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How we deliver outpatient hysteroscopy in primary care

Women with heavy menstrual bleeding receive one-stop shop care in a unique service. Dr Anne Connolly and Dr Sian Jones explain

Women with heavy menstrual bleeding receive one-stop shop care in a unique service. Dr Anne Connolly and Dr Sian Jones explain

Collaboration between primary and secondary care clinicians and support from PCT commissioners has resulted in a pioneering abnormal uterine bleeding (AUB) service in Bradford.

41193333It is believed to be the country's only service offering an outpatient diagnostic and treatment hysteroscopy service in primary care, including endometrial ablation performed under local anaesthesia.

Large practice-based commissioning consortiums with budgetary clout or PCTs could transform their gynaecological services by considering our model, which has delivered care closer to home, reduced the distress of heavy menstrual bleeding, reduced referrals for hysterectomy and maximised nurse and GP skills.

Origins of the service

Our model grew out of the opinion-based GPSI gynaecology service set up in 2000 by Bradford South and West PCT (now merged into Bradford and Airedale Teaching PCT) and provided by Dr Anne Connolly.

Nationally, Bradford has been at the forefront of developing GPSI services in many specialties by focusing on building good relationships between primary and secondary care. In gynaecology, consultant gynaecologist Dr Sian Jones, based at Bradford Royal Infirmary, had mentored Dr Connolly, and trained her as a hysteroscopist in 2003/4.

We were frustrated at the limitations of secondary care provision for women with AUB. The hospital did not offer an outpatient endometrial ablation service under local anaesthesia, because of lack of staff and space for patient recovery; and some patients had to attend an outpatient clinic before being listed as a day case.

In 2004, Dr Connolly showed Dr Jones the PCT-built Westwood Park Diagnostic and Treatment Centre (DTC), which had two theatre spaces and a recovery area, and the idea of an out-of-hospital service was born.

How the service developed

We talked to the PCT about our objectives of a new service offering:

• a nurse-led outpatient clinic for patients with AUB who would previously have been sent to hospital for a consultant opinion

• a one-stop diagnostic and treatment service, including resection of small endometrial polyps and fibroids, removal of ‘lost IUDs' and insertion of Mirena

• an outpatient endometrial ablation service under local anaesthesia

• direct listing of patients needing resection of endometrial pathology or endometrial ablation under general anaesthetic at the local secondary care provider

• streamlined access to multidisciplinary team meetings and cancer care network when necessary.

Our care guidelines were based on recommendations from the RCOG, since reinforced by NICE clinical guideline 44, Heavy Menstrual Bleeding, published in January 2007.

The PCT commissioning team collected data from GP practices to assess demand for a service and the finance team developed a business case. The PCT already funded the DTC and the GPSI service, so their main new investment was for scoping equipment (costing an estimated £45,000-£65,000).

We use Gynecare verascopes as they are a small rigid scope with an operating channel, allowing the option of undertaking one-stop operative procedures. A procedure in the DTC would cost around £350, compared with the only other option at the time, a day case at the hospital, costing £550-£650.

41193332The PCT would also need to pay nurse Helen Ludkin, also from Bradford Royal Infirmary, for the weekly clinic she would run at the DTC, and reimburse the hospital for the weekly session Dr Jones would provide at the centre as part of her consultant job plan.

We launched in April 2005. The PCT initially funded one theatre while it assessed clinical risk and later funded the second theatre.

How the service runs

Dr Connolly triages 100-140 general gynaecology referrals every month from the PCT's GPs, about 50-60% of which are sent to the GPSI clinic, the nurse-led clinic or directly listed into our outpatient hysteroscopy clinic.

The nurse-led clinic runs once a week in the morning. Ms Ludkin sees about 10-12 patients, either managing them herself or referring for investigations, scans or hysteroscopy. She can directly access the hospital's surgery list, and as a practitioner is trained to fit Mirenas and carry out cervical cautery and hysteroscopy herself.

In the afternoon of the same day, the three of us (Dr Connolly, Dr Jones and Ms Ludkin) run the outpatient hysteroscopy service.

We can carry out 16 a session – eight in each theatre. If we're ablating, we do three ablations and three diagnostic scopes.

Dr Connolly and Ms Ludkin are about to complete training for endometrial ablation through a course run by Bradford University and the British Society for Gynaecological Endoscopy, in order to perform procedures unsupervised.

