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Outpatient hysteroscopy in general practice

Dr Nisha Kedia explains how cutting-edge technology has allowed patients to have diagnostics and consultation in the same appointment and created real continuity of care

Dr Nisha Kedia explains how cutting-edge technology has allowed patients to have diagnostics and consultation in the same appointment and created real continuity of care

Our primary care gynaecology Clinical Assessment and Treatment Service (CATS) offers patients a one-stop shop, bringing waiting times down to two weeks and cutting costs by up to 40%.

41231102Patients can be offered hysteroscopy within the clinic, which boosts the service and means we can retain even more women within primary care.

The CATS was developed by St Albans and Harpenden Commissioning group (STAHCOM), which covers 13 practices and 140,000 patients in west Hertfordshire.

STAHCOM's chief executive, Mo Girach, was aware GPs were dissatisfied with the local acute trust. Patients were facing at least eight-week waits – often longer – and having to attend outpatients, return for diagnostics at a later date and then wait again for a further appointment with a consultant.

Mo was also aware that STAHCOM had to deal with West Hertfordshire PCT, which was in financial deficit. So we needed to shift more work from secondary to primary care to free up resources for investment in new services. Against this background we set up our CATS programme to cost-effectively improve care.

There are six schemes in operation, covering areas such as musculoskeletal, urology, ENT and dermatology.

The gynaecology CATS was launched in July 2007. It is led by acute consultants, working with GPSIs, and sees patients with conditions such as abnormal menstrual bleeding, pelvic pain, infertility and urinary incontinence.

New technology

As far as we know, we are the only service performing outpatient hysteroscopy in general practice in the country. It was the possibility of using state-of-the-art equipment that allowed us to make this huge leap forward.

STAHCOM commissioners asked us how we could do more in primary care. We realised investing in the latest equipment would allow us to offer people outpatient hysteroscopy, instead of referring them to hospital.

Gynecare hysteroscopes, called Alphascopes, were launched in April 2009 globally by Johnson & Johnson. They are ultra-thin, so pass through the neck of the womb causing minimal discomfort. This makes it possible to investigate abnormal bleeding associated with heavy or irregular periods, or after menopause, without a general anaesthetic.

The scope is passed through the cervix, giving a clear view of the inside of the womb – patients can even watch on the monitor. A small biopsy can be taken if required and small polyps can be removed, or lost coils retrieved. The field of vision is also far greater than in the older forms of hysteroscope.

Carrying out the procedure in primary care offers a 40% saving on the price in secondary care, on a cost per case basis. The cost per hysteroscopy is £627 compared with £1,003 in secondary care (including market forces factor). So far more than 1,700 patients have been seen within the CATS and feedback has been excellent.

How we set up the service

The path has been far from straightforward. We struggled to get consultant buy-in for the CATS and to get our hysteroscopy business case approved. There was a lot of bureaucracy to get through – our business case had to be agreed by the STAHCOM board, then go to the commissioning council with representatives from all 13 practices.

The next stage was to seek approval from West Hertfordshire PCT PBC governance committee, and finally get sign-off from the PCT's finance department.

We fell at the first hurdle when our business case was rejected by the STAHCOM board due to the high price of the equipment. It had a new policy of not owning equipment and commissioning only on a cost-per-case basis.

The equipment cost between £50,000 and £60,000. As well as the hysteroscopes, we had to buy the ‘stack' – a trolley with shelves holding a light source, TV screen and recording facilities for images. In addition there were annual maintenance costs.

One concern was the risk of breakages and the cost of replacement. The scopes contain very fine fibre-optic lenses, so if you drop one, that's £5,000 down the drain.

So we had to go back to the drawing board. The new business plan saw our practice taking on the upfront financial burden, with STAHCOM reimbursing us on a cost-per-case basis. Our plan now is to break even over three years.

Finding consultants

Once the finances were agreed, the next hurdle was who was going to carry out the hysteroscopy. We had two local consultants who were keen. As clinical lead of the CATS,

I had completed my PG postgraduate diploma in gynaecology and enrolled on a hysteroscopy training course.When we were setting up the CATS, in 2007, our local acute trust, West Hertfordshire Hospitals Trust, was finding it difficult to commit consultant time. However, STAHCOM and the PCT were happy for us look elsewhere.

There was much enthusiasm from the other trusts that take referrals from our area. We emailed gynaecology consultants and got quick responses. Barnet General Hospital put us through to the clinical director, who invited us for a chat that afternoon – we had a ‘yes' within 48 hours.

We now have five consultants, from three local acute trusts: Barnet & Chase Farm Hospitals, the East & North Hertfordshire NHS Trust and the Luton & Dunstable Hospital NHS Foundation Trust. The consultants had experience in community clinics and were comfortable working outside the hospital environment.

Their trusts have been supportive in terms of releasing them as they recognise this is the way services are going. Consultants are reimbursed for their time – there are no extra incentives. We went through a rather cold phase with West Hertfordshire Hospitals Trust, but once it saw we were going to deliver the scheme anyway, and that it was a high-quality consultant-led service involving three different trusts, it had to take note.

We hope it recognises we are helping it to achieve its 18-week targets. The trust itself is having to outsource surgery to the private sector at above-tariff prices. We remain hopeful of being able to recruit a consultant from West Hertfordshire in the near future.

