The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012

PART 9 Standing rules: waiting times

Interpretation

44.—(1) In this Part—

“appropriate treatment” means treatment that is the first treatment provided to a person as a result of, and in response to, an elective referral;

“eligible referrer” means—

(a)

a general dental practitioner,

(b)

a general medical practitioner,

(c)

a person approved to make an elective referral under arrangements made by the relevant body which has responsibility for the person being referred, and

(d)

any other person whose request to refer is accepted by—

(i)

a consultant,

(ii)

a member of a consultant’s team, or

(iii)

persons providing interface services where a person who has been referred may be referred on from those services to a consultant or consultant-led team,

who is to provide the assessment or treatment required as a result of a referral;

“elective referral” means referral by an eligible referrer to a health service provider for assessment or treatment that is not identified as being immediately required at the time of referral;

“each data collection period” means each calendar month and the end of such a period means the end of the last day of the calendar month in question;

“interface services” means services that are provided otherwise than by a consultant-led team, which provide clinical triage, assessment and treatment services, but does not include mental health services or services provided under a primary care contract;

“registered healthcare professional” means a person who is a member of a profession regulated by one of the following bodies—

(a)

the General Medical Council,

(b)

the Nursing and Midwifery Council, or

(c)

the Health and Care Professions Council;

“specialist” means a registered healthcare professional working as a consultant, or as part of a consultant-led team, who specialises in the area of professional practice which is most appropriate for the diagnosis and treatment of the type of suspected cancer in question;

“start date” means the date on which the person’s referral request was received by the health service provider to whom that person has been referred for the provision of health care services by—

(a)

in regulations 45 to 51─

(i)

an eligible referrer; or

(ii)

themselves, with the prior approval of an eligible referrer, or

(b)

in regulations 52 and 53, a general medical practitioner, a general dental practitioner or a person authorised to act on their behalf;

“suitable health service provider”, in relation to a person who has been referred for assessment or treatment, is a health service provider who—

(a)

can provide services which consist of, or include, treatment which is clinically appropriate for that person in response to the reasons for the referral, and

(b)

will provide those services pursuant to a commissioning contract with a relevant body;

“treatment” means an intervention that is intended to manage a person’s disease, condition or injury and, insofar as reasonably practicable, avoid further interventions, but does not include a therapy or healthcare intervention referred to in regulation 46(3);

“treatment for suspected cancer” means—

(a)

assessment by a specialist in order to progress towards a diagnosis, or

(b)

treatment for suspected cancer that is provided by a specialist;

“Waiting Times Directions” means the Primary Care Trusts and Strategic Health Authorities (Waiting Times) Directions 2010 which came into force on 1st April 2010(1).

(2) For the purposes of this Part, where reference is made to an appointment date being reasonable, it is reasonable if it falls at least 3 weeks after the date on which the offer of the appointment was made.

Duty to meet the maximum waiting times standards

45.—(1) A relevant body must make arrangements to ensure that persons—

(a) for whom the relevant body has responsibility; and

(b) who require an elective referral,

commence appropriate treatment in accordance with paragraph (2).

(2) The requirement referred to in paragraph (1) is that at the end of each data collection period, appropriate treatment has commenced within the period of eighteen weeks beginning with the start date in not less than—

(a) 95% of cases where the appropriate treatment is provided during that data collection period without admitting as an in-patient a person receiving that treatment; and

(b) 90% of cases where a person is admitted as an in-patient in order to receive that treatment during that data collection period.

(3) A relevant body must make arrangements to ensure that at the end of each data collection period, not less than 92% of the persons falling with paragraph (4) have been waiting to commence treatment for less than 18 weeks.

(4) A person falls within this paragraph if—

(a) the relevant body has responsibility for that person;

(b) there has been a start date in respect of that person; and

(c) the person’s waiting time period, as specified in regulation 46, has not come to an end.

(5) Where—

(a) a decision has been made to admit a person to hospital for treatment as an in-patient as a result of, and in response to, an elective referral;

(b) that person has been offered at least two different reasonable appointment dates for admission to hospital for that treatment but has declined to attend on any of the dates offered,

the period of time described in paragraph (6) may be excluded from the calculation of the period of time for which that person has been waiting to commence appropriate treatment for the purpose of calculating the percentage of persons falling under paragraph (2)(b).

