The National Association for Premenstrual SyndromeOne day update on Gynaecology

19th June 2015

Developments in Community Gynaecology

Dr Carrie Sadler

GP with a Special Interest in Gynaecology

Southern Derbyshire

A culture change in gynaecology ---

The background Why it is happening How it is happening Southern Derbyshire CCG Community Gynaecology Pilot The benefits and the difficulties How will it reduce costs for the NHS? Key messages

The NHS Plan, DH 2000

‘Improvements in access, quality and responsiveness of services, which in turn

would lead to better patient care and satisfaction’

High Quality Women’s Healthcare: A proposal for change

Royal College of Obstetrics and Gynaecology, July 2011

Care should be provided closer to home. Patients should be seen in a hospital setting for complex care

Healthcare standards must be consistent, evidence based and applicable to all providers

Providing the right care, at the right time, in the right place and provided by the right person, enhancing the woman’s experience

Women should be at the centre of their own care described as a ‘life course’ approach

Other key points from policy documents

The development of practice based commissioning - GPs to be involved in the provision of new services

Patients should have a stronger voice- not only with respect to their own health but also in the strategic development of new and existing services

Health professionals have responsibilities in line with their level of expertise and experience with the development of specialist roles within primary care

The GP with a Special Interest, GPwSI

‘A GP with appropriate experience who is able to deliver a service in the community working in an

area outside the normal remit of General Practice’

Why it has to happen A political drive

Financial pressures against a backdrop of rising demand there has been a year on year rise in referrals for outpatient obstetrics and gynaecology. They account for the highest volume of outpatient attendances at 11.4% of all annual referrals

Increasing complexity of secondary care: Need for consultant cover on the labour wards Improved outcomes in cancer 5 year survival rates with improved specialist care

-------- the delivery of women’s healthcare in the current configuration cannot be sustained

‘There has been a year on year rise in referrals for outpatient obstetrics and gynaecology. They account for the highest volume of outpatient attendances at 11.4 % of all annual referrals’

High Quality Women’s Health Care: A proposal for change

Royal College of Obstetrics and Gynaecology, July 2011

Gynaecological conditions that could be managed in the community

• Menstrual disorders (including pipelle sampling)• Removal of small cervical polyps• Polycystic ovarian syndrome/amenorrhoea• Menopause• Continence, pelvic floor and ring pessaries• Premenstrual disorders• Complex contraception/ difficult coil removals/fittings• Sterilization counselling• Pelvic pain/endometriosis• Vulval disorders

--- and with the right skills and equipment

Colposcopy

Hysteroscopy

Southern Derbyshire CCG Community Gynaecology Pilot

Aim: To explore a new model of service delivery looking at demand, costings, patient and GP satisfaction

Running for 6 months from April to September

One morning a week based at St Oswald’s hospital

Ashbourne. Ultrasound facilities available

Accepts referrals from four local practices

Facility for GPs to seek advice by direct contact with clinic,

e-mail enquiry

Referrals received and triaged through C&B

Facility for direct listing for hysteroscopy Royal Derby Hospital

Refferals accepted

Abnormal uterine bleeding in pre and perimenopause

- not postcoital or postmenopausal bleeding

Removal of cervical polyps

Difficult coil insertions and removals

Management of menopause and premenstrual

disorders

Management of PCOS and amenorrhoea (not fertility)

Summary of first 20 patients contacts in Community Gynaecology Pilot Clinic

All patients triaged and appointment confirmed within

48 hours and seen within 4 weeks 11 discharged back to GP 2 referred back to GP to action a 2ww referral 4 referred directly for hysteroscopy (2 endometrial

polyps, 2 abnormal scans) 3 ongoing referral through C&B to RDH

- 2 for endometrial ablation

- 1 for laparoscopy +/- ablation No DNAs 2 follow up- patient request

Early feedback from Community Gynaecology Pilot

Patient feedback:

‘Fantastic facilities, so close to home. Don’t have the trauma of travelling to Derby, parking etc.’

‘Access very good in terms of speed of appointment provision and location, including parking. An otherwise unpleasant experience improved immensely.’

‘It was fantastic to be seen quickly, at a local hospital with a local Dr. Excellent service-

can’t fault it’

‘I felt very well looked after and listened to. I had a womb biopsy and a Mirena coil fitted. So the whole thing was excellent, thank you’

‘Very happy with the service and would recommend it to other people. Very pleased indeed’

‘The fact I had continuity of care close to my home was a great benefit and the fact that the procedure was carried

out by my GP was good’

GP involvement: Eleven advice requests received – aim to respond within 5 days GP evaluation planned for July Development of training programme for pipelle endometrial sampling for GPs with an interest in gynaecology

Evidence for the benefits of community based services

1. Modernisation Agency: Activity analysis; Action on ENT Modernisation Agency: Action on ENT, (2002). www.modern.nhs.uk

2. Evaluation of a general practitioner with special interests led dermatology service in primary care: randomised controlled trial (RCT) and economic evaluation

Coast et al (2005). BMJ 331, 1444-1449

3. A study of GP and women’s views on management of and service provision for the menopause in primary care

Sadler et al (2007). Menopause International 13, Vol4, 206

4. Telephone conversations with 9 colleagues around the country GPwSIs, gynaecologists and a sexual health services consultant ( June 2013)

What has worked well

Better access, shorter waiting times and efficient management of the problem Access to ultrasound: essential in enabling provision of a wide range of gynaecology care in the community Triage of referrals by a clinician so the patient can be seen by the right person in the right place The facility to give advice to the GP avoiding unnecessary referrals and improving referral patterns in the future Having a good relationship and working with hospital colleagues Opportunities for training Patient and personal satisfaction

- and the problems

Ensuring robust administration and IT support

Secondary care and GP colleagues not engaging

Capacity and demand

GPwSIs and consultants working on their own can feel isolated and pressured

Can we reduce costs ?

Lower tariff costs, fewer overheads

Referral management: structured feedback to GPs

One stop shops

Collaboration of primary and secondary care: ability for GPwSI to refer directly onto hospital lists

Key messages and aims

Work towards a network of care rather than across organisational boundariesThe person should be seen in the right place, at the right time by the right person One stop shops with follow ups kept to a minimum are acceptable to patients and reduce costs Need robust IT and administrative support Good working relationships between primary and secondary care is key to success

Thank you

Dr Carrie Sadlercarolynsadler@nhs.net