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DELIVERING CANCER WAITING TIMES
A Good Practice Guide
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TABLE OF CONTENTS
Introduction _______________________________________________________________ 5
Overview _____________________________________________________________ 5
How the guide works and its intended audience ______________________________ 5
Key to the guide ____________________________________________________________ 6
Understanding principles and rules ________________________________________ 7
Individual patient rights under the NHS Constitution __________________________ 7
NHS assessment of performance – the provider standards ______________________ 7
NHS foundation Trusts __________________________________________________ 8
National guidance ______________________________________________________ 8
Rules and definitions ___________________________________________________ 8
1. Managing capacity and demand ___________________________________________ 9
Overview _____________________________________________________________ 9
Guiding principles ______________________________________________________ 9
Dos and don’ts _______________________________________________________ 10
Information requirements ______________________________________________ 12
Role of demand and capacity in supporting cancer care delivery ________________ 14
Getting help _________________________________________________________ 14
2. Governance – reporting and performance management ______________________ 17
Overview ____________________________________________________________ 17
Cancer leadership structures ____________________________________________ 17
Communicating cancer across the organisation ______________________________ 19
Attributing accountability and responsibility for cancer waiting times within the
organisation _________________________________________________________ 19
Staff code of conduct __________________________________________________ 20
Processes to build trust around cancer data quality __________________________ 20
Conflicts of interest ____________________________________________________ 21
Board assurance ______________________________________________________ 21
Board training ________________________________________________________ 21
Reports to the board ___________________________________________________ 21
Training _____________________________________________________________ 22
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3. Core functions ________________________________________________________ 23
Patient tracking _______________________________________________________ 23
Pathways ____________________________________________________________ 23
Staff roles ___________________________________________________________ 24
MDT coordinator ______________________________________________________ 25
Two week wait office __________________________________________________ 25
Specialty manager/support service manager (e.g. endoscopy, imaging) ___________ 26
Cancer manager ______________________________________________________ 26
4. Reporting ___________________________________________________________ 27
Tracking list __________________________________________________________ 27
MDT meeting ________________________________________________________ 27
Cancer PTL___________________________________________________________ 28
Tracking systems ______________________________________________________ 28
Breach analysis and reporting ___________________________________________ 30
Data quality checks ____________________________________________________ 32
5. Processes and meetings ________________________________________________ 32
Trust PTL meeting _____________________________________________________ 32
Pre-PTL meeting/specialty meeting _______________________________________ 33
Access policy _________________________________________________________ 34
6. Operational delivery ___________________________________________________ 35
Pathways capable of delivering shorter waits _______________________________ 35
Managing patients along their cancer pathway ______________________________ 35
Pre-referral __________________________________________________________ 35
Right to obtain treatment within the maximum waiting time ___________________ 36
Centralised administrative teams _________________________________________ 36
Referral receipt _______________________________________________________ 36
Scheduling appointments _______________________________________________ 37
Straight to test (STT) pathways ___________________________________________ 37
One stop clinics _______________________________________________________ 38
Booking appointments _________________________________________________ 38
Clinic templates_______________________________________________________ 39
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Overbooking _________________________________________________________ 39
Did not attends (DNAs) _________________________________________________ 39
Pathway adjustment for DNAs to first attendance ____________________________ 40
Pathway adjustment for admitted pathway _________________________________ 40
Cancellations (by patient) _______________________________________________ 41
Subsequent cancellations (by patient) _____________________________________ 42
Cancellations (by hospital) ______________________________________________ 42
Transfer of patients between provider organisations _________________________ 42
7. Diagnostics __________________________________________________________ 45
Useful resources: _____________________________________________________ 45
Paper referrals________________________________________________________ 45
Advantages of electronic referrals ________________________________________ 45
Registration of referrals ________________________________________________ 46
Pre-registration checks - the minimum dataset ______________________________ 46
Vetting of referrals ____________________________________________________ 46
Electronic vetting of referrals ____________________________________________ 47
Scanning protocols ____________________________________________________ 47
Booking of appointment ________________________________________________ 47
Confirming appointments _______________________________________________ 48
Patient preparation ____________________________________________________ 48
Scanner utilisation and scheduling ________________________________________ 48
Reporting ___________________________________________________________ 49
Reporting performance monitoring _______________________________________ 49
Management of DNAs _________________________________________________ 50
Unexpected findings ___________________________________________________ 50
8. Scheduling, pausing, booking, theatres ____________________________________ 51
9. Acknowledgements ___________________________________________________ 59
10. Revisions process _____________________________________________________ 60
11. Contact information ___________________________________________________ 60
APPENDIX 1: Website addresses __________________________________________ 62
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NHS improving quality – challenges and improvements in diagnostic aervices across
aeven _______________________________________________________________ 63
NHS Managers Code of Conduct 2002 _____________________________________ 63
Royal College of Radiologists – Standards and Recommendations for the Reporting and
Interpreting of Imaging Investigations by Non Radiologists Medically Qualified
Practitioners and Teleradiologists: ________________________________________ 63
APPENDIX 2 __________________________________________________________ 64
Cancer care access policy development guidelines: ___________________________ 64
Sign off _____________________________________________________________ 64
Choose & book (C&B) __________________________________________________ 64
Access standards ______________________________________________________ 64
Definitions ___________________________________________________________ 65
Referral pathways _____________________________________________________ 65
Cancer referrals _______________________________________________________ 66
Patient information ____________________________________________________ 66
DNAs and cancellations ________________________________________________ 66
Training and role clarity ________________________________________________ 66
Reporting suites ______________________________________________________ 67
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INTRODUCTION
Overview
Achievement of the national cancer waiting
times (CWT) standards is considered by
patients and the public to be an indicator of
the quality of cancer diagnosis, treatment and
care NHS organisations deliver.
Delivering timely cancer pathways is crucial
for the following reasons:
Despite improving survival rates, cancer is
the fourth leading cause of death in the
UK;
Patients continue to present late to their
GP with their symptoms, resulting in
delayed referral;
There is variation in 2 week wait (2WW)
referrals across the country suggesting
that GPs are not always identifying
suspicious symptoms;
Once a patient has been referred, they
want to be told “It’s not cancer” as soon
as possible or have their treatment
planned in a timely manner;
Where the diagnosis is cancer, a speedy
diagnostic pathway is critical for 62 day
compliance.
Despite consistent achievement of the cancer
standards at a national level, it is recognised
that many organisations either struggle to
maintain compliant performance on a
consistent basis or achieve below-standard
performance.
NIGEL COOMBER
DIRECTOR, ELECTIVE CARE INTENSIVE
SUPPORT TEAM
APRIL 2014
How the guide works and its
intended audience
The guide is designed to walk you through the
essential elements of a pathway for suspected
cancer; from pre-referral advice and
outpatients, all the way through diagnostics
to patient admissions. The guide also covers a
number of key areas which support the
operational delivery of a good pathway for
elective cancer, including demand and
capacity planning, cancer access policies,
governance (performance management and
reporting).
The guide is a collection of the advice and
expertise from the NHS IMAS Elective Care
Intensive Support Team (IST), which has been
built up over the years through supporting
various NHS organisations across the country
delivering high quality pathways for patients
and sustaining low waiting times for
treatment.
Delivering Cancer Waiting Times – A Good
Practice Guide is an accompanying guide to
the NHS IMAS IST Elective Care Guide.
The intended audience for this document is
primarily NHS staff who are involved in any
aspect of pathway management for suspected
cancer and who want to understand how best
to manage or deliver these pathways. This will
include staff within acute trusts, NHS
Foundation Trusts, Area Teams (ATs) and
Clinical Commissioning Groups (CCGs).
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Understanding principles and rules
The NHS has set maximum waiting time standards for access to healthcare. In England, waiting
time standards for cancer care come under two headings:
the individual patient right (as per the NHS Constitution);
the standards by which, individual providers and commissioners are held accountable by the
Department of Health for delivering (as per the NHS Operating and NHS Performance
Frameworks)
Individual patient rights under the NHS Constitution
For English patients (from an individual patient perspective) the current maximum waiting times
for cancer care are set out in the NHS Constitution and the handbook to the NHS Constitution.
This can be found at:
NHS CONSTITUTION
HANDBOOK TO THE NHS CONSTITUTION 2013
The NHS Constitution sets out the following rights for patients with suspected cancer:
to access certain services commissioned by NHS bodies within maximum waiting times, or
for the NHS to take all reasonable steps to offer you a range of suitable alternative
providers if this is not possible;
to be seen by a cancer specialist within a maximum of two weeks from GP referral for
urgent referrals where cancer is suspected.
The handbook also lists the specific circumstances where the right will cease to apply and those
services which are not covered by the right.
NHS assessment of performance – the provider standards
In addition to the individual patient rights as set out in the NHS Constitution (and its supporting
handbook) there is a set of waiting time performance measures for which the NHS is held to
account for delivering by NHS England.
There are a number of government pledges on waiting times, including:
a maximum one month (31-day) wait from the date a decision to treat (DTT) is made to the
first definitive treatment for all cancers;
a maximum 31-day wait for subsequent treatment where the treatment is surgery;
a maximum 31-day wait for subsequent treatment where the treatment is a course of
radiotherapy;
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a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer
drug regimen;
a maximum two month (62-day) wait from urgent referral for suspected cancer to the first
definitive treatment for all cancers;
a maximum 62-day wait from referral from an NHS cancer screening service to the first
definitive treatment for cancer;
a maximum 62-day wait for the first definitive treatment following a consultant’s decision
to upgrade the priority of the patient (all cancers);
a maximum two-week wait to see a specialist for all patients referred with suspected
cancer symptoms
a maximum two-week wait to see a specialist for all patients referred for investigation of
breast symptoms, even if cancer is not initially suspected.
These measures are set out in the current NHS England document: Everyone Counts: Planning
for Patients 2013/14.
EVERYONE COUNTS: PLANNING FOR PATIENTS 2013/14
NHS Foundation Trusts
NHS Foundation Trusts are held accountable through Monitor via the NHS Foundation Trust
(NHSFT) Compliance Framework.
NHS FOUNDATION TRUST COMPLIANCE FRAMEWORK
National guidance
Rules and definitions
In order to ensure that reported performance is consistent and comparable across providers,
the measurement and reporting of waiting times is subject to a set of rules and definitions.
For cancer services the guidance on cancer waiting times can be found at:
GOING FURTHER ON CANCER WAITS STANDARDS
It is important that there is a consistent approach to the interpretation and implementation of
national guidance across NHS organisations. In some circumstances it is for the NHS locally to
decide how these guidelines are applied to individual patients, pathways and specialties. It is
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important that decisions should be based on clinical judgment and in consultation with other
NHS staff, commissioners and, of course, patients. The guidance is designed to ensure that
reported waiting times are a true reflection of patients’ experiences.
1. MANAGING CAPACITY AND DEMAND
Overview
This section of the cancer guide will explore good practice principles in relation to
modelling demand and capacity for cancer services.
The following areas will be explored:
the various outputs that services should look to gain from demand and capacity
modelling;
good practice approach and things to avoid when undertaking the modelling;
mechanisms to build confidence and assurance around waiting times performance
sustainability
Guiding principles
The successful delivery of any maximum waiting time standard (e.g. two week waits) is
predicated on the following factors:
patient pathways are capable of delivering a short wait, and clearly describe what
should happen, in what order and when;
a balanced position between demand and capacity;
a maximum number of patients waiting that is consistent with the level of demand
and key pathway milestones e.g., maximum time from referral for suspected cancer to
the first outpatient appointment;
patients are treated in order by clinical priority; and against the two week wait
standard;
patients are actively managed against the pathway for their condition and the key
milestones.
While all of these factors are important, a balanced position between demand and
capacity is essential. If demand exceeds capacity then the numbers of patients waiting
will grow and waiting times will lengthen and the ability to provide short waits will
deteriorate.
Of equal importance is the size of the waiting list that is consistent with the delivery of a
two week wait target or shorter where internal stretch targets dictate.
The most efficient way of understanding
the dynamic between demand and
capacity and to calculate maximum list
sizes, is to use a modelling tool. There are
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many different modelling tools both
commercial and in-house developed
solutions. The model an organisation
chooses to use is not necessarily
important – the models are there to
improve understanding and support
discussions around how a service can
predict demand and plan services
accordingly.
TIPS
a balanced position between demand
and capacity is essential
when demand exceeds capacity then
the number of patients waiting will
grow, along with the waiting time for
an appointment
size of waiting list is equally important
modelling tools will be useful to help
establish a good understanding of your
demand and capacity
It is very difficult to model services for the 31 day and 62 day standards in their entirety.