(6) The period of time to be excluded for the purposes of the calculation referred to in paragraph (5)—

(a) begins with the date of the earliest appointment date that was offered; and

(b) ends on the date on which the person is available again for admission to hospital for the treatment required as a result of, and in response to, the elective referral, where that person has notified the health service provider, whether verbally or in writing, of that date.

The waiting time period

46.—(1) The waiting time period for a person, as referred to in regulation 45(4)(c), begins with the start date and ends when any of the following paragraphs applies.

(2) The referred person received appropriate treatment.

(3) The referred person commenced therapy or received a healthcare science intervention where a consultant, a member of a consultant-led team or an individual providing an interface service decides that the therapy or that intervention is the treatment that is most appropriate for that person.

(4) A person’s name is added to a national transplant waiting list.

(5) The referred person is notified, verbally or in writing, that the calculation of the period of eighteen weeks beginning on the start date no longer applies in their case because—

(a) it is more appropriate for that person to receive treatment from a primary care service;

(b) a clinical decision is made to start a period of monitoring of that person prior to any decision being made as to what, if any, treatment should be provided;

(c) a clinical decision is made that no treatment should be provided to that person;

(d) they did not attend the first appointment made as a result of the referral by the health service provider to whom they were referred and they—

(i) had been made aware of the consequences of not attending an appointment, and

(ii) had not requested in advance of the date for the first appointment that the appointment be re-arranged for a different date; or

(e) they are being discharged back in to the care of their general medical practitioner because they did not attend an appointment, other than an appointment referred to in sub-paragraph (d), made as a result of the referral by the health service provider to whom they were referred and they—

(i) had been made aware of the consequences of not attending an appointment, and

(ii) had not requested in advance of the date for that appointment that the appointment be re-arranged for a different date.

Application of duty to offer an alternative provider

47.—(1) Regulation 48 applies if the conditions in paragraph (2) to (6) are met.

(2) A person has been referred to a health service provider (“the relevant health service provider”) for the provision of health care services by—

(a) an eligible referrer; or

(b) themselves, with the prior approval of an eligible referrer.

(3) The referral is for assessment or treatment in the course of the provision of health care services by—

(a) a consultant;

(b) a member of a consultant’s team; or

(c) persons providing interface services where a person who has been referred may be referred on from those services to a consultant or consultant-led team.

(4) The relevant health service provider, or the relevant body which has responsibility for the person referred, has been notified that the person referred—

(a) has not commenced appropriate treatment; or

(b) will not have commenced appropriate treatment,

within eighteen weeks, beginning with the start date.

(5) The notification referred to in paragraph (4) was given by—

(a) in the case of the relevant health service provider or a CCG, the person referred or a person lawfully acting on their behalf; or

(b) in the case of the Board, a CCG which has been notified by the person referred or a person lawfully acting on their behalf.

(6) The relevant body which has responsibility for the person referred is satisfied that the person has not commenced or will not commence appropriate treatment within eighteen weeks, beginning with the start date.

Duty to offer an alternative provider

48.—(1) Subject to regulation 49, where this regulation applies, the relevant body which has responsibility for the person referred must take all reasonable steps to ensure that that person is offered an appointment in accordance with paragraphs (2) to (4).

(2) The appointment offered must be with a consultant, or a member of a consultant’s team, at a suitable health service provider other than the relevant health service provider.

(3) The appointment must be an appointment to commence treatment earlier than the person referred would have commenced treatment if they had continued to wait for treatment at the relevant health service provider.

(4) If there is more than one suitable health service provider, the person referred must be offered a choice of appointment with more than one suitable health service provider that meets the requirements of paragraphs (2) and (3).

(5) In this regulation and regulation 49, “relevant health service provider” has the meaning given to it in regulation 47(2).

Exceptions to the duty

49.—(1) Regulation 48 does not apply in the circumstances described in any of paragraphs (2) to (10).

(2) The person referred did not attend an appointment made by the relevant health service provider in response to the referral where—

(a) the date for the appointment was reasonable;

(b) that person had been made aware of the consequences of not attending appointments; and

(c) that person had not requested in advance that the date for that appointment be re-arranged.

