NHSScotland waiting times guidance: November 2023

6. Offers of Appointment

6.1 Reasonable Offers

A reasonable offers package is the offer of two or more different dates of appointment for each stage of the patient’s pathway.

Guidance

An offer of appointment from a Health Board to a patient is reasonable:

• if at least 10 calendar days’ notice is given.
• if the appointment is at any location across NHS Scotland deemed clinically appropriate for the patient’s needs.
• if a date is provided (not location only).
• if the patient consents to the mode of contact used to communicate the offer (e.g. video, phone call).
• regardless of whether it is offered pre- or post-TTG date.
• at short notice if accepted by the patient.

A patient can be referred back to the referring clinician, following a clinical review, or have their clock reset after refusal of two reasonable offers. The clinical review should be completed within the receiving service.

Additionally, Health Boards must ensure patients are informed of the impact of declining offers, Did Not Attend and Could Not Attend.

Communication with patients should be in a format appropriate to their needs, for example, letters that are large print, easy to read, in the patient’s primary language, or verbal. Please see the ‘Additional Support Needs’ section for further guidance.

Best Practice

A Health Board should:

• give at least 14 calendar days’ notice.
• treat patients as locally as possible with capacity taken into account as well as what procedures are offered in which location.
• have a reminder system in place, this will ensure patients are given a second notification of their appointment date and time.
• ensure the patient is notified as soon as possible and is advised of the support they will receive for travel outwith their Health Board area.

6.2 Appointment Location

Guidance

An offer of appointment at any location in NHS Scotland is considered reasonable. Health Boards must use judgement based on what is clinically appropriate according to the patient’s circumstances.

• The Health Board should include service locations in their published Local Access Policy, which for example could be:
• any site within that Health Board area providing the required service.
• any site outwith the Health Board area where treatment is routinely provided, for example, another Health Board, the Golden Jubilee University National Hospital, or a National Treatment Centre.
• the limited use of alternative providers, within or out with the Health Board area, including the independent sector.
• Patients are to be advised as early as possible if they need to travel for their appointment or treatment.
• The Health Board of initial receipt of referral is responsible for the cost of any transport and accommodation arrangements reasonably incurred by the patient and their carer (if necessary) if they must travel outwith their local Health Board for an appointment.
• Under regulation 4A of the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012, a patient may request 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, having considered the patient’s health and wellbeing, if it is deemed reasonable and clinically appropriate to offer the patient an alternative appointment in a specific location for the agreed treatment to be carried out.
• A request to be seen in their local Health Board should only be allocated by the Health Board to ensure continuity of care, patient safety or for other clinical or exceptional reasons.
• If a patient chooses to wait to be seen in their local Health Board, the period between the date of the original offer and the date of the alternative offer does not count towards the calculation of waiting time.

Best Practice

Patients should be seen and treated in their local Health Board wherever possible. It may not always be possible for Health Boards to provide access locally for all patients and for all services if they are constrained by geography or specialist services for example.

6.3 Named Consultant

Guidance

• Patients will be referred to a clinical team and seen by an appropriate member of that team rather than to an individual consultant.
• Each Health Board’s Local Access Policy should set out that a reasonable offer of appointment relates to a clinical team as part of the consultant-led service.
• Under regulation 4A of the Patient Rights (Treatment Time Guarantee) (Scotland) Regulations 2012, a patient may request to be seen by a specific named consultant. The responsible Health Board may agree this, taking into account the patient’s health and wellbeing, if it is deemed reasonable and clinically appropriate to offer the patient an alternative consultant for the agreed treatment to be carried out.
• A named consultant should only be allocated by the Health Board to ensure continuity of care, patient safety or for other clinical or exceptional reasons.
• If a patient chooses to wait for a specific consultant, the period between the date of the original offer and the date of the alternative offer, does not count towards the calculation of waiting time.

6.4 Patient Refuses a Reasonable Offer

Guidance

When a patient does not accept two reasonable offers of appointment, it is considered a patient refusal. In this instance, a clinical review should be completed for all patients, regardless if they are urgent or routine.

The clinical review is to determine if the patient should be removed from the list and referred back to the referrer or if they should be offered another appointment. 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 General Practitioner (GP) or referring clinician (where possible), 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 (and the clock may be reset to zero). The clock must be reset to zero from the date the patient advised they were not accepting their second offer of appointment.

Figure 1:

This applies to all new outpatients, inpatient and day-case patients. This does not change how patients are tracked through Urgent Suspicion of Cancer pathways; this should continue to follow the cancer waiting times data and definitions manual.

• Patient refuses two reasonable offers of appointment.
• A clinical review must take place to confirm it is appropriate for the patient to be removed from the waiting list; this should be undertaken by receiving service.
  • Patient is given another offer of appointment if deemed clinically necessary.
  • Clock resets for relevant patients (urgent and routine) if clinically appropriate.
  • Following clinical review remove patient from waiting list where appropriate.