Waiting lists should be validated and prioritised in two or three stages:

Stage 1 – Administrative validation: ensure the waiting list is accurate and up to date. All patients on an admitted pathway should receive either a telephone call or letter to identify their preferred next step to establish one of the following preferences:

• remain on the waiting list and proceed to treatment planning.
• remain on the waiting list and postpone treatment.
• remove from the admitted waiting list.

In order to ensure the best possible outcomes and safeguard vulnerable patients, patients should not be removed from the waiting list without a clinical decision and communication and agreement with the patient.

Stage 2 – If the patient requires treatment and does not need a clinical review: The clinician may decide to prioritise the patient without further discussion, but only if there is enough information to clinically prioritise, and feedback from the patient supports this approach. This decision should take into account any other ongoing medical investigations or interventions or any potential barriers or considerations regarding ethnicity, language barriers, multi-morbidity or other factors relating to health inequalities. It should also include an assessment whether the patient meets the criteria of the EBI guidance where they are waiting for one of the 17 EBI interventions.

Stage 3 – Where it is determined that a full clinical review is required with the patient: If a clinician and/or patient determines a full shared decision-making conversation is required to determine the next steps with the patient then this must occur. This includes an assessment as to whether the patient meets the criteria of the EBI guidance where they are waiting for one of the 17 EBI interventions.

The outcome of any conversation or decision should be communicated to the patient and their GP and/or referrer in writing, ensuring that patients are provided with an appropriate point of contact for any queries.

There is EBI guidance for the 17 surgical interventions on the Academy of Medical Royal Colleges website.

Appendix G in the clinical validation of surgical waiting lists framework also has more information.

There are five categories, of which four relate to the clinical prioritisation of elective care patients (P1 relates to emergency patients). Categories P2-P4 relate to the period of time in which it would be clinically appropriate for a patient to wait for their procedure. The P6 Category should be used for patients who wish to delay their procedure. The descriptions of the categories are show in appendix D of the clinical validation of surgical waiting lists framework.

Please refer to the draft national dataset requirements for further information. This can either be captured on a local system or on e-Review which is designed to capture the correct information.

Existing patients within P5 should be re prioritised and contacted to establish their preferences. Those choosing to continue to wait will move into the P6 category in line with local access policies. Patients wishing to proceed should be re prioritised into the appropriate priority category.

The RTT clock will remain active and continue for the P6 patient cohort. Recording this information will enable the provider and the wider NHS to understand the impact of these patient cohorts on the waiting list and RTT performance.

Yes – it would be helpful to ensure you are recording the data required at the time of the appointment and avoid the need for a retrospective process.

If the validation was completed before 1 June 2020, please repeat as the clinical condition of the patient and their wishes may have changed. If you have communicated with patients on their prioritisation category since 1June 2020, only undertake the administrative part of the validation process.

In phase 1, providers are asked to validate and prioritise all active patients on an elective admitted pathway waiting list. There will be some circumstances where patients who are not on a referral to treatment (RTT) pathway are clinically appropriate to include within the validation programme. This should be determined locally.

We recognise that the total size of the admitted waiting list may be different to the total incomplete RTT pathway dataset.

It is at the provider’s local discretion to determine if this cohort of patients is reviewed.

Patients should be allocated a P code when the decision to admit is made. The patient should be re-reviewed if the patient isn’t booked within the indicated timeframe for the priority level, or if otherwise indicated as required, or, at the latest, after 6 months.

It is important for providers to record whether any of the patients in this cohort are P6, that is, if they have delayed or wish to delay their treatment, as this category was only established from October 2020.

If a patient wishes to delay their treatment, it is critical they are informed of the risks and impact of the delay on their health and wellbeing. If the patient insists on delaying treatment despite the risks associated, a suitable follow-up appointment should be agreed with them to review their care and offer appropriate support. The patient’s record should be updated to P6 (. The outcome of any conversation or decision should be communicated to the patient and their GP and/or referrer in writing, ensuring that patients are provided with an appropriate point of contact for any queries.

Providers may wish to highlight high risk P6 patients who were previously categorised as P2 or P3. This will ensure these patients are re-reviewed in an appropriate timescale.  Each patient must be given a date by which they will be re-reviewed in the future. For high risk patients this will be a shorter timeframe.

Yes – all referrals for an admitted pathway.

No – we anticipate that most clinical reviews will be undertaken by clinical staff at the direction of the consultant. This could include registrars, specialist nurses, extended scope practitioners. There will be a cohort of patients the consultant will wish to personally review, and this should be determined locally.

Reporting should be in line with the national clinical prioritisation programme. We would ask that the priority categories are mapped across for reporting purposes.

Patients should have been validated and prioritised by the NHS provider as part of the decision to transfer treatment to the independent sector. There is no requirement for the independent sector provider (ISP) to re-review this cohort of patients.

Where the patient has been directly referred to the ISP, the patient will still require validation and prioritisation in line with national access reporting requirements.

Clinical prioritisation should not be used as a mechanism to help meet an access target.  Prioritisation must be based solely on the clinical needs of the patient in line with the Royal College of Surgeons guidance and prioritisation codes (see Appendix C).  Providers must not change a patient’s ‘P’ code simply because they have waited over a specific time threshold if their level of clinical need has not changed.

Where a clinician has determined, following review, that further delays to a patient’s procedure or treatment would be detrimental to their mental or physical health – taking into account comorbidities and other health needs – then a change in clinical prioritisation would be appropriate.  A change in prioritisation code should be discussed and agreed with the patient so that they are aware and happy to proceed with any change in timeframes for the delivery of their treatment. Patients should continue to be re-prioritised in line with the timeframes attached to their prioritisation code.

We recognise that the timeframe covered within the P3 category is broad, and there may be variation in the level of clinical need within that category. Providers may wish to implement their own local clinical and operational guidelines in order to further prioritise P3 patients and manage this variation. Patients should not be moved into a higher category unless deemed appropriate following clinical review, in line with FSSA guidance.

In line with National RTT rules, a patient’s RTT clock would continue to tick should they choose to delay treatment for personal or social reasons. These patients should be prioritised and recorded on local systems as a P6.

Section 7.1.1 of the recording and reporting RTT waiting times guidance, which relates to the duration of patient-initiated delays, states that “Trusts must not have blanket rules that apply a maximum length to patient-initiated delays that does not take account of individual patient circumstances. Trusts should have mechanisms in place to protect patients who may come to harm by choosing to delay their treatment”.

Delays as a result of patient choice are taken account of in the tolerance of 8% set for achievement of the incomplete pathway waiting time operational standard.

It is good practice to monitor whether patients are being booked in for treatment within the timescale indicated for their priority level. For example, a patient categorised as P2 should be treated within one month of the date that their priority coding was assigned. It is also important to ensure that all new patients are assigned a P code as soon as possible, ideally as part of the decision-making process when being added to the admitted waiting list. It is advised that patients with a decision to admit but no P code are also monitored. Integrated Care Systems (ICSs) may find it useful to ensure they have an understanding of providers’ process and timescale for recording P codes, so that compliance with these timescales can be monitored effectively.