Download Cancer Access Policy - Southend University Hospital NHS

Cancer Access Policy
SPONSOR (Information Asset Owner)
Jon Findlay, Chief Operations Officer
AUTHOR (Information Asset Administrator):
Mondel Mings, Interim Cancer Manager
RATIFIED BY:
Document Management Group
APPROVED BY:
Cancer working Group
Cancer Services Board
TARGET AUDIENCE:
All Staff Involved in Care of Patients with Cancer
POLICY NUMBER:
CM93
STRATEGY CATEGORY:
Corporate Management (CM)
This document is available in large print format and alternative
formats. Should you or someone you know require this in an
alternative format please contact us on 01702 435555 x6455 or
email [email protected]
This is an uncontrolled copy of this policy. To check if this is a copy
of the latest version please view this policy on-line on StaffNet
Southend University Hospital NHS Foundation Trust
Cancer Access Policy / CM93 / v2
Date
April 2014
September
2015
VERSION AND REVISION RECORD:
Ver. No
Details
1
New Policy
2
reviewed
This is an uncontrolled copy of this policy. To check if this is a copy
of the latest version please view this policy on-line on StaffNet
Review date
April 2015
September
2017
Southend University Hospital NHS Foundation Trust
Cancer Access Policy / CM93 / v2
Table of Contents
1 Introduction .................................................................................................. 4 2 Definitions .................................................................................................... 5 3 Duties and Responsibilities .......................................................................... 7 4 Monitoring Responsibilities ........................................................................ 11 5 Key Principles ............................................................................................ 11 6 Suspected Cancer Referrals ...................................................................... 15 7 Diagnostic & staging part of the referral to treatment pathway .................. 17 8 Screening Pathways .................................................................................. 18 9 Consultant Upgrades ................................................................................. 20 10 Rare Cancers ............................................................................................ 20 11 Treatments ................................................................................................ 21 12 Recurrences .............................................................................................. 23 13 Metastases ................................................................................................ 23 14 Clock stops, pauses and adjustments ....................................................... 23 15 Reasonable offers...................................................................................... 24 16 Inter-Trust Referrals................................................................................... 26 17 Performance Management ........................................................................ 26 18 Training Requirements .............................................................................. 28 19 Monitoring Compliance and Effectiveness ................................................. 28 20 Associated Documents .............................................................................. 28 21 Equality Impact Assessment ...................................................................... 28 22 References ................................................................................................ 28 Page 3 of 29
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Cancer Access Policy / CM93 / v2
1
Introduction
This policy describes how the Trust manages and reports accessing cancer services
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 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 Going Further on Cancer Waits
GFOCW 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.
1.1. Objectives
To ensure all staff involved in cancer waiting times management are aware of and
follow the processes outlined in this document in order to provide equitable access
for patients through effective cancer tracking, to enable the Trust to achieve the
required access standards, taking into account national rules and guidelines.
The key principles of this policy are:
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improve the patient experience as they move through the clinical pathways,
minimising unnecessary delays where possible;
ensure patients receive treatment according to clinical priority in the first
instance, followed by actual waiting time;
escalate bottlenecks in cancer-waiting-time pathways at an early stage to
Directorate Management teams;
provide timely, consistent and accurate data-recording for patients on cancer
waiting-time pathways
1.2. Scope
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This policy applies to all Southend University Hospital NHS Foundation Trust (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). 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.
1.3 Patients excluded from the cancer waiting times standard:
Any patient
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2
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
Definitions
Page 5 of 29
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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.
MDS (Minimum
Dataset Form)
Chronological
order (in turn)
A MDS form is agreed by the cancer Network to be completed
when a patient’s care is transferred between NHS trusts. A
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.
CD
CWT
Decision to admit
(DTA)
Clinical Directorates
Cancer Waiting Times
Where a clinical decision is made to admit the patient for either
day case or inpatient treatment.
Decision to treat
(DTT)
Did Not Attend
(DNA)
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.
DoH
Elective
admission /
elective patients
Elective Planned
Elective waiting
EROD
First definitive
treatment
Incomplete
pathways
Somerset
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
Page 6 of 29
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Multi-Disciplinary
Team (MDT)
MDM Coordinator
Patient Tracking
List (PTL)
Peer Review
To Come In (TCI)
TCSB
SCR
COSD
GP/GDP
GFOCW
3
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
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.
Trust Cancer Services Board
Somerset Cancer Registry Database
Cancer Outcomes and Services Dataset
General Practitioner
Going Further on Cancer Waits
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.
The Trust Cancer Services Board (TCSB) - is responsible for reporting into the
Trust Executive as part of the trust-wide Governance arrangements. Key duties
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 Clinical Directorates in
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the delivery of their action plans to address issues relating to patient pathways
and care delivery
4.2 Duties of Individuals within the Trust
Chief Executive
As the Trust’s accountable officer has overall responsibility for ensuring Southend
University Hospital Foundation Trust has robust, complete and up to date procedures
in place to govern and guide activities so that legal and national requirements are
met.
Lead Manager Cancer Services
The Lead Manager Cancer Services will ensure that all cancer services core team
staff involved in cancer-pathway tracking are aware of this policy and the importance
of following the procedures. Training will be provided to the cancer services core