In cancer services, pressure on the 31 day target should be seen as an indicator of true
treatment capacity issues rather than the 62 day target. However key stages of the
patient’s cancer pathways can be modelled separately to identify capacity constraints.
For example, two week wait, waits for endoscopy, waits for imaging, waits for treatment
once a decision to treat has been made.
Later in this section are details on how to access the models that the IST routinely use
when working with client organisations to help them understand their particular service.
Issues such as appropriate levels of capacity to deal with variation in demand are
explained within the models.
Dos and Don’ts
The following list of dos and don'ts is based on the practical experience gained by the IST
of helping organisations develop and use demand and capacity models. They are designed
to act as simple checklists to avoid the most common pitfalls.
involve clinicians from the start of the process;
adopt a logical and consistent approach to the process;
ensure the demand and capacity planning process is led by the
general/service managers or cancer managers and involves the information
team, rather than the other way around;
agree the common data requests based on the inputs of the models to
avoid multiple ad-hoc information requests;
decide what’s in and what’s out so you compare like for like in terms of
demand, capacity and what is on the waiting list(s);
document important information and decisions about the data and any
assumptions you have used, especially when building models at sub-
specialty or consultant level. Try and keep this information in a separate
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spread sheet within the model;
sense check data with those closest to the operational challenges e.g.,
service managers should sense check data with booking staff and cancer
managers should have a good overview of the service as a whole. This is
especially important when verifying core capacity;
sense check for logical relationships between related data items e.g. the
size of a waiting list at the beginning and end of the year. Does this make
sense when you look at how many patients were added and removed (for
all reasons) over that same period;
sense check any step changes in demand against national awareness
campaigns. Use national data available on expected increases in referrals
to verify these;
review demand and capacity on a rolling basis - monitor trends in demand
and revise capacity plans if required;
share plans and ensure all the key stakeholders, including commissioners,
are signed up to, and understand the plans;
consider six month, annual, and one to three year horizon scanning sessions to
be held separately with each specialty to develop forward planning
incorporating service changes as a result of new technologies, and awareness
campaigns - to include commissioners and finance;
work with commissioners to review retrospectively the impact of awareness
campaigns.
become a slave to the models - they are there to support conversations and
improve understanding, not to replace them;
be concerned when the first run through/population of the model doesn't
work perfectly. Some of the data items may not currently be commonly
requested reports and may require refinement to get them right. There may
be some variation in the type of data that is required when modelling
cancer services;
when looking at current core capacity don’t count over-bookings, ad-hoc or
out-sourced activity;
see demand and capacity planning as a one-off exercise. Models should be
regularly reviewed particularly with regard to the anticipated level of
demand. Some of the data items may have been based on an
educated/informed guess rather than hard data;
forget that by their very nature, a modelled position will never exactly
match reality. Even the most sophisticated model cannot predict the precise
nature of the variables that were used to create the model scenario;
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When working with NHS organisations to develop demand and capacity models, the IST
often uses a set of simple comparisons to sense check the initial inputs into the model.
These include:
compare number of referrals against the number of first out patients seen for last 12
months with cancer referrals / activity reviewed separately;
compare number of additions to the waiting list against actual admissions;
consider whether major differences in the above can be explained by changes in the first
outpatient or admitted waiting lists.
Information requirements
As stated above, service managers / cancer managers will need the help of information
colleagues to pull together the various data items required to complete the demand and
capacity models. It is important therefore that both the operational management and
information teams go through the models together to understand the various data inputs.
The information team will need to be very clear as to exactly what is “in” and what is "out"
when they are writing queries to extract the data. Experience shows that this can be an
iterative process and it's quite normal not to get it right the first time.
Whilst models are subtly different, the list of data items might well include the following:
52 weeks of historical two week wait referral data (including breast symptomatic);
52 weeks of historical decision to admit (DTA) / additions to the waiting list data to
include all patients types (cancer, urgent, routine), although with a clear separation of
cancer patients;
removal other than treatment (ROTT) rates for both the first outpatient and admitted
waiting list;
first outpatient attendances for the last 12 months (this may include cancer patients
only if two week wait services are modelled separately);
first outpatient Did Not Attends (DNAs) for the last 12 months;
first outpatient DNAs rebooked for the last 12 months;
admissions for the last 12 months with cancer patients clearly separated;
cancelled admissions (if capacity was genuinely lost) for the last 12 months;
rebooked cancelled admissions for the last 12 months;
the current sizes of the first outpatient and admitted waiting lists (both with and
without dates);
model cancer services in isolation, they need to be considered in the
context of the overall service and the various patient groups that pull on the
same resources.
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the waiting list sizes of the first outpatient and admitted waiting lists (both with and
without dates) at the beginning and end of the 52 week referral / activity data collection
period;
the baseline core capacity to see first and follow-up outpatient attendances, including
dedicated cancer slots (taking account of clinics lost due to annual leave, study leave,
bank holidays, on-call, etc.); and
the baseline core capacity to undertake surgical procedures, including dedicated
admission slots for cancer patients (again factored down for the elements as described
above).
Some of the data items (e.g. first outpatient ROTT rate, cancelled surgical admissions,
where capacity was genuinely lost) are not common sets of routinely extracted data.
Perhaps surprisingly, robust, clean referral data is often quite challenging for organisations
to extract. Given that referrals are, for the vast majority of cancer pathways, the initial
driver it is important that providers understand their demand data.
Agreeing (and testing) initial trawls and
extraction of the common data items
should standardise the requests made to
the information team and avoid multiple
ad hoc requests where the specification
of the data items may vary based on an
individual's understanding of what is
required. However it is likely that when
modelling cancer services, requests may
be a little more specific depending on
which tumour site is being reviewed.
TIPS
collaboration between the Service /
Cancer Managers and information
team is essential to pull together data
required for the modelling;
where information is not available,
it’s important to clarify and document
how figures are calculated;
testing initial data trawls and
extraction helps information team
standardise information request
responses and avoids multiple ad hoc
requests.
When working with clients to develop demand and capacity models, the IST often uses a
set of simple comparisons to sense check the initial inputs into the model.
Some of these are set out below:
compare number of referrals against the number of first outpatients seen for the last 12
months with cancer referrals / activity reviewed separately;
compare number of additions to the waiting list against actual admissions;
consider whether major differences in the above can be explained by changes in the
first outpatient or admitted waiting lists.
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Role of demand and capacity in supporting cancer care delivery
Some models include an option both to plan required dips in activity to meet the
anticipated demand and also to record "actuals" as they occur. This is most helpful as it
provides metrics against which the delivery of the plan can be measured and service areas
be held accountable for their individual performance.
For example, if a modelled waiting list is not at a predicted size at a particular point in time,
the base drivers can be reviewed to understand why this might be so. Given the waiting list
size will be principally dictated by the additions and the removals from it (i.e. activity) one
should be able to determine whether the level of demand differs from that originally
anticipated or the planned level of activity has not been delivered.
In reviewing demand and capacity dynamics, it is often the case that there is a shortfall in
capacity that is adversely affecting waiting times. Shortfalls in capacity can be addressed
through increasing the level of resource, making the current resource more productive, or a
combination of the two.
There are many existing resources focused around increasing productivity and this paper
does not aim to duplicate them. Colleagues however may find the following links offer help
in signposting them to these resources:
STEYN IMPROVING PATIENT FLOW WEBSITE
NHS IMPROVING QUALITY – PRODUCTIVE OPERATING THEATRES
NHS IMPROVING QUALITY – ENHANCED RECOVERY
Getting help
Through its experience of working with NHS trusts and commissioners, the IST has
developed a series of demand and capacity models designed to help organisations
achieve an appropriate balance between demand and capacity, and to ensure that waiting
lists are of an appropriate size. These models can act as a helpful starting point for
organisations to better understand demand and plan capacity accordingly.
While it would appear that it is only the IST two week wait model which has been
specifically developed for a cancer pathway, many of the models can be used to model
cancer services, whether this is completed by modelling the entire patient pathway to
include all patient types (cancer, urgent and routine) or to only monitor the cancer aspect
of the pathway. Generally the IST suggests modelling services in their entirety, however
with the ability to separate out cancer as necessary.
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THE MODELS ARE FREELY AVAILABLE VIA THE NHS IMAS WEBSITE
It is likely the following IST models will be of more use than the others related to
modelling of cancer pathways. Details and links of the models available are provided
below:
TWO WEEK WAIT CANCER CAPACITY AND DEMAND TOOL
To model the pathway between GP referral for suspected cancer to the first
outpatient attendance. This will model patients who are on a two week wait pathway
for suspected cancer only.
OUTPATIENT DEMAND AND CAPACITY TOOL
To model the pathway between GP referral to first outpatient attendance. This would
be used to model the entire pathway, with cancer and urgent patients being a subset
of all referrals.
ENDOSCOPY DEMAND AND CAPACITY TOOL
To model the demand for endoscopy service in its entirety. This would model demand
for all endoscopy patients with cancer patients being a subset of demand.
DIAGNOSTIC IMAGING DEMAND AND CAPACITY TOOL
To model demand for the radiology service with the demand for cancer patients
included within the model as a subset.
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INPATIENT / DAYCASE CAPACITY AND DEMAND TOOL
To model the demand for admission services from decision to treat to admission for
treatment. The model can either be used to model the entire service or just the
demand for the cancer patients if the capacity for the service is separated.
ADVANCED FLOW THROUGH TOOL
To model the entire pathway from referral to treatment (62 day standard) in weeks.
Again this can be used to model just the cancer element of the service or the entire
service.
The outputs of the models can be used to inform and influence cancer pathway mapping
and support work with CCGs and commissioners.
For those organisations who are challenged in their delivery of the maximum waiting time
standards and/or who wish to receive external assurance around their demand and
capacity planning processes, requests can be made, to receive support from the NHS
IMAS Elective Care Intensive Support Team (IST).
Details of NHS IMAS and the IST are available through the NHS IMAS website. NHS
organisations can contact the IST Director, Nigel Coomber:
NHS IMAS INTENSIVE SUPPORT TEAM WEBSITE:
WWW.NHSIMAS.NHS.UK/IST
NIGEL.C[email protected]
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2. GOVERNANCE – REPORTING AND PERFORMANCE MANAGEMENT
Overview
This section of the cancer guide will explore good practice governance principles in
relation to CWT system confidence.
The following areas will be explored:
good practice CWT leadership and staff structures for ownership and accountability,
communication and engagement;
processes which ensure organisations can trust their cancer data;
mechanisms to build confidence and assurance around waiting times performance
sustainability.
Cancer leadership structures
There is recognition there are special, distinctive leadership structures within each
organisation that provides cancer services (the core cancer management team). The IST
has seen a number of different approaches within different trusts to the way in which
cancer is structured and where it sits within the organisational structure. The IST has
seen cancer structures work well both within an operational structure i.e. sits within a
clinical division, and separate to an operational structure i.e. sits as a corporate function
within the organisation.
Although it is clear that one size will not fit all and that there is no one best staffing
structure for cancer within the NHS, what is essential is that organisations develop local
governance structures that reflect the complexities of their own organisations.
It is vitally important that the remits and level of authority of the core cancer
management team and individuals within the team are:
clear and communicated across the organisation;
accountability for cancer delivery is clearly identified;
board level support for the structure is articulated;
sufficient time resource is made available for individuals to enact their
roles; and
there is a clear governance framework in place.
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The more common core cancer team management structures include the roles are outlined below, summarised in terms of broad remits.
EXECUTIVE
DIRECTOR
WITH A REMIT
FOR CANCER
A single executive lead for cancer with board level accountability for CWT and cancer delivery. This person is not
usually the CEO but this does not negate the need for CEO personal involvement when necessary.
LEAD CANCER
CLINICIAN
A named designated clinical lead with an overall responsibility for ensuring high standards of cancer clinical care
across the organisation in a timely manner, leading the development of the cancer strategy with director, managerial
and clinical support. This person is usually but not exclusively a consultant with responsibility for facilitation of the
delivery of CWT performance. This individual has professional management responsibility for the Multi Disciplinary
Team (MDT) clinical leads in their roles as such, responsible for delivery of CWT within their tumour site.
