Managing Waiting Times: A Good Practice Guide

MANAGING WAITING TIMES: A GOOD PRACTICE GUIDE

CHAPTER TWO
HOSPITAL SERVICES

2.1 MANAGING THE AVAILABILITY OF PATIENTS FOR TREATMENT

• Once a patient has been placed on a waiting list a commitment has been given to provide treatment within a reasonable period of time.

• It is not acceptable to allow patients to remain on a waiting list as an alternative to assessment or treatment.

• It is sometimes the case that a patient is correctly placed on a waiting list but will not be available for treatment for a period of time.

The NHS in Scotland has managed such patients by utilising a deferred waiting list where patients have, at some point in time, been unavailable for treatment, and availability status codes which describe the reasons for a patient's unavailability for treatment.

Availability Status Codes may also be used to describe particular circumstances relating to the patient's treatment, specifically if the procedure the patient is waiting for is judged to be of low clinical priority or to be of a highly specialised nature.

The process of managing patients who are unavailable for treatment is being modernised by NHSScotland. The deferred waiting list was abolished from 1st April 2003 and a revised process for managing periods of unavailability and applying status codes will be introduced from 1st April 2004.

When managing patients who are, or have at some time been unavailable for treatment, or have an Availability Status Code attached to their treatment, then a number of fundamental principles should be adhered to:

• The original date of placing the patient on the waiting list, whether this is an outpatient, operative or diagnostic list, should always be retained.

• NHS Boards should set a clear audit standard for the maximum length of time allowed for a period of unavailability or application of status code before patients circumstances and clinical status are reviewed.

• Hospitals and NHS Boards should ensure that the codes are being interpreted accurately and should monitor the application of all Availability Status Codes.

The following recommendations are provided for the application of Availability Status Codes

Code 2 - where the patient has asked to delay admission for personal reasons or has refused a reasonable offer of admission.

Once the period of unavailability ends and the patient is able to attend for treatment, then the patient should be admitted as soon as possible, taking account of their original date placed on the waiting list and according to clinical priority.

Code 3 - in individual cases where, after discussion with the patient, the treatment has been judged of low clinical priority.

The application of the code for low clinical priority should only be applied after full discussion with the patient. The patient should be advised of the likely timescale for their treatment and be advised of any changes to this timescale.

Code 4 - with highly specialised treatments identified at the time of placing the patient on the waiting list.

This code is intended for treatments which are clearly of a highly specialised nature and should therefore be identified and applied at the time the patient is added to the waiting list. The consequences of the application of this code should be fully discussed and explained to the patient and the patient should be advised of the likely timescale for treatment and updated of any changes to this timescale.

Code 8 - where the patient did not attend or give any prior warning.

This code should always be applied when a decision is taken to retain a patient on a waiting list following a failure to attend. Local protocols should be in place to determine if the patient is given another opportunity to attend or if the patient should be returned for care to general practice and removed from the waiting list.

Code 9 - in circumstances of exceptional strain on NHS such as a major disaster, major epidemic or outbreak of infection, or service disruption caused by industrial action.

This code must only be applied following agreement by the Scottish Executive Health Department and the code may only apply to patients for an agreed and limited period of time.

Code A - patients under medical constraints (conditions other than that requiring treatment) which affect their ability to accept an admission date if offered.

These circumstances should be fully discussed with the patient at the time of placing on the waiting list and the likely consequences for their waiting time outlined. Once the patient is medically available they should be admitted as soon as possible, taking account of their original date placed on the waiting list and according to clinical priority.

Code X - temporary code valid until September 2003 for patients transferred from the deferred waiting list where the original reason for placing on the deferred list is not known.

By September 2003 all patients who have had this code applied must either be covered by a valid availability status code, be removed from the waiting list because they are no longer waiting, or have been admitted to hospital.

Identifying the start and end point of a waiting time period

A waiting time exists for a patient from the point in time the patient requests, or has a request made on their behalf, for access to a particular healthcare service. Typical examples of a healthcare service are an appointment with your General Practitioner, attendance at a hospital outpatient clinic for diagnosis or advice or admission to hospital for investigation or an operation.

The waiting time period normally begins when:

a. the patient requests to see a member of the primary care team;
b. the general practitioner refers the patient for a hospital outpatient appointment. In most cases measurement is from the date the referral is received at the hospital;
c. the hospital doctor agrees with the patient that an appropriate investigation or treatment should take place.

