Download Cancer Access Policy - Southend University Hospital NHS

Cancer Access Policy
SPONSOR (Information Asset Owner)
Jon Findlay, Chief Operations Officer
AUTHOR:
Femi Odewale, Interim General Manager
Nathan Hall, Cancer Access Manager
RATIFIED BY:
Procedural Document group
APPROVED BY:
Cancer Services Board
TARGET AUDIENCE:
All staff involved in the care of patients with cancer
POLICY NUMBER:
CM93
STRATEGY CATEGORY:
Corporate Management (CM)
This document is available in large print and alternative
formats. Should you or someone you know require this in an
alternative format please contact us on 01702 435555 Ext.
6455 or e-mail [email protected]
Date
April 2014
Ver. No
1
VERSION AND REVISION RECORD:
Details
New Policy
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Review date
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Southend University Hospital NHS Foundation Trust
Southend University Hospital Cancer Access Policy / CM93 / Version 1
Contents
1 Introduction .................................................................................................. 3 2 Purpose ....................................................................................................... 3 3 Definitions .................................................................................................... 4 4 Duties and Responsibilities .......................................................................... 6 5 Main Procedural Document Points (Process) .............................................. 9 6 Monitoring Compliance and Effectiveness ................................................. 25 7 Associated Documents .............................................................................. 26 8 Equality Impact Assessment ...................................................................... 26 9 References ................................................................................................ 26 Page 2 of 26
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1 Introduction
This policy outlines the Trust’s approach to the management of patients requiring
chemotherapy treatment whilst ensuring patients are seen:
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According to their clinical urgency (including 2 week wait target patients) in order of
date received (i.e. on a first come first served basis)
In the shortest time appropriate for their clinical need
This policy applies to all members of staff dealing with patients who have cancer and
require chemotherapy treatment.
2 Purpose
This policy describes how the Trust manages and reports performance relating to cancer
waiting times.
For patients it will make sure that people:
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Suspected to have cancer and/or with a confirmed cancer diagnosis receive treatment
in accordance with the cancer standards relevant to their cancer pathway and
according to their choice
Are treated according to clinical priority and those with the same clinical priority are
treated in chronological order.
For clinician and non-clinicians it will make sure that:
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Teams and individuals are aware of their responsibilities for moving patients along the
agreed clinical pathway in accordance with the national Cancer Reform Strategy
standards as set out in the Cancer Waiting Times CWTs 8.0.
Clinical support departments adhere to and monitor performance against agreed
maximum waiting times for tests/investigations in their department.
Everyone involved in the Cancer pathway has a clear understanding of their roles and
responsibilities.
Accurate and complete data on the Trust’s performance against the National Cancer
Waiting Times is recorded in Somerset and reported to the National Cancer Waiting
Times Database (Open Exeter) within predetermined timescales.
This policy applies to all SUH staff involved in the management of patients within the
cancer pathways.
Please note that In the event of an infection outbreak, flu pandemic or major
incident, the Trust recognises that it may not be possible to adhere to all aspects of
this document. In such circumstances, staff should take advice from their manager
and all possible action must be taken to maintain on-going patient and staff safety.
This policy is applicable to patients cared for under Cancer Wait Times. Within the NHS in
England this is defined as activity with ICD codes C00-C97 (excluding basal cell
carcinoma) or D05 (carcinoma in situ with the exception of breast). This includes:
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Patients treated as part of a clinical trial
Patients whose cancer care is undertaken by a private provider on behalf of the NHS
Patients with care sub contracted to another provider private or NHS and paid for by
an English trust
Patients diagnosed with a second new cancer
Any skin squamous cell carcinoma
The 31 day standard applies to NHS patients with a newly diagnosed cancer,
recurrence of a previously diagnosed cancer; regardless of the route of referral. It
includes patients who may be diagnosed during routine investigation for another
condition e.g. an incidental finding.
The 62 day standard applies to patients referred through a two week referral route by
the GP or GDP with suspected cancer, patients who are referred to a specialist
because of breast symptoms where cancer is suspected, when cancer is suspected
from any national cancer screening programme, or the patient is upgraded by a
consultant because cancer is suspected.
Patients excluded from the cancer waiting times standard:
Any patient
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with a non-invasive cancer i.e. carcinoma in situ (with the exception of breast)
basal cell carcinoma
the patient dies before treatment can begin
receiving diagnostic and treatment privately unless the patient chooses to be seen
privately but is then referred for treatment under the NHS or the patient is seen under
the 2 week standard chooses to have diagnostic tests privately but returns to the NHS
for further treatment.
patients who refuse to undergo diagnostic tests are excluded for the 62 day standard,
but if they are subsequently diagnosed with cancer they will follow the 31 day
treatment standard.
patients who decline treatment
3 Definitions
TERM
DEFINITION
Active monitoring Where it is clinically decided to start a period of monitoring in
secondary care without clinical intervention or diagnostic
procedure at that stage.
Active waiting list The list of elective patients who are fit and able to be treated at
that point in time. The active waiting lists is also used to report
(elective waiting
national waiting time statistics
and elective
planned)
If the trust cancels a patient’s operation or procedure on the
Cancelled
day of, or after admission for non-clinical reasons – the Trust is
operations /
required to rearrange treatment within 28 days of the cancelled
procedures
date or within target wait time whichever is soonest.
A MDS form is agreed by the cancer Network to be completed
MDS (Minimum
when a patient’s care is transferred between NHS trusts. A
Dataset Form)
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Chronological
order (in turn)
BU
CWT
Decision to admit
(DTA)
Decision to treat
(DTT)
Did Not Attend
(DNA)
DoH
Elective
admission /
elective patients
Elective Planned
Elective waiting
EROD
First definitive
treatment
Incomplete
pathways
Somerset
Multi-Disciplinary
Team (MDT)
MDM Coordinator
PTL
Peer Review
TCI (To Come In)
form provides information to the on the current pathway status
of a patient, including the referral and breach dates.
The general principle that applies to patients categorized as
requiring routine treatment. All routine patients should be seen
or treated in the order they were initially referred for treatment.
Business Unit
Cancer Waiting Times
Where a clinical decision is made to admit the patient for either
day case or inpatient treatment.
Where a clinical decision is taken to treat a patient as an
inpatient, day case or outpatient setting.
Patients who have agreed or been given reasonable notice of
their appointment / treatment and who without notifying the
Trust fail to attend.
Department of Health
Inpatients are classified in two groups, emergency and
elective. Elective patients are so called because the Trust can
‘elect’ when to treat them.
Patients admitted having been given a date or approximate
date at the time that the decision to admit was made. This is
usually part of a planned sequence of clinical care determined
mainly on clinical criteria.
Patients waiting elective admission
Earliest reasonable offer date
An intervention intended to manage a patients disease,
condition or injury and avoid further intervention. What
constitutes first definitive treatment is a matter of clinical
judgment in consultation with other as appropriate, including
the patient.
Patients either on an admitted, non-admitted or diagnostic
pathway still waiting for treatment.
A system in which all cancer patients are tracked and
monitored. Somerset is also used to support our reporting
processes.
An MDT comprises of medical and non-medical professionals
who are responsible for the cancer patient's care. It includes
clinicians from a variety of disciplines, the exact constituent are
described for each tumor site as part of Peer Review
requirements.
Multi-Disciplinary Meeting Coordinator
Patient Tracking List, a report used to ensure the maximum
waiting time targets are achieved by identifying the patient wait