LEAD CANCER
MANAGER
A senior manager should be designated with responsibility for facilitation of the delivery of cancer waits. This
manager will have a corporate responsibility for cancer, including monitoring cancer waiting data quality,
implementation of the cancer strategy, and may incorporate a lead role in coordinating peer review, and usually has
the remit of management of the cancer trackers (MDT coordinators) and 2WW referral booking office.
LEAD CANCER
NURSE
A named lead nurse for cancer with co-responsibility for facilitating the delivery of CWT. This role should also
include developer of cancer nursing strategy, and may also incorporate a lead role in coordinating peer review.
This person should have either direct line management or professional line management responsibility for cancer
specialist nurses within the organisation who in turn have a role to play in supporting patients through their cancer
pathways in a timely manner. This person often has a professional line management link to the director of nursing.
MDT CLINICAL
LEAD
There should be a named lead from the MDT assigned for each of the tumour sites (as per peer review
requirements). This same person should be accountable for CWT delivery, management of the PTL (including data
quality and completeness), breaches avoidance and learning (with support from the relevant senior specialty
manager, e.g. general manager).
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Communicating cancer across the organisation
Cancer is an organisation-wide service, cross-cutting into the vast majority of specialties
and diagnostic services. To maintain its importance as one of the organisation’s clinical
priorities, it is important there are formal and timely communication channels both from
the core cancer team to specialties and the wider organisation, and vice versa, that
specialties keep the cancer team abreast of any challenges or planned service
developments.
There should be a number of formal meetings in place to support communication of CWT
and the wider cancer agenda across the organisation:
cancer performance meeting and local (tumour level) cancer PTL review meetings (see
Section 3: Core Cancer Function.
cancer steering group /cancer board meeting – a monthly or quarterly meeting chaired
by the cancer lead clinician or executive lead, attended by cancer senior management
team, MDT leads, and representatives from diagnostics and other cancer support
services.
the cancer lead manager should also attend the organisation’s wider performance
meeting (e.g. RTT PTL meeting) to raise awareness around cancer waits and escalate
issues.
in addition, representatives of the cancer senior management team should attend
specialty business meetings, as appropriate, to update on cancer performance issues
and relevant national or local initiatives that will impact on service delivery e.g. cancer
awareness campaigns.
Attributing accountability and responsibility for cancer waiting
times within the organisation
Responsibility for CWT should be well integrated within operational delivery structures. It
should be clearly explained and understood who is responsible for which elements of the
delivery the CWT standards.
For example, the specialty/tumour site management team could be held responsible for
ensuring the clinical service runs efficiently; there is sufficient capacity to meet demand,
clinicians adequately prepare patients for each step of their cancer pathway; and whilst
the cancer core team could be held responsible for ensuring that MDT coordinators
escalate any identified capacity issues to the service, that cancer patient tracking is
undertaken in a conscientious and timely manner and concerns are escalated to speedy
resolution by the tumour site management team.
The executive lead for cancer should reinforce the lines of responsibility and ownership to
ensure accountability for cancer waits delivery sits with those in a position to deliver i.e.
ultimate responsibility will sit within the specialty, rather than within the remit of support
structures such as the core cancer team, service improvement, etc.
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MDT clinical leads and managerial leads (tumour site management team) for each cancer
site should be accountable for CWT delivery, management of the PTL (including data
quality and completeness), and breaches. The cancer lead clinician/ executive lead
should meet at regular intervals with the tumour site management team to review
tumour level performance and agree remedial or improvement actions as appropriate.
Outside of this meeting structure, there should be clear lines of escalation in place.
Staff code of conduct
The culture of delivering services in line with nationally determined standards is deeply
embedded in the NHS. Whilst it is recognised that the framework of setting and
complying with these “targets” is ultimately in the interests of individual patients and the
public, there is an acknowledgement that sometimes this becomes an unhealthy focus
within NHS organisations on “hitting the target” which has in a small number of cases led
to individuals acting dishonestly in fear of failure.
The continual and relentless public scrutiny that organisations face presents a challenging
and demanding environment for NHS managers and staff yet it is crucial that the public
can both trust that services are being delivered, as well as the promises of timely
treatment that the NHS has made in such documents as The Operating Framework and
The NHS Constitution.
The NHS Managers’ Code of Conduct impresses on managers their responsibility to
ensure that both they and their staff act at all times with integrity and probity; and that
indeed staff are able to raise concerns around alleged wrong-doing in a blame-free and
supportive environment.
THE CODE OF CONDUCT FOR NHS MANAGERS
Processes to build trust around cancer data quality
The key to building trust around cancer data quality is the implementation of validation
(checking) systems to ensure the data that has been recorded is accurate and complete.
Clean data is crucial for effective pathway management and critically important prior to
mandatory upload to the National Cancer Waiting Times database, hosted by Open
Exeter, which collects information from all Acute Trusts across NHS England.
The majority of CWT databases have various integrated reports built in as standard which,
when run, allow data conflicts to be flagged and subsequently, manually resolved. There
should also be a monthly review of breaches and a sample of non-breaches to provide
further assurance for data quality as well as learning opportunities. A programme of spot
checks (e.g. one or two tumour sites per month) of what is contained in the hospital
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record versus what is entered into the CWT database and PAS is also a robust data
accuracy checking tool. These validation checks also act as a tool to identify where staff
training and supervision may be required.
Conflicts of interest
In addition to these basic data checks, organisations should also adhere to best practice
governance principles around avoiding conflicts of interest in the case of self-reporting
one’s own performance data, for example there should be a separation of duties and
responsibility around each of these elements: that there should be separate individuals
undertaking the tasks of:
1. data inputting;
2. validating the data that has been inputted;
3. performance management; and
4. breach reporting.
Board assurance
It is the responsibility of the Trust Board to ensure it has the right level of knowledge and
access to timely and accurate data to effectively challenge both good and non-compliant
CWT performance. The core cancer team should provide support, guidance and training
to the Board to enact this responsibility.
Board training
The Chairman, CEO, non-executive directors and the rest of the Board should receive
basic training on CWT rules and key factors influencing performance. There should be
some awareness training around the metrics and KPIs used by the organisation to trigger
alerts regarding potential performance issues. This knowledge and information will
encourage the Board to challenge performance, rather than just accepting compliant or
“green” performance as such; and moving beyond “are we going to breach the target” to
more relevant questions such as “exactly how long are patients waiting?”.
Reports to the Board
The Board should receive routine reports on CWT performance and also ask for exception
and remedial action plans (as appropriate). Trend analysis and prospective reports can be
far more useful that retrospective reports as these allow managers to identify and avoid
issues which may impact on performance.
Generally, good quality reports should include:
graphical trend analysis;
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benchmarking against the previous year’s performance and/or local or national
comparators;
separation of breaches into ‘unavoidable’ (patient choice and clinical reasons) and
‘avoidable’;
use of intelligent indicators such as median and percentile waiting times; and
breach trend analysis.
The information contained in any one or a combination of these reports may trigger the
Board to instigate internal and/or external audits as appropriate.
Training
Each Trust should give full consideration to what training and learning processes need to
be in place to ensure organisational practice is in line with national rules and guidance.
There should be basic CWT rules training for all staff involved in the delivery of cancer
performance (managerial, administrative, nursing, clinical, including staff from diagnostic
and other support services). Refresher training should form part of an annual training
cycle and where possible this should form part of the essential training for staff directly
involved in CWT delivery e.g. clinical leads, managers, admissions and outpatient booking
staff, etc.).
There should be more in depth role-related training for 2WW booking clerks and MDT
coordinators to include PAS, CWT database, diagnostic IT systems, tracking, access policy,
and practical implementation of standard operating procedures (as appropriate to the
roles). Achievement of this training should be monitored throughout the year and should
form part of the annual staff appraisal process.
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3. CORE FUNCTIONS
This section aims to explain the core cancer functions often, but not necessarily, delivered
by a cancer team, in the operational delivery of the cancer standards.
It is important for local health economies (LHEs) to take a pathway approach to managing
cancer services. The introduction of the cancer waits standards, particularly the
development of the Going Further on Cancer Waits standards, has been to help
organisations manage patients’ care on a pathway basis and to remove hidden waits.
GOING FURTHER ON CANCER WAITS STANDARDS
It is recommended organisations establish a detailed understanding of pathways at a sub-
tumour site level – within urology, for example, there may well be different pathways
covering renal, bladder, prostate and testicular cancers amongst others. Establish for each
pathway where and when key milestones occur. For colorectal cancers, for example,
there may well be a number of steps required in order to diagnose a patient’s cancer; for
many skin cancers, however, it is often the case that the diagnosis and treatment are one
and the same.
Taking a pathway approach to managing cancer services brings the following benefits for
cancer patients and to NHS organisations:
it helps manage the cancer standards (at tumour site level);
it identifies any hidden waits;
it allows organisations to track patients correctly;
it identifies any specialty specific issues; and
provides an opportunity to deliver more sustainable and timely services.
NHS organisations must also consider the information flows to support the management
of patients in a pathway approach as well as identifying what reporting tools will help
identify bottlenecks in cancer RTT (referral to treatment) pathways.
Patient tracking
Pathways
Due to the tight timescales involved it is not feasible for organisations to expect patient
pathways to deliver themselves with no intervention. It is good practice for organisations
to have in place staff, systems and processes to ‘pull’ cancer patients along their diagnosis
and treatment pathways. In order to ‘pull’ a patient through a cancer pathway it is
necessary to know what the pathway should look like (what the steps are) and how long
each step takes (how they fit together to deliver a 62 day pathway).
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This level of understanding is necessary at sub-tumour site level e.g. there is a separate
pathway for renal, prostate, bladder, testicular and penile cancer and not just one for
urology.
Staff roles
Responsibility for daily tracking varies considerably amongst NHS organisations and may
cover one post of MDT Coordinator or may be part of several related roles with titles such
as Cancer Pathway Navigator, Cancer Data Officer, Cancer Tracker and Patient Pathway
Coordinator. Similarly while smaller organisations might have a lead cancer manager with
line management responsibility for MDT Coordinators, cancer information and for the
management of cancer waits, larger trusts may have these responsibilities spread over
several roles.
BENEFITS TO CENTRALISATION OF THIS FUNCTION INTO ONE OR TWO JOB ROLES CAN
INCLUDE:
easier assurance of adherence to rules, protocols and standard operating procedures;
the ability of staff to share knowledge and experience;
clearer lines of responsibility;
consistency across tumour sites/specialties/divisions; and
clearer pathways for escalation.
BENEFITS TO DECENTRALISATION, INCLUDING EMBEDDING STAFF WITHIN SPECIALTY
TEAMS, MAY INCLUDE:
closer integration with MDTs;
easier and more ready communication with Clinical Nurse Specialists;
better working with, and understanding of, the specialty/business unit;
supports the corporate responsibility for the delivery of CWT within each business
unit, rather than in a centralised cancer team; and
staff get a better understanding of the delivery of cancer services as part of the wider
trust, rather than in isolation.
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Whatever the staff configuration there are several primary responsibilities with respect specifically to cancer tracking:
MDT Coordinator
DAILY/SEVERAL
DAYS PER WEEK
Review of a patient list for specific tumour site(s), with a focus on pathways requiring action such as
arranging/expediting appointments
Liaison with key administrative/booking staff in outpatients, the inpatient waiting list, endoscopy, imaging,
pathology, oncology etc.
WEEKLY
Review of all ‘at risk’ patients for specific tumour site(s) in advance of pre-PTL and PTL meetings
Review to ensure that post-PTL meeting actions have been carried out
Contact partner organisations such as tertiary/secondary trusts where patients have been referred to/from
Review of missing data/data quality reports (see Tracking systems)
AD-HOC
Detailed review of each patient breaching any of the CWT standards, preferably taking place as each
treatment is recorded (not at month end)
Two Week Wait Office
DAILY
Booking clerk reviews and chases all un-appointed patients and escalates unresolved issues.
SEVERAL DAYS
PER WEEK
Booking clerk ‘hands over’ attended patients to relevant MDT Coordinators.
Supervisor/Manager reviews Two Week Wait PTL and escalates appropriately.
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Specialty Manager/Support Service Manager (e.g. endoscopy, imaging)
SEVERAL DAYS
PER WEEK
Review of a patient list for specific tumour site(s) or support service(s), with a focus on pathways requiring
action such as arranging/expediting appointments;
Review and action escalations from Two Week Wait office;
Act on patients escalated as per the trust escalation protocol (see
Access policy).
WEEKLY
Review of all ‘at risk’ patients for specific tumour site(s) or support service(s) in advance of pre-PTL and PTL
meetings;
Review to ensure that post-PTL meeting actions have been carried out.
