NHSScotland: national access policy

5. Responsibilities

This policy details the responsibilities that will ensure equity and consistency in approach to access to services both within Health Boards and across NHSScotland as a whole.

Health Boards are required to ensure that their Local Access Policies and procedures reflect the principles laid out in this National Access Policy. Health Boards should implement this policy in a manner that best meets the needs of their patients.

The five key responsibilities under the National Access Policy are:

1. to communicate effectively with patients.

2. to manage referrals effectively.

3. to manage waiting lists effectively.

4. to use information to support improvements in service provision.

5. to report patients’ waiting times accurately and in a timely manner.

5.1 Communicate Effectively With Patients

There is a need to ensure that patients are appropriately informed at all stages of the patient journey. Communicating effectively with patients will help to inform them of when, where and how they are to receive care and their responsibilities in helping to ensure that this happens.

• Each patient must be provided with sufficient information about their treatment to facilitate their informed discussion in the decision making process.
• It is important that patients are provided with clear, accurate and timely information about how processes will operate as close to the beginning of their journey as possible.

Full details can be found in the NHSScotland Waiting Times Guidance November 2023 but examples include:

• the impact on the patient if they refuse reasonable offers of appointment.
• what happens when a patient Does Not Attend (DNA), Could Not Attend (CNA) or is unavailable, and the impact this could have on the care they receive.
• the consequences of not responding promptly to hospital communcations, and the impact this could have on their waiting time.
• instructions on how and when to contact the hospital, as well as the timeframe in which to do this.

• Health Boards have a duty to ensure that patients are provided with information they can easily understand, and that appropriate support is put in place as required. Additional needs must be taken into account where these have been communicated by the patient, the patient’s carer, or a medical practitioner.
• Where possible, GP/referring clinicians should advise patients at the point of referral of the possible locations for their appointment/treatment, as described in the Local Access Policy.
• Where treatment occurs outside the Health Board area, or where clinics are held infrequently, it is particularly important that the arrangements and the reasons for this are made clear to patients at the beginning of their care journey including the process of organising their appointment and/or admission to hospital.
• Health Boards must advise patients that the costs associated with travelling to an appointment outwith their local Health Board area, including accommodation, and any other relevant expenses, for the patient and their carer (if necessary), can be covered by the Health Board. Local Access Policies should provide details of what would be covered i.e. accompanying carer, cheapest travel option, accommodation where required.
• Health Boards should consider whether it may be appropriate to provide transport to support a patient to attend an appointment.
• Patients should be given clear and accurate information about how their waiting time is calculated, including when clock adjustments are made and how these affect their treatment time clock.
• Communications with patients should be in a format appropriate to their needs e.g. large print, community language, and in a method agreed by them i.e. letter, phone or digitally.
• Patients should be made aware that if they no longer wish to have their outpatient appointment or admission, for whatever reason, they must advise the hospital.
• Any communication being issued to the patient should also be sent to the referrer.
• Where patients are referred back to their GP, the Primary Care team should have arrangements in place to follow up with the patient prior to re‑referral.

5.2 Manage Referrals Effectively

Improvements in waiting times should be delivered through an effective partnership between Primary and Secondary Care, with appropriate protocols and documentation in place.