time along that pathways and patients who are at risk of being
treated outside the pathway requirements
An annual assessment specific to each specialty against
national standards.
A proposed future date for an elective admission.
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4 Duties and Responsibilities
4.1 Duties within the Trust (Committees)
Clinical Assurance Committee (CAC) – is responsible for providing assurance and
support on patient access to the Trust Board. It will monitor through the receipt of regular
audit reports; that national and statutory requirements for access to services are being
met.
Referrals Management Group – is responsible for the review and update of this policy,
ensuring national and statutory requirements are fully reflected. In addition, it will facilitate
the embedding of patient access requirements within Trust processes.
Information about Cancer Services Board
The Trust Cancer Services Board (TCSB) will report into the Trust Executive as part of the
trust-wide Governance arrangements. Key areas of responsible include:
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Overseeing the successful delivery of the Trust’s Cancer Action Plan, providing
assurance to the Trust Board that the Plan is being adequately managed
Overseeing compliance with Improving Outcomes Guidance, Peer Review and related
action plans
Overseeing the development of, and delivery of the Trust’s Cancer Strategy, including
service change and development in discussion with Commissioners and key
stakeholders
Monitoring performance across the Trust and tumour sites against cancer standards,
supporting the Multidisciplinary Teams and Business Units in the delivery of their
action plans to address issues relating to patient pathways and care delivery
4.2 Duties within the Trust (Individuals)
Business Unit (BU) Directors and Assistant/Associate Business Unit Directors
(ABUD)
The Business Unit Directors/Assistant Directors and General Managers for each BU have
overall responsibility for implementing and adherence to this policy within their BU. This
includes:
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Ensuring that effective processes are in place to manage patient care and treatment
that meet national, local and NHS Constitution targets and standards for each
specialty within the BU.
Managing resources allocated to the BU with the aim of achieving access targets. This
includes having the staff and other resources available to operate scheduled
outpatient clinics, patient treatment and operating theatre sessions and avoid the need
to cancel patient treatment.
Working with other BU Directors/Assistant Directors and General Managers of service
to provide a joined-up approach to implementing this policy and achieving the cancer
access targets, particularly around outpatient and operating theatre capacity and
availability of diagnostic services.
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Achieving cancer access targets.
Ensuring that the duties, responsibilities and processes laid down in this policy are
implemented within the BU.
Ensuring all BU staff that need to operate this policy are aware of this policy and
receive training so that they can meet the policy requirements.
Implement effective monitoring systems within the BU to ensure compliance with this
policy and avoid breaches of the targets: escalate any actual or potential breaches to
the Chief Operating Officer.
Implementing systems and processes that support data quality and for validating data
to ensure that all reports are accurate and produced within agreed timescales
Day to day operational management of this policy will be delegated to Business Units and
Service/Operational managers as set out in the governance arrangements for each BU.
Consultants
Each consultant is responsible for:
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Managing the patients care and treatment and working with their BU
Directors/Assistant Directors, General Managers and clinical colleagues to ensure that
this is provided within timescales laid down in national, local and NHS constitution
targets and standards.
Alerting the BU General Manager of any potential or actual breaches of targets
Managing staff within the medical team to ensure that scheduled outpatient clinics,
patient treatment and operating theatre sessions are held and avoid the need to
cancel patients.
Managing waiting lists and deciding on patient admissions / treatments in line with
clinical priority.
Working with colleagues to prevent the cancellation of patient admissions for nonclinical reasons and taking action to reschedule any patients cancelled in line with
timescales set out in this policy.
Communicating accurate waiting time information to patients, their families and carers
and dealing with any queries, problems or complaints in line with trust policy.
Assisting with the monitoring of data quality and production of reports.
Multi-Disciplinary Meeting Coordinators
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Tracking patients on the PTL for the tumour site that they are responsible for
coordinating
Monitoring the PTL relevant to their tumour site to identify where interventions are not
being planned within the appropriate timescale
Escalating to the relevant individual where necessary when alternative action needs to
be taken so that the patients pathway can achieve the required standard
Make sure that all the necessary clinical and non-clinical information is available to
allow the patient to be discussed holistically
Provide the administrative support so that there is accurate, accessible and timely
recording of the treatment plan agreed by the MDT
Planning communicating and interacting with clinicians regarding issues relating to the
patient pathway
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Ensuring that referrals/appointments for patients on the cancer pathway are made in
timely manner
Receive and process referrals into the MDT so that they are tracked and bought to the
MDT in a timely manner for discussion and planning of treatment
Multi-Disciplinary Team
An MDT comprises of medical and non-medical professionals who are responsible for the
cancer patient's care. It includes clinicians from a variety of disciplines, the exact
constituent are described for each tumor site as part of Peer Review requirements. It
supports delivery of cancer standards by:
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Bringing together designated cancer specialists to discuss patient care and agree a
treatment plan for individual patients
Making sure care is planned according to national guidelines and to support clinical
governance
Identifying and supporting entry of patients into clinical trials
Monitoring attendance so that there is good attendance by core members of the MDT
so that decision making relevant to good practice and achievement of the cancer
pathway
Supporting the collection of good quality data relevant to clinical care and service
improvement
Reviewing its performance in terms of achieving safe and timely care in line with good
practice and Cancer pathways standards
Taking responsibility for changing pathways as required and identified as a result of
audit, data collection and performance information
MDT Clinical Lead
Each tumor site will be led by a clinician who has site specific specialist knowledge of
treating cancer. The clinical lead will:
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Make sure that objectives of MDT working are met.
Have in place mechanisms to support entry of eligible patients into clinical trials,
subject to patients giving fully informed consent.
Take overall responsibility for ensuring that the MDT meet peer review quality
measures.
Make sure attendance levels of core members are maintained, in line with quality
measures.
Ensure that a target of 100% of cancer patients discussed at the MDT is met.
Provide the link to network and other relevant speciality groups, either by attendance
at meetings or by nominating another MDT member to attend.
Lead on, or nominate lead for service improvement.
Organise and chair an annual meeting, examining the functioning of the team and
reviewing operational policies and collate any activities that are required to ensure
optimal functioning of the team (for example training for team members).
Ensure MDT’s activities are audited and results documented.
Ensure that the outcomes of the meeting are clearly recorded and clinically validated
and that appropriate data collection is supported.
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Ensure target of communicating MDT outcomes to primary care is met.
General Medical / Dental Practitioners and other referrers’
The trust relies on GP’s and other referral sources, supported by local commissioners to
ensure patients understand their responsibilities and potential pathway steps and
timescales when being referred. This will help ensure patients are:
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Referred under appropriate clinical guidelines
Offered a choice of provider as outlined in national guidance
Aware of the speed at which their pathway may be progressed
In the best possible position to accept timely appointments throughout their treatment
All staff
All staff are responsible for ensuring that any data created, edited, used or recorded on the
Trusts information systems (Medway PAS and Somerset) within their area of responsibility
is accurate and recorded in accordance with this policy and other trust polices relating to
