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Patient access and safe waiting times policy

1 Policy summary

The patient access and safe waiting times policy provides guidance to colleagues to ensure that all patients who require access to all outpatient clinical services provided by our organisation are managed consistently, according to national and local frameworks and policy, including the national access and waiting times standards. This policy details how the trust has extended these guidelines across all its services, even where they do not fall into the national scope. This policy describes the structure of the access route for patients and generic rules which apply across all directorates across the trust as well as actions that should be taken to ensure patients are kept safe while they wait.

2 Introduction

Offering all patents timely access to the Rotherham, Doncaster and South Humber NHS Foundation Trust’s (RDaSH) services underpins the health of the local population, the delivery of high-quality evidence-based healthcare and the related key service deliverables. It is therefore vital that the trust ensures all its patient activity is efficiently and effectively managed. A robust governance framework exists to ensure the continued delivery of high-quality services, whilst working within local policy and procedures and national guidance. This framework applies to all services in the trust where a waiting list is held, irrespective of service and also expects that there will be management accountability for access to services and for the standard of those services.

The length of time a patient needs to wait for treatment is an important visible, public indicator of the quality of services provided by the trust.

Within our strategy, promise 14 focuses on delivery of an improvement around waiting times for our patients.

In promise 14 we promise to “assess people referred urgently inside 48 hours from 2025 (or under four where required) and deliver a four-week maximum wait for all referrals from April 2026, maximising the use of technology and digital innovation to support our transformation.”

This promise is over and above the national NHS England recording and reporting referral to treatment (RTT) (2021) requirement to see 92% of patients within 18 weeks.

Our policy also includes locally and nationally agreed standards for access to care based on the referral to treatment waiting times. The trust has in 2024 and 2025 identified and refreshed which services fall into scope as referral to treatment pathways (appendix A) for formal reporting to NHSE from 1 April 2025 onwards. Referral to treatment principles will be applied to all waiting lists within the organisation, regardless of whether formal reporting is required.

As per the national guidance for referral to treatment waits for consultant led services there will be zero tolerance of any wait over 52 weeks.

Services that provide immediate or rapid access care and treatment to patients, such as for individuals requiring access to crisis services, will follow the principles and sentiment of the policy, however the timescales will be much shorter, often patients will need to be seen within a 1-hour to 48-hour window from referral as directed by clinical need and, or the service specification. In addition, some services have a target waiting time of two weeks. In these services our ability to offer patient choice will be more restricted and governed by the level of clinical urgency or expediency.

3 Purpose

This access and safe wait policy is intended to ensure that all patients who are referred to and treated within the trust receive fair and equitable access to high quality care and services and that all patients are safe while they are waiting to be seen, and that waits are recorded in a standardised way across the trust.

This policy has been developed in line with the Referral to Treatment Pathways: A Guide for Managing Efficient Elective Care (NHS Improvement 2017), a guide to the required standards of practice in the management of elective care and Referral to Treatment Consultant-led Waiting Times: Rules Suite (October 2022). It is based on current legal requirements and professional best practice whilst also meeting the rights of patients under the NHS Constitution (updated 2023).

Whilst no service should have a wait time over 18 weeks from referral to receiving treatment, and no longer than 4 weeks from March 2026, the trust also recognises there is sometimes a gap between the first clinical contact and the commencement of subsequent programmes of treatment, review or follow-up appointments. The trust will monitor this alongside initial waiting lists to ensure all treatment pathways are being conducted in a timely and efficient way.

The overall aim of this policy is to ensure patients are treated in a timely and effective way, specifically to:

  • ensure that patients receive treatment according to their clinical priority, with routine patients and those with the same clinical priority treated in chronological order, thereby minimising the time a patient spends on the waiting list and improving the quality of the patient experience
  • reduce waiting times for treatment and to ensure patients are treated in accordance with agreed waiting times for each service
  • reduce the number of cancelled appointments for non-clinical reasons
  • allow patients to maximise their right to patient choice in the care and treatment they need
  • reduce the number of did not attends (DNAs), was not brought’s (WNBs), and patient led cancellations
  • ensure trust adherence to all the mandated milestones and standards of measurement relating to all of the referral to treatment pathways

The extent to which this policy is fulfilling its function will be measured via monitoring of did not attend rates, the number of patients on waiting lists (compared to 1 April 2024 baseline), the length of time patients wait (compared to 1 April 2024 baseline), and achievement of national and local waiting time targets, including those reported formally to the integrated care board and nationally. These metrics are monitored through the integrated quality and performance report on a monthly basis, which reports into the operational management group and clinical leadership executive. Waiting times are monitored weekly in more detail for all services via care group and trust wide waiting list meetings.