(3) The person referred did not attend a re-arranged appointment made by the relevant health service provider in response to the referral where—

(a) that person had re-arranged the date of the appointment;

(b) the original date for the appointment had been reasonable; and

(c) that person had been made aware of the consequences of not attending appointments.

(4) The patient chose to commence treatment on a date falling after the end of the period of 18 weeks beginning with the start date where—

(a) that patient had been offered a reasonable appointment date falling within that period; or

(b) they decided that they did not want to be offered any appointment dates within that period.

(5) The person referred decided that they did not want to commence treatment.

(6) The person referred was unable to commence treatment during the period of 18 weeks beginning with the start date for reasons not related to the relevant health service provider, or relevant body which has responsibility for that person, where that person—

(a) has been offered a reasonable appointment date falling within that period; or

(b) was unable to make themselves available for any appointment dates within that period.

(7) A person falling within regulation 47(3)(a), (b) or (c) has assessed the person referred and decided—

(a) that it is in the best clinical interests of that patient to commence treatment after the end of the period of 18 weeks beginning with the start date;

(b) that the person does not need treatment; or

(c) to refer the patient back to primary care services prior to any treatment commencing.

(8) A person falling within regulation 47(3)(a), (b) or (c) has assessed the person referred and decided that the person requires a period of monitoring which consist of or includes being re-assessed at intervals within the period of 18 weeks beginning with the start date.

(9) The patient is placed on the national transplant waiting list.

(10) The patient is referred for the purpose of receiving maternity services.

Duty to have regard to guidance

50.  In carrying out its duties under regulations 45 and 48, a relevant body must have regard to the document entitled “The Referral to Treatment Consultant-led Waiting Times Rules Suite” dated January 2012(2).

Duty to notify

51.  Where—

(a) a person meets the conditions in regulation 47(2) and (3);

(b) the Board has responsibility for that person in respect of the health care service to be provided on referral; and

(c) a CCG receives notification from that person, or a person acting lawfully on that person’s behalf, that they—

(i) have not commenced appropriate treatment; or

(ii) will not commence appropriate treatment,

within 18 weeks beginning with the start date,

that CCG must notify the Board in writing of that information.

Duty to make arrangements to provide an appointment with a specialist for those patients urgently referred for treatment for suspected cancer

52.—(1) A relevant body must make arrangements to ensure that persons—

(a) for whom the relevant body has responsibility; and

(b) in respect of whom an urgent referral for suspected cancer is made by—

(i) a general medical practitioner or a person authorised to act on their behalf, or

(ii) a general dental practitioner or a person authorised to act on their behalf,

are provided with treatment for suspected cancer in accordance with paragraph (2).

(2) The requirement referred to in paragraph (1) is that at the end of each data collection period, treatment for suspected cancer has commenced within the period of 2 weeks beginning with the start date in not less than 93% of cases where that treatment is provided in that data collection period.

(3) Where—

(a) the person referred did not attend an appointment made by a health service provider in response to the urgent referral; and

(b) that person had not requested in advance of the appointment that the date for that appointment be rearranged,

the period of time described in paragraph (4) is to be excluded from the calculation of the period of 2 weeks beginning with the start date referred to in paragraph (2).

(4) The period of time to be excluded for the purposes of paragraph (3)—

(a) begins with the start date; and

(b) ends on the date on which the health service provider receives notification from the person who has been urgently referred that they are available again for an appointment for treatment for suspected cancer.

(5) In carrying out its duties under this regulation, a relevant body must have regard to the National Institute for Health and Clinical Excellence Referral Guidelines for Suspected Cancer dated June 2005(3).

Duty to offer alternative provider for treatment for suspected cancer

53.—(1) Paragraph (2) applies where—

(a) a person has been referred urgently for treatment for suspected cancer to a health service provider (“the relevant provider”);

(b) the referral is made by—

(i) a general medical practitioner or a person authorised to act on their behalf, or

(ii) a general dental practitioner or a person authorised to act on their behalf;

(c) the referral is for an appointment with a specialist with a view to diagnosis or treatment of cancer;

(d) the referred person, or a person lawfully acting on their behalf, notifies the relevant provider or the relevant body which has responsibility for the person referred, that they have not had an appointment, or will not have an appointment, within two weeks beginning with the date on which the person’s referral request is received by the relevant provider (“the relevant period”); and

(e) the relevant provider or the relevant body is satisfied that the person referred has not or will not have an appointment within the relevant period.