the collection, storage and use of data in order to maintain the highest standards of data
quality and maintain patient confidentiality.
All patient referrals, treatment episodes and waiting lists must be managed on the Trust’s
Medway PAS system and all information relating to patient activity must be recorded
accurately and in a timely fashion.
4.3 Monitoring Responsibilities
This policy will be formally approved by the Senior Management Team and agreed with
commissioning partners. Alterations and amendments to this policy will be approved and
ratified by these bodies. Issues around interruption and application of this policy will be
initially resolved by Head of Performance where any matter cannot be resolved at this
level it will be escalated to the Cancer Service Group and Chief Operating Officer for
resolution. Compliance with this policy will be monitored as outlined in the Monitoring
Compliance and Effectiveness section.
5 Main Procedural Document Points (Process)
5.1 Key Principles
This policy will be applied consistently and without exception across the Trust. This will
ensure that all patients are treated equitably and according to their clinical need. This is
inclusive of military patients. Cancer patients will be prioritised according to national
guidance. Non-NHS patients including overseas visitors are not covered by this policy and
should be managed according to the overseas visitor policy and clinical priority.
The process of waiting list management for patients suspected of or diagnosed with
cancer will be transparent to the public and communications with patients (or
parents/carers and vulnerable patients) will be timely and informative clear and concise.
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Waiting lists will be managed equitably with no preference shown on the basis of provider
or source of referral.
Patients will be added to the waiting list if there is a real expectation that they will be
treated and are willing to make themselves available for treatment.
The Cancer Waits standards are described in detail in “Going Further on Cancer Waits”
(GFOCW). The standards are summarized below:
2 week wait
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All patients referred from GP/GDP as suspected cancer will be seen within 14 days of
receipt of referral
All patients referred with breast symptoms irrespective of whether cancer is suspected
or not, will be seen within 14 days of receipt of referral.
62 day
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All patients referred by their GP/GDP as suspected cancer or breast symptomatic, who
are subsequently diagnosed with cancer, will commence treatment within 62 days of
receipt of referral.
All patients referred from screening programmes (bowel, breast, cervical) as
suspected cancer who are subsequently diagnosed with cancer, will commence
treatment within 62 days of receipt of referral.
All patients that are upgraded by Consultants as suspected cancer will commence
treatment within 62 days of the date of upgrade.
31 day
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All patients that are having a subsequent treatment for cancer will receive treatment
within 31 days of the decision to treat.
All patients diagnosed as a new cancer will receive treatment within 31 days of
decision to treat irrespective of treatment.
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As a general principle, the Trust expects that before a referral is made on a cancer
pathway the patient is both clinically fit for assessment and possible treatment of their
condition, and ready to start their pathway within two weeks of the initial referral.
Any referral made under the 2 week rule guidance starts the 62 day clock. This includes
referrals from the following:
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General Practitioners (GPs) and General Dental Practitioners (GDPs)
Optometrists and Orthoptists
Accident and Emergency, Minor Injury Units or Walk in Centres
Genito-urinary medicine clinics
National screening programs
Prison health services
Military Medical Centre’s / Sickbays
Consultant or Consultant led services
Triage service
The 62 day clock starts at the point the referral is received.
5.2 Private Patients transferring to NHS Care
Where a patient has been seen by a clinician privately but then decides to transfer their
care to the NHS, and they are transferring onto a Cancer pathway then the relevant clock
(62/31 day) starts at the point at which clinical responsibility for the patients care transfers
to the NHS (i.e. when the Trust accepts the referral for the patient.) Private patients
transferring in this way will be treated in turn within the terms of this access policy.
If first definitive treatment has already started or been given, then a referral from private to
NHS care would not start a new 62 day clock unless the patient requires a substantially
new course of treatment in which case the clock would start at the point clinical
responsibility for the patients care transfers to the NHS (i.e. when the Trust accepts the
referral for the patient).
5.3 Clock Stops
2 Week Wait
The 2 weeks wait clock stops when a patient is first seen in outpatients.
62 or 31 day clock
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The 62 or 31 day clock stops when the patient receives the first definitive treatment or
subsequent treatment as required by the MDT plan for the treatment of their cancer. First
Definitive Treatment is defined as an intervention intended to manage a patient’s disease
condition.
Clinical Decisions
The following clinical decisions stop the clock, on the date the decision is communicated to
the patient, GP or original referrer if not the GP:
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First definitive treatment (consultant led, treatment in an interface service or therapy in
secondary care if most appropriate way to manage the patient.)
Decision not to treat – e.g. decision is for non-specialist palliative care
Decision to start a period of active monitoring
Patient declines treatment
Patients have a right to expect to be seen and treated within national operational
standards for waiting times. In addition to this the department of health has set out other
patient expectations which include:
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To be seen by a health professional whom they trust
To get a clear explanation of their condition and what treatments are available
To know what the risks, benefits and alternative treatments are
To give written consent before any operation or procedure
To see their patient records and be sure that the information recorded will remain
confidential (data protection act 1998)
Young people aged 13 – 19 yrs also have standards that affect their care in an
outpatient setting (You’re welcome standards).
5.4 Patient Choice
Going Further on Cancer Waits guidance encourages patients to be referred at the earliest
opportunity. The operational standard applied to the two week wait standard (i.e. 93%)
takes account of the volume of patients likely to be seen outside of 2 weeks due to patient
choice.
In order to be able to accommodate patient choice, specialties must be able to offer
appointments within both week 1 and week 2 of the 2 week standard. In order to achieve
this, median waits of 8 days must be achieved. This must be carefully monitored.
Patients should be given appropriate information to help them understand the importance
of being seen quickly. Specialties should develop information leaflets to help this. These
should be available for download along with the specialty referral proformas.
Patients cannot be referred back to the GP because they are unable to accept an
appointment within the 2 week standard unless they do not attend or cancel two times or
more (see section 7).
A referral can only be “downgraded” by the referring GP.
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5.5 Suspected Cancer Referrals
This policy assumes all GPs/GDPs are informing patients that they are being referred as a
2ww and that as a fast track pathway a patient may be offered a series of appointments at
short notice.
All suspected cancer referrals should be referred by the GP/GDP on the relevant body site
proforma and submitted via choose and book or fax to The Outpatient Booking Centre/Call
Centre.
All patients must be seen within 14 days of receipt of referral to comply with national
standards and day 0 is date the referral is received.
5.6 Patient Cancellations
Patients may cancel an appointment due to ill health, social or other reasons. A
cancellation where the patient contacts the Trust prior to the appointment regardless of the
notice will not stop the clock.
Patients must be re-appointed after a first cancellation. In the event where a patient
cancels and re-books an appointment, they must still be dated within 14 days of the
referral.
The Cancer Waiting time guidance does not allow patients to be referred back to the GP
after multiple cancellations unless this has been agreed by the patient. However, it is
good practice to let the GP know that a patient has deferred appointments, as they may
wish to either contact the patient or possibly downgrade the referral.
In the event of a patient cancelling two or more first appointments within the 2 weeks rule
timescale they will be contacted by the speciality booking administrator and advised of the
impact of the cancellation in terms of timely diagnosis and treatment. If the patient agrees