4 Scope

This policy details how patients on waiting lists will be managed from an administrative perspective, at all their points of contact with the trust (RDaSH). It is the responsibility of all colleagues associated with this process, to understand the referral to treatment pathway (RTT) principles and definitions.

5 Procedure

Clinical, managerial, and administrative colleagues all have an important role in managing the process of referral to treatment effectively, whilst ensuring the best clinical outcomes and patient experience for everyone within that process. Reliable, valid data collection systems and appropriate training for key colleagues is essential to the accuracy of referrals and waiting list information and management.

Further support and guidance relating to correct data entry and capture please refer to the clinical systems on the intranet (staff access only).

For corporate responsibilities please refer to the performance management framework (staff access only).

5.1 Quick guide

5.1.1 Management of waiting lists

Ensure patients receive timely, equitable access to treatment in line with national access standards, Rotherham, Doncaster and South Humber NHS Foundation Trust’s promise 14 and the NHS constitution. Ensure that waiting lists are managed effectively, and a high quality of service to patients is maintained.

5.1.2 Referral to treatment targets

Ensure patients have the right to access certain services commissioned by NHS bodies within maximum waiting times, or take all reasonable steps to offer a range of suitable alternative providers if this is not possible.

5.1.3 Waiting times

The NHS Constitution sets out that patients should wait no longer than 18 weeks from GP referral to treatment.

There will be zero tolerance of any wait over 52 weeks.

5.1.4 Specialist services

Individual access targets for certain specialist services such as early interventions in psychosis and perinatal.

5.1.5 Good practice

Reliable, valid data collection systems and appropriate training for key colleagues is an essential requirement.

5.2 Clinical records and data quality

Intrinsic to the use of any clinical system and therefore waiting list management is accurate clinical record keeping. Refer to the link provided on overarching guidance on best practice:

In addition, the trust’s health informatics directorate will take all reasonable steps to configure the trust’s clinical system in a format that supports users with entry and service access management and monitoring.

This is to include mechanisms for notification to clinical colleagues and service and team managers in relation to errors and omissions within clinical records.

Management of data quality is key to ensuring clinical records are accurate, and that information used for waiting list management is reliable. All services where patients wait to receive an intervention should hold a waiting list. This includes where patients are waiting for group sessions, and for dialectical behaviour therapy (DBT) programmes. It is imperative that services fully validate all patients on their waiting lists every 12 weeks, in line with national guidance, to ensure data quality errors are rectified. All patients who are waiting beyond 4 weeks for an appointment should be administratively reviewed through care group waiting list meetings on a weekly basis to ensure that plans are being put in place to minimise their wait.

5.3 Fast track access to services

The following cohorts of patients have been determined to have a right to fast-track access to services delivered by the trust in accordance with national guidance and legislation:

  • Armed forces veterans receive priority access to NHS community services, where this is known and for any conditions which are likely to be related to their service
  • children in care and children leaving care
  • post-partum or expectant mothers requiring perinatal mental health services

5.4 Access and safe wait process

The following outlines the trust’s procedure for the management of waiting times.

As stated above, the principles contained within this policy reflect the national requirements for referral to treatment pathways and for consistency, these principles and definitions will be applied for all outpatient pathways in the organisation, whether these pathways are determined to be within the scope of the national guidance or not. Roles and responsibilities for monitoring the adherence of the requirements of the policy are detailed below:

5.4.1 Chief executive and chief operating officer

The chief executive officer (CEO) and chief operating officer (COO) have overall responsibility for the implementation of this policy and board level accountability for the delivery of the elective care access standards. The chief operating officer is responsible for ensuring the delivery of services to meet targets and monitoring compliance standards for elective care access.

5.4.2 Clinicians

Clinicians have a responsibility for adhering to key internal procedures in the proactive management of patients along their referral to treatment journey. Key examples are the timely and accurate completion of documentation within the electronic patient record (EPR) for each patient and undertaking swift reviews of incoming patient referrals.

