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How we set up a one-stop menstrual disorder clinic

Bringing gynaecological ultrasound into the community has dramatically reduced waiting times and referrals, writes Dr Kalpesh Shah

Bringing gynaecological ultrasound into the community has dramatically reduced waiting times and referrals, writes Dr Kalpesh Shah

For women who suffer from menstrual disorders, getting help to diagnose the cause and to ease their discomfort can be a long and drawn-out process. Often they need to make three visits to outpatients, with no guarantee they will see a consultant or even the same clinician.

41231083N35 PBC group in Croydon wanted to offer an alternative referral route for those requiring a gynaecological opinion. Now our one-stop community-based service for menstrual disorders is improving patient access – reducing average waiting time to see a senior clinician from eight weeks to two. Of the 931 patients we have seen from May 2008 until April this year, only 90 have been referred to secondary care.

Patient need

N35 PBC group, of which I am a board member, looked at the possibility of a gynaecology diagnostic project during a round-table discussion in 2007. I am particularly interested in this specialty, having trained in obstetrics and gynaecology before becoming a GP.

The group examined the findings of a PCT patient satisfaction survey, where women from different practices in Croydon were asked to give feedback on their experiences of gynaecological services in the area. Patients said they were frustrated with the time it took to see a clinician (eight to 10 weeks), and that they had to make at least three visits to outpatients before they were given a diagnosis. They were concerned that at each appointment they saw a different doctor, which meant having to repeatedly explain their problems. Clearly there was room for improvement.

At the same time, through my interest in the specialty, I was in contact with a local GP who had a background in obstetrics and gynaecology, the late Dr John Ogeah. We were like-minded clinicians, who wanted to improve menstrual disorder services for women. We came up with the idea of a one-stop clinic – a flexible community service where patients could be seen by a senior clinician and diagnosed that same day.

Dr Ogeah and I shared our idea with N7 PBC group. Initially there were seven practices in the PBC group but it is now the only PBC group in Croydon, with 65 practice members covering 360,000 patients. Having gained the PBC group's backing, we met with Croydon PCT. It was supportive of our proposal, as it encourages PBC schemes that aim to simplify diagnostic pathways.

Service development

This positive feedback encouraged us to define our service aims, which included:

• simplifying and shortening the pathway

• reducing waiting times for menstrual disorders (helping the 18-week target)

• providing one-stop GPSI and consultant care with access to diagnostics on the day of the first appointment.

We also wanted to adhere to NICE guidance on menorrhagia, to keep DNAs to less than 10% and referrals to secondary care to less than 10%.

The PCT commissioned our practice, at Norbury Health Centre where I am a GP partner, along with Dr Sarjit Handa, who is a senior partner, and Dr Noureen Chaudery, who is also a PBC board member, to run a pilot gynaecology diagnostic scheme for six months. We were given £26,000 to cover the cost of running the service, including staffing, plus an additional £25,000 to purchase an ultrasound scanner.

It was important to prove financial viability as well as quality of care. We demonstrated through our business plan that we would deliver at or below tariff.

Up and running

The service began in December 2007, receiving referrals from GPs and nurse practitioners at the 14 practices in the north of Croydon, where half have above-average rates of attendances in secondary care gynaecology (25%-30% more patients with gynae problems). The practice has two private consultation rooms and a room where trans-vaginal ultrasound scanning is carried out.

The service is led by me as medical director, with clinical input from a consultant in gynaecology (seconded from secondary care on a rotational basis), a GPSI in gynaecology, a sonographer, nurse and healthcare assistant. All of the team – apart from the nurse and healthcare assistant, who work for the surgery full-time – are employed by us on a sessional basis.

This team works at the clinic every Wednesday afternoon until 7.30pm, and on Saturday afternoons. In choosing these times we hoped to improve access for women with children and those who are working and find it difficult to attend in normal surgery hours. Patients can also have a prearranged phone consultation with a consultant between 6.30pm and 7pm.

We have established a truly one-stop service where the patient has an appointment to see a senior clinician within two weeks of a referral (go to www.practicalcommissioning.net to see our referral form). We see women with all kinds of menstrual problems, apart from those whose symptoms could indicate cancer, who are given two-week referrals.

Women referred to the clinic receive a letter preparing them for what to expect and the tests they will receive. All referrals are directed to the triage service held at our practice, which is manned by a GPSI, with advice and guidance from the hospital consultant.

The service uses a referral protocol to ensure patients are referred to the right place at the right time. If a patient is seen by the GPSI, the latter discusses the care plan with the consultant before it is given to the patient.

One of the unique aspects of our scheme is that a clinic letter is given to the patient just 10 minutes after being seen. In addition, the patient receives a copy of the letter their GP will receive, which is also immediately faxed to the referrer. So there are no excuses that people have not received a communication about the recommended next steps of the patient's journey.

Outcomes

Having completed the six-month pilot period, the PCT gave us the green light to take referrals from all Croydon practices. Since then we have exceeded our original aims. The cost of our service for a first acute care appointment is well below the national tariff of £148 plus a market forces factor. Any savings are reinvested in the PBC group, to create services for the community.

Between May 2008 and April 2009 referrals to secondary care were reduced from 90% (who would otherwise have gone to hospital) to 9.67%. The ones who were referred on to hospital needed operative intervention. Through word of mouth, the number of patients we are seeing is gradually rising: from 113 to 154 between March and April this year.

Patients not only see a senior clinician within two weeks of a referral, but those needing operative intervention have direct access to surgery. This is either through local secondary care or a private provider, with surgery carried out within six weeks of attending our service – well below the 18-week waiting target.

Prompt access to a senior clinician means patients benefit from a speedy diagnosis and treatment of problems such as ovarian cysts which have been picked up on the scan when a patient has presented with a menstrual disorder. Their appreciation of the service is clear from their responses to the questionnaire I give them before they leave the clinic. Some 96% say they are ‘absolutely happy with the service'. One woman described it as ‘fast, professional and stress-free' and that she ‘didn't feel like just a number', while another expressed relief that her experience ‘wasn't painful or embarrassing' as she had feared.

These excellent results have been achieved due to enormous support from colleagues, particularly from my partners, and sterling work by the practice manager Rasiklal Shah and staff at Norbury Health Centre.

Lessons learned

To those looking to set up a similar scheme, be prepared for a slow start – it takes time for word about the service to spread. Engage all parties, from primary care and secondary care colleagues to the PCT. On reflection we could have done more to make everyone aware, including patients, as to how the service would improve gynaecological care.

Now the project has shown it can enhance services, those anxieties have been allayed. By proving the potential for gynaecological services to be delivered in the community, we believe the bar has been raised in terms of standards of future PBC projects in Croydon.

Consultants from secondary care were involved from the outset, although one of our learning points was that this needed to be even more in-depth to prevent the inevitable reservations about another service.

In the current environment the concern from secondary care is around the loss of activity. What I have repeatedly emphasised is that the patients are, and should remain, the centre of the pathway. Community-based services should not be seen as a threat but be seen as providing a better patient pathway that will allow senior hospital-based clinicians to concentrate more on what secondary care excels at.

Dr Kalpesh Shah FRCGP is a board member of the N35 PBC group, Croydon, and a partner at Norbury Health Centre

Dr Kalpesh Shah: patients previously reported having to make at least three visits to outpatients before getting their diagnosis Dr Kalpesh Shah: patients previously reported having to make at least three visits to outpatients before getting their diagnosis 60-second summary1

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