to be discharged back to their GP, the consultant should write to the referrer within 5
working days explaining the reason for the discharge.
5.7 Patients who do not attend
Patients may DNA (did not attend) an appointment for the same reasons as a cancellation;
ill health, social or other reasons. “Did not attend” means that a patient did not arrive for
their appointment and did not cancel the appointment regardless of the notice given.
If a patient does not attend, the patient must be seen within 7 days of the date of the DNA.
Patients must be re-appointed after the first DNA but can be referred back to the GP after
a second DNA, except where a clinician decides the patient should be rebooked for clinical
reasons. Patients with a suspected cancer who DNA an appointment will be contacted by
the outpatient team to ascertain the reason for the DNA and rebooked if appropriate.
All dates for cancer patients, whether for outpatients, diagnostic tests, or treatment should
be dates that are subject to choice and agreed with the patient.
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If it is the patients wish not to attend for the agreed care, then a letter will be sent to the
GP or referring clinician informing them of the patient’s decision.
Prior to the patient being discharged back to the referrer the consultant will be informed.
The consultant will write to the GP within 5 working days to inform them of the action so
that the patient can be followed up if needed within primary care.
If the patient does not have an appointment at day 3 the process should be escalated.
Please refer to page 23 point 15 for adjustments applicable to patients that did not attend
an appointment.
5.8 Emergency admissions/attendances during 2 week rule period
In the event of a patient being seen/admitted as an emergency prior to attending for a two
week wait appointment for the same condition as the referral; they should no longer be
recorded against the two week wait standard. However, such a patient could still be
upgraded onto the 62 day upgrade pathway if the Consultant suspects that cancer is the
cause of the admission).
If it is for another condition, the 2ww referral still applies.
5.9 Downgrading referrals
A referral can only be downgraded with the consent of the referring GP. Therefore if a
Consultant, on reviewing the proforma, considers the referral should be downgraded they
should contact the GP for agreement. Once this has been done Medway PAS must be
amended by removing the 2ww criteria and highlighted in ‘additional comments’ that the
referral has been downgraded.
If an incomplete referral is received, the Outpatient Booking Centre/Call Centre should
contact the referring GP/GDP immediately to minimize the delay in the pathway. This does
not constitute a reason for making a pause to the pathway; patients should not be referred
back to their GP to stop a pathway.
In circumstances where the minimal data set it not complete the referral will not be paused
or referred back to the GP. The referral must continue to be processed so that the
patient’s treatment is not delayed while the missing information is sought from the referring
practitioner.
5.10 Two referrals on the same day
If two referrals are received on the same day, both referrals must be seen within 14 days
and, if two primary cancers are diagnosed, treatment for both cancers must start within 62
days of receipt of referral if clinically appropriate.
5.11 Breast symptomatic referrals
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All patients referred with breast symptoms must be seen within 14 days or receipt of
referral. This excludes patients referred for mammoplasty or family history; these referrals
should be booked within normal waiting time standards.
If there are any doubts over a referral, the patient should be booked within 14 days
Referrals to the breast symptomatic service can be received from a wide range of health
care professionals including other clinicians in secondary care. All breast symptomatic
referrals must therefore be sent immediately to the Outpatient Booking Centre to ensure
the 14 day standard is met.
Diagnostic & staging part of the referral to treatment pathway
5.12 General Pathway Standards
The diagnostic part of the overall pathway is critical to meeting the overall standard. Any
patient failing to meet the standards will be flagged via the Cancer Dashboard, and must
result in escalation action.
5.13 Booking of diagnostic tests
As a result of the first appointment, diagnostic appointments should be directly booked
while the patient is in the hospital. No patient should leave the hospital without a date for
at least the next step in their pathway. Specialties should create “reserve” lists, or other
means of enabling this. Reserved diagnostic slots for staging examinations are available to
each specialty as part of this.
All tests should be made for the earliest available appointment and agreed with the patient.
5.14 Patient unavailability, DNA or cancellation
The operational standard applied to the 62-day standard takes account of the volume of
patients likely to defer appointments or be unfit at stages of their pathway. There is
therefore no clock-pause for these reasons and patients cannot be downgraded to a 31day only pathway for these reasons.
For multiple cancellations, the patient should be contacted by the specialty team rather
than just giving multiple re-appointments. Patients may not understand the details of the
test being requested, or may be anxious and require reassurance. If the patient does not
wish to proceed then they should be referred back to their GP.
If a patient refuses proposed diagnostic tests that may diagnose cancer, they have
effectively removed themselves from the 62-day pathway. If they agree at a later stage
they should then be monitored against the 31-day standard only.
5.15 Communication of Diagnosis to the GP or referrer
The GP should be notified of confirmed new diagnosis via letter within 24 hours hours of
the diagnosis being discussed with the patient.
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Screening Pathways
5.16 Breast Screening
62-day standard
Breast
Cancer
Screening
Abnormality
spotted by
reader
Reader
generates
referral
Cancer
referral to
treatment
period start
date (62days)
Cancer
treatment
period start
date (31days)
Date first
seen
Treatment
start date
(cancer)
Referral is triggered by the final reader who initiates the assessment appointment.
The pathway starts from receipt of referral to the assessment clinic (date of receipt of
referral is Day 0.
Referrals will not be automatically created in Somerset, and the MDT co-ordinator for
Breast must therefore manually create a record in Somerset.
5.17 Bowel screening
62-day standard
Abnormailty
spotted in
FOBT
sample
Automatic
referral made
by screening
service (the
“hub”)
Cancer
referral to
treatment
period start
date
Date first
seen
Cancer
treatment
period start
date
Treatment
start date
(cancer).
Referral will be triggered by a positive faecal occult blood (OB) result.
The pathway will start from the date the hub book the nurse pre-assessment clinic (date
booking initiated is day 0).
The hub is responsible for entering all information onto the Bowel Screening Open Exeter
system.
Referrals will not be automatically created in Somerset, and the administration lead for
Bowel Screening must therefore manually create a record in Somerset.
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5.18 Bowel Screening Surveillance
Patients being monitored under the surveillance scheme who subsequently are diagnosed
with cancer will be monitored under the 31 day standard not the 62 day pathway.
5.19 Cervical Screening
62-day standard
Potentially
significant (non
mirror)
abnormality
spotted in
sample
Referral
back to GP
Direct referral
from
screening
service
Cancer
referral to
treatment
period start
date
Date first
seen
Cancer
treatment
period start
date
Treatment
start date
(cancer)
Decision to refer
date (cancer
and breast
symptoms)
2-week wait
62-day wait
Suspected cancer referral will be triggered by the following smear result:
-
Moderate and severe dyskaryosis
Glandular neoplasia (possible adenocarcinoma of cervix)
Invasive (possible squamous cell carcinoma of cervix)
The pathway will start from receipt of result/referral from Cytology.
Patients that do not fulfil the above criteria but then subsequently are diagnosed with
cancer will be tracked on the 31 day pathway.
Patients will be seen in accordance with QA screening recommendations.
Cytology is responsible for sending all reports/results to the Gynaecology Department.
Referrals will not be automatically created in Somerset, and the MDT Co-ordinator for
Gynaecology must therefore manually create a record in Somerset.
5.20 Consultant Upgrades
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Hospital specialists have the right to ensure that patients who are not referred urgently as
suspected cancer referrals but who have symptoms or signs indicating a high suspicion of
cancer are managed on a 62 day pathway.
Any patient that is not already on a 62 day pathway i.e. referred from a GP/GDP as an
urgent suspicion of cancer referral or with breast symptoms (i.e. 2ww) and who is not
referred through the screening programmes may be upgraded onto a 62 day pathway by
the receiving specialty. The 62 day target starts on the date the upgrade decision is made.
The points in the pathway where a referral may be upgrade are:



On receipt or triage of referral where this may meet IOG criteria for suspicion of cancer
During or following initial visit where there is a suspicion of cancer
During or following diagnostic procedures where imaging or histology/cytology indicate
or confirm the presence of cancer
On or before the multi-disciplinary team (MDT) meeting date
Upgrade must occur before the decision to treat date. Patients not upgraded by this point
will be measured against the 31 day decision to treat to first definitive treatment. The
upgrade will only be applicable for patients that have a suspicion of a new cancer not
those who may be suspected of a recurrence.
5.21 Rare Cancers
Referrals for suspected testicular/children’s cancer and acute leukaemia have to meet a
31 day target from receipt of referral to treatment.
5.22 Treatments
First treatment
For newly diagnosed cancers all patients should be treated within 31 days of decision to
treat date (DTT) irrespective of the treatment.
First definitive treatment is normally the first intervention which is intended to remove or
shrink the tumour. Examples of which are listed below:







Surgery
Chemotherapy
Hormone therapy
Immunotherapy
Radiotherapy
Brachytherapy
Specialist palliative care
Other treatments may be considered as first definitive treatment provided the intension is
therapeutic or no other active intervention is intended.
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Where there is no definitive anti-cancer drug almost all patients will be offered a palliative
intervention (e.g. stenting) or Specialist Palliative Care, which would be counted as the first
definitive treatment.
Subsequent treatments
This 31 day standard currently only applies to those treatments either curative or palliative
that aim to remove/shrink or delay the growth/spread of tumour/cancer.
All patients will be treated within 31 days of Decision To Treat.
Offers of treatment
All offers of treatment should be made within a reasonable timeframe under the guidance
of Section 4.1.44 Cancer Waiting Times guidance.
Surgery
Includes all outpatient, day case and inpatient surgical treatments where intent is to
remove the tumour. Admission date is classed as treatment date even if it is before the
surgical procedure date.
If a patient is admitted as an emergency and during the admission undergoes surgery that
subsequently diagnoses a cancer, the admission date is classed as the treatment date for
the purposes of cancer waiting times.
If on receiving the histology report surgical margins are not clear of cancer as long as the
intent was to remove the tumour this will still be classed as a treatment.
If a diagnostic procedure is undertaken but it is subsequently found to have removed the
entire tumour then this would be classed as a treatment.
If a wider excision is required following a previous cancer treat but no tumour is found in
the histology, this is still classed as a cancer subsequent treat and tracked/reported for
cancer waiting times.
If patients are admitted for a procedure which is intended to treat the cancer but on
operating the surgeon is unable to proceed due to clinical findings this would be classed
as “open and close” surgery and would still class as treatment as the intent was to treat.
This does not apply if the patient is reviewed pre op and deemed unfit to proceed.
Specialist palliative care
Patients requiring symptomatic and supportive care provided by the specialist palliative
care team this could be either a first or subsequent treatment.
Treatment commences when the team assess the patient.
Enabling treatments
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Most enabling treatments that are carried out prior to active treatments are not classed as
first definitive treatments for example: PEG/RIG tube insertions prior to radiotherapy are
not classed as first treatment unless the radiotherapy commences during the same
admission as the PEG then the date of admission is the date of first treatment.
However some exceptions do apply:





Colostomy for bowel obstruction as part of a palliative care package
Insertion of oesophageal stent
NSCLC stent
Ureteric stenting for advanced cervical cancer
Insertion of pancreatic stent if planned to resolve jaundice before the patient has a
resection or starts chemotherapy.
Clinical Trials
If a patient is entered into a clinical trial and may or may not receive a placebo this would
still count as first/subsequent treatment and treatment must still be provided within 31 days
of DTT.
Blood transfusions
If a patient is not planned to have active anti-cancer treatment, a blood transfusion would
count as first treatment as part of a palliative care treatment package, in all other cases
blood transfusion would not count as first treatment.
5.23 Recurrences
A recurrence is defined when a patient has been diagnosed and treated for an original
primary and informed that they are free of disease and then cancer returns in the same
site. Clinical input is required to determine if the patient has a recurrence or a second
primary in the same site. Treatment of a recurrence is classed as a subsequent treatment
and such cases are monitored against the 31 day pathway only irrespective of the route of
referral. Therefore if a patient on a 62 day pathway is diagnosed with a recurrence then
they are removed off the 62 day pathway and will be tracked under the new 31 day target.
5.24 Metastases
Metastases are defined as a cancer that has spread from another primary site. Data
entry/monitoring is reliant on clinical input to determine if the treatment is to the primary or
metastatic site. Treatment to metastatic disease is classed as a first treatment only if there
is an unknown primary. If the primary is known and treatment is given to the metastatic
site first this is still classed as a subsequent treatment and monitored under the 31 day
pathway even if this occurs before the treatment to the primary site. If the patient is on a
62 day pathway the clock does not stop with the metastatic treatment, it continues until the
primary site is treated.
5.25 Clock stops, pauses and adjustments
The 31 day and 62 day pathways end at treatment, or when a patient refuses treatment.
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Pauses and adjustments to the cancer pathway
All cancer targets can be extended for patients under limited circumstances. An
explanation for any adjustment must be clearly documented in the patient’s notes and or
on Somerset.
Pause for DNA of Initial outpatients appointment.
If the patient does not attend a first appointment, then the clock can be adjusted from the
date of referral to the date the patient re-books their appointment:
ORIGINAL
REFERRAL
REQUEST
RECEIVED
DATE
PATIENT
DNA
PATIENT RE-BOOKS
APPOINTMENT
DATE FIRST
SEEN
UBRN
CONVERSION
62-DAY START DATE
WAITING TIME ADJUSTMENT
(FIRST SEEN)
Pause or adjustment as a result of decline of reasonable offer for treatment as inpatient
If the patient declines an offered date for treatment, in an inpatient setting , for personal
reasons provided that the offered date is within target, an adjustment can be made from
the date that the patients declines to the date the patient is available for treatment. An
adjustment can also be made if the patient volunteers, before a treatment date is offered
and accepted that they are unavailable for treatment for a certain amount of time.
Clinically initiated delays - as a general rule the clock cannot be adjusted for clinical
reasons. Patients who require anaesthetic assessment prior to treatment should be
managed within target. Patients whose condition deteriorates so that the intended
management is no longer applicable and require a substantially different modality of
treatment should be managed within target where possible. Any resulting breaches should
be reviewed clinically using national guidance. It should be noted that the tolerance within
the target is to allow for clinically complex patients.
5.26 Reasonable offers
All patients offered outpatient (both new and follow-up) and diagnostic appointments must
be given reasonable notice.
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