5.4.3 Care group directors, deputy care group directors and service managers

Operational managers within care groups are responsible for ensuring that their colleagues are fully trained to reach competence in the management of waiting lists. Where necessary this will include performance management against the principles. Managers have the further responsibility to manage their services’ capacity and demand for each specialty. This includes managing and adjusting appointment “polling ranges” accordingly. The care group management structure is additionally responsible for monitoring waiting lists on a weekly basis through weekly waiting list meetings, and escalating any issues identified through the performance management framework.

5.4.4 Administration colleagues

All administrative colleagues must also abide by the principles within this policy and the supporting standard operating procedures.

All patients should receive their first definitive treatment, within 18 weeks of a referral to the trust. This time starts from the time that the referral is received into the trust and this timeframe relates to all services.

5.5 Prior to accepting referrals

5.5.1 Management of referrals

Referring agents (as agreed with commissioners), may include:

  • general practitioners (GPs)
  • secondary and tertiary care
  • social care
  • patients and their families
  • carers
  • health care professionals

Referrals should only be sent to the trust if the patient is willing and able to be treated within the maximum access times target and should not be sent if the referrer knows the patient is unavailable (that is, on a tour of duty, extended holiday or work or study commitments which prevent ability to attend appointment).

All referrers have the responsibility to ensure that any referrals are clear, concise and are sent to the appropriate service. Referrals should contain the patients NHS number and information on any special requirements, including patients’ entitlement of priority treatment in the care of veterans in the armed forces and service families.

All referrals must be logged in the electronic patient record within 24 hours of receipt 7 days per week.

5.5.2 Accepting and declining of referrals

Each service within the trust will have specific inclusion and exclusion criteria as agreed in their service specification.

An 18 weeks’ pathway “clock” commences when any healthcare professional, authorised by an NHS commissioning body to make such a referral for a:

  • a consultant led service, regardless of setting with the intention that the patient will be assessed and if appropriate, treated before responsibility is transferred back to the referring health professional or general practitioner
  • an interface, referral management or assessment service, which may result in an onward referral to a consultant led service before responsibility is transferred back to the referring health professional or general practitioner

A waiting time clock also starts upon:

  • a self-referral by a patient to the trust’s services, where these pathways have been agreed locally by commissioners and providers and once the referral is ratified by a care professional permitted to do so.
  • a new waiting time clock starts when a patient rebooks their appointment following a first appoint did not attend (DNA) that stopped and nullified their earlier clock.
  • when the provider receives a paper or electronic referral letter or electronic referral to any other trust service. Where there is a single point of access (SPA), the clock will start when the referral is received by the single point of access and not when it is received by the treatment team. The trust will however only determine that a referral has been received when it contains sufficient information for the referral to be processed by the organisation. In the event that a referral is received that does not contain sufficient information, the referral will be determined to be an inappropriate referral and returned to the referrer
  • for eating disorders services only, where a primary reason for referral is not recorded as suspected eating disorder, but this is identified during triage or single point of access, the clock start date should be the date of initial referral. However, if this is not suspected during triage but at a subsequent assessment then the date the clock starts should be when the suspicion is first raised. If a person is already in contact with mental health services, the clock should start when suspicion of eating disorders is first raised (not backdated to their initial contact with the mental health service)

A new waiting time clock should start following completion of a consultant-led referral to treatment (RTT) period when:

  • upon the decision to start a substantively new or different treatment that does not already form part of that patient’s agreed care plan
  • when a patient is re-referred into a consultant-led, interface or referral management or assessment service as a new referral
  • when a decision to treat is made following a period of active monitoring which has stopped the clock

The acceptance of the referral by a service will occur if the criteria for the service are met. In the case of referrals that are not accepted for legitimate reasons, including where the referral is incomplete or inappropriate, a written communication will be sent to the referrer within 72 hours detailing why the referral has not been accepted. A copy of this should be saved in the patient’s electronic record. Patients or carers may be copied into this communication where relevant.

Where the referral has been sent to the wrong service for support, the referral should be sent to the appropriate service when appropriate so to not delay care for the patient. In instances where this is not possible, signposting information should be included in the communication back to the referring professional to ensure they are able to quickly refer the patient to the appropriate service to meet their needs.