Cancer Manager
SEVERAL DAYS
PER WEEK/AD-
HOC
Ad-hoc discussion of ‘problem’ pathways with MDT Coordinators. Ad-hoc discussion of ‘problem’ pathways
with Two Week Wait office.
WEEKLY
Review of all ‘at risk’ patients in advance of PTL meeting;
Review to ensure that post-PTL meeting actions have been carried out;
Weekly discussion with cancer managers at other provider organisations regarding patients on shared PTLs
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4. REPORTING
Due to the smaller patient numbers and shorter timescales involved, cancer information
typically has a greater level of patient detail than might be found in relatively less-urgent
areas of elective care.
Tracking list
A detailed patient list is needed for patient tracking, showing all patients currently on a 31
or 62 day pathway and allowing easy filtering by tumour site or by hospital area
(pathology, radiology etc.). This list should enable tracking staff to see clearly where each
patient is in their cancer pathway, what next step(s) each patient is awaiting and the
deadline by which it needs to be done. It should be clear which patients are currently at
risk of missing a milestone on their pathway.
This report should be live using data from the cancer information system, or at be least
refreshed every day. Whilst this report may look very similar to the PTL and must contain
the same patients, the purpose and audience is different – the patient list is to help MDT
coordinators day-to-day and may require data items specific to this which represent and
unnecessary level of detail for the trust PTL.
It can be beneficial to review the information and order of fields provided in the PTL – and
ensure the fields are ordered in a way which is most useable for teams of staff booking,
and that patients are ordered from longest wait at the top to shortest wait at the bottom.
Whilst patient level detail is essential, the use of a pivot table on a worksheet within the
spreadsheet, can provide a useful overview of patients and their respective wait, for each
tumour site. Additionally, it can be beneficial to remove any unnecessary fields from the
PTL, to aid its usability and reduce the file size.
MDT meeting
The MDT meeting is not just a clinical discussion: it is important to discuss the patient
pathway and teams should make time for this formally as part of the agreed minimum
dataset for each patient discussed at the MDT meeting. It is also good practice for real-
time data entry of information to support both cancer waits and national audit
requirements. The Characteristics of an Effective MDT has further detailed information.
Part of the MDT Coordinator role is typically to prepare the MDT meeting agenda each
week. It is important discussions and decisions at MDT meetings give consideration to
patients’ position and waiting time along their cancer pathway, and therefore necessary
the MDT meeting agendas contain breach dates where applicable. Ideally this would be
generated automatically using the cancer information system; if this is not possible then
dates should be added manually by the MDT Coordinator.
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NATIONAL CANCER INTELLIGENCE NETWORK WEBSITE: MDT DEVELOPMENT
Cancer PTL
A report to support the PTL meeting (and, if in place, the pre-PTL meeting) is required.
This should again be at patient level but need not necessarily contain all patients on a
pathway: provided the trust has sufficient assurance of data quality, timeliness and
completeness on the cancer information system, this need only include patients whose
pathways are at risk of breaching key milestone targets (either approaching the deadline
without a date, or with a date beyond the deadline) for:
a Two Week Wait appointment (this may be less than 14 days depending on the local
pathway/ organisational stretch targets);
a diagnostic test;
diagnosis;
MDT discussion;
transfer to a tertiary provider;
date of decision to treat; and
treatment.
Where technically possible it is good practice to distinguish new issues from any
unresolved since the previous PTL meeting.
In addition to a patient list as described above it is also necessary to provide an overview
to give a more visual feel for where patients are on their pathways, split by either tumour
site or hospital business unit, specialty etc. as appropriate. Ideally this will show how
many patients are waiting at each key pathway milestone (DDT, diagnosis etc.).
An indicative layout for three PTL-style overview reports is shown in Error! Reference
source not found. but whatever format is used key principles are:
Forward-looking: what needs to happen next and not what has already happened.
Exception-based: making it easy to identify those pathways which are cause for
concern.
Summarised appropriately: split by (sub) tumour site, specialty, business unit as
required to fit the structure of the PTL meeting.
Tracking systems
NHS organisations typically have a stand-alone cancer information system in addition to
the core Patient Administration System (PAS). To manage a patient through their cancer
pathway it is necessary to understand the pathways that patients are expected to take
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and, in order to monitor patient waiting times and experience, information is needed for
each pathway event for each patient.
As a minimum the information system used for cancer patients must allow staff to collect
data on key milestones such as:
first outpatient appointment;
key diagnostic test or tests;
diagnosis;
decision to treat;
multi-disciplinary team (MDT) discussion;
transfer to another provider; and
treatment itself (or decision not to treat).
For milestones which relate to appointments the ability to record a request date, an
appointment/TCI date and a final attendance date is vital to enable prospective tracking.
The data required to track cancer patients will typically sit within a number of other
systems such as:
demographics (PAS);
referrals (PAS);
DNAs, cancellations and attendances (PAS);
Forthcoming outpatient appointments (PAS)
new diagnoses (pathology);
histological staging information (pathology)
report highlights/text (pathology);
new diagnoses and ‘red flags’ (radiology);
report highlights/text (radiology);
radiological staging information (radiology)
new diagnoses and ‘red flags’ (endoscopy);
report highlights/text (endoscopy);
new treatment courses and subsequent treatments (chemotherapy);
regime details (chemotherapy);
new treatment courses and subsequent treatments (radiotherapy);
details, fractions etc. (radiotherapy);
treatment TCIs (PAS admitted waiting list);
subsequent treatments (PAS admitted waiting list); and
new/ subsequent treatments (theatres).
Where technically possible it is ideal to implement automated information feeds from
these primary systems into the cancer information system. This has the threefold benefit
of reducing the time staff are required to spend manually-entering data into the
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database, keeping cancer tracking (and audit) data up-to-date and ensuring that
transcription/data quality errors are minimised. The majority of trusts have at least a
basic feed from PAS of demographic information but organisations should also explore
interfaces to other systems.
NHS organisations should utilise the range of data quality check reports available on the
National Cancer Waiting Times database and ensure that any data discrepancies are
resolved, in the case of shared pathways, jointly, with other organisations.
Breach analysis and reporting
The tolerances provided by the national cancer waiting time standards are to take into
account patients who choose to wait longer for their treatment, for whom waiting longer
is clinically appropriate, or where pathways include a complex diagnostic element.
Avoidable versus unavoidable breaches
Analysis of waiting time standard breaches helps organisations identify and distinguish
between unavoidable breaches (e.g. patient choice, a more complex diagnostic pathways, or
that the wait was a clinical exception and that waiting longer was in the best clinical
interest of the patient), and avoidable breaches due to administrative and capacity issues.
Where breaches were not for clinical reasons or patient choice (i.e. avoidable breaches),
analysis will identify where there are systemic problems which need to be understood
and addressed in order to eliminate unnecessary waits and introduce improvements in
patient experience.
Patient choice breaches
In declaring that the primary reason for a breach is legitimately the result of patient
choice or patient non-cooperation, Trusts should be able to demonstrate that the patient
generated the delay by asking to wait longer. It would not be appropriate to state that
patient choice was the reason for a breach if the organisation provided extremely short
notice appointments or little genuine choice for patients.
Review of breaches
A detailed review should be undertaken of each patient breaching any of the cancer
waiting time standards and, as a minimum, detailed reviews of 31 day and 62 day
breaches should be undertaken. Typically, this review would be in the form of a ‘root
cause analysis’ (RCA) for each breach, examining in detail the reasons why it occurred.
This is best done at the time that the patient first breaches and reviewed and updated as
necessary when the patient is treated. Analysis should identify the primary reason why a
patient waited longer than the waiting time standards i.e. the reason which accounted for
the largest proportion of the breach and should be recorded using the Department of
Health breach reasons.
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Detailed breach analysis requires an assessment of the entire pathway by staff who
understand the organisation’s processes, systems, and its local access policy. Analysis
should include a timeline of key points along the patient pathway with how long the
patient waited at each stage. Comparing the actual patient pathway against locally agreed
milestones by tumour site or sub-tumour site pathway will be helpful in identifying
delays. The number of days of avoidable and unavoidable delay should be identified and
recorded for each stage of the pathway and aggregated for the whole pathway. Wherever
possible, delays should be identified and recorded in real time as any delay could
contribute to more patients having an unnecessary wait in the future.
Whilst the patient pathway timeline is often, most conveniently drawn up by the MDT
coordinator other member of the cancer administration team, the breach reporting and
RCA process should be owned by the operational and clinical team. Patient level breach
analysis reports are best completed within one month of the breach occurring and where
the breach was avoidable actions should be put in immediately place to prevent further,
similar avoidable breaches. Breach analysis reports should be signed off by both the
treating and lead clinician and findings and remedial actions should be presented back at
an appropriate forum, such as the MDT meeting, detailing the reason why the breach
occurred and lessons learned.
Ownership of the breach review process
In order to ensure accuracy, consistency and transparency of the reasons for breaches the
individual RCA reports should be reviewed by an appropriate manager, often the cancer
manager, and aggregated to identify patterns and trends at tumour site, consultant and
organisational level. Action plans should be drawn up to address any issues identified and
should include clear timescales and responsibilities for action to prevent similar future
breaches.
In order to prevent future avoidable breaches and promote organisational learning,
breach reports should be shared with clinical, operational and management teams.
Typically this would include:
tumour site MDT - detailed individual patient level breach analysis and over all trends and
patterns;
trust cancer PTL meeting - trend analysis, review of previous weeks’ breaches, reasons
and actions taken to prevent future breaches;
specialty / business unit meeting - detailed breach reporting;
cancer Board - aggregated breach reporting, including themes and lessons learnt.
Monitoring delivery of actions within the breach action plan;
trust Board – number and percentage of breaches and reasons for breach, patterns and
the volume of breaches that occur by trend.
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Data quality checks
Where an interface is not available it is good practice to implement a reconciliation of the
data held on the cancer system with the original source systems. This is important both
to offer organisational assurance of the accuracy of cancer data and to assist with the
identification of new diagnoses, treatments etc.
Ideally a regular (at least weekly) alert of missing information should be available to MDT
coordinators showing items not already recorded on the cancer system including:
new histological diagnoses;
new radiology ‘red flags’;
patients added to the waiting list for chemotherapy or radiotherapy; and
patients added to the admitted waiting list for common cancer procedures and/or
under cancer surgeons.
In addition to these checks it is recommended that information is cross-checked on a
monthly basis against these systems as well as compared to clinical coding to ensure that
no patients are missed from the monthly upload.
5. PROCESSES AND MEETINGS
Organisations successfully delivering against the cancer standards typically have two or
three tiers of cancer PTL management, two of which sit within the core cancer service.
Trust PTL meeting
A Cancer PTL Meeting should be held weekly and be chaired by the senior manager
responsible for the delivery of the cancer operational standards. Whether an
organisation holds a joint cancer and RTT PTL ‘elective care’ meeting or a separate cancer
meeting is not significant. It can be beneficial to hold a separate meeting if the cancer
agenda is large or if there is a risk the RTT 18 week agenda dominating to the detriment
of cancer, with cancer issues not fully covered. Benefits of a combined meeting are that
cancer remains part of standard elective care/access management, and that often many
of the same staff will be involved making a joint meeting is potentially a more efficient
use of management time.
If a joint meeting is used sufficient time and attention must be paid to cancer issues; it
can be useful to place cancer before RTT on the agenda, in order to prevent the meeting
being dominated by RTT 18 week issues. The meetings need to be attended by the team
with the operational responsibility for delivering the standards.
The PTL meetings must be action-orientated and focused upon:
performance management and accountability;
breaches and prospective management of patients along cancer pathways;
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identification of pathway ‘exceptions’ – patients waiting too long at each step of the
pathway;
delivery of cancer pathways and any related bottlenecks; and
monitoring and managing the number of patients waiting at key pathway stages (first
seen, diagnostics and treatment).
Even if a live PTL is available online, a snapshot PTL report should be produced on a
weekly basis, preferably a day or two in advance to enable discussion of the detail of a
consistent PTL at the meeting without the distraction of staff having conflicting
information. Providers should hold the PTL meetings at the same time each week.
It is important that any agreed actions are followed through and reviewed the following
week to ensure they have been addressed. It is advisable to have an audit trail of the
actions and when they have been dealt with. In addition, organisations will want to be
able to see the impact of the actions in the following week’s PTL. Providers should have
clear escalation processes in place to support staff where issues are not resolved between
the weekly PTL meetings, often as part of a wider cancer escalation policy. The relevant
service or general manager must take the lead in dealing with patient-level issues raised
during the PTL meetings. Where service/business unit manager attendance is standard it
is good practice for a more senior general manager additionally to attend on a less
frequent basis.
