1. The National Association for Premenstrual Syndrome One day update on Gynaecology 19 th June 2015 Developments in Community Gynaecology Dr Carrie Sadler GP with a Special Interest in Gynaecology Southern Derbyshire

2. 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

3. The NHS Plan, DH 2000 ‘Improvements in access, quality and responsiveness of services, which in turn would lead to better patient care and satisfaction’

4. 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

5. 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

6. 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’

7. 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

8. ‘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

9. 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

10. --- and with the right skills and equipment  Colposcopy  Hysteroscopy

11. 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

12. 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)

13. 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

14. 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

15. 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.ukwww.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)

16. 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

17. - 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

18. 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

19. Key messages and aims  Work towards a network of care rather than across organisational boundaries  The 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

20. Thank you Dr Carrie Sadler carolynsadler@nhs.net