5.2.1 Referrer

• Prior to referral, the clinician should explain to the patient the range of options to be considered. This should include that patients may not need to access specialist or consultant‑led services.
• The referring clinician should advise patients why they are being referred and the expected waiting time, and outline to patients their responsibilities for keeping appointments and the consequences of not attending.
• The referring clinician should ensure that the patient is available to commence treatment. When the referrer is aware that the patient will be unavailable for a period of time, the referrer should either delay sending the referral until they know the patient is available, or clearly note the patient’s unavailability period on the referral form/letter.
• Referrals should be made electronically, where possible, and as per local protocols.
• Referring clinicians should make referrals to a clinical service and not a named consultant.
• Wherever possible, patients should be referred for diagnostics tests prior to the referral being made for the first outpatient appointment. However, if the Health Board is aware of long waits locally, it should add the patient to both waiting lists to ensure they are not disadvantaged.
• If the patient requires an outpatient appointment regardless of the diagnostic results, the patient should be added to both waiting lists to prevent any unnecessary delays in treatment.
• Referrers must provide accurate, timely and complete information within their referral including:
  • CHI identifier (unless they don’t have one);
  • full demographic details including name, address, ethnicity, postcode;
  • up-to-date mobile and home telephone numbers, email address, if applicable;
  • preferred method of contacting patient i.e. letter, phone or digitally;
  • patient’s unavailability period, if applicable;
  • Armed Forces/veteran status, if applicable, and;
  • Additional Support Needs.

5.2.2 Receiving Location

• There should be a structured and transparent approach to the management of referrals, scheduling and booking for all patients.
• The advanced vetting practice of Active Clinical Referral Triage (ACRT) should be implemented to ensure patients are on the optimal pathway for them. This will avoid unnecessary outpatient appointments. All ACRT outcomes should be recorded to allow for PHS data collection which will allow the impact of this process to be measured.
• Where treatment cannot be provided locally, and the patient needs to travel elsewhere, the patient should be made aware of that as early as possible.
• Referrals should be triaged electronically, where possible.
• The date of receipt of all referrals must be recorded.
• Patients should be booked as close to the date of receipt of referral as reasonably possible.
• Systems and procedures should be put in place to triage and prioritise referrals in accordance with referral category (e.g. Urgent).
• Patients referred with suspected cancer must be marked as ‘Urgent – Suspicion of Cancer’. All urgent cancer patients are required to be seen as soon as possible within cancer waiting time standards.
• Armed Forces personnel, veterans and their families who move between areas retain their relative point on the pathway of care within the national waiting time targets.
• No veteran (including those who have served as reservists) or their family should be disadvantaged as a result of their membership of the Armed Forces, when accessing NHS services. Further detailed guidance for veterans can be found at Armed_Forces_Covenant_Duty_Statutory_Guidance.pdf (publishing.service.gov.uk)

5.2.3 Receiving Clinician

• Receiving clinicians must ensure that waiting lists properly reflect their clinical priorities and are managed effectively.
• It is the receiving clinician’s responsibility to communicate with the referrer to offer advice on whether a referral is suitable.
• Any referrals received for a service that is not delivered in that Health Board area should be returned to the original referrer with advice.
• Where it is judged that a referral received would be more appropriately managed by another service provided by the Health Board, the referral will be passed to that service internally and the referrer informed.

5.2.4 Patient Transfer

• Appropriate documentation and information should be provided to the receiving Health Board (or Private Sector provider where appropriate).
• Any transfer of data must comply with standards in relation to data security and confidentiality.
• Private patients opting to transfer to NHS treatment must be referred back to the GP to discuss their options and if appropriate referred to local NHS provider.
• If the patient requests to be seen in a specific location within the area of the responsible Health Board, where the original offer was for treatment outside of that area, the responsible Health Board may agree this if it is deemed reasonable and clinically appropriate to offer the patient an alternative reasonable offer of appointment as set out in the Health Board’s Local Access Policy.
• A request for a specific location will only be allocated by the Health Board to ensure continuity of care, patient safety or for other clinical or exceptional reasons.

5.3 Manage Waiting Lists Effectively

To support delivery of waiting times standards there is a need for Health Boards to manage their waiting lists effectively. This includes triaging of referrals, management of patients and accurate recording of clinic outcomes.