Pre-PTL meeting/specialty meeting
Dependent upon the size of the organisation, it is often useful to hold tumour-site or local
business unit meetings a day or two prior to the organisation-wide PTL meeting; local
meetings also need to be held on the same day each week.
The purpose of the local meeting is to ensure:
the business unit managers are sufficiently prepared for the PTL meeting;
to have management plans at individual patient level;
to have addressed the majority of key issues;
to have an action plan for those issues to be resolved; and
to escalate any issues that cannot be resolved within the business unit.
It is advised a consistent agenda and reports are reviewed at the local business unit
meetings which mirror the requirements of the organisation-wide PTL weekly meeting to
ensure the same approach is taken at both levels. This will include a specialty-level review
with patient-level enquiry, actions and follow through.
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Access policy
Managers seeking to develop an effective Access Policy may find the guidelines in
Appendix 2 (p 50) helpful; they include the key areas to be considered when developing a
Cancer Access Policy (CAP). Some Trusts include cancer access policy details as part of a
Trust wide access policy, including both Cancer and Elective Access policy details, whilst
other Trusts have found it beneficial to develop separate elective and cancer policies.
Where organisations have implemented separate policies, they should make reference to
each other.
CAPs should be developed in partnership with all participants of the Local Health
Economy (LHE), including agreement in line with each agencies clinical governance
arrangements. Within the organisation, CAPs development should involve discussion with
clinical leads, diagnostic leads, and specialty managers.
CAPs should be made available to the public, via the provider website although the policy
should also be made available in formats for those who are not able to, or do not have
access to web-based information. Examples include printed copies in outpatients or in the
Patient Advisory Liaison service. Consideration should also be given to the languages
there are produced in. A summary of the completed policy may also be developed for
patients.
The CAP should be supported by a series of Standard Operating Procedures (SOPs) which
can be adapted and amended as relevant local or national policy changes occur. SOPs
should include the escalation process for dealing with issues that arise with clearly set out
timescales for response and resolution. The SOPs provide staff with a single reference
point which enables them to understand their role in ensuring the CAP is consistently
applied throughout the organisation. These should be referenced, as appropriate,
throughout the CAP. The SOPs may be provided as an appendix to the CAP.
It is important that LHEs have an agreed access policy in place. The agreed versions must
be shared with primary care colleagues and be made available to GPs electronically and
signed off by commissioners. This will enable GPs to make patients aware of their rights to
have treatment within the defined standards, and in accordance with the NHS
Constitution. It also helps GPs outline to patients prior to referral the patient’s
responsibilities to attend appointments and how cancelling or not attending
appointments can delay timely diagnosis and treatment. LHEs must ensure the
appropriate mechanisms are in place locally to support this work.
In implementing CAPs, a formal launch of the policy, including road shows or training
sessions for key groups of staff is essential, along with ensuring staff are aware of the
supporting SOPs (for example DNA or cancellation management).
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6. OPERATIONAL DELIVERY
Pathways capable of delivering shorter waits
This section aims to explain how to operationally deliver the cancer standards, and the
Importance of a pathway approach.
It is important for local health economies (LHEs) to take a pathway approach to managing
cancer services, which is particularly important for condensed pathways. Cancer
standards have helped organisations manage patients’ care on a pathway basis, along
with removing hidden waits, ensuring patients have timely access to cancer services.
It is recommended organisations establish a detailed and good understanding of
pathways at a tumour type level and not just at an aggregate tumour site level. This
includes establishing where and when key milestones occur. For example; for a tumour
site “X”, first outpatient attendances should occur at day 7 of a cancer pathway, and first
definitive treatment after GP referral on a current cancer pathway to occur before day 42.
Taking a pathway approach to managing cancer services is essential in to support NHS
organisations; it helps manage to the cancer standards (at tumour site level), it identifies
any hidden waits, allows organisations to track patients correctly, identifies any tumour
site and specialty specific issues and delivers more sustainable services.
NHS organisations must also consider the information flows to support the management
of patients in a pathway approach as well as identifying what reporting tools will help
identify bottlenecks in cancer pathways. Services will benefit from establishing and
monitoring agreed milestones and performance against targets.
Managing patients along their cancer pathway
Pre-referral
Some providers work with referrers to confirm referral criteria for tumour site pathways.
As part of confirming referral criteria, it is considered good practice to establish referral
proforma for each tumour site, which clearly includes the minimum data set, and enable
the ready identification of patients who may be suitable for direct access diagnostic or
one stop clinic pathways. To improve the quality of referrals, providers should ensure an
agreed referral proforma has been agreed, which will provide the referral criteria to
ensure referrers have considered the referral criteria, and undertaken necessary clinical
evaluation before referring.
Providers will benefit from agreeing arrangements for dealing with referrals where
referral criteria has not been met. Providers may benefit from confirming urgent access
pathways and milestones for non-cancer referrals, and ensuring sufficient capacity is in
place, which may reduce the number of inappropriate 2WW referrals.
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Right to obtain treatment within the maximum waiting time
Providers should take steps to ensure patients are aware of their rights and of steps they
need to take if their rights are not met. The DH Guidance, Implementation of the Right to
Access Services Within Maximum Waiting times, confirms that patients who are about to
breach/have breached their maximum waiting time, who qualify for the right, and who
wish to be seen more quickly can request to be offered an alternative provider or
appointment from the dedicated contact. Where possible, alternatives should include
both NHS providers and private providers.
Commissioners, providers and GPs should work together to develop patient information
leaflets to inform patients about the two week wait pathway, to raise patient awareness
of the process and support patients in being fully corporative in undertaking their
pathway in a timely manner.
Centralised administrative teams
A number of Trusts have established central booking teams for the scheduling of 2WW
appointments. This enables a single point of receipt, as well as visibility of potential
demand and capacity issues. The central team may also have responsibility for the
booking of diagnostic imaging and endoscopy appointments, to enable timely access for
direct access pathways where identified.
Staff with a responsibility for the referral management process, whether as part of a
devolved structure or working in a central team, should receive appropriate mandatory
training on a regular basis in the following areas which should also form part of the formal
annual appraisal process:
patient administration system (PAS) referral registration and appointment booking
functions (including processes relating to DNAs and cancellations), and discharging
processes;
choose and book;
provider elective access policy;
18 Weeks rules; and
cancer waiting times rules.
Referral receipt
On a pathway for cancer, the clock starts at the point of receipt of referral, and therefore
it is essential there is no delay between referral receipt and registration once it has been
received within the organisation. Choose and Book should be encouraged as the primary
method of referral, and all providers should have all suspected two week wait services
published on Choose and Book, along with urgent and routine services, or have action
plans with clearly defined timeframes in place to implement this.
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Some providers have a central fax for the receipt of cancer referrals, where 2WW referrals
are received, registered and then allocated to the relevant departments. Electronic faxes
can provide the added advantage of receiving the fax electronically, and enable timely
processing, and negate the need to scan the documentation. Providers should ensure
clear guidance regarding the management of referrals sent to other locations, to ensure
they are registered in a timely manner, and to ensure timely contact to arrange an
appointment.
Providers should clarify expectations with regard to referral registration. Good practice
would suggest a maximum same day referral registration. Referrals should be registered
on the Patient Administration System (PAS) no later than 24 hours after receipt, and
should also be registered on the provider’s cancer waiting time database, to enable
cancer pathway monitoring by the cancer team and MDT Coordinators/Patient Pathway
Coordinators.
In the instance where Trusts have available clinic slots within Choose and Book along with
a dedicated fax service, there should be processes to ensure Choose and Book referrals
are checked and actioned at regular and frequent intervals, along with processes to
ensure duplicate referrals are identified.
Scheduling appointments
Once the referrals have been registered, providers should contact patients to offer an
appointment date within 48 hours of date of receipt.
Bookings staff should ensure patients receive any guidelines or instructions relevant to
their appointment, particularly where there is a one stop clinic, or where there is a
diagnostic prior to their appointment, for example, fasting instructions.
Straight to Test (STT) pathways
With clear referral criteria, there are opportunities to create straight to test (STT)
pathways (where a diagnostic procedure is arranged as the first episode of care), enabling
patients to be appointed to a diagnostic appointment within 2WW in place of an
outpatient appointment.
The advantage of a STT pathway is it can reduce the time period from referral to
diagnosis, and also enable earlier treatment (for example STT endoscopy). Additionally, it
can improve patient experience by reducing the number of attendances required, as well
as providing earlier assurance of diagnosis.
A clear understanding of the clinical pathways for each tumour site pathway enables
development of referral criteria to identify patients suitable for STT pathways.
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As with 2WW capacity, it is important for Trusts to confirm clear escalation processes for
booking staff, in the event there are insufficient STT appointment slots within the
required time. The Trust should ensure there is sufficient STT capacity, and ideally avoid
booking patients into 2WW clinics in the absence of diagnostic capacity where possible.
One stop clinics
One stop clinics provide an opportunity for first new appointment, diagnostic and follow
up attendance to be consolidated into a single attendance for the patient. There are
many advantages including those outlined above in straight to test pathways, but can also
potentially enable the confirmation of diagnostic and discussions of treatment plan in the
one stop clinic.
One stop clinics may take some time to establish, as there is a need to clearly understand
the requirements for the one stop service, and to enable suitable
diagnostic/imaging/pathology support on the day of attendance, in addition to clinical
staff.
Trusts should ensure patients receive any guidelines or instructions relevant to their
diagnostic test prior to their appointment, for example, fasting instructions.
Booking appointments
Due to the short timeframes in ensuring suitable and timely access for 2WW patients, it is
essential that all patients are contacted by telephone to agree an appointment(s). Trusts
should clearly define expectations with regard to contacting patients, including the
number of times the Trust attempts to contact patients by phone, and specify the need to
enable contact on different days and times. The Trust should ensure the contact centre is
staffed to make calls outside business hours, and ideally also at weekends.
In the event the patient cannot be contacted, the Trust should ensure there is a process in
place that requires the confirmation of patient demographics and to send a letter to the
patient requesting them to make contact. It is good practice for patient correspondence
and telephone conversations to highlight to the patient the urgent need for review, along
with a need to exclude cancer, to assist the patient to understand the importance of
making contact.
Whilst there is a requirement to schedule 2WW patients within 14 days, an aspirational
timeframe can provide an opportunity to reschedule patients within the 14 day
timeframe should they cancel their appointment or for any other reason the appointment
does not go ahead. For example their could be an aspiration that patients could be
offered appointments, within 7 days of receipt, with no patients dated over 10 days from
receipt.
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Patient correspondence should always be sent by First Class post, and some Trusts also
provide email and / or text confirmation of appointment times.
Clinic templates
Trusts vary in their approach to managing capacity requirements for 2WW patients. In
some Trusts, capacity is incorporated as part of existing templates, either as urgent
appointment slots, or designated 2WW cancer slots within general clinics. Some Trusts
have designated 2WW clinics, which enables the planning of other services to coincide
with the clinic, and also enables members of the team to be present in clinic ie Clinical
Nurse Specialist. Designated 2WW clinics may also support one stop clinics, where
patients can attend for a diagnostic (for example), and then be reviewed with diagnostic
results in clinic.
Overbooking
Invariably 2WW capacity can fluctuate week on week, and it is important services have a
good understanding of demand and capacity requirements for each tumour site, and
ensure a minimum capacity is allocated for 2WW access each week. Where designated
2WW slots/clinics are allocated, it is important for Trusts to confirm a timeframe by which
clinic appointments can be released for other urgent non 2WW appointments if they are
not required for 2WW appointment capacity, for example 48 hours before the day of
clinic.
Did Not Attends (DNAs)
DNAs are a very costly waste of resource within the NHS and so it is important for
providers to have a focused plan of action to proactively manage them. As a very
minimum, organisations should be monitoring data around DNAs such as DNA rates by
specialty per month and making a local decision on what is an acceptable DNA rate for
the organisation or specialty to meet.
Providers may like to consider including a leaflet confirming their DNA policy with the
booking letter. As cancer appointments should be offered with choice, and fully booked,
there is an opportunity to ask the patient to write down the appointment details which
helps them to commit to memory. Vulnerable patient groups, such as suspected cancer
patients may be exempt from DNA policy for routine patients, according to the local
agreement.