(2) Where this paragraph applies, the relevant body which has responsibility for the person referred must take all reasonable steps to ensure that the person is offered an appointment in accordance with paragraphs (3) to (5).

(3) The appointment must be with a specialist at a suitable health service provider other than the relevant provider.

(4) The appointment must be at an earlier date than the appointment the person would have had if they had continued to wait for an appointment at the relevant provider.

(5) If there is more than one suitable health service provider the patient must be offered an appointment falling within paragraphs (2) and (3) at more than one such provider.

(6) Paragraph (2) does not apply if the person—

(a) was made aware of the consequences of not attending appointments and did not attend an appointment made by the relevant provider in response to the referral; or

(b) chose not to attend an appointment within the relevant period.

Advice and assistance

54.—(1) Each CCG must—

(a) establish a service for the purpose of providing advice and assistance to persons—

(i) for whom it has responsibility, and

(ii) who meet the conditions set out in regulation 47(2) and (3) or 53(1)(a) to (c) (“relevant persons”);

(b) publish the name and contact details of the service; and

(c) take reasonable steps to communicate the name and contact details of that service to any relevant persons for which it has responsibility.

(2) Each CCG must make arrangements to ensure that any health service provider providing services to a relevant person pursuant to a commissioning contract with that CCG—

(a) establishes a service for the purpose of providing advice and assistance to relevant persons referred to the provider;

(b) publishes the name and contact details of that service; and

(c) takes reasonable steps to communicate the name and contact details of that service to any relevant persons referred to the provider for whom the relevant body is responsible.

Transitional provision

55.—(1) Where, before the relevant date—

(a) a Primary Care Trust or Strategic Health Authority is responsible for a person pursuant to direction 1(4) or (5) of the Waiting Times Directions;

(b) that person falls within direction 3(2) and (3) of the Waiting Times Directions, having been referred before the relevant date,

the relevant body that has responsibility for that person on and after the relevant date must comply with paragraph (2).

(2) The relevant body must ensure that, in respect of a person specified in paragraph (1), it complies with directions 3 to 6 of the Waiting Times Directions in respect of the person as if—

(a) the Waiting Times Directions continued in force on and after the relevant date;

(b) references to “Primary Care Trust” or “Strategic Health Authority” in those directions, and any relevant guidance referred to in those directions, were a reference to the relevant body that has responsibility for that person on and after the relevant date; and

(c) the relevant body had had responsibility for that person from the date on which that person was referred for the purpose of calculating any periods of time referred to in those directions or that guidance.

(3) Where, before the relevant date—

(a) a Primary Care Trust or Strategic Health Authority is responsible for a person pursuant to direction 1(4) or (5) of the Waiting Times Directions; and

(b) that person falls within direction 9(1)(a), (b) and (c) of the Waiting Times Directions, having been referred before the relevant date,

the relevant body that has responsibility for that person on and after the relevant date must comply with paragraph (4).

(4) The relevant body must ensure that, in respect of a person specified in paragraph (3), it complies with directions 9 and 10 of the Waiting Times Directions in respect of the person as if—

(a) the Waiting Times Directions continued in force on and after the relevant date;

(b) references to “Primary Care Trust” or “Strategic Health Authority” in those directions, and any relevant guidance referred to in those directions, were a reference to the relevant body that has responsibility for that person on and after the relevant date; and

(c) the relevant body had had responsibility for that person from the date on which that person was referred for the purpose of calculating any periods of time referred to in those directions or that guidance.

(1)

The Directions can be found at www.dh.gov.uk/en/publicationsandstatistics/Publications/PublicationsLegislation/ DH_113557.

(2)

The Rules Suite can be found at transparency.dh.gov.uk/2012/06/29/rtt-waiting-times-guidance/.

(3)

The Guidelines can be found at www.nice.org.uk/CG027.