The clock does not stop if a provider rejects a referral, stating that their service is not appropriate for this patient. The provider must re-refer the patient to an appropriate service or transfer responsibility for the patient’s care back to the referring professional without delay to ensure that waiting times are minimised.

Waiting lists can only be closed to new referrals following approval of the chief operating officer. Requests for closure should be made in writing with clear recovery plans and timescales for re-opening to be agreed prior to closure.

5.5.3 Triage and clinical prioritisation

Clinical triage is the process of determining the priority of patient’s treatment based on the urgency or severity of their condition by an appropriate clinician. This can be paper based, whereby a clinician reviews the referral form and the patient’s medical record, or can be done in conjunction with the patient, normally via telephone.

Each service will have an identified resource to triage referrals during operating hours.

The triaging clinician will assign a priority level to the referral and also decide on the most appropriate grade or skill of clinician to make the first clinical contact. Triage will also determine the most appropriate mode of initial contact which might include a telephone or virtual contact or a face-to-face contact in a clinic, home or educational setting.

The clinician will ensure that the patient is placed on the appropriate waiting list, the correct priority is clearly identified in the electronic patient record and that appropriate safe waiting actions are taken. See Safe Waiting section.

5.5.4 Clinical questionnaires

In some cases, a service may determine that more information is required ahead of arranging a clinical contact. This may take the form of seeking further information from the referrer or through the use of clinical questionnaires.

Clinical questionnaires are comprehensive questionnaires completed by patients or parents or carers as appropriate that explore a patient’s symptoms, needs, motivations and goals in order to inform assessment, tailor interventions or support and personalise care.

Where questionnaires are used, they should not delay the onset of care. Time spent completing and returning questionnaires will count towards the patients overall waiting time. Patients, parents, or carers should be given clear instructions on how to complete and return questionnaire and the expected time frame. They should also be given a contact telephone number for the service if they should encounter any difficulty in completing the questionnaire. Adjustments should be made for patients who are unable to complete the questionnaire for any reason, including but not limited to language barriers and inability to complete the form, these patients should have this completed as part of their initial assessment.

Patients, parents, or carers should be advised that failure to return the questionnaire within the expected time frame could result in their referral being closed with advice on how they can be re-referred in the future if required. This should only be considered if clinically appropriate and in line with the patient disengagement policy. This policy is under review but will stand until new guidance is implemented. For children and vulnerable adults’ failure to respond to a questionnaire should be considered in line with non-attendance at an appointment and managed in line with the patient disengagement policy.

5.5.5 Waiting list management

Oversight of waiting lists should always be through the waiting list dashboard on the RePortal, which pulls data directly from SystmOne, which is where all pertinent data required for managing waits must be recorded. Teams can use a variety of SystmOne functionality, including caseloads, referral allocation and waiting lists to monitor information at a local level, however the trust reported position will be taken from the dashboard.

The accuracy and reliability of waiting list information is the responsibility of all colleagues who are involved in the processing and management of referrals and admission to the service.

It is the role of the triaging clinicians for each service to monitor waiting lists regularly and ensure any patients waiting who are breaching their safe waiting timescales are highlighted, so the referral is prioritised to be seen.

Regular monitoring and reporting of waiting times should be completed weekly at team, service and care group level. There should be weekly care group waiting list meetings, which feed into weekly trust wide waiting list meetings, which report into operational management group. These meetings provide an opportunity to all levels of management to maintain oversight, and collectively, with clinical teams, review, challenge and agree service and trust priority data that feeds into the relevant committees. These meetings provide the opportunity to monitor the adherence of services to the requirements of this policy, with an update by exception provided to operational management group on a quarterly basis.

5.5.6 Recording waiting times

All clock start data is pulled from SystmOne and is based on the referral date to each specific team or pathway.

The clock start date should always be the date the referral was received and must be linked on SystmOne to the current referral.