The waiting time period normally ends when the date is reached for:

a. the appointment with general practice;
b. the hospital out-patient appointment;
c. admission to hospital for investigation or treatment.

The waiting time period does not end if the general practitioner or hospital cancels a patient's appointment or if following admission the patient is sent home before treatment commences.

Sometimes the time it takes for a patient's period of care to be completed includes one or more diagnostic investigations for which the patient is required to wait. These investigations may relate to serious conditions such as heart disease or cancer. NHSScotland has therefore set specific waiting times for investigation for coronary heart disease and a total waiting time standard from referral to commencement of treatment for cancer (Appendix A).

2.2 ADDING AND REMOVING PATIENTS FROM THE WAITING LIST

Audit Scotland has recommended that all patients waiting for services should be entered onto a waiting list to allow monitoring of waiting times and early warning of pressures in service areas. The level of information recorded for a patient placed on a waiting list should be proportional to the requirements for appropriate clinical management and the delivery of waiting time standards.

Patients should only be placed on a waiting list if:

1. There is a clear clinical indication that the proposed assessment or treatment is required and will be beneficial. A patient is not to be placed on a waiting list as a holding device until the patient's condition reaches an appropriate stage or the patient reaches a certain age.
2. Services are available within the hospital to provide the planned assessment or treatment.
3. There is a valid expectation that the assessment or treatment will be carried out within the agreed waiting time standard. If this is not the case then the hospital in partnership with the NHS Board and primary care should make arrangements for the provision of care at an alternative facility or through an alternative and appropriate method of treatment.

A patient should only be removed from a waiting list when:

1. The patient has been seen or admitted and the planned episode of care has commenced.
2. Within agreed protocols if the patient has failed to attend or repeatedly asked for appointments to be rearranged.
3. There is another valid reason for removal; for instance the patient no longer wishes treatment, has moved out of the area or has received treatment at another provider.

Patients should not be removed from the waiting list:

1. If, after being added to the waiting list at one hospital, it is agreed that their care will be provided at another hospital. In such an instance the patient's waiting time continues to be counted from the original date on the waiting list.

2. If the hospital cancels an appointment or admission or if the hospital sends a patient home after admission prior to the commencement of treatment.

Removing patients from the waiting list for reasons other than treatment

Hospitals should set targets for the maximum number of removals from a waiting list for reasons other than attendance or admission.

These targets should, where appropriate, be sub-divided by reason for removal, speciality of care, condition and proposed procedure. The hospital should calculate the removals for reasons other than admission as a rate against the total number of patients coming off the waiting list. Hospitals should benchmark the rates for removal for reasons other than admission against hospitals with similar services.

High levels of removal for reasons other than admission are indicative of problems in the policy and practice of adding patients to a waiting list, whether for outpatient or inpatient/day case care. Hospitals should ensure removals are at an acceptable level.

2.3 MANAGING INPATIENT/DAY CASE WAITING LISTS AND WAITING TIMES

Patients should be ranked in order of clinical priority in a consistent, equitable and auditable manner. This should normally be the responsibility of a senior clinician.

Assignment of a patient's clinical priority should be in keeping with NHS Quality Improvement Scotland guidelines, including SIGN guidelines.

A hospital waiting list is an amalgamation of a number of separate waiting lists. The hospital waiting list can be broken down into waiting lists for individual specialities, individual procedures and for individual consultants. Waiting lists should be managed at an appropriate level of detail. It is recommended that a senior clinician with management responsibility should provide leadership to ensure that each sub-division of the hospital's total waiting list is managed to deliver the agreed waiting time standards. If appropriate this may involve the pooling of waiting lists for designated procedures or for routine referrals across a group of consultants.

In keeping with any national definitions, hospital services should agree with NHS Boards and primary care the criteria which constitute a reasonable offer of admission to a patient. It is recommended that a reasonable offer for attendance or admission should be notified to the patient no later than 3 weeks prior to the planned appointment or admission.

Failure to offer patients reasonable notice to attend may result in prioritising patients who are available at short notice. This may have the progressive effect of significantly admitting numbers of patients out-of-date order and therefore allowing some patients to wait excessively long times. Short notice booking also has a potential to disrupt good theatre planning.

The original date of placing the patient on a waiting list should always be retained. This date should be retained irrespective of the number of occasions the patient has asked for appointments to be rearranged, has become unavailable for treatment or has failed to attend. This date is required to ensure that patients do not remain on a waiting list when there is no prospect of admission, and to ensure that patients are not "lost" on a waiting list when their clinical condition may be deteriorating.