Having consultants from three trusts has been a huge advantage. They all have different perspectives, experience and expertise, covering sub-specialties such as infertility, abnormal bleeding and pelvic pain, urogynaecology and gynaecology scanning.

Consultants may not necessarily meet many other consultants from outside their own trust on a professional level, but here we are getting input on our clinical pathways from across Hertfordshire. The consultants enjoy working in primary care. They have a high level of ownership here and can get things done quickly.

We also have two other GPSIs, one of whom like me has completed her postgraduate diploma in gynaecology at the University of Bradford. We all have experience in gynaecology but at first we saw patients with a consultant. As our experience and confidence has grown, we can work alone with suitable patients, but the consultant is there for advice if needed.

Getting GPs on board

Getting referring GPs to sign up was the final challenge. We offered all 13 surgeries a visit from the consultant and GPSI leads so they knew who they were referring to and we could talk them through the pathway.

It took more than a year from launch to build the monthly numbers up towards the 80% of all gynae referrals from GPs that we are expecting to see. Once people understood it was a consultant-led service, with an integrated pathway and diagnostics on site, confidence grew.

How it works

Patients are referred by their GP and seen within a maximum of two weeks – we are now on Choose and Book. We exclude cases that would come under the two-week suspected cancer wait, and patients with multiple pathology.

The service runs four times a week, with a choice of mornings or afternoons. Most sessions are run in-between standard GP surgeries, so we have to hot-room and get out of the clinic on time so the doctor can get in for the next surgery.

Patients are triaged to see either a consultant or a GPSI. As a GP, it is reassuring to know the consultant is just next door.

If a minor procedure is required, we can do it there and then under local anaesthetic. We also have a high specification ultrasound scanner on site, so consultants can scan patients at their appointment. Patients find it helpful to discuss their problems directly with the consultant, particularly things such as pelvic pain where there is a lot of anxiety.

The patient pathway allows us to manage people entirely within primary care where possible. If they need to be referred for surgery or to a fertility centre, we can offer them Choose and Book at the appointment, rather than writing letters or sending them back to their own GP. We can even put patients directly on the theatre list at the Spire Hospital in Harpenden, or the BMI group.

These private hospitals were already on Choose and Book offering procedures at NHS prices as part of the extended choice network. The consultants working at CATS also work at these hospitals and patients appreciate the continuity of care offered by this pathway.

Outcomes

We were aiming for a 60% retention rate at the start but are achieving 75%. This means three out of four patients seen by CATS are not referred on to a hospital. If the scheme was purely GPSI-led, the retention figures would be a lot lower. People often want to speak directly to a surgeon about whether they should commit to an operation or not.

Benefits for patients are the shorter wait, being able to have diagnostics and consultation in one appointment and the continuity of care offered by being managed within the service as far as possible. They can be put straight on to a theatre list and get seen, treated and discharged within four weeks.

It is a massive advantage for infertility patients, especially as historically there have been long waits in St Albans, with tests being repeated as patients have not been seen until months later, causing a lot of anxiety.

Patients have said it is hard to get hold of anyone at hospitals and end up leaving lots of messages on answerphones. Here they can talk directly to their doctor. In the two years we have been running the service we have not had any clinical complaints.

The little things help. For people who are feeling vulnerable, a GP surgery is a much friendlier environment than an acute hospital and they appreciate free parking.

It would be reasonable to say we have helped the local acute trusts meet their 18-week targets, although we can't put a figure on our contribution as there are so many other factors, such as theatre work being outsourced to private hospitals.

Recognition of our efforts came by being nominated for a Health & Social Care Award by the NHS Institute of Innovation & Improvement in May. We were one of three finalists from more than 140 entries.

The future

The PCT has approved a business case to provide a colposcopy service in primary care. We have had a number of patients needing colposcopy who had to go to the hospital. It has taken time to work up the case, as we had to demonstrate we had good systems in place to meet the requirements of the NHS cancer screening programme.

Now we are looking at other procedures where we could avoid patients having to have a general anaesthetic, such as endometrial ablation and hysteroscopic sterilisation.

Lessons learned

We are very excited about the service, but it has taken two years to get to this point. There have been points along the way where we felt we had had enough, such as the tense negotiations about finance.

And not getting initial support from West Hertfordshire Hospitals was a big let-down. You have to accept that it will be a bumpy ride. Things like this don't just happen overnight, but if you have the right mindset you can do it. It is not just about turning up and doing a clinical session.

You have to be able to change the way people think and convince them about your specific proposal. And it takes a lot of time – support from colleagues is needed when you have to set off for yet another meeting (our set-up time has not been funded).

But nobody will dispute moving care into the community is the right way for services to go and there is no doubt about this being a better pathway for patients and doctors. That makes it rewarding working in the service, especially when you get good patient feedback.

Dr Nisha Kedia is clinical lead of Verulam Gynaecology Clinical Assessment and Treatment Service, St Albans, Hertfordshire

Dr Nisha Kedia (front, centre) with consultant gynaecologist Mr Pratik Shah and her team (from left): care co-ordinator Jenny Whitley, nurse Vourneen Mahoney, care co-ordinator Jo Cooke and senior patient care co-ordinator Laura Nicholson Dr Kedia (front, centre) and her team 60-second summary

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