It will be essential for staff to directly book the new appointment with the patient at the
time of contact. It is also good practice to advise the referrer of a DNA for patients with
suspected cancer. Providers must ensure there are local policies in place to deal with
DNAs and patient cancellations, which reflect the spirit of cancer access guidance, but are
also in line with the organisation’s access policy.
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There are useful tools for managing DNA’s.
NHS IMPROVING QUALITY– REDUCING DNA’S
Organisations may also like to benchmark DNA performance against other organisations:
NHS COMPARATORS
Pathway adjustment for DNAs to first attendance
If a patient DNAs their outpatient appointment or diagnostic clinic attendance that would
have been recorded as DATE FIRST SEEN then the clock can be stopped from the date of
the receipt of the referral to the date the patient rebooks their appointment as shown
below:
Pathway adjustment for admitted pathway
If a patient has to be offered a to come in date (TCI) date for admitted care (ordinary
admission or day case) within the 31 or 62 day period, and the 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 as shown below:
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Management of initial appointment DNAs
If a patient DNAs their initial outpatient appointment, the patient will automatically be
offered a further appointment. Should a patient DNA for a second time, it is good
practice for the clinician (who will review all patient hospital notes at the end of a clinic),
to authorise for a further appointment to be offered.
When a patient DNAs twice the GP will be asked to ensure the patient still requires an
appointment and re-refers if appropriate.
The outpatient clinic receptionist is responsible for entering the DNA outcome on the PAS
but the 2WW office is generally responsible for rebooking any patients (on a 14 day
pathway) who DNA their appointment.
Where a patient on a suspected cancer pathway DNAs their initial appointment for the
second time, then they should be discharged and referred back to the GP/General Dental
Practitioner (GDP). This is to ensure that the patient is not left “unmonitored” in the
system. The hospital clinician must be informed before a patient is discharged back to the
referring practitioner after two or more DNAs. This must be noted in the patient’s PAS
entry or outpatient notes.
Cancellations (by patient)
Patients have the right to cancel their appointment ahead of the appointment time, if
they are unable to attend. In the event of a patient cancellation, it is considered good
practice to agree a date for another appointment at the time of the cancellation where
possible. Where a patient requests to rearrange their appointment, the appointments
offered should be provided before their timed pathway milestone where possible to
reduce likelihood of potential breach. In the event a replacement appointment cannot be
offered before the breach date, this should be escalated to the responsible manager. It is
important to confirm the patient’s availability for a future appointment, along with a time
they may be available to agree an appointment time. This will enable appointments to be
negotiated with patients when they are available to both discuss and attend.
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Subsequent cancellations (by patient)
Where a patient cancels a subsequent appointment, it will be necessary for the notes to
be reviewed by the consultant to decide the most appropriate action to be taken. If the
patient fails to attend a second appointment, the consultant or member of the clinical
team should consider contacting the patient to discuss their non-attendance at the
appointment. Where there is subsequent or continued non-attendance, the consultant
should consider whether is appropriate to discharge back to the referrer. This process
will need to be set in the Trust Access / Cancer Access Policy.
Cancellations (by hospital)
The cancellation of patients’ appointments by the hospital is very poor practice which
causes inconvenience to the patient and reduces the efficiency of the service. Given the
timeframes associated with 2WW access, incidents of hospital cancellations should be
significantly reduced by good adherence to Trust leave notification policies.
Cancellations of patients’ appointments by the provider, particularly for 2WW pathways,
should be a rare occurrence that should only be authorised where no other options to
cover the clinic are available or appropriate.
Providers should adhere to the following principles when developing local
clinic/appointment cancellation policies:
implementing policies encouraging clinicians to book annual leave requests for the
year ahead;
a minimum cancellation timescale in place for requests to cancel clinics e.g., minimum
six weeks;
limiting “acceptable” clinic cancellation reasons to sickness, immediate family
emergency, etc.; and
implementing “fire-break” clinics at six to eight week intervals to manage unforeseen
circumstances.
Transfer of patients between provider organisations
Referral pathways across providers
Where a patient is referred by one NHS provider to another NHS provider for cancer
treatment, this is known as an inter-trust referral (ITR) or an inter-provider transfer (IPT).
The patient will be covered by the 62 day standard if they were initially referred as a
2WW referral with suspected cancer or 2WW breast symptomatic, referred via the
screening programmes, or upgraded to the cancer pathway as a consultant upgrade.
Where a patient’s care is commenced at the originating organisation (Trust A) and
treatment is undertaken at another provider (Trust B) and the patient is on a 62 day
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cancer pathway, both providers share responsibility for ensuring that the patient’s
treatment is delivered within 62 days (in total) and ensuring that their respective parts of
the dataset are uploaded.
Whilst from a patient perspective, timeliness of investigation and treatment should not
depend on the hospital to which they are initially referred, however, in practice, intervals
between referral and treatment are generally longer for patients who require an IPT than
for those treated at the hospital to which they were initially referred by their GP.
Although there is no nationally agreed transfer date by which referrals to a treating
provider should be received and after which time the treating provider does not need to
share a breach, in a number of health communities, day 38 or day 42 appear to be the
commonly recognised agreed maximum transfer periods. For some pathways, the
diagnostic pathway can be comfortably arranged so that patients are in fact ready for
transfer in advance of these agreed transfer timescales. However, it is recognised that in
a some cases it is considered a challenging timescale to work-up patients for transfer to
the treating provider, an this can be further complicated in pathways where a patient
accesses services at three or four providers.
For the treating provider, receiving the patient at day 38 or day 42 may be a challenging
timescale to treat patients both in cases where preparation for treatment may take time
and/ or where scheduling of treatment to start on a particular day of the week is
significant factor e.g. scheduling radiotherapy to start on a Monday.
To support smooth delivery of IPT pathways, it is vital that patients are appropriately
“worked up” at the originating organisation. Prior to transfer, diagnostic investigations
should be undertaken and reviewed as appropriate. The patient should be transferred in
a timely manner in line with an agreed minimum dataset and clinically agreed criteria.
For these pathways to be effective from a patient experience perspective, both the
referring and receiving organisations have important roles to play.
COLLABORATIVE WORKING BETWEEN REFERRING AND RECEIVING ORGANISATIONS
identify correct, named individual at receiving Trust to send the referral;
develop an agreement of standardised good practice clinical pathways across providers taking
into account the good practice that is already being followed in several of the teams. This
work should be supported as part of a “network” approach across a number of providers.
Where appropriate, agreements across the whole health community should be discussed and
communicated, e.g. TRUS biopsy to be undertaken by day 20 of the pathway for prostate
patients, CT to be undertaken prior to first appointment for lung patients;
agree administrative processes for referring and receiving referrals across providers, including
clarifying what constitutes a referral or a ”worked-up” patient, what clinical
information/results should accompany the referral within an agreed timescale, how a transfer
date will be defined, agreeing acknowledgement and communication expectations, agreeing
processes and timings for escalation of issues and non-adherence;
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develop and implement clear and comprehensive cancer access policies to ensure consistency
of application of cancer waiting times rules and equity regarding the management of patients
on a cancer pathway and access to services, and expectations of the organisation, GP and
patient;
ensure clear communication of roles, responsibilities and contact details of key roles within
each organisation;
ensure clear communication of escalation processes and timelines in relation to management
of information between organisations.
REFERRING TRUST
identify correct, named individual at receiving Trust to send the referral;
collate all relevant information, including, minimum data set, relevant health records,
all diagnostic reports and images;
send written confirmation of decision to refer to the patient and their GP within
24hours of decision to refer;
courier/send electronically all hard copies of the patients records within 24hours of
decision to referrer; and
confirm the referral and records have been safely received
RECEIVING TRUST
provide a named contact for referrals for each tumour site. Provide these contact
points to referring providers;
confirm receipt of referrals and patients records, images etc. with the referring
organisation;
contact all referred patients within 24 hours of receipt of referral to arrange an
appointment.
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7. DIAGNOSTICS
Efficient booking of patients referred for diagnostics underpins delivery of 2WW cancer
pathways. Below is a suggested list of tasks relating to the management of diagnostic
processes, and staff should be aware of and understand their role in ensuring patients
receive timely access to diagnostics.
Useful resources:
Transforming your Radiology Service, Focus on: Improving Booking Processes (No longer
available electronically).
NHSIMPROVING QUALITY– RAPID REVIEW OF ENDOSCOPY SERVICES
NHS IMPROVING QUALITY – CHALLENGES AND IMPROVEMENTS IN
DIAGNOSTIC SERVICES ACROSS SEVEN DAYS
THE NHS ATLAS OF VARIATION IN DIAGNOSTIC SERVICES
Paper referrals
Also refer to Section 6 Operational Delivery – Referral Receipt.
Diagnostic departments should actively encourage the use of standard request forms to
provide clarity of required information and to identify incomplete referrals. Referrer self-
vetting criteria should be confirmed to minimise inappropriate referrals. Referral forms
should also include clear requirements to flag urgent 2WW referrals.
Sufficient guidelines should be provided to enable administrative staff to book diagnostics
reducing the need for clinical input in this process. This should be supported by a clear
escalation process which clarifies the steps for staff needing to raise queries regarding
specific diagnostic requirements, or who need to escalate capacity issues.
In addition to the training described in the Outpatients section above, administration
teams will also require confirmation of milestones for access to diagnostics, which should
normally be completed no greater than two weeks after referral.
Advantages of electronic referrals
Organisations should aim to transfer to electronic referrals as they enable single point
electronic capture of information and transfer to the diagnostic information system,
providing:
reduced clinical risk due to accurate demographics and legible clinical details;
the minimum data is provided on the referral before submission;
instant availability of request in the diagnostic department;
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reduced administrative time, eliminating referral registration;
reduced delays contributing to shortened inpatient stay and achieving access
timeframes; and
reduced paper and storage costs.
Registration of referrals
Also refer to Section 6 Operational Delivery.
All referrals should be registered on the organisation’s diagnostic information system, and
providers should set clear turnaround timescales for receipt of referral to registration.
Referral registration upon receipt is essential to ensure timely vetting of referrals on the
same day, or in the morning of the following day where received late in the day. This also
ensures diagnostic departments have visibility of true waiting list size, and can make
arrangements to accommodate 2WW cancer referral requests. Hard copy referrals should
be registered prior to forwarding to clinical staff for vetting and a scanned copy of the
referral should be retained. The use of electronic referral processes facilitates the
automatic registration of referrals and the ability to go direct to vetting, with limited
administrative input.
Pre-registration checks - the minimum dataset
Organisations should clarify the expected minimum data that is required for a referral to
be valid, and consider implementing a standard referral proforma for referrals. Regardless
of the format of the referral (whether proforma or traditional letter), it is considered best
practice that all referrals should contain a minimum dataset (see Appendix one) and
should be accurate and legible.
Organisations should have a clear process in place to manage incomplete referrals so as to
not unfairly disadvantage the patient. Providers should have a robust system in place for
monitoring referral demand on an on-going basis, by modality, to ensure capacity is
sufficient to meet demand.
Vetting of referrals
Timely, clinically-led vetting of referrals will ensure referrals are appropriate, assist in
identifying whether an alternative diagnostic modality is more suitable for confirming
diagnosis, and ensures Ionising Radiation (Medical Exposure) Regulations (IRMER)
requirements (where applicable) are adhered to. Vetting of urgent 2WW cancer referrals
should ideally be completed on the day or the morning of the following day. There should
be mechanism to ensure 2WW and suspected cancer referrals are prioritised for vetting.
The vetting can be carried out by an appropriately trained pool of staff1 which increases
the vetting capacity and minimises the delay in vetting referrals. The staff should follow
clear protocols and be subject to on-going monitoring and audit.
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Where the radiologist feels the referral urgency may be revised, this should be discussed
with the referring clinician before downgrading.
Please refer to Appendix Three for good practice principles.
Electronic vetting of referrals
Referrals should be vetted in order of urgency and date of receipt to ensure there are no
undue delays. Electronic vetting enables the referral to be available for booking
immediately once it has been vetted, rather than waiting for the paper copy to be
returned to the bookings team for review. Diagnostic information systems can provide
functionality to enable electronic vetting of referrals reducing the need to print referrals
for review by the clinical team and can enable electronic work lists to be produced which
support workload prioritisation and reduce the variation in referral vetting times between
patients.
Scanning protocols
Providers should ensure diagnostic areas (modalities) have standardised scanning
protocols agreed by the diagnostic department.