The majority of patients on a speciality waiting list are often waiting for the most common procedures. These patients may also have the longest waiting times. Hospitals should put in place plans to manage the waiting times for the most common elective procedures, making best use of resources available and promoting the greatest co-operation between consultant teams through the pooling of workload where appropriate.

Hospitals should monitor and review the cancellation of theatre sessions and operations. Targets should be set to reduce cancellations where these are at an unacceptable level. It is recommended that a theatre session should only be cancelled following consultation with a designated director, and specific protocols should be in place for action following the cancellation of a theatre session by a hospital.

The requirement to review the status of all patients after a stipulated period of waiting should ensure that patients on a waiting list are actively waiting for treatment or their reason for unavailability is understood and managed. There should, however, be a formal written policy for the validation and review of both inpatient/day case and outpatient waiting lists.

Pre-assessment clinics should be considered, where appropriate as a means of reducing failures to attend and improving waiting times.

Performance benchmarking against comparable services should be employed as a means of assessing the efficiency of services in delivering waiting time standards. Typical performance benchmarks are; bed utilisation, theatre utilisation, length of stay in hospital and the number of operations carried out as day cases.

2.4 MANAGING OUTPATIENT WAITING LISTS AND WAITING TIMES

Hospitals should take action to identify referrals considered to be inappropriate and, for selected services, work with primary care and NHS Board's public health departments to produce joint referral protocols.

The prioritisation and management of outpatient referrals should be reviewed by consultant staff in partnership with primary care.

This process should be of mutual benefit to general practitioners and consultants in improving the entire referral process, and consideration should be given to the involvement of primary care referral advisers.

There should be the opportunity for general practitioners to refer directly the most urgent patients with the minimum of waiting time.

The management of follow-up outpatient appointments should be as systematic and thorough as the management of new outpatient appointments.

Hospitals should consider setting a standard for the number and type of referral from primary care which may receive a notification of receipt of referral. This may be particularly valuable where waiting times are particularly long and may have the benefit of reducing patient anxiety.

The recording of certain outpatient procedures is now mandatory. The information available should be utilised to set standards for the actual waiting times for these procedures.

The Information and Statistics Division (Scotland) have a data development programme in place to record an increased range of outpatient services that are not consultant-led. Hospitals should ensure that they are effectively managing the waiting times and services for all outpatient clinics regardless of the designation of the health care professional.

Hospitals should monitor and review the cancellations of outpatient clinics and set targets and reduce cancellations where these are at an unacceptable level. It is recommended that a clinic should only be cancelled following consultation with a designated director, and specific protocols should be in place for action following the cancellation of a clinic by a hospital.

Outpatient services should be managed in accordance with the clinic template, also known as the clinic rules or clinic profile. It is recommended that the clinic template should contain as a minimum the following information for each clinic:

1. Clinic location and start and end time for the clinic.
2. Lead clinician for the service being provided.
3. Clinician holding the clinic.
4. Number and duration of urgent new outpatient slots.
5. Number and duration of routine new outpatient slots.
6. Number and duration of return slots.

Hospitals, in conjunction with primary care, should consider the introduction of booking systems which give patients early notification of their appointment time. This approach is convenient for the patient, promotes efficient use of services and assists in reducing failures to attend.

2.5 MANAGING FAILURES TO ATTEND FOR AN APPOINTMENT OR FOR ADMISSION TO HOSPITAL

There should be a written policy for the management of patients who fail to attend for appointment or admission. This policy should be agreed between the NHS Board, hospital services, and primary care. It is recommended that the policy on failure to attend should contain the following elements:

1. A senior member of staff should be identified as responsible for implementing and auditing the failure to attend policy. A senior doctor should be responsible for ensuring the clinical appropriateness and effectiveness of the failure to attend policy.
2. Specific action should be stipulated to follow a patient's failure to attend.
3. Action following a failure to attend should take account of the patient's provisional diagnosis and proposed procedure. Patient notes should be updated with details covering the failure to attend.
4. The general practitioner should be formally notified of the patient's failure to attend.
5. Hospitals should normally contact patients who have failed to attend and explain the actions which follow from this event. General practitioners should normally discuss with patients the consequences and options following their failure to attend.
6. Hospitals should promptly remove patient's from the waiting list where the decision has been taken to return the care of the patient to primary care.
7. The decision to retain a patient on a waiting list following a failure to attend should always be an explicit decision in keeping with local guidance.
8. Following a failure to attend, the patient's status against waiting time standards should be updated in keeping with national and local guidance.
9. The patient's original date of joining the waiting list should always be retained if the patient remains on the list following a failure(s) to attend. This is to ensure that patients are not retained on the waiting list for inappropriately long periods, and to identify the possibility of a deteriorating clinical condition.
10. The management of failures to attend should be supported by regular audit of the accuracy of patient contact details.
11. The local health system should develop and improve their means of contacting patients in an efficient and cost effective manner. For instance through the utilisation of mobile phones and e-mail in addition to conventional methods.

