NHSScotland waiting times guidance: November 2023

12. Waiting Time Calculation

12.1 New Outpatients

Guidance

The Health Board that agrees the new outpatient appointment is responsible for ensuring that the patient is seen within the waiting times standard of 12 weeks.

The following must be captured on the appropriate systems.

• Clock start is the date when the referral is received.
• Any clock adjustments. Examples of adjustments can be found in Annex 3.
• Clock stop is the date of the new outpatient appointment, or the date a patient is removed from the outpatient waiting list.

For patients with a Long-Term Condition with an exacerbation or recurring symptoms, a new waiting time clock must be started for new referrals for the same condition. This does not apply to patients who are on Patient-Initiated Review (PIR).

For patients waiting for sequential bilateral treatment the waiting time for the second outpatient appointment is measured as a separate, second pathway with a new waiting time clock. The waiting time clock for the second outpatient appointment should not start until the clinician and patient agree to the treatment. The sequential treatment must not be managed as a Planned Repeat.

For consultant-to-consultant referrals a new waiting time clock will be started on receipt of the referral by the new consultant-led service if the referral is for a new condition or speciality.

For patients transferred to a planned service via an urgent care service e.g. Accident & Emergency, Rapid Access Service, or a Minor Injuries Unit, a formal referral will not always be sent. The waiting time clock will start on the date of attendance at an urgent care service where the purpose of the appointment is for treatment, not a follow-up to treatment already started within an urgent care service.

For patients who self-refer or opt in via an Active Clinical Referral Triage (ACRT) pathway, a new waiting time clock starts on the date that the patient contacts the service.

For patients changing their permanent residence to another Health Board area, whose waiting time clock has already started and who request to be treated within that other Heath Board area (i.e. the Health Board of their new residence), their previous waiting time clock should be taken into account.

12.2 New Inpatient/Day Case Patients (Treatment Time Guarantee)

Guidance

The Health Board that agrees the treatment with a patient is required by law to take all reasonable steps to ensure that patients access their treatment within 12 weeks. Exceptions to the Treatment Time Guarantee can be found in Annex 4.

• Clock start is the date when the patient agrees treatment with their clinician.
• Any clock adjustments. Examples of adjustments can be found in Annex 3.
• Clock stop is the date that the patient starts to receive the agreed treatment, or the date the patient is removed from the waiting list.

Most patients will agree treatment at their outpatient appointment. This is when the patient’s waiting time clock for their inpatient / day case treatment should start.

However, before the treatment can be agreed, some patients may be required to undergo a diagnostic test. The patient will be contacted about the test result, normally by phone or at a return outpatient appointment. In such cases, the treatment would be agreed at that time, which would be the start date of the Treatment Time Guarantee.

Should the patient indicate that they would like to have time to consider whether to proceed with the treatment, in this circumstance the patient’s waiting time clock will not start until the patient agrees to proceed with the treatment.

Normally, the patient will be admitted to hospital on the day of treatment, and the patient’s waiting time clock should stop on this day.

In some circumstances, the patient may be admitted for treatment the day before their surgery. Where this occurs in order to start the initial stages of treatment, for example, to administer medication or to clinically prepare the patient, this date should be recorded as the start of treatment.

For Referral to a One-Stop Service for patients seen on an inpatient or day case basis, the date the patient agrees treatment and the date of the treatment will be the same. The patient will have a zero-wait recorded against the Treatment Time Guarantee. For any patients for whom treatment cannot be undertaken on the day, the waiting time clock will continue.

For patients with a Long-Term Condition with an exacerbation or recurring symptoms, a new waiting time clock must be started for new referrals for the same condition. This does not apply to patients who are on Patient-Initiated Review (PIR).

For patients waiting for sequential bilateral treatment the waiting time for the second appointment is measured as a separate, second pathway with a new waiting time clock. The waiting time clock for the second appointment should not start until the clinician and patient agree to the treatment. The sequential treatment must not be managed as a Planned Repeat.

For patients transferred to a planned service via an urgent care service e.g. Accident & Emergency, Rapid Access Service or a Minor Injuries Unit, a formal referral will not always be sent. The waiting time clock will start on the date of attendance at an urgent care service where the purpose of the appointment is for treatment, not a follow-up to treatment already started within an urgent care service.

For patients changing their permanent residence to another Health Board area, whose waiting time clock has already started and who request to be treated within that other Heath Board area (i.e. the Health Board of their new residence), their previous waiting time should be taken into account.

