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How to use telemedicine to diagnose BPH

Trained GPs can diagnose benign prostatic hyperplasia in primary care with the right equipment and support, says Dr Ashok Desphande

Trained GPs can diagnose benign prostatic hyperplasia in primary care with the right equipment and support, says Dr Ashok Desphande

Elm Park Consortium is one of Havering PCT's seven PBC groups and comprises three large practices covering around 30, 000 patients. Provision of an innovative diagnostic service for benign prostatic hyperplasia from one of those practices, Wood Lane Surgery, and an intermediate gynaecology service, was an integral part of the consortium's PBC business plan approved by the PCT.


The service was originally started under fundholding with a pilot of 50 patients and has since developed to be commissioned under PBC for the PCT's entire population.

Before the service was developed, patients with suspected BPH were referred by their own GP to a consultant urologist at Barking, Havering and Redbridge Hospitals NHS Trust, and had to wait for about 30 weeks to be seen in outpatients. We submitted a business plan to improve patient care by:

• providing diagnostic services for BPH and promoting medical management in primary care

• improving patient access and convenience

• reducing waiting time for BPH diagnosis

• improving the appropriateness of referrals to secondary care

• reducing the acute trust's waiting time for outpatients to under 18 weeks, to free up the consultant's time for more complex cases.

A panel comprising a GP clinical governance lead, a consultant urologist from the acute trust, a public health representative, a PCT project development officer and a locality lay member recommended the service be given the go-ahead.

Under the new system, men who are experiencing lower urinary tract symptoms (LUTS) caused by possible prostatic hyperplasia are referred to the primary care assessment service that I run in two sessions each week from my practice.

This service is a shared-cared urology programme developed in conjunction with a local consultant urologist, which builds on the pathway recommended by the British Association of Urological Surgeons (BAUS) guidelines.

Patients are offered full clinical assessment of BPH/LUTS, including ultrasound scans of prostate, bladder and kidneys, along with uroflowmetry. During the consultation, images of the ultrasound scans are transmitted through an ISDN link to a radiologist at the University of Portsmouth, who reads them in real time. This link-up also includes audio and video contact, to allow direct discussion while the patient is being examined.

The high-quality ultrasound machine with a built-in computer can save up to 6, 000 images. It is connected to a standalone PC loaded with video-conferencing software. Both the ultrasound machine and PC are connected via an ISDN link (128kb/sec) to the university.

After assessment the treatment plan is then discussed with the patient and communicated with his own GP.


Initially there was resistance from hospital consultants to the plan, particularly to the idea of a GP carrying out scans. Luckily, one of the consultants decided to support the scheme and acted as my mentor while I gained a postgraduate diploma in urology from the University of Middlesex. This required practical experience of carrying out 200 supervised scans.

An audit of the service was presented to the National Association of Primary Care's annual conference in 2006. It shows:

• The primary care service has cut referrals to secondary care by 76%, with the remainder referred to the acute trust's one-stop clinic.

• The cost of providing the primary care service is £100 per patient (including ultrasound scans and uroflowmetry) as against £400 in secondary care, agreed through a service level agreement between the practice and PCT.

• The capital costs of establishing the service – £32, 500 for the ultrasound scanner, uroflow meter, stand alone PC, videoconferencing software and an ISDN line – were recouped within the first year.

• Overall the scheme saves about £62,000 per 200 patients.

The quality of shared and forwarded images (SAFIs) generated in our service has been independently analysed by a consultant radiologist against hard copy images; 90% of them were regarded as highly significant for diagnostic and technical quality (Journal of Telemedicine and Telecare 2004;10: 180-2).


41164932 Patients and GPs are delighted with this service. A survey carried out independently by the PCT's direct booking service showed 87% of patients thought the service was excellent and not one gave it a negative remark.

The majority of patients wait no longer than 10 minutes to be seen. This innovative project has been able to cut waiting times at the local acute hospital below 13 weeks. Moreover it has helped to relieve the anxiety developed in patients before diagnosis of prostatic problems.

It has also demonstrated that it is fasible for trained and supervised GPs to undertake tele-ultrasound consultations. This can improve their job satisfaction and motivation, enhance the GP's clinical judgment and result in appropriate and authoritative referrals.

The scheme is now attracting attention from many quarters. Health minister Ben Bradshaw (who is responsible for PBC) is due to visit our practice this month to see how the service works.

In my opinion, PBC is here to stay whether we like it or not. And rather than be left with no choice over how services are delivered, you might as well be in the driving seat.

Dr Ashok Deshpande is a GP and GPSI in urology in Hornchurch, Essex

60 second summary Audit Urology Patient Care Pathway LUTS/BPH Assessment Urgent Care Pathway Dr Ashok Deshpande performs an ultrasound scan Dr Ashok Deshpande performs an ultrasound scan

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