• Processes and resources should be in place to ensure that all staff are adequately trained to use local systems to help manage access to services.
• All new referrals should be triaged electronically, with all new appointments having a corresponding waiting list entry.
• As far as possible, patients should be seen within agreed waiting time standards and booked in turn, taking clinical urgency into account.
• Ensure that details of patients on the waiting list, who are admitted as emergency admissions, are communicated for recording on the Patient Administration System.
• Patients should only be added to a waiting list when they are available to commence treatment.
• Wherever possible, patients should be referred for diagnostics tests prior to the referral being made for the first outpatient appointment. However, if the Health Board is aware of long waits locally, it should add the patient to both waiting lists to ensure they are not disadvantaged.
• If the patient is being referred for diagnostic tests but requires an outpatient appointment regardless of the diagnostic results, the patient should be added to both waiting lists to prevent any unnecessary delays in treatment.
• Systems and procedures should be in place to ensure that waiting list managers are aware of any patient who has cancelled on the day of or after admission.
• Systems and procedures should be in place to review and validate waiting lists regularly to ensure accuracy and delivery of national and local access times. In addition to local three-stage validation, the National Elective Coordination Unit (NECU) are available to support Health Boards with national waiting list validation. Further details of the work NECU do can be found here: National Waiting List Validation - How it works | The nation (nhscfsd.co.uk)
• Health Boards should ensure that they maintain a Directory of Services.
• Ensure that new outpatients only receive a return appointment if there is a clinical need.
• Ensure that all patients undergoing a procedure have indicated, in writing, that they consent to treatment.
• Ensure effective communication is in place to notify the referring clinician on the decision to treat e.g. treatment to be provided, treatment delayed because medically unavailable.
• Ensure systems and procedures are in place to communicate, manage and record electronically all outcomes at clinics and additions or alterations to the waiting list.
• Patients who require treatment for different conditions may be on two separate pathways. Health Boards should have arrangements in place to identify what condition should take precedence, and manage these appointments accordingly.
• Regularly review clinic templates to ensure they reflect changing demand patterns.

5.4 Use Information To Support Improvements In Service Provision

The ability to effectively monitor and manage services requires good-quality data. This helps to inform performance and identify areas for future improvement.

• Ensure any factors which influence waiting times are regularly monitored, and management action is taken in sufficient time to ensure waiting time standards are met as far as possible.
• Ensure the development and implementation of processes is person-centred and does not unfairly impact individuals and groups.
• Health Boards should work with the CfSD to accelerate implementation of high impact changes, freeing up additional capacity in the NHS system. These CfSD improvement programmes will support delivery of waiting times standards, ensure that long-waiting patients can access treatment more quickly and provide sustainable solutions for the future.
• Review reasons why patients may DNA or cancel appointments and take necessary steps to address any issues and barriers as necessary.
• Ensure the effective monitoring of efficiency and productivity and support necessary change where required.
• Benchmarking information should be used wherever possible in reviewing clinic templates and efficiency.
• Health Boards should complete local Equality Impact Assessments (EQIAs) for their processes, to identify impacts on different groups and people with protected characteristics. Health Boards should address these impacts and mitigate where possible. The EQIAs should continue to be reviewed as needed.

5.5 Report Patients’ Waiting Times Accurately

To support delivery of waiting times standards, patient waits must be recorded and reported accurately to ensure completeness and consistency.

Reporting Responsibilities Regarding Patient Records

• The Health Board of receipt of referral (HBR) is required to collect the following data and provide it to the Health Board of Treatment (HBT) on transfer:
• start date (e.g. Date of Referral Received for outpatients or Decision to Treat for inpatients/day cases).
• clock adjustment dates and reasons.
• any additional relevant information.
• The HBT is responsible for reporting the entire patient wait to Public Health Scotland (PHS). This includes:
• existing waiting times from data transfers.
• all relevant information received from the Health Board of Referral.
• The quality-assured data should be provided by the HBT to PHS in a timely manner. This is to provide consistency for reporting, and is not in relation to Waiting Times performance.

Reporting Responsibilities only Regarding Eight Key Diagnostic Tests And Investigations

• The Health Board of Initial Receipt of Referral is responsible for providing an aggregated return of the results of all 8 of the key tests to PHS.