For a verbal appointment offers, reasonable notice has been agreed locally as two
appointment dates on different days within at least 7 days from when the offer is
made.
For a written appointment offer, reasonable notice has been agreed locally as an
appointment date with at least two weeks from when the appointment letter is dated.
If a patient accepts an offer at shorter notice this also represents a reasonable offer in
respect of subsequent cancellations and delays.
Where the patient does not respond to letters or phone calls, i.e. tried for a least a week
with two phone calls in working hours plus one out of hours, or have not responded to an
appointment letter within two weeks of the letter date, then the patient is not fulfilling their
obligation to make themselves available for appointments and they can be discharged
back to their GP. In the event that no message can be left then a letter will be sent to the
patient explaining the process and that their care is being transferred back to their GP.
This will stop the clock.
If an offer of admitted care is declined, the clock can be stopped from the date the declined
appointment would have been to the point when the patient could make themselves
available for an alternative appointment.
Patient thinking time
It is good practice to allow patients a period of thinking time prior to considering treatment.
Where this is short, there is no clock pause. Pathways need to take account of this and be
able to accommodate a reasonable period for the patient to consider options. If a longer
period of thinking time is agreed, it may be appropriate to agree Active Monitoring as a
treatment and therefore a clock stop. For this to be genuine there would need to be a
follow-up appointment agreed. It is not acceptable to use Active Monitoring to avoid
breaches where the agreed thinking time is reasonable.
Earliest Clinically Appropriate Date (ECAD)
This applies if there has been a previously agreed and clinically appropriate period of
delay before the next treatment can commence. When determining the ECA date, only
patient issues should be considered, capacity constraints do not apply.
Some examples of ECAD


Patient with rectal cancer to have radiotherapy then surgery 6 weeks post
radiotherapy. ECAD date would be 6 weeks after radiotherapy completed
Patient with breast cancer to have surgery then radiotherapy. The patient would not
be fit for radiotherapy until they can lift arm above their head. Therefore the ECAD
date would be set when radiotherapy planning commences.
An ECAD can be reviewed and changed as long as the date has not passed. If an ECAD
is set but on patient review on/prior to the ECAD the patient is clinically not able to
progress to the next treatment the ECAD can be changed to a later date.
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If the patient is unwell after the ECAD then the ECAD cannot be reset and a wait time
adjustment will not apply.
Active monitoring
This could be either a first or subsequent treatment where the intention is for long term
surveillance where the decision had been taken to monitor the progress of the disease.
For example, a slow growing tumour where there is not an immediate problem and it is
clinically appropriate to step back and monitor the situation until an active intervention is
more appropriate.
Treatment starts when this is discussed and agreed with the patient.
5.27 Inter-Trust Referrals
A Memorandum of Understanding (MOU) is currently in place between respective
Hospitals in South Essex in advance of a more detailed inter-provider transfer policy.
This document provides a memorandum of understanding (MOU) between the following
organisations:




NHS Basildon & Brentwood Clinical Commissioning Group
NHS Southend Clinical Commissioning Group
Basildon & Thurrock University Hospital Foundation Trust
Southend University Hospitals Foundation Trust
The MOU sets out breach allocation across four cancer pathways:




Lung
Gynaecological
Urology
Gastro-intestinal
5.28 Performance Management
Managing Performance
Cancer performance needs to be managed on 3 levels, i.e.:



Through defined, timed pathways.
Through case and caseload tracking, with escalation of exceptions to plan.
Through continuous improvement, in particular through root cause analysis of
deviations to the Trust standard, with appropriate countermeasures being enacted.
Defined, timed pathways

All specialties will be expected to operate pathways that have been defined and are
timed. “Timed” means that the time for the completion of each step and when it is
expected to take place are explicit.
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


In particular, steps in the pathway will be expected to link together through direct
booking. No patient should leave the Trust without a date for at least the next step in
their pathway.
As part of defined pathways, possible risks and causes of delay should be identified
and escalation plans devised, so that these can be quickly enacted if required to
recover performance.
Pathways will be supported by capacity and demand metrics for the identified key
steps
Case and caseload tracking


The Trust’s cancer information tool Somerset will be used both to track individual
patients (cases) and actions requiring to be undertaken at key stages (caseloads)
In particular, the real-time PTL provide the tool for identifying all patients where the
Trust standards are not being met for any stage of care. The triggers and escalation
process to recover performance are described in the appendices.
Continuous improvement
Alongside caseload tracking, each specialty will be expected to identify common themes in
breaches of either stage of care or of overall targets, to undertake root cause analysis, and
to implement countermeasures.
Daily, weekly and monthly action required to deliver performance
Daily actions


Review and update the Somerset worklists for patient tracking, and initiate escalation
actions for any patient outside the escalation standards, with a timescale for
completion
Follow-up the completion of the escalation actions
Weekly actions
 Review the overall PTL and weekly performance data ahead of the weekly corporate
PTL meeting.
 Through the corporate PTL meeting, identify common issues and concerns, and
ensure solutions are enacted for any issues not resolved through initial escalation.
 Review capacity plus any performance issues for the week ahead, escalating any
unresolved issues.
Monthly actions


Review breaches and escalation issues for the month, ensuring root causes and
recurring themes are identified and appropriate countermeasures are enacted.
Review capacity & demand metrics and ensure the service is able to consistently
operate at the pace of demand. Make changes to respond to changes in demand as
required.
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
Review predictable changes for the period ahead, such as annual leave and bank
holidays. Ensure appropriate actions in place.
5.29 Training Requirements
All new clinical service centre staff including clinical staff involved in the implementation of
this policy will undertake initial training as part of their local induction arrangements. This
will include training undertaken by PAS trainers on the Medway PAS and Somerset
system which will include specific reference to the requirements relating to Cancer Wait
Times.
6 Monitoring Compliance and Effectiveness
Aspect of
Monitoring Individual
Frequency Group/Committee/forum
compliance
Method
department of the
which will receive the
or
responsible monitoring findings/monitoring
effectiveness
for the
activity
report
being
monitoring
monitored
National /
statutory
Audit
Business
6 Monthly
Clinical Assurance
requirements
Units
Committee
on access to
services are
being met.
Committee/indivi
dual responsible
for ensuring the
actions are
completed
Clinical
Assurance
Committee
Compliance with this policy will be monitored as set out below.

Weekly validation checks as part of Cancer PTL review

Monthly validation checks -All data fields are completed and submitted as required
Totals are correct – e.g. that the total is a sum over all treatment functions
Large changes in volumes compared to previous months will be investigated.
 Quarterly validation checks
The Trust Cancer Services Board (TCSB) will report into the Trust Executive as part of the
trust-wide Governance arrangements. Key areas of responsible include:




Overseeing the successful delivery of the Trust’s Cancer Action Plan, providing
assurance to the Trust Board that the Plan is being adequately managed
Overseeing compliance with Improving Outcomes Guidance, Peer Review and related
action plans
Overseeing the development of, and delivery of the Trust’s Cancer Strategy, including
service change and development in discussion with Commissioners and key
stakeholders
Monitoring performance across the Trust and tumour sites against cancer standards,
supporting the Multidisciplinary Teams and Business Units in the delivery of their
action plans to address issues relating to patient pathways and care delivery
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7 Associated Documents
This policy is linked to the following policies:










CL15 - Cancer Two Week Wait Policy
CM52 - Policy checklist
CM56 - Record-Keeping and documentation in clinical records
CM41 - Management of PAS alert field
CM21 - Admissions and Bed management
CM38 - Records management guidance
IS09 - Data Protection and Code of Confidentiality Policy
IS18 - Management of Computer Access and Passwords
IS-26 - Policy for the Management of Data Quality
RM10 - Incident and Near Miss Reporting
8 Equality Impact Assessment
This policy has been the subject of an Equality Impact Assessment. The output of the
assessment demonstrates that no one as a consequence of this policy is placed at a
disadvantaged over others.
9 References
1. Cancer wait times
2. The NHS Constitution
3. http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages/Overvie
w.aspx
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