Written questions by Pochin.

Whether he plans to review national protocols that require the automatic cessation of Clozapine following a single red blood result, in the context of cases where such results have subsequently been found to be spurious.

Clozapine is used to treat people with schizophrenia in whom other medicines have not worked and it is also used to treat severe disturbances in the thoughts, emotions, and behaviour of people with Parkinson’s disease in whom other medicines have not worked.Clozapine is associated with potentially life threatening side effects including the risk of agranulocytosis. Patients must have regular blood tests to ensure their white blood cell count doesn’t drop too low which is classified as a red result. Clozapine may only be taken if the patient has a normal blood count.As with all medicines, the safety of clozapine is kept under continual review by the Medicines and Healthcare products Regulatory Agency (MHRA) using a number of data sources including reports of suspected side effects through the Yellow Card Scheme, data from marketing authorisation holders, and research published in the scientific literature.The MHRA is currently reviewing the blood monitoring requirements associated with clozapine, to ensure these continue to minimise the risk of agranulocytosis whilst allowing patients to access clozapine when needed. Currently, the product information for clozapine, including the summary of product characteristics states that patients must stop clozapine if a red result is obtained and that they should not be re-exposed to clozapine.

What assessment he has made of the reliability of current systems for transporting and processing serum Clozapine blood samples across NHS providers.

No specific assessment has been made of the reliability of current systems for transporting and processing serum Clozapine blood samples across National Health Service providers. Operational responsibility for the collection, transport, and processing of clozapine blood samples lies with individual NHS providers and their commissioned pathology and courier services. Further information on sample type and transport stability is available via individual NHS trust laboratory webpages.Testing for clozapine levels is carried out within the same accredited pathology framework used for other biochemical assays, with defined requirements for sample collection, labelling, storage and transport to maintain sample integrity. Laboratories providing clozapine assays hold UKAS ISO 15189 accreditation and are required to undertake internal quality control and participate in national External Quality Assessment schemes to ensure accuracy and reproducibility of results.Samples are transported through contracted courier services operating temperature controlled logistics, chain of custody processes and turnaround time requirements. These arrangements form part of routine clinical governance, incident reporting and performance management across NHS pathology services to prevent sample loss and provide assurance on the reliability of testing. Detailed operational arrangements are managed locally by individual pathology providers.

What steps he is taking to prevent serum Clozapine blood samples from being lost in transit within the NHS.

No specific assessment has been made of the reliability of current systems for transporting and processing serum Clozapine blood samples across National Health Service providers. Operational responsibility for the collection, transport, and processing of clozapine blood samples lies with individual NHS providers and their commissioned pathology and courier services. Further information on sample type and transport stability is available via individual NHS trust laboratory webpages.Testing for clozapine levels is carried out within the same accredited pathology framework used for other biochemical assays, with defined requirements for sample collection, labelling, storage and transport to maintain sample integrity. Laboratories providing clozapine assays hold UKAS ISO 15189 accreditation and are required to undertake internal quality control and participate in national External Quality Assessment schemes to ensure accuracy and reproducibility of results.Samples are transported through contracted courier services operating temperature controlled logistics, chain of custody processes and turnaround time requirements. These arrangements form part of routine clinical governance, incident reporting and performance management across NHS pathology services to prevent sample loss and provide assurance on the reliability of testing. Detailed operational arrangements are managed locally by individual pathology providers.

How learning from serious incidents involving accidental Clozapine withdrawal is being recorded and shared nationally across NHS mental health services.

Clozapine is used to treat people with schizophrenia in whom other medicines have not worked. It is also used to treat severe disturbances in the thoughts, emotions, and behaviour of people with Parkinson’s disease in whom other medicines have not worked.The known side effects of clozapine are outlined in the product information, the Summary of Product Characteristics (SPC) for healthcare professionals, and the Patient Information Leaflet which is provided in each pack of the medicine. The SPC states that clozapine should be stopped in a number of clinical situations including after developing a low white blood cell count, fever above 38oC, high blood glucose, also known as hyperglycaemia, as well as jaundice or clinically relevant increases in liver enzymes. If clozapine is restarted it must be carefully titrated and monitoring requirements followed.Inadvertent withdrawal of clozapine is an issue that is included in the National Health Service’s Time Critical Medicines Safety Improvement Programme, with further information available at the following link:https://www.sps.nhs.uk/articles/safer-use-of-time-critical-medicines-programme/The programme is supporting over 50 NHS hospitals to improve the reliability of administration of Time Critical Medicines such as clozapine.In July 2024 a thematic review of clozapine safety conducted in the North West of England was shared with the NHS England National Medication Safety Officer Network. This included a range of clozapine safety resources published online, such as:- Managing the risks associated with patients prescribed clozapine, which is available at the following link: https://www.sps.nhs.uk/articles/managing-the-risks-associated-with-patients-prescribed-clozapine/;- Clinical considerations for patients prescribed clozapine, which is available at the following link: https://www.sps.nhs.uk/articles/clinical-considerations-for-patients-prescribed-clozapine/;- Managing constipation in people taking clozapine, which is available at the following link: https://www.sps.nhs.uk/articles/managing-constipation-in-people-taking-clozapine/;- Clozapine use in adults with swallowing difficulties, which is available at the following link: https://www.sps.nhs.uk/articles/clozapine-use-in-adults-with-swallowing-difficulties/;- Managing specific interactions with smoking, which is available at the following link: https://www.sps.nhs.uk/articles/managing-specific-interactions-with-smoking/; and- Managing complexities of medication use across care boundaries, which includes a podcast on clozapine safety and which is available at the following link: https://www.sps.nhs.uk/articles/managing-complexities-of-medication-use-across-care-boundaries/. As with all medicines, the safety of clozapine is kept under continual review by the Medicines and Healthcare products Regulatory Agency (MHRA) using a number of data sources. The MHRA is currently reviewing the blood monitoring requirements associated with clozapine.