There are legitimate reasons why a patient may breach the 18 weeks’ target:

  • exceptions: applicable to referral to treatment pathways, where it is in the patient’s best clinical interest to extend their treatment beyond the standard time frames
  • choice: applicable where patients choose to extend their pathways via rescheduling a previously agreed appointment or an admission date offered, the trust is committed to the principle of patient choice throughout this process
  • co-operation: applicable where patients do not attend their previously agreed appointment or admission dates

Ultimately it is for the professionals in charge of the patient’s care, to decide whether waiting longer than 18 weeks is in the patient’s best interests and to communicate this decision to the patients concerned. However, the following points developed in discussion with clinicians, should be considered in identifying an acceptable clinical exception to the 18 weeks’ standard:

  • at its simplest, the definition of clinical exception is where waiting longer than 18 weeks is in the patient’s clinical interest. However, this does not include clinically complex patients who nevertheless can and should start their treatment within 18 weeks. Neither does it include patients who choose to delay their treatment beyond 18 weeks for personal or social reasons
  • where a patient’s treatment does not begin within 18 weeks, primarily because it has been difficult to reach a potential diagnosis and a number of diagnostic tests have already been undertaken, this would be an example of clinical complexity, rather than a clinical exception
  • where a patient’s treatment has not begun within 18 weeks due to a necessary sequence of diagnostic tests that for clinical reasons could not be performed within a shorter time period, this would be considered a clinical exception
  • where clinically complex patients have multiple conditions, or co-morbid factors that can delay the start of treatment, these are not clinical exceptions, and in many of these patient pathways, it may be appropriate to stop the 18 weeks clock for these patients and start a new one when the patient is medically fit and ready to re-start their treatment

5.7 Clock stops and disengagement

5.7.1 Clock stops

The clock stops when:

5.7.1.1 First clinical contact

A first clinical contact will usually be an initial assessment appointment, but it can be any contact where a patient’s clinical needs are discussed and personalised clinical advice and or treatment is given or advised to form the patient’s first definitive treatment. This does not include telephone contacts with a patient, parent/carer where only appointments are arranged or universal or signposting guidance is given, but can include a telephone consultation where a clinician explores and assesses clinical need and provides advice or support tailored specifically to that patient. For example, the children’s and young people’s mental health service (CAMHS) could have a telephone consultation with a teacher, or any other appropriate proxy, to design an appropriate plan for treatment or support. Treatment will often need to continue beyond the first definitive treatment, and also after the clock has stopped.

5.7.1.2 There is a decision not to treat

The clock will be stopped if the patient or referrer contacts the service with further information that now means the referral is no longer clinically appropriate or required

5.7.1.3 Patients who do not attend (DNA) or were not brought (WNB)

Any appointment other than a new appointment can be removed from the list, if the Trust can demonstrate that the patient was made a reasonable appointment offer and it is clinically appropriate to write to formally discharge the care of the patient back to their GP or referring provider (with at least three weeks’ notice). This should be done on a risk assessed basis in line with the trust disengagement policy and only if every reasonable effort to engage the patient has been exhausted. Children and young people who are not brought to their appointments should be managed on a risk assessed basis in line with the trust safeguarding policy. For the purpose of removal of patients from waiting lists for non-attendance at appointments, services must be able to evidence that they have attempted to work with the patient to ensure attendance, that a reasonable appointment offer was made with a minimum of 4 weeks’ notice, and that alternative appointment times have been offered if requested by the patient. This does not prohibit appointments being made with less notice in order to meet the 4-week maximum waiting time target by March 2026, but ensures that patients are not unable to access care if they require more notice to attend appointments.

Note, stopping the clock does not remove a patient from a waiting list. A patient who has declined or not attended a reasonable appointment offer may remain on the waiting list and will be offered the next available appointment time according to their clinical priority.

5.7.2 Pausing the clock

There is no longer any provision to apply pauses or suspensions to a referral to treatment pathway, for patient-initiated delays for social or personal reasons. It is good practice to maintain a local record of all patient-initiated delays, to aid good waiting list management and to ensure that patients are treated in their order of clinical priority. The trust must be able to identify those patients who are choosing to wait longer than 18 weeks and to ensure that they are offered a reasonable appointment, four or more weeks from the time that the first appointment offer was made.

It is not good practice to allow open ended delays and future appointment dates should be agreed directly with the patient, at the time they first request for a delay to avoid the risk of future patient cancellations.

There is no blanket rule on the maximum length of a patient-initiated delay. If a patient chooses to delay their treatment, for a period longer than that which is clinically appropriate and in the spirit of patient choice, the patient must be referred back to the referring professional until they are fit, willing and available to begin their treatment.