The booking team should be provided with clear principle-based guidelines for the
booking of diagnostic examinations including for each examination:
diagnostic procedures;
specific equipment requirements (i.e. differentiated by physical equipment
limitations);
the length of time slot required;
requirement for delayed imaging (i.e. Nuclear Medicine);
who can perform the examination and when;
what preparation is required;
special patient instructions; and
if there is a requirement for direct consultant participation, based on their clinical
specialisation.
In addition, timeslots for procedures should be minimised with procedures falling into
one of three or less time slots to facilitate capacity and demand planning. For example,
10, 20 and 30 minutes.
Booking of appointment
Diagnostic appointments should be booked correctly, quickly and efficiently every time.
Due to the nature of the referrals, it is essential Trusts ensure a patient-focused process
geared towards offering the patient a choice of appointments in a set period, with urgent
2WW cancer referrals being dated in priority over routine appointments. Administrative
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staff should book patients under standard written guidance from the relevant clinician,
such as senior radiographers, radiologists and technologists. It is essential to have
administrative cross-cover to ensure all modalities are booked to minimise the impact of
absenteeism and leave.
Confirming appointments
In line with good practice, and for suspected cancer patients in particular, it is important
for providers to facilitate direct booking of diagnostics via an electronic booking system
(i.e. choose and book) or by proactively contacting the patient, or enabling patients to
contact the department for an appointment following their outpatient attendance.
A diagnostic Patient Tracking List (PTL) will ensure patients are prioritised appropriately.
Patient preparation
Bookings staff should ensure patients receive any guidelines or instructions relevant to
their diagnostic procedure prior to their appointment, for example, fasting instructions.
They should also ensure patients have contact details for the department should they
wish to seek further clarification or information about their procedure. A member of the
clinical team should confirm if the patient requires more extensive preparation. Pre-
assessment may be required for certain procedures for example, interventional radiology
and endoscopy. Appropriate preparation of the patient prior to their appointment will
minimise the likelihood of the cancellations on the day and the appointment having to be
rescheduled.
Providers should ensure removal of paper diaries where an electronic schedule is
available.
Scanner utilisation and scheduling
Providers should ensure that they have in place appropriate capacity to meet the demand
and that the capacity is used effectively so, for example, DNAs are minimised and
appointment slots are not wasted. Where possible, diagnostic departments should work
with tumour sites to try to align capacity to outpatient clinics, providing opportunities for
one stop attendances where this is possible.
Providers should therefore:
work with specialties to identify opportunities to align diagnostic capacity with
outpatient attendance;
ensure booking requirements are based on key criteria (refer to booking section
above);
confirm release timeframes where the equipment will be released for booking other
procedures if the equipment time is not fully utilised;
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have in place a system of on-going monitoring of equipment to ensure effective
utilisation; and
have a forward plan of scheduled service and quality assurance activities to minimise
the effect these activities have on the capacity required to meet service demand.
Also see Section 6 Operational Delivery for general good practice guidance in establishing
booking principles.
The capacity within the schedule should be sufficiently flexible to meet variations in
demand such as emergencies, inpatients, urgent and planned patients. Extended day and
weekend working will increase capacity to meet this variation as well as address any
temporary backlogs in individual modalities.
Reporting
The National Imaging Board guidance states that investigations will be seen and
accurately reported within a short a time as possible. It also stresses the importance of
providing high quality and effective patient-centred imaging services to support the whole
patient pathway through the reporting of images in a timely manner. The guidelines set
an expectation that urgent cases will be reported immediately (within 30 minutes).
The guidance recognises that exceptions will occur where multi-disciplinary team
discussions or specialist opinion is required and therefore stated that a tolerance of 90
per cent achievement is reasonable.
THE ROYAL COLLEGE OF RADIOLOGISTS – STANDARDS AND
RECOMMENDATIONS FOR THE REPORTING AND INTERPRETING OF
IMAGING INVESTIGATIONS BY NON-RADIOLOGIST MEDICALLY QUALIFIED
PRACTITIONERS AND TELERADIOLOGISTS.
Reporting performance monitoring
The provider should ensure:
there is on-going improvement of reporting turnaround times until standards are
achieved to support effective management of the service and appropriate support to
clinical specialties and referrers;
on-going monitoring of report turnaround time, including:
report completion turnaround times;
report verification turnaround times (including minimum, average and maximum
report times by modality to inform initiatives to reduce variation); and
unreported monitoring for those not reported within the agreed reporting timeframe,
and ensure follow up and work prioritisation.
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consultant rotas are designed to allocate sessions to be covered by a pool of reporters
so they are not adversely affected by annual leave. Radiologists / Consultant schedules
could be revised to allow shorter sessions that enable more focused reporting and
reduce the impact of annual leave and multidisciplinary meeting attendance on the
modality;
radiographer/technologist/technician/advanced practitioner-led reporting to clinical
protocols is in place to provide improved reporting times; this requires the agreement
of the team and appropriate training for the staff; and
a process for clinical audit is in place to ensure reporting quality is achieved
particularly where reporting is completed by non-consultant staff.
Management of DNAs
Also refer to Section ii Outpatients on management of DNAs.
Booking staff should explain the DNA policy to the patient at the time of booking, remind
patients of their responsibility to inform the organisation if they are unable to attend in
advance. There should be clear expectations regarding patient management in the event
of consecutive DNAs.
Unexpected findings
Diagnostic departments should ensure clearly defined processes to manage unexpected
findings, to ensure there is a process to alert referring clinicians, and other appropriate
people (GP, MDT Coordinator), to results that may require urgent review. The procedures
should ensure organisations meet the National Patient Safety Guidance, NPSA 16:
NATIONAL PATIENT SAFETY GUIDANCE, NPSA 16
Amendments to the unexpected findings procedure should be managed and agreed by
the Trust management team.
Where a referral is received internally (a patient under the care of clinicians at the Trust),
it is important to notify both the referring clinician and the clinician referring for
diagnostics, along with the MDT coordinator. Where a referral has been received by a
clinician outside the Trust, the procedure should ensure the referrer is advised, along with
notifying the cancer management team within the Trust.
It is essential that processes ensure receipt of patient alerts are acknowledged, and
followed up where acknowledgment is not confirmed. Trusts should include details of
the relevant nominated tumour site contact for each tumour site, or a central point of
receipt if appropriate.
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8. SCHEDULING, PAUSING, BOOKING, THEATRES
The efficient and timely booking of 2WW admissions requires a good understanding of demand and capacity requirements, and
ensuring there is sufficient capacity for urgent 2WW cancer admissions, reducing the likelihood of cancellations of routine patients.
GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
1.
Operational managers must ensure that To
Come In (TCI) cards are completed for all
decisions to admit (DTA), and agree a
timeframe for entering on PAS (for
example on the day of clinic). It is essential
there is a clear process that enables 2WW
TCI cards to be readily identifiable.
As part of completing the clinic after each
session it will be important that DTA cards
are received where appropriate, and to
flag anywhere they have not been
received.
This will ensure that all 2WW TCI cards can be
readily identifiable and prioritised for
admission scheduling. The timely completion
and registration of the TCI card will ensure
that all the correct details including the type
of operation, patient’s details, any surgical kit
requests and comorbidities are recorded. It
will also ensure the admitted PTL is kept up to
date.
No patient waiting more than 1 hour to
be placed on a waiting list for surgery.
Organisations using electronic booking
systems to reduce duplication of efforts
and errors.
Organisations using manual TCI’s should
ensure clear requirements with regard
to flagging 2WW admission requests.
2.
General Managers must check that 2WW
patients are booked as clinical priority.
Where insufficient capacity is provided,
there should be clear escalation processes
to provide additional capacity. The service
should investigate additional capacity in
the first instance, to negate rescheduling of
It is important 2WW capacity for admissions
is provided within the specialty theatre
session planning. This will enable timely
admission, and minimise the need for
additional ad hoc capacity, and rescheduling
of routine patients.
There should be clear timeframes for
assessing and managing 2WW
admission capacity for urgent and
routine admissions where appropriate.
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GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
routine patients where possible.
3.
Timely, clinically led review of prospective
lists.
This should be done looking at theatre lists
i.e. three to four weeks in advance to ensure
lists are full and will not over run and should
be led by a lead clinician who has the
experience and authority to increase a list
where possible.
A reduction over time of theatre lists
that overrun and improved theatre list
productivity.
An opportunity to highlight shortfalls in
2WW capacity, so additional capacity
can be arranged.
4.
General Managers should confirm with
each tumour site, internal milestone
targets for decision to admit, and in
particular, where patients are referred to
other centers for treatment.
It is important to complete this at tumour site
level, and for each pathway, as there may be
elements of care provided by different
centers, or within the Trust. The milestones
should be developed in consideration of
ensuring suitable time for treatment within
target.
Each specialty has clear milestones
which are compliant with cancer wait
time goals.
Early warning and escalation systems in
place to detect deviations from the
specialty specific milestones.
5.
With 2WW pathways, it is essential that
organisations telephone patients to
arrange their admission, providing a choice
of admission date.
The patient should be offered the soonest
Given the urgency of the admission
timeframe, patients may not receive three
weeks’ notice of admission.
Trusts should ensure patients are advised of
the need for admission prior to being
Patients are contacted by admissions
staff over the phone to be offered a
choice of dates for surgery.
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GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
available admission date.
contacted by the admissions team.
6.
Admissions staff must escalate if they do
not have sufficient capacity to book the
patient within target.
Provider organisations should have an
agreed escalation process
This helps manage capacity issues
prospectively, and helps prevent patients
waiting beyond targeted admission time.
Efficient and responsive systems in place
to alert booking staff to vacant lists in
order to resolve capacity issues.
Clear escalation policies in place, along
with clear roles and responsibilities, and
named contact points when capacity
issues are identified.
7.
Operational managers should meet with
consultants to share their admitted PTL
(those patients dated and undated)
This will help communicate progress against
the national operational standards and make
the individual consultants aware of their
waiting list sizes.
Consultants have an accurate
understanding of the size of their
admitted PTLs and case mix on a weekly
basis.
8.
Operational managers should implement
processes for double-checking TCI lists.
This helps pick up errors or issues such as
patients who are listed as coming in the next
day but who failed to attend pre-operative
assessment.
This list should be checked on paper and on
the PAS.
2WW patients should be readily identifiable
Electronic booking systems in place
which automatically flag patients with
an imminent TCI who failed pre-
operative assessments or who have not
confirmed their TCI.
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GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
to ensure they are not cancelled on the day.
9.
A suggested 24hour cut off to creating final
theatre lists should be agreed, with a clear
escalation process and details of who is
permitted to make any changes
This avoids last minute re-organisation that
lead to lists over running or running late
Booking systems which automatically
freeze theatre lists 24 hours before the
day with good control systems in place
to manage any changes.
10.
All conversations with patients should be
recorded clearly with dates and names in
the waiting list entry on PAS
This includes conversations around social
pauses and dates offered (earliest reasonable
offer dates). If a patient has previously
agreed to a reasonable offer which they
subsequently cancel, the patient cancellation
does not stop or pause the clock. However as
part of the rebooking process, the patient
should be offered alternative dates for
admission. If at the rebooking stage the
patient declines another reasonable offer (ie.
within the start and end point of the 31 or 62
day period) then the clock can be paused. The
clock is paused from the date of the earliest
reasonable offer given as part of the
rebooking process. The end of the pause will
be the new date from which the patient
states they are available.
Waiting list systems with detailed
accurate audit trails of contact with
patients.
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GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
11.
Staggered admission times should be used,
with sufficient staff to admit patients. It is
seen as good practice to have a central
admissions team to manage all
inpatient/day case waiting lists.
This helps prevent delays on the day of
surgery and provides a better patient
experience
Low waiting times for patients between
admission time and operation start time
(less than 2.5 hours average).
12.
Where possible and clinically appropriate
look to pool surgical lists.
This helps to offer patients more choice,
equalise waiting lists for surgery and prevents
patients waiting longer than necessary for
their treatment. Patients should be aware
their surgery may not be performed by the
clinician they have previously seen through
their pathway.
Patients have surgery performed by
clinically appropriate staff with lower
waiting times; the pooling of lists allows
for optimal use of theatre capacity as
well as clinical skills and expertise.
13.
Where appropriate, pre-operative
assessment can be provided on the day.
Where this is not appropriate, the patient
should be provided with details of the pre-
operative assessment requirements, and
the Trust should ensure the patient is
advised of the timeframe for contact with
the patient to confirm date for pre-
This will ensure the patient can be assessed
for admission, and enable the admission date
to be planned.