team on this policy together with the Trust’s Access Policy. Training will also be
provided to new members of the team at induction.
The Lead Manager Cancer Services is responsible for reviewing this policy.
Directors and Associate Directors
The Directors/Associate Directors and General Managers for each Directorate have
overall responsibility for implementing and adherence to this policy within their
Directorate.
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 Directorate.
Managing resources allocated to the Directorate 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 Directors/Associate 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.
Achieving cancer access targets.
Ensuring that the duties, responsibilities and processes laid down in this policy
are implemented within the Directorate.
Ensuring all Directorate staff that needs 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 Directorate to ensure
compliance with this policy and avoid breaches of the targets: escalate any
actual or potential breaches to the Chief Operating Officer.
Page 8 of 29
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
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 Directorate
and Service/Operational managers as set out in the governance arrangements for
each Directorate.
Consultants
Each consultant is responsible for:
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Managing the patients care and treatment and working with their
Directors/Associate 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 Directorate 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
non-clinical 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
Ensuring that referrals/appointments for patients on the cancer pathway are
made in timely manner
Page 9 of 29
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
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 tumour 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
Surveillance) 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.
Ensure target of communicating MDT outcomes to primary care is met.
Page 10 of 29
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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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4
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
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 Board Group and
Chief Operating Officer for resolution. Compliance with this policy will be monitored
as outlined in the Monitoring Compliance and Effectiveness section.
5
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.
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.
All patients with suspected or diagnosed cancer will be managed in line with NHS
cancer targets.
All relevant patients will be added to the Somerset Cancer Registry Database (SCR)
which will hold full and comprehensive records for each patient. Patient records will
include MDT discussion and a full Cancer Outcomes and Services Dataset (COSD).
Patients will be tracked against the appropriate local and national standards and any
bottlenecks or pathway breaches will be actioned and / or escalated as appropriate.
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Compliance/ breaches of target will be reported in line with national reporting
guidance.
Data quality checks will be undertaken.
Cancer team members will receive comprehensive induction and refresher training to
allow them to undertake their duties.
The Cancer Waits standards are described in detail in “Going Further on Cancer
Waits” (GFOCW). The standards are summarized below:
5.1 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.
5.2 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.
5.3 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.
Page 12 of 29
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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 Centre’s
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.
5.4 Private Patients transferring to NHS Care
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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).
5.5 Clock Stops
2 Week Wait
The 2 weeks wait clock stops when a patient is first seen in outpatients.
62 or 31 day clock
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 – i.e. 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).
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5.6 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.
6
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.
6.1 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.
Going Further on Cancer Waits 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
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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 Booking Centre Manager 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.
6.2 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 14 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.
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.
Regardless of the reason (cancellation or DNA) if it is not possible to offer an
appointment either due to time constraints, e.g. cancelled on day 13 of pathway or no
second appointment available to offer within the target time then the escalation
process must be followed.
Patients that cancel after day 11 of the pathway should be immediately booked into
the next available appointment to reduce the impact on the 62 day pathway and
prevent further pathway delays.
The first appointment can be either an outpatient appointment with a consultation or
investigation relevant to referral i.e. straight to test.
If the patient does not have an appointment at day 3 the process should be
escalated.
6.3 Emergency admissions/attendances during 2 week rule period
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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.
6.4 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.
6.5 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.
6.6 Breast symptomatic referrals
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.
7
Diagnostic & staging part of the referral to treatment pathway
7.1 General Pathway Standards
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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.
7.2 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.
7.3 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 31-day 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.
7.4 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.
8
Screening Pathways
8.1 Breast Screening
62-day standard
Breast
Cancer
Screening
Abnormality
spotted by
reader
Reader
generates
referral
Cancer
referral to
treatment
period start
date (62days)
Date first
seen
Cancer
treatment
period start
date (31days)
Treatment
start date
(cancer)
Referral is triggered by the final reader who initiates the assessment appointment.
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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.
8.2 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 FOB 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.
8.3 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.
8.4 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
Decision to refer
date (cancer
and breast
symptoms)
2-week wait
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62-day wait
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Treatment
start date
(cancer)
Southend University Hospital NHS Foundation Trust
Cancer Access Policy / CM93 / v2
Suspected cancer referral will be triggered by the following smear result:



Moderate and severe dyskaryosis
Glandular neoplasia (query adenocarcinoma of cervix)
Invasive (query 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.
9
Consultant Upgrades
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.
10 Rare Cancers
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Referrals for suspected testicular/children’s cancer and acute leukaemia have to
meet a 31 day target from receipt of referral to treatment.
11 Treatments
11.1 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
Active monitoring
Other palliative treatments e.g. radiofrequency ablation
Other treatments may be considered as first definitive treatment provided the
intension is therapeutic or no other active intervention is intended.
Where there is no definitive anti-cancer drug almost all patients will be offered a
palliative intervention (e.g. stenting) or palliative care, which would be counted as the
first definitive treatment.
11.2 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.
11.3 Offers of treatment
All offers of treatment should be made within a reasonable timeframe under the
guidance of Section 15.6 Reasonable Offers and the Going Forward On Cancer
Waits guidance.
11.4 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.
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If a patient is admitted as an emergency and during the admission undergoes surgery
which 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.
11.5 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.
11.6 Enabling treatments
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.
11.7 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.
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11.8 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.
12 Recurrences
A recurrence is classed as subsequent treatment and 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.
Recurrent cases are monitored against the 31 day pathway only irrespective of 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.
13 Metastases
Metastases are classed as a subsequent treatment and are defined as a tumour 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.
A metastatic treatment 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.
14 Clock stops, pauses and adjustments
The 31 day and 62 day pathways end at treatment, or when a patient refuses
treatment.
14.1 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:
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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)
14.2 Pause or adjustment as a result of decline of reasonable offer for
treatment as in-patient
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.
14.3 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.
15 Reasonable offers
All patients offered outpatient (both new and follow-up) and diagnostic appointments
must be given reasonable notice.



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
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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.
15.1 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.
15.2 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.
15.3 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




If a patient is booked for a check cystoscopy following a treatment for cancer
and during the cystoscopy a recurrence is diagnosed and resected then the
ECAD and treatment is the date of the cystoscopy.
If the patient is diagnosed but then booked for treatment the ECAD is the date
of the cystocopy and the treatment must be booked within 31 days.
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.
If the patient is unwell after the ECAD then the ECAD cannot be reset and a wait time
adjustment will not apply.
15.4 Active monitoring
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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.
16 Inter-Trust Referrals
A Inter Provider Transfer Policy provides an understanding 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 Inter Provider Transfer Policy sets out breach allocation across four cancer
pathways:




Lung
Gynaecological
Urology
Gastro-intestinal
17 Performance Management
17.1 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.
17.2 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.
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.
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

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.
17.3 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.
17.4 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.
17.5 Daily, weekly and monthly action required to deliver performance
Daily actions


Review and update the Somerset work lists 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 data completeness and accuracy via the Somerset work lists.
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.
18 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.
19 Monitoring Compliance and Effectiveness
Aspect of
compliance or
effectiveness
being
monitored
National /
statutory
requirements
on access to
services are
being met.
Monitoring
Method
Audit
Individual
department
responsible
for the
monitoring
Clinical
Directorates
Frequency
of the
monitoring
activity
Group/Committee/forum
which will receive the
findings/monitoring report
6 Monthly
Clinical Assurance
Committee
Committee/individu
al 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
20 Associated Documents
CM31 Patient Access Policy
CL37 Treatment Escalation Plan (Currently awaiting ratification)
21 Equality Impact Assessment
Each procedural must go through an Equality Impact Assessment (EIA). Please list
here the outcome of the one completed.
22 References
1.
GFOCW – Going Forward On Cancer Waits
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2.
3.
4.
Cancer wait times
The NHS Constitution
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages/
Overview.aspx
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