All patient-initiated delays must have an end date. If the patient is unable to give a date by which they will be available, then the patient disengagement policy must be followed. This could result in the patient being removed from the waiting list and returned to the care of their GP until they become available for treatment if all reasonable efforts to engage the patient have failed and it is clinically appropriate to do so.

Once the patient is available for treatment, the GP should refer them back for reconsideration of the intended treatment. The patient should re-enter the care pathway at the point from which they left it, depending on what is clinically appropriate as their condition may have changed, but a new 18 weeks’ clock would begin.

5.9 Escalation process

When an issue with data quality or waiting times compliance is detected by the trust’s corporate services this will be escalated to the appropriate service manager in the first instance for investigation. The issue will subsequently be escalated through the trust’s management structure as necessary and proportionate to the significance of the issue identified.

When an issue with data quality or waiting times, compliance is detected in operational services, this will be actioned in accordance with the performance management framework.

All issues with data quality or waiting times, whether detected by corporate or operational services, should in addition be escalated through the governance structure in place around waiting lists. These issues will be discussed at the weekly trust wide access meeting, and escalated through operational management group to clinical leadership executive to ensure appropriate action is being taken to address long waits and, or data quality issues.

6 Safe waiting

Each service will monitor their waiting list which will be reviewed and managed through the risk management framework detailing how they maintain patient’s safety while patients are waiting for their first clinical contact, and while they are waiting for treatment.

Services should ensure they consider and put in place appropriate waiting well initiatives that will support people while they wait. This can include universal advice and signposting to self-care resources. Service specific templates should be completed on the form included as appendix B to ensure that all possible steps are taken and documented to support safe waiting. For all services not meeting their wait time target, this form should be attached to a risk on the care group risk register to ensure monthly monitoring.

All services must advise patients of an expectation of their wait time and what to look out for while they are waiting. They should be advised of what they should do and where to seek support if they identify any urgent signs or symptoms. They should be advised how to contact the service if they are concerned and feel they need to be seen sooner. Patients who do contact the service should be re-triaged and re-prioritised as appropriate.

The trust will regularly contact patients to confirm they remain on a waiting list, to prompt them to contact the service if their condition has changed and to ensure they still need to be waiting for this service. This will happen on a monthly basis during their wait and done centrally by text message via SystmOne.

7 Patient responsibilities

The trust must support individuals to promote and manage their own health. Services must reflect, and should be co-ordinated around and tailored to, the needs and preferences of patients, their families and their carers.

The NHS Constitution for England sets out rights for patients under consultant-led treatment only. However, it does set out responsibilities of patients, including the responsibility to attend appointments. According to the constitution, patients: “Should keep appointments or cancel within a reasonable time. Receiving treatment within the maximum waiting times may be compromised unless patients observe this important practice”.

Missed and cancelled appointments should be managed in accordance with the trust disengagement policies:

8 Safeguarding

Where there are children and young people or adults for whom there are any safeguarding concerns who fail to attend an appointment, the referrer should be contacted to advise for their non-attendance so appropriate action or support can be put into place.

The clinician may be required to offer a degree of flexibility with regard to re-booking appointments where this may affect a Child protection plan or a vulnerable adult plan, whilst working within the retrospective waiting times for the relevant service (Care Act (2014) and Children’s Act (2006)).

Please see the trust disengagement policy for further information.

9 Waits for intervention, review and follow-up

Once seen for an initial clinical contact patients may be required to wait again for a follow-up appointment or review within a set, clinically appropriate time. The trust does not use the 4-week and 18-week clock on SystmOne to record these waits. However, each service should apply the principles in this policy to subsequent waits and ensure that their safe waiting plans include appropriate actions to keep patients safe while they wait at all stages of their pathway.

10 Patient impact and harm

The experience of waiting for an assessment and, or intervention can, on occasions, have adverse impacts for some patients.

10.1 Patient impact

Refers to any adverse consequence the patient has experienced as a result of an extended wait. Example may include experiencing extended periods of limited social participation, ability to participate in activities of daily living, limited mobility, diet or communication that may impact negatively on their social, emotional, physical or developmental needs. This needs to be an issue that could have been reasonably addressed and mitigated if the patient had been seen sooner but does not need to raise to the level of actual harm.

