinician decides treatment is appropriate but the patient declines treatment. The date the patient declines treatment should be used as the end date for the RTT clock.
- Did Not Attend (DNA) and Patient Cancellations. Every effort will be made to support patients attending their appointments. The team will attempt contact with a patient to ascertain the reasons behind the DNA/cancellation and if appropriate a further appointment may be offered. If all attempts at contact fail or if the patient does not wish to attend, the STC will inform the GP and refer the patient back to them. It is important that the patients GP is kept informed that their patient potentially has outstanding care needs.Discharge back to the care of the GP will stop the 18 week clock. Upon completion of an 18 week pathway, a new clock only starts:
a)When a patient becomes fit, willing and ready for the second of a consultant-led bilateral procedure.
b)Upon the decision to start a substantively new or different treatment that does not already form part of that patient’s agreed care plan, e.g. should a patient require a related surgery/treatment the consultant will inform the referring GP via letter and continue with
surgery. If the treatment is considerably different a new referral will be required.
c)Upon a patient being re-referred in to a medical or surgical consultant-led interface, i.e. after a period of active monitoring.
d)At the first point of contact after a patients first DNA and only if it is deemed there is a good reason for the patient pathway to be re-instated.
Referral for Direct Access Diagnostic Procedures
In the case of referral to the direct access service for endoscopic procedures patients will be given a To Come In date (TCI) within 6 weeks following receipt of referral to the STC. The service will also be available for booking via the e-Referral system.
It is expected that a patient referred for to the direct access service will be discharged back to the referrer following completion of the endoscopic procedure. The responsible endoscopy consultant may request the patient returns for a further procedure within a short period of time to review the condition. Patients may be reviewed should their condition warrant that they are seen over a period of time under a surveillance programme. In this case the patients GP will be informed that the patient is on the surveillance programme and the Endoscopy Department staff at the STC will be responsible for managing appropriate and timely recall and for updating the patients GP with results.
Other aspects of the 6 week patient pathway will follow the same guidelines as for patients on an 18 week pathway.
Summary of STC Referral Admission Procedures for Patients on an 18 Week Pathway
This section gives a brief summary of referral, diagnostic and admission management procedures in place at the STC.
- Outpatient Referrals
Methods currently employable to access services:
- Directly bookable via referral to the e-Referral System (ERS)
- Paper referral letters (post and fax) from GP and GDP practices and Tier 2 services who are not using the directly bookable e-Referral Service.
- Email via the nhs.net email system
- To note – the NHS Standard Contract will require that all referrals be made via ERS by September 2018
Reasonableness of Appointment:
For patients not appointed through ERS the STC should offer appointments with at least three weeks’ notice, although patients can still take an earlier appointment if they wish. Appointments should be available and offered for a period up of six weeks. The patient should be offered up to three appointments within this period if the first appointment offered is not suitable. Every effort will be made to see patients in a timely manner. However in some cases a patient may choose to postpone their appointment until week six, subject to negotiation. After this time every effort will be made to arrange a mutually convenient appointment with the patient, however if they are unable to accept any appointmentwithin 8 weeks they will be discharged back to the referrer. Under the 18 week guidance the STC is unable to pause the clock for patients who choose to delay appointments.
Open Referrals:
Referrals should in the majority of cases be addressed on a specialty or sub specialty basis rather than to named consultants. This is to ensure that the delivery of the referral to treatment time is not compromised.
Patients who cannot be contacted on referral:
Patients who cannot be contacted at the first attempt will be telephoned once more the next day. One call will be made after 6pm. If telephone contact is unsuccessful a letter will be sent to the patient requesting they make contact with the Booking team. If contact is not received from the patient after 10 days the patient will be discharged back to the referrer.
Did Not Attend:
Every effort will be made to support patients attending their appointments. The team will attempt contact with a patient to ascertain the reasons behind the DNA/cancellation and if appropriate a further appointment may be offered. If all attempts at contact fail, or if the patient does not wish to attend, the STC will inform the GP and refer the patient back to them. It is important that the patients GP is kept informed that their patient potentially has outstanding care needs. Discharge back to the care of the GP will stop the 18 week clock.
Can Not Attend:
As above
- Outcomes from Pre-Assessment
Patients who have been listed for surgery and attend a pre-assessment will be offered a surgery date providing they are fit for the procedure.
When a patient is admitted for surgery, it is the final stage of the referral to treatment episode and the clock will stop on that date. A patient may however choose to be admitted for surgery outside of the 18 week contract period.
The decision to add patients to the waiting list will be made by the consultant after discussion with the patient. Patients will only be added to the waiting list if there is an expectation of treating them and when the patient has accepted the clinicians’ advise on elective treatment. The patient will be added to the waiting list within one working day of the Decision to Admit (DTA).
- Diagnostic Appointments
A diagnostic test is defined as a test or procedure used to identify a person’s disease or condition and which allows for a medical diagnosis to be made. A diagnostic test may be required as part of the patient’s pathway to enable a treatment plan to be made. In this case the treatment time clock continues until such time a treatment or decision not to treat is made, or the patient is not ready, willing and able.
Diagnostic appointments are subject to the same guidelines as for outpatient and treatment appointments. However, the maximum standard waiting time for diagnostic tests is 6 weeks.
If a patient cancels or fails to attend their diagnostic appointment that has been offered under “ reasonableness criteria” (usually 3 weeks’ notice) then the diagnostic waiting time for that test is set to zero and the waiting time starts again from the date of the appointment that the patient cancelled or missed.
Patients who do not meet the inclusion criteria
Wherever possible the Treatment Centre staff will onward refer the patient to the appropriate setting for the care of the patient and inform the GP of their actions. If this is not clear or known and the patient cannot be treated at Southampton Treatment Centre, the patient will be discharged back to their GP to be managed in primary care. The discharge letter will make it clear to the GP why the patient has been discharged.
Patients not fit for surgery or clinically initiated delays
If a patient is not fit for surgery the STC will ascertain the nature and likely duration of the delay.
If the reason is that the patient has a secondary condition that itself requires active treatment they will be either discharged back to the care of their GP or will be actively monitored for their original condition. Either action results in the 18 week clock being stopped. A re-referral to the STC will be required in the event the patient’s condition has been managed so that they meet the STC criteria.
If the reason is transitory, e.g. a cold or flu, the patient will be offered a further surgery date within four weeks. This will allow patients with minor acute clinical reasons for delay time to recover and the clock will continue to run during this time.