NHSScotland waiting times guidance: November 2023

10. Non-Attendance

10.1 Could Not Attend

Guidance

If the patient has accepted a reasonable offer of appointment but gives the hospital notice that they will not attend that appointment, it is classed as a Could Not Attend (CNA). A patient may advise the Health Board they cannot attend an agreed appointment any time prior to attending their appointment. Systems should be in place to record this information.

After the first or second cancellation, a patient must be given another reasonable offer of appointment. At both the first and second cancellation, the Health Board may reset the patient’s clock if clinically appropriate. If the patient cancels three or more agreed appointments, a clinical review must be undertaken to confirm if it is reasonable and clinically appropriate to refer the patient back to their referring clinician. In cases where referring back to the referrer is not appropriate, the Health Board may reset the patient’s clock to zero (regardless of whether any waiting time standard has been breached), and offer the patient another appointment. This review is be undertaken by the receiving service. The date of the decision to refer the patient back to their referring clinician must be recorded on the patient administration system (PAS).

Figure 4:

• Patient cancels first or second appointment.
• Patient offered third appointment.
  • Patient attends appointment.
  • Patient cancels third appointment.
    • A clinical review must be undertaken to confirm if it is reasonable and clinically appropriate to refer the patient back to their referring clinician or reset the patients clock.

If the patient is to be referred back to their referring clinician, the Health Board must record why this was appropriate. Health Boards must inform patients (or where appropriate the patient’s carer) and the patient’s referring clinician when the patient has been removed from the waiting list.

If following a clinical review, it is not reasonable to refer the patient back to their referring clinician, a further appointment should be offered. The clock should be reset to zero from the date the patient advised they were cancelling their third agreed appointment.

If the patient informs the Health Board that they have an illness, which they feel may prevent them from attending the appointment on the agreed date, clinical advice may need to be sought as to the clinically appropriate course of action.

• In some cases, Health Board staff may be able to confirm whether the patient’s illness is likely to prevent their attendance, without the need for clinical input.
• If the clinician has advised that the patient’s illness will prevent the agreed appointment or treatment from proceeding on the agreed date, a known period of medical unavailability should be applied. This would normally be for a short period only, for example, up to two weeks.
• If the clinician has advised that the patient’s illness will not prevent the agreed appointment or treatment from proceeding on the agreed date, the appointment should go ahead as planned.

Health Boards need to inform patients of the consequences of cancelling an agreed appointment.

10.2 Did Not Attend

Guidance

If the patient does not attend (DNA) an agreed appointment and has not given the Health Board any notice of this, a clinical review must be undertaken to confirm if it is reasonable and clinically appropriate to either refer the patient back to their referring clinician, reset the patient’s clock to zero (from the date of the missed appointment), and offer the patient another appointment. This review should be undertaken by the receiving service. The date of the patient’s non-attendance must be recorded on the patient administration system (PAS).

If the patient is to be referred back to their referring clinician, the Health Board must record why this was reasonable and clinically appropriate. Health Boards must inform patients (or where appropriate the patient’s carer) and the patient’s referring clinician when the patient has been removed from the waiting list.

If following a clinical review, it is not reasonable to refer the patient back to their referring clinician, a further appointment should be offered. The clock should be reset to zero from the date the patient did not attend their agreed appointment.

Health Boards should inform patients of the consequences of not attending an agreed appointment as soon as possible after treatment is agreed.

Figure 5:

• Patient does not attend agreed appointment.
• A clinical review must be undertaken to confirm if it is appropriate to refer the patient back to their referring clinician, whether the patient should be offered another appointment, and whether the patient’s clock should be reset to zero.

10.3 Could Not Wait

Guidance

It is important that patients are advised prior to attending their appointment of the expected duration of their appointment. If the appointment is planned to consist of more than one consultation the patient must be made aware of this in advance.

If the patient is not willing to wait for their consultation/all consultations within the appointment, this should be recorded as a CNA. If this is the patient’s first or second CNA, the patient should be made another reasonable offer of appointment, however if the patient has on three or more occasions cancelled an agreed appointment the CNA guidance should be followed.

All patients must be advised of any delay to their appointment. There may be occasions where the patient has registered their arrival for an appointment but cannot wait to be seen. The effect on the patient’s clock will depend on the reason for the delay as seen below.

• If there is a delay, caused by the service, which is much longer than the patient could reasonably be expected to wait, then this should be recorded as ‘Cancelled by Service’. The patient must be given another reasonable offer of appointment as soon as possible. For instance, a reasonable wait could be anything up to 30 minutes.
• If there is a delay in the appointment of less than 30 minutes and the patient is not willing to wait, then the outcome should be recorded as CNA. If this is the patient’s first or second CNA, the patient should be made another reasonable offer of appointment; however if they have cancelled three or more agreed appointments previously, the CNA guidance should be followed.

Local judgement and flexibility will be necessary in these scenarios, and this should be detailed in the Health Boards Local Access Policy.

10.4 Cancelled By Service

Guidance

Patients must not be disadvantaged as a result of cancellations resulting from operational circumstances. Should this occur, there should be no change to the patient’s waiting time clock and the patient should be made a further reasonable offer as soon as possible. Where possible, this should be within the waiting time standards and Treatment Time Guarantee; however, this prioritisation to the start of treatment must not be to the detriment of another patient with a greater clinical need for treatment.

If, having been admitted, a planned treatment is unexpectedly cancelled, the patient cannot be recorded as having started treatment. The patient must still undergo treatment within the waiting time standards and Treatment Time Guarantee where possible.