10.2 Patient harm

Refers to deterioration in a condition or a disease directly related to the patient’s extended wait and not related to the natural course of the patient’s illness or underlying condition. It is defined as permanent lessening of bodily functions, sensory, motor, physiological or intellectual and include brain damage or function, removal of wrong limb, loss or removal of an organ. The impact of a patient’s wait should be captured on the SystmOne impact review template on any occasion that a patient is seen outside commissioned wait times. Clinicians should seek to ask and record the patient’s own view on the impact of their wait.

Where harm is identified the following complexities and level of assessment should be considered:

  • the harm has been as a result of waiting and not from disease of condition progression
  • the decline in health, understood as increased disability or distress and can vary across health conditions and settings
  • the experience of distress and disability and the coping response can be highly subjective
  • the harm should be defined for each patient group and at service level
  • the reported harm should be used to influence further implementation of the safe waiting protocols and safety netting advice to patients
  • personalised care planning which reflects the risk stratification applied and includes contingency and self-care planning

An incident report (IR1) must be completed for any harm identified and duty of candour must be followed. Where moderate harm or the potential for significant learning has been identified, learning will be reviewed, communication and reported. Please see the trust patient safety incident response framework for further guidance.

11 Training implications

There are no specific training needs in relation to this policy, but the following colleagues will need to be familiar with its contents: and any other individual or group with a responsibility for implementing the contents of this policy). But the following colleagues will need to be familiar with its contents:

  • service managers
  • clinical colleagues
  • administration colleagues
  • Contracts, Performance and Commissioning for Quality and Innovation (CQUIN) team
  • Information and Quality team
  • any other individual or group with a responsibility for implementing the contents of this policy

As a trust policy, all colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through:

  • one to one meetings or supervision
  • local Induction
  • team talk
  • communications daily emails

11.1 Dissemination

The effective implementation of this policy will support openness and transparency. The trust will:

  • ensure all colleagues and stakeholders have access to a copy of this policy via the organisation’s website
  • communicate to colleagues any relevant action to be taken in respect of issues
  • ensure that relevant training programmes raise and sustain awareness of the importance of effective waiting list and service access management

This policy will form part of the NHS standard contracts with each of the trust’s main NHS commissioners.

11.2 Training

The Clinical Systems team provide training and support for TPP SystmOne to all colleagues within the trust.

The following suite of training is available for colleagues in relation to the trust’s clinical systems and therefore service access management and monitoring:

  • TPP SystmOne
  • NHS information technology skills pathway (for example Microsoft Office)
  • basic information technology skills

All colleagues will be offered relevant training commensurate with their duties and responsibilities, aligned to use of the clinical system. Please refer to section 1.5.

Colleagues requiring support should speak to their line manager in the first instance. For queries please contact:

12 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

12.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

12.1.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

No issues have been identified in relation to this policy.

12.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

12.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

No issues have been identified in relation to this policy.

14 References

The following legislation and guidance has been taken into consideration in the development of this policy.

Guidance containing general principles to adhere to:

15 Appendices

15.1 Appendix A trust pathways determined to meeting definition of consultant-Led referral to treatment pathways

15.1.1 Services

  • North older people’s (memory service Doncaster)
  • South older people’s (memory service Doncaster)
  • East older people’s (memory service Doncaster)
  • Central older people’s (memory service Doncaster)
  • Young onset dementia (memory service)
  • Young onset dementia service
  • Rotherham memory services
  • North Lincolnshire memory services
  • Doncaster community Parkinson’s disease
  • Long Covid
  • Doncaster Neurological Rehabilitation Outreach team
  • Rotherham community neurological rehab

15.2 Appendix B safe waiting plan

Refer to appendix B: safe waiting plan (staff access only).

Document control

  • Version: 3.
  • Unique reference number: 472.
  • Approved by: clinical leadership executive.
  • Date approved: 19 November 2024.
  • Name of originator or author: head of contracting, performance and commissioning for quality and innovation (CQUIN).
  • Name of responsible individual: chief nursing officer.
  • Date issued: 29 July 2025.
  • Review date: 31 July 2028.
  • Target audience: all operational colleagues.
  • Description of change: review.

Page last reviewed: July 30, 2025
Next review due: July 30, 2026

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