What assessment he has made of the adequacy of laboratory and record-keeping systems supporting Clozapine treatment, and whether they meet the standards expected for equivalent safety-critical medicines in physical healthcare.

NHS England’s National Patient Safety Team collect records of all patient safety incidents recorded by National Health Service trusts via the Learn From Patient Safety Events service. These records are used to identify new and under-recognised risks to patient safety and to understand themes and trends. The insight generated informs work to improve patient safety across the NHS. Further information is available at the following link:https://www.england.nhs.uk/patient-safety/patient-safety-insight/learning-from-patient-safety-events/using-patient-safety-events-data-to-keep-patients-safe/#The safety of clozapine is kept under continual review by the Medicines and Healthcare products Regulatory Agency (MHRA) using a number of data sources, including reports of suspected side effects through the Yellow Card Scheme, data from marketing authorisation holders, and research published in the scientific literature.Each clozapine marketing authorisation holder operates a Patient Monitoring Scheme which focuses on the blood monitoring requirements for clozapine. However, regular contact with healthcare professionals caring for patients receiving clozapine has resulted in a high proportion of suspected side effects being reported through the Yellow Card scheme. These reports are published by the MHRA in the interactive drug analysis profile for clozapine, with further information available at the following link:https://yellowcard.mhra.gov.uk/idaps/CLOZAPINE The Summary of Product Characteristics for clozapine outlines the monitoring requirements needed to minimise the risks of possible side effects for healthcare professionals. However, the MHRA does not regulate clinical practice or audit NHS record-keeping systems.

Whether his Department was consulted prior to the publication of the British Medical Journal article concerning terminology used in relation to female genital mutilation.

The Department was not consulted prior to the publication of the British Medical Journal Article concerning terminology used in relation to female genital mutilation.The Government does not tolerate female genital mutilation which can cause extreme and lifelong physical and psychological suffering to women and girls. The focus remains on preventing these crimes from happening, supporting and protecting survivors and those at risk, and bringing perpetrators to justice.This includes a mandatory reporting duty for regulated health professionals to report cases of female genital mutilation in girls under 18 years of age to the police.

Whether NHS England has issued guidance to clinicians on appropriate language to use when recording, reporting and discussing cases of female genital mutilation.

The Home Office, the Department for Education, and the Department of Health and Social Care issued multi-agency statutory guidance on female genital mutilation (FGM), which as updated in July 2020. The guidance ensures that health and other staff understand their role in responding to FGM, and that there are policies and procedures in place to protect women and girls who have undergone or are at risk of FGM.NHS England is currently updating the e-learning training for the Healthcare FGM Module for publication in 2026. This training has a section on communication and includes the importance of sensitive language, including asking healthcare staff to check which terminology the woman or girl prefers. The training will provide healthcare staff with the skills to consider, recognise, and discuss FGM with the women and girls they support, and provide sensitive and trauma-informed response.

What data sharing agreements are in place governing access to PATHWAYS trial participant data by external researchers or academic institutions.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

What role NHS England played in determining the eligibility criteria for children recruited into the PATHWAYS trial.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

What steps he plans to take to ensure that Parliament is provided with adequate opportunities for scrutinising progress and outcomes of the PATHWAYS trial while it is ongoing.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

Which international clinical guidelines were used in the design of the PATHWAYS trial.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

If he will take steps to ensure that the PATHWAYS trial does not adversely affect a participant’s future access to NHS care.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

What assessment has been made of the compatibility of the PATHWAYS trial with the Cass Review recommendations on clinical caution and evidence thresholds.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

Whether Ministers approved the commencement of the PATHWAYS puberty blocker trial.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

Whether children previously discharged from NHS gender services will be eligible for the PATHWAYS trial.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

Whether the Department has received formal representations from professional medical bodies regarding the PATHWAYS trial since ethical approval was granted.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

What indemnity arrangements are in place for clinicians involved in prescribing puberty blockers under the PATHWAYS trial.