It is important, where pre-operative
assessment cannot be undertaken on the day,
to have agreed timeframes to contact the
patient to arrange it.
Pre-assessment as part of outpatient
attendance can expedite arrangements
for treatment, but may not always be
appropriate. Robust systems are
necessary for ensuring contact with
patients to arrange within defined
timeframes. Some Trusts will agree the
admission date first, and plan pre-
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GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
operative assessment.
assessment around the admission date.
14.
Monthly reports should be run by the
information team and checked by the
admissions team as part of normal data
quality duties to pick up those patients
who were admitted incorrectly to the
hospital for another condition or as an
emergency but where the TCI waiting list
entry was used on PAS incorrectly.
This helps pick up pathways that clerks need
to amend and also picks up patients not
coming in for their surgery. Some patients
disappear from booking lists and PTLs this
way.
A reduction in patients admitted
incorrectly using the waiting list entry
each month.
15.
Each business unit or admissions offices
must confirm process for dealing with
cancellations by the hospital
There are clear national standards for
rebooking patients whose operations have
been cancelled on the day of their operation
within 28 days.
It is important the admissions office can
demonstrate their processes meet the
requirements for this standard.
All patients who are cancelled on the
day to be re-dated within 28 days and to
leave the hospital with a new date for
their surgery – or for the treatment to
be funded at the time and hospital of
the patient’s choice
16.
Agree KPIs for theatre productivity. For
example downtime between surgical cases
These can be identified and agreed from the
Productive Operating Theatre documentation.
Regular review of KPIs with corrective
actions devised.
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GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
17.
Organisations should aim to outline local
timescales for periodic checks of theatre
lists.
This approach is seen as good practice to
ensure theatre lists are fully booked and it
helps to reduce cancellations on the day.
Providers may want to change the timescales.
Six weeks check patients are booked,
four weeks finalised lists, two weeks
ensure equipment ordered, a final one
week review to enable urgent cases to
be scheduled. Trusts need to balance
good theatre utilisation while ensuring
suitable capacity for cancer patients,
releasing cancer capacity at a particular
timeframe for routine admissions.
18.
General managers must ensure there are
local policies in place to deal with DNAs
and patient cancellations of operations,
which reflect the spirit of 18 weeks and
2WW but are also in line with the provider
organisation’s access policy.
This should clearly outline how patients who
are vulnerable and the clinical needs of
patients will be considered before discharging
patients following a DNA or cancellation.
In admission offices, visible and well
documented policies for booking staff to
use. Policies reflect up-to-date 2WW
national guidance and are assessed
regularly.
19.
General managers are advised to have in
place audit arrangements to ensure good
practice admissions processes are being
followed.
This helps to pick up any training issues as
well as keeping the admissions processes up-
to-date. For example outline timescales for
dating patients and implementing escalation
processes when there is no capacity to date
patients.
Yearly audit arrangements in place and
carried out.
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GOOD PRACTICE
COMMENTS
WHAT DOES GOOD LOOK LIKE?
20.
General managers should ensure there are
clear and detailed standard operating
procedures in place and readily available to
staff.
This will help with cover arrangements for
admissions staff, ensure staff are working to
agreed practices and in line with the national
2WW rules. It will also make it easier to train
new admissions staff.
Clear and detailed standard operating
policies with clear timelines and contact
numbers.
21.
General managers should ensure there are
regular and detailed training programmes
in place for admissions staff to support the
use of any standard operating procedures,
which clearly clarify differences between
RTT 18 week patient management and
2WW patient management.
Relying on initial training offered at induction
or training on the job by peers is not sufficient
to provide assurance of ongoing competency.
Six month training programmes in place,
underpinned by a process to evaluate
and assess competency.
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9. ACKNOWLEDGEMENTS
The IST would like to acknowledge and thank the following individuals for their
contribution to the creation of this guide:
Colleague
Organisation
Mel Warwick
Aintree University Hospitals NHS Foundation Trust
Badriya Maghrabi
Epsom St Helier NHS Trust
Vicky Shosanya
Epsom St Helier NHS Trust
Cathy Wybrow
Imperial College Healthcare NHS Trust
Gareth Gwynn
Imperial College Healthcare NHS Trust
Danya Taylor
King's College Hospital NHS Foundation Trust
Graham Browning
Kingston Hospital NHS Foundation Trust
Alan Thorne
Kingston Hospital NHS Trust
Nicola Chandler
NHS Elect
David Cheesman
North West London Hospitals NHS Trust
Helen Baker
Oxford University Hospitals NHS Trust
Anna Foulkes
Poole Hospital NHS Foundation Trust
Wade Norcott
Princess Alexandra Hospital NHS Trust
Nicky Browne
Royal Marsden Hospital NHS Foundation Trust
Anita Vincent
Surrey and Sussex Healthcare NHS Trust
Kevin Nicholson
University College London Hospitals NHS Foundation Trust
Sian Sutton
West Middlesex University Hospital NHS Trust
And members of NHS IMAS and the Intensive Support Team.
Page 60 of 68
10. REVISIONS PROCESS
Each month the IST will collect feedback from stakeholders on the use and contents
of the guide. This feedback will be used to make any changes or updates the
following month.
Feedback can be provided to the IST:
11. CONTACT INFORMATION
NHS Interim Management and Support - Intensive Support Team (Cancer):
NHS INTERIM MANAGEMENT AND SUPPORT – INTENSIVE SUPPORT TEAM
(CANCER) WWW.NHSIMAS.NHS.UK/IST
Page 61 of 68
APPENDICES
Page 62 of 68
APPENDIX 1: Website Addresses
Everyone Counts: Planning for Patients 2013/14
Going Further on Cancer Waits Standards
Handbook to the NHS Constitution 2013
National Cancer Intelligence Network Website - MDT Development:
NHS Comparators:
NHS Constitution 2013
NHS Foundation Trust Compliance Framework
NHS IMAS website:
http://www.england.nhs.uk/everyonecounts/
http://www.ncin.org.uk/collecting_and_using_data/data_collection/gfoc
w
https://www.gov.uk/government/uploads/system/uploads/attachment_d
ata/file/170649/handbook_to_the_nhs_constitution.pdf
http://www.ncin.org.uk/cancer_type_and_topic_specific_work/multidisci
plinary_teams/mdt_development
https://www.nhscomparators.nhs.uk/nhscomparators/login.aspx
https://www.gov.uk/government/uploads/system/uploads/attachment_d
ata/file/170656/nhs_constitution.pdf
http://www.monitor-nhsft.gov.uk/our-publications/browse-
category/guidance-foundation-trusts/mandatory-guidance/compliance-
framework-
Page 63 of 68
NHS Improving Quality - Rapid Review of Endoscopy Services:
NHS Improving Quality – Challenges and Improvements in Diagnostic Services across
Seven Days:
NHS Improving Quality - Productive Operating Theatres:
NHS Improving Quality - Reducing DNA’s:
NHS Managers Code of Conduct 2002
Royal College of Radiologists – Standards and Recommendations for the Reporting
and Interpreting of Imaging Investigations by Non Radiologists Medically Qualified
Practitioners and Teleradiologists:
Steyn Improving Patient Flow website:
www.nhsimas.nhs.uk/ist
https://www.gov.uk/government/uploads/system/uploads/attachment_d
ata/file/215123/dh_133058.pdf
http://www.nhsiq.nhs.uk/resource-search/publications/diagnostic-
challenges-7-day.aspx
http://www.institute.nhs.uk/quality_and_value/productivity_series/the_
productive_operating_theatre.html
http://www.institute.nhs.uk/quality_and_service_improvement_tools/qu
ality_and_service_improvement_tools/dnas_-
_reducing_did_not_attends.html
http://www.nhsemployers.org/sitecollectiondocuments/code_of_conduct
_for_nhs_managers_2002.pdf
http://www.rcr.ac.uk/docs/radiology/pdf/bfcr(11)2_reporting.pdf
http://www.steyn.org.uk/
Page 64 of 68
APPENDIX 2
Cancer Care Access Policy Development Guidelines:
STATEMENT OF INTENT
Policy
The purpose of a CAP is to ensure patients are treated with equity and efficiency and it
should be expressly focussed around patient care ensuring the best interests of the patients
are foremost. The document needs to reflect the current iteration of the Operating
Framework and its stated standards; it also needs to ensure compliance with the NHS
Constitution.
SOP
The standards applicable at the time of writing should be clearly indicated and modified
when these standards are updated. Any locally agreed additional rules or processes should
also be clearly expounded.
Sign off
Policy
The CAP should be agreed and signed off by LHE representatives. A review date should be
clear and the individual(s) / group(s) responsible for the review stated.
Choose & Book (C&B)
Policy
The CAP should describe the C&B management system
SOP
The standards should advise staff on how to process C&B referrals and where to escalate any
problems or concerns.
Access Standards
Policy
The CAP should clearly indicate locally and nationally agreed standards for access to care.
Key performance will be outlined in the policy. Details of reasonable notice should be
included for cancer (both admitted and non admitted pathways) and diagnostic pathways.
The importance of treating patient in chronological order, making allowances only for clinical
urgency and patient choice.
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SOP
The SOP will give details of patient pathways and indicate milestones and trigger points
(time to 1st OPA, time to decision to admit, time to admission etc) where escalation may be
required.
Definitions
Policy
Key definitions will be included to guide staff in understanding the rules and their
application. Any local anomalies or ‘special’ situations may be usefully described in
supporting SOPS.
TIPS
The definitions, which may be presented in the format of a glossary for ease of use, should
include:
‘clock start’, ‘clock stop’, ‘social pause’, ‘entitlement to NHS treatment’, ‘active
monitoring/surveillance’, ‘reasonable notice’, ‘standards for changing, amending or
cancelling appointments by the provider’, ‘patient cancellations’, ‘did not attend (DNA)
events’, ‘patient choice’, ‘reasonableness’, ‘consultant upgrades’, ‘patient fitness’,
‘downgrading referrals’, ‘thinking time’, ‘subsequent treatment’, ‘earliest clinically
appropriate date’, and ‘transfers between providers’.
Please note this list should not be considered exhaustive and should be developed for the
LHE.
Referral pathways
Policy
Details of the processes required prior to referral, such as requirements with regard to
referral proforma, including any pre-referral work up and diagnostic processes should be
outlined in the policy. The process for managing inappropriate referrals must be referenced.
Any triage which is performed as part of the internal referral management process should be
included. The expectations associated with the content of patient letters (outpatient,
diagnostic, preadmission and assessment) should be included.
SOPs
Details of the patient pathways and actions to be taken if these are not adhered to should be
linked to the pathways (see Access Standards above), including individuals to be contacted in
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the case of inappropriate referrals. Pathways scenarios / examples may be provided within
the SOPs as illustrations of good / best practice.
Cancer referrals
Policy
The development of supporting SOPs will be determined by the integration or otherwise of
elective and cancer requirements. The management of patients upgraded following a
referral from another route, should be described within the cancer access policy ECAP.
Patient information
Policy
The CAP should advise of the written information available to patients and when they may
expect to receive such information.
SOPs
Details of the information proffered to patients at key stages of their pathways can be
detailed in the SOPs associated with patient pathways (see Access Standards above).
DNAs and cancellations
Policy
The policy must note DNA and cancellations as separate events and indicate the action to be
taken when each occurs. The policy should also indicate the action to be taken if or when
the Trust is the source of any cancellation.
Processes associated with both the planned and short notice cancellation of operations and
or procedures should be incorporated as well as processes associated with planned and
short notice clinic cancellations, and ensure cancer patients are not cancelled if avoidable.
SOP
The SOP should offer details of the individuals to be notified of actions taken following
patient cancellations and or DNAs and the escalation process associated with the
management of vulnerable patient groups.
Training and role clarity
Policy
The role of training as an on-going aspect of staff development as well as an integral aspect
of induction should be outlined in the policy, identifying those individuals responsible for
both delivery and assessing competence post training. The frequency of refresher training
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should be included and measures to be taken when staff fail to adhere to the policy noted.
Clear links to local disciplinary and or competency policies should be included.
Reporting suites
Policy
Details of the Trust reporting suites, including the links between specific information and the
report to which it will be aligned. There should also be links to inform users of which reports
are available to them and the information each should encompass.
SOPs
Any audit processes indicating where problems arise and where appropriate action was not
taken, should be specified within the SOPs. The feedback methods, based on this
information, should be outlined, including reports to Trust Boards.
