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Practical Commissioning editor Rebecca Norris explores why urology schemes are underdeveloped in primary care

Practical Commissioning editor Rebecca Norris explores why urology schemes are underdeveloped in primary care

Urology was one of the six specialities selected in 2006 by the Department of Health in which to test out ‘care closer to home'during a year-long project. Yet it is telling that only one of the five urology demonstration sites directly involved GPs. In that case, forward-thinking urologists in Bradford trained GPs to carry out diagnostic flexible cystoscopies in a community setting. In the other sites, care was shifted from acute trust settings but still carried out by secondary care employees, such as a community-based ultrasound service for testicular lumps.

Similarly, there has been a dearth of urology projects set up under practice-based commissioning compared with other specialties such as orthopaedics or dermatology. A mix of practical, professional and financial factors seems to have caused the lack of schemes.

Urology is a big earner for hospitals, and foundation trusts in particular may be reluctant to support community-based schemes that rob them of income. Managers may pressure consultant urologists to resist overtures from would-be GPSIs looking for mentors or from PBC groups wanting to discuss new pathways.

THE SKILLS GAP

GPs themselves may not have the time or inclination to acquire new diagnostic skills and diplomas to allow them, for example, to carry out flexible cystoscopies. This could

create a skills gap that makes new services unsustainable. The independent evaluation of the care closer to home sites, published in June by the National Primary Care Research and Development Centre at Manchester University, warned that new community models should not revolve around a sole specially trained professional whose role cannot be covered when they take holiday or sick leave – or if they leave the service or area altogether.

Clinic and equipment availability – as well as decontamination requirements – are also considerations for some service redesigns. In Bradford, the community service co-exists on a site where endoscopy procedures are performed by other specialists to cover the costs involved, the evaluation noted.

The barriers facing GPs are brought to life in Dr Jonathan Rees'article about his efforts to set up a microscopic haematuria service. But with a supportive PCT, friendly urologist, or persuasive costeffectiveness plan, GPs can pioneer changes – as Dr Ashok Deshpande describes in his tale on telemedicine and Dr Mike Callander explains in the story of his erectile dysfunction service.

AN IDEAL OPPORTUNITY

The Department of Health's own report on the care closer to home sites, published in October, argues that urology's increased medicalisation, combined with increasing portability of diagnostic equipment, provides ‘an ideal opportunity to start managing a growing urological workload in community settings'.

In particular, LUTS (prostatism), andrology (impotence, infertility and penile lesions), testicular symptoms (pain and lumps), and incontinence (mainly female) will be suitable for investigation and treatment in the community carried out by suitably trained staff, including GPSIs. There are also many instances of out-of-hours problems in patients with chronic low-risk conditions that would ‘benefit enormously' from being managed closer to home, adds the report.

The catalyst for this shift may arrive next April, when the first of new-style consultants complete their training. They have been through a revamped programme introduced in response to the advances and changes in urology, which equips them to work both in the community and acute sector. According to the department's report, they ‘could form the backbone of a new, seamless urology service'.

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