The typical patient is 40, and complaining of heavy periods – a subjective problem for her, because it's not the amount of bleeding that is most important, it's how that affects her quality of life.

Following the NICE guidance, we encourage women to try Mirena first, and 70% of them are happy to do this.

If they don't want to use it or previous treatment has caused unpleasant side-effects or had no benefit, we discuss endometrial ablation. We always do a diagnostic scope first then decide whether to offer ablation under a local anaesthetic at our centre or under a general elsewhere.

Ablations are performed using the NovaSure device. Women are advised to have lunch at home and arrive 90 minutes before the procedure, to be premedicated with diclofenac, cyclizine, and tramadol. They receive local anaesthesia beforehand and are discharged one hour after the procedure, taking more antibiotic and analgesia at home. Someone must accompany them home.

Results and patient satisfaction

Since April 2006 we have carried out more than 50 ablations under local anaesthetic. The fact that nearly 90% of women have no periods or only spotting a year after treatment is brilliant (see box above), as other ablative techniques can end up with only a 50% success rate. The treatment dramatically changes women's lives – they can start new jobs, wear white trousers again and gain new confidence.

Longer term results for NovaSure elsewhere have shown a hysterectomy rate after five years of just 3%, compared with 10-15% for other second generation techniques (The Journal of Reproductive Medicine 2007;52:467-72).

We have demonstrated hysteroscopy can be done perfectly well – in fact, better – in primary care, because women need not worry about going to hospital and seeing a consultant. We know many women find it easier talking to nurses and our patients say they are counselled well by Ms Ludkin.

Women also tell us they prefer the quieter environment, good parking facilities and convenient location of the DTC.

How the service affects the local market place

Women from outside our catchment area are now asking to be referred here, thanks to local publicity – especially after we won a NICE shared learning award last year, and the fact we are the only provider locally to offer procedures under local anaesthetic.

The hospital has also referred some women to us after they have carried out diagnostic scoping, because they are at a high risk for general anaesthesia (for example, obese) or because they have requested a local.

However Bradford Royal Infirmary seems to have preserved its business for women needing procedures under a general. There are seven secondary care providers locally but because they have often first met Dr Jones in the DTC, they will often choose the hospital to continue to be treated by her.

Training and governance

GPSIs in Bradford must be approved by a PCT panel every three years by meeting training and governance requirements. Gynaecology specialists and GPSIs meet three times a year to talk about patient management in Bradford.

On top of their hysteroscopy and ablation training, Dr Connolly and Ms Ludkin last year gained a practitioner with a special interest diploma. Dr Connolly has recently been accredited for a further three years to carry on as GPSI.

Our most recent service audit also confirmed we were following NICE guidance. Patients are regularly surveyed, and we held a focus group for those who had undergone ablations, which led to minor alterations being made to our information leaflets.

The future for our service

The next step is to pioneer the first outpatient hysteroscopic sterilisation in primary care. One existing device is excessively expensive but we have been asked to be a pilot site for a new device coming to the market soon and hope to offer this service in the coming months.

Advice for clinicians and commissioners

The only way this model will work is by ensuring GPs do not set up services in isolation and have a good relationship with local consultants. If we need to admit

a patient urgently, we want a relationship in place to access acute hospital beds and ask for advice. You also have to identify the local need for a service, have secure premises and equipment and ensure staff are trained. We have shown most women can tolerate procedures under a local, as long as the training, safety, governance, and support are there.

GPs with MRCOG might be natural pioneers of such services, and equally GPs with an interest in women's health can gain the necessary skills, as we have shown in Dr Connolly's case.

There is no dedicated hysteroscopy course for GPs, however GPs can attend the national nurse hysteroscopist training run by Dr Jones since 2001 in conjunction with Bradford University. Further details can be found in a paper in Reviews in Gynaecological Practice (2005;5:196-199).

Dr Anne Connolly is a part-time job-sharing GP and a GPSI in gynaecology in Bradford


Dr Sian Jones is a consultant gynaecologist in Bradford and immediate past president of the British Society for Gynaecological Endoscopy

Consultant gynaecologist Dr Sian Jones

Dr Sian Jones (left) and GPSI Dr Anne Connolly say a good working relationship between primary and secondary care is vital Dr Sian Jones (left) and GPSI Dr Anne Connolly Audit results 60 second summary

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