The Government is committed to supporting research that delivers a robust, evidence-based understanding of the needs, and support and treatment options for children and young people living with gender dysphoria. A partnership between NHS England and the National Institute for Health and Care Research (NIHR) is working to fund and deliver independent research that fulfils that aim.One element of this is the PATHWAYS trial, a carefully designed clinical trial to assess the relative benefits and harms of puberty-suppressing hormones as a treatment option for children and young people with gender incongruence. The trial protocol is publicly available on the NIHR website, at the following link:https://fundingawards.nihr.ac.uk/award/NIHR167530.This positively responds to the Cass Review’s recommendation that a clinical trial, alongside a broader programme of research, was necessary to gather the evidence required into the most effective way to care for this group of children and young people.The trial was designed and will be delivered by an independent research team. This was in conjunction with patient and public involvement as well as independent clinical and legal experts, including those who specialise on medical ethics. This team is responsible for the protocol design, including eligibility criteria, consent, and outcomes.The proposal has been through all the usual review and approval stages ahead of set up and opening to recruitment. These include independent academic peer review, NIHR funding committee consideration, and a full regulatory review, including a focus on ethics. It has obtained approval from the regulatory authorities, including the Health Research Authority Ethics Committee and the Medicines and Healthcare products Regulatory Agency.

What guidance his Department provides to NHS bodies regarding engagement with external academic publications that discuss practices which are illegal under UK law.

In the United Kingdom, regulated healthcare professionals are required by law to maintain standards in competence, ethics, patient safety, and accountability. Failure to meet these standards can result in investigation, restrictions, suspension, or permanent removal from the register. Responsible employment practices are an important element in ensuring all those working in the research and innovation system can thrive and deliver high quality research.Researchers funded through UK Research and Innovation (UKRI), National Institute for Health and Care Research (NIHR), and other publicly funded sources are expected to comply with the highest standards of research ethics and integrity, including responsible publication practices. Both UKRI and NIHR are signatories to the Concordat to Support Research Integrity.The NIHR's support for the San Francisco Declaration on Research Assessment aligns with its dedication to research integrity, transparency, and fostering a culture where research excellence is measured in a more holistic and meaningful way.

What assessment his Department has made of the potential impact of peer reviewed medical journals publishing articles that propose alternative terminology for practices that are criminal offences in the United Kingdom on patient safeguarding and public confidence.

In the United Kingdom, regulated healthcare professionals are required by law to maintain standards in competence, ethics, patient safety, and accountability. Independent professional regulators, such as the General Medical Council and the Nursing and Midwifery Council, safeguard public health by establishing and enforcing standards. They maintain registers and ensure accountability. Although they operate independently from the Government, they function within statutory frameworks and are accountable to Parliament.Funders of research, including UK Research and Innovation (UKRI) and the National Institute for Health and Care Research (NIHR), builds assessment of skills into the research funding process. During the grant application process, proposals undergo expert peer review where all relevant skills, including statistical skills are assessed. In addition, UKRI and NIHR are signatories to the Concordat to Support Research Integrity.The Department has not made an assessment of the potential impact of peer reviewed medical journals publishing articles that propose alternative terminology for practices that are criminal offences in the United Kingdom on patient safeguarding and public confidence.

If he will commission an independent audit of pre-listing referral management processes and reporting of delays across NHS trusts.

For referral to treatment (RTT) pathways that start within an interface service, which is any form of intermediary clinical triage, assessment, and/or treatment between primary and secondary care, a patient's clock start will begin at the point the general practice referral is made and not the date that the referral is received by the secondary care provider. Further information can be found in the RTT consultant-led waiting times: rules suite guidance document, which is available at the following link:https://www.gov.uk/government/publications/right-to-start-consultant-led-treatment-within-18-weeks/referral-to-treatment-consultant-led-waiting-times-rules-suite-october-2022The complete time elapsed between referral and treatment will be recorded on the published consultant led RTT waiting time data, at the following link:https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-data-2025-26/Advice and Guidance (A&G) is where a general practitioner requests advice from a specialist digitally, prior to or instead of a referral, and it has helped divert over 655,000 referrals between April and August 2025. The NHS Electronic Referral System, the platform used for most A&Gs, can allow the specialist to "convert" a request into a referral. An RTT waiting time clock would not commence unless the request is converted to a referral. Where a referral to the waiting list is not required, we expect patients to receive care sooner, in a more convenient setting, having benefitted from specialist advice to inform their care management plan.The Medium-Term Planning Framework, published in October 2025, outlines plans to move toward delivering care through a ‘Single Point of Access’. This describes a model where all appropriate referrals and requests, other than those for urgent suspected cancer, are directed through a single ‘front door’ to support triage to the most appropriate next step or outcome for the patient. This will help ensure a more consistent approach to triage which provides quicker access to patients.There are no plans for an independent audit of pre-listing referral management processes and reporting of delays across National Health Service trusts.