The policy on failures to attend should be developed to cover patients who repeatedly ask for appointments to be re-arranged.

Hospitals should set target rates for failures to attend as a percentage of total attempted appointments or admissions. This is known as the Did Not Attend (DNA) Rate. The hospital should benchmark their rate against similar services and aim to improve performance in this area. Targets for cancellation/failure to attend rates should be subdivided into Specialty or condition specific targets to take account of clinical circumstances.

A high failure to attend rate is generally an indicator of:

1. Long waiting times.
2. Poor communication with patients and management of patient contact details.
3. Inappropriate referral levels from primary care
4. A poorly managed hospital outpatient service.

Overbooking available outpatient appointment slots is not good practice and is a compensation approach to the management of outpatient services. Failure to attend rates should be managed and outpatient slots provided to meet the projected demand for services.

2.6 MEETING THE NEEDS AND EXPECTATIONS OF PATIENTS

Hospitals should work to ensure that patients are as fully involved as possible in their treatment process. Patients should normally have one clear contact point to go to for advice or to notify if their situation changes.

Hospitals should set targets for the quality of contact information held on patient records, for example targets covering:

1. Percentage of patient records holding a telephone number.
2. Percentage of patient records holding a mobile telephone number.
3. Percentage of patient records holding an e-mail address.

It may at times not be possible to offer all patients treatment at the first choice hospital or with the consultant who received the original referral. Where there is a particularly high level of demand for certain services consideration should be given to asking the patient at the time of being placed on the waiting list if they would be agreeable to receiving treatment by another appropriate consultant or at another suitable hospital.

Hospitals should aim to provide the patient with a simple list of rights and responsibilities when they are placed on either an outpatient or inpatient/day case waiting list. It is recommended that this information should include the following:

1. The service for which the patient is waiting
2. The doctor or other clinician responsible for the patient's care.
3. The expected time the patient will have to wait.
4. Any waiting time standard which applies to the patient.
5. Confirmation if the patient is available at short notice.
6. The amount of notice the patient will be given prior to their proposed attendance or admission date.
7. How the patient will be contacted by the hospital, for example by letter or by phone.
8. The actions required of the patient when notified of their appointment or admission date.
9. One contact point at the hospital in case of any queries.
10. The action the patient should take if they wish to re-arrange an appointment, notify a change in their circumstances or if they no longer wish to take up the offer of an appointment or admission.
11. The consequences for the patient if they fail to attend for an appointment or admission.
12. The action the hospital will take if it is necessary to cancel an agreed appointment or admission date.
13. Confirmation that the patient will be informed if they are not likely to be admitted within their expected waiting time.
14. Confirmation if the patient has agreed to treatment with an alternative consultant or at another hospital in order to provide quicker treatment within national or local standards.

2.7 SUPPORTING ACTIONS TO REDUCE WAITING TIMES

Actions to improve waiting times should be supported by actions to maintain service standards in other areas, such as emergency care and the discharge of patients following a stay in hospital.

Hospitals should aim to develop programmes for integrated care through a "whole systems approach" which take account of the entire patient pathway from referral by General Practitioner through consultation and investigation to treatment and discharge home. This approach will help avoid a fragmented care process where work may be duplicated and the focus on the patient may be lost.

Written protocols should be in place for the management of waiting times which are in keeping with required practice and guidance. The effectiveness of written protocols should be regularly audited. Specifically there should be a written policy and procedure for training staff in the management of waiting lists and waiting times. There should be the opportunity for refresher training for key staff.

A consistent approach should be applied to the management of waiting lists and waiting times across all hospital services, in keeping with the specific requirements of individual specialities.

There should be adequate leave and sickness cover for key staff involved in the management of waiting lists and waiting times.

Access to details of individual patients on waiting lists should be entirely within current guidance on confidentiality.