Best Practice

If the patient does not agree the treatment and has not been added to the waiting list, Health Boards should try to ascertain from the patient how long they wish to consider their options for treatment. They should also agree a date with the patient when the hospital will contact them to discuss the treatment further.

The waiting time clock starts on the date the patient is contacted if on this date the patient agrees treatment.

Should the patient wish for more time to consider the treatment, a discussion should be held with the appropriate clinician to determine if a further contact date should be agreed or if the patient should be referred back to the referring clinician.

Figure 7:

• Patient receives diagnostic results.
  • Patient agrees treatment. Patient’s waiting time clock starts.
  • Patient requests time to consider options following diagnostic results.
    • On agreed date, hospital contacts patient and patient agrees treatment. Patient’s waiting time clock starts.
    • On agreed date, hospital contacts patient and patient requests more time to consider options. Clinician should determine if further time given, or patient referred back to referrer.

Guidance

Once the patient has agreed treatment and their waiting time clock has started, there will be a pre-operative assessment. The pre-operative assessment appointment is intended to ensure that the patient is fit for treatment which has already been agreed. This does not constitute agreeing to treatment so must not be taken as the start date of the patient’s waiting time clock.

12.3 18 Weeks Referral-To-Treatment

Guidance

The 18 Weeks Referral-To-Treatment (RTT) standard applies to the entire patient journey from the initial referral to the start of treatment. Achieving the standard depends on waiting times for diagnostic tests, new outpatient appointments, inpatient and day case treatment.

The Health Board of receipt of initial referral is responsible for ensuring that the patient is treated within 18 weeks, irrespective of the Health Board of treatment. This applies to:

• patients on a cancer pathway; and
• all patients added to a waiting list for planned treatment.

The following must be captured on the appropriate systems.

• Clock start is the date when the referral is received.
• Any clock adjustments. Examples of adjustments can be found in Annex 3.
• Clock stop is the date that treatment commences, appointments are concluded, or if the patient is removed from the waiting list.

For patients with a Long-Term Condition with an exacerbation or recurring symptoms, a new waiting time clock must be started for new referrals for the same condition. This does not apply to patients who are on Patient-Initiated Review (PIR).

For patients waiting for sequential bilateral treatment the waiting time for the second outpatient appointment is measured as a separate, second pathway with a new waiting time clock. The waiting time clock for the second outpatient appointment should not start until the clinician and patient agree to the treatment. The sequential treatment must not be managed as a Planned Repeat.

For consultant-to-consultant referrals a new waiting time clock will be started on receipt of the referral by the new consultant-led service if the referral is for a new condition or speciality. If the consultant-to-consultant referral relates to the same condition that the patient was initially referred for, then the existing clock will continue, and a new clock should not be started.

For patients transferred to a planned service via an urgent care service e.g. Accident & Emergency, Rapid Access Service or a Minor Injuries Unit, a formal referral will not always be sent. The waiting time clock will start on the date of attendance at an urgent care service where the purpose of the appointment is for treatment, not a follow-up to treatment already started within an urgent care service.

For outpatients that self-refer or opt in via an Active Clinical Referral Triage (ACRT) pathway, a new waiting time clock starts on the date that the patient contacts the service.

For patients changing their permanent residence to another Health Board area, whose waiting time clock has already started and who request to be treated within that other Heath Board area (i.e. the Health Board of their new residence), their previous waiting time clock should be taken into account.

12.4 Eight Key Diagnostic Tests and Investigations

Guidance

Diagnostic tests and investigations are used to identify a patient’s condition, disease, or injury to enable a medical diagnosis to be made.

The Health Board that receives a request for a test or procedure is responsible for ensuring that investigation is undertaken, and the verified report is received by or made available to the requester within the 6-week waiting times standard.

• Clock start is the date the responsible Health Board of initial referral area receives the request for the test or procedure.
• Any clock adjustments. Examples can be found in Annex 3.
• Clock stop is the date the verified report has been received by or made available to the requester, or the date the patient is removed from the waiting list.

The Eight Key Diagnostic Tests and Investigations covered by the standard are:

• Upper Endoscopy
• Lower Endoscopy (excluding Colonoscopy)
• Colonoscopy
• Cystoscopy
• Computer Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Barium Studies
• Non-Obstetrics Ultrasound

For patients who require more than one diagnostic test, each procedure should be recorded as a separate new referral.

Health Boards are required to have a robust process in place to ensure results are communicated to patients in a timely manner.