This site is intended for health professionals only

At the heart of general practice since 1960

Pitfalls in planning a microscopic haematuria service

GPs may need to overcome many hurdles when commissioning a one-stop service,writes Dr Jonathan Rees

GPs may need to overcome many hurdles when commissioning a one-stop service,writes Dr Jonathan Rees

There are many opportunities within urology to provide primary care-based services. In recent years, the specialty has become increasingly medicalised with the advent of effective pharmaceutical treatments for conditions such as benign prostatic enlargement and erectile dysfunction. The difficulty at times is trying to select the most appropriate area in which to attempt to provide a service.

Microscopic haematuria has long been a contentious problem, with GPs unclear how to manage, which patients to refer, when to refer and even whom to refer to. Currently, patients may be referred to a hospital haematuria clinic where they have some form of upper tract imaging followed by a flexible cystoscopy.

If this proves negative, the patient is told that all is well, and a letter is sent to their GP saying no cause found for microscopic haematuria. Most urologists have little interest in nephrology, so the GP is either told to refer the patient to a renal physician, or this aspect of the disease is conveniently ignored.

The GP and patient can thus be falsely reassured that there is no pathology and the patient left believing that no further action or monitoring is required, or conversely the patient can end up with an unnecessary referral to a renal physician.

A primary care-based, holistic microscopic haematuria service could offer significant advantages to patients and to GPs. It would allow GPs to manage the patient both according to potential urological diagnoses and renal guidelines, and also educate local GPs – thereby potentially reducing inappropriate referrals.

For instance, we could emphasise the lack of evidence for screening for microscopic haematuria in new patient checks. As is so often the case with PBC, however, deciding on the service you wish to provide is just the first step on a long road.

This is particularly so for those of us who are natural ‘performers'rather than those who are better at the political and negotiation skills involved in setting up a new service.

I proposed the idea of the service at a PBC away day held by North Somerset PCT and it was greeted with enthusiasm. But my experience in putting together a business plan has shown there are many things for a GP to consider, such as the following, when setting up such a service. Be prepared to face some obstacles. . .

Can you accurately establish demand for the service?

Establishing the demand for such a service in the absence of adequate activity data from secondary care has been a major difficulty in our area. Further complicating matters is the fact that practices within our PBC cluster refer to three different hospital haematuria services.

Primary care data generally codes for ‘haematuria'without reliably separating into macro- and microscopic. It is likely that to exactly define activity we will need to perform a labourintensive retrospective audit around the practices, unless we accept an estimate based on national prevalence statistics.

How will patients be referred into the service?

We have established that GPs would need to provide sufficient information to enable a definitive management plan to be made – a blood pressure reading, serum creatinine (eGFR) and a dipstick result for proteinuria.

If urological investigation proved negative, an assessment could then be made as to whether the patient should either be referred to a renal physician or managed in primary care as stage 1/2 CKD with annual monitoring. A proposed pathway into the service is shown in the box (right).

Who will carry out flexible cystoscopies?

Although I am trained and experienced in carrying out flexible cystoscopies, there are understandably no other GPs in our area qualified to help. This raises the question of whether hospital-based urologists, including trainees, should be recruited.

With the advent of nurse cystoscopists, an adequately trained nurse might be able to assist with the workload, although this raises issues of governance for a nurse working outside a hospital environment.

Can the service meet the national cancer target?

Microscopic haematuria in patients over 50 years old is subject to the national cancer target of a ‘two-week wait'. This places significant demands on a small primary care-based service and emphasises the importance of securing experienced staff to carry out cystoscopies.

How do you establish an evidence-based pathway?

There are varying guidelines and protocols that will influence the care pathway. NICE guidelines for referral of suspected cancer suggest non-urgent urological referral for patients under 50, whereas the UK CKD guidelines produced by the Renal Association suggest that for those patients under 50 without proteinuria or impaired renal function, primary care management according to CKD guidelines is appropriate. Managing the patient according to both potential urological diagnoses and renal guidelines seems appropriate.

Should macroscopic haematuria be included?

Studies of haematuria clinics suggest overall cancer rates of about 20% in macroscopic haematuria, versus about 4% in patients with microscopic haematuria. Given the much higher prevalence of significant disease in the macroscopic population it seems prudent to send these patients direct to a secondary care service, whereas the microscopic haematuria patients seem more likely to benefit from a holistic primary care-based service.

Can you provide a one-stop service?

If the patient is required to attend the local hospital for an ultrasound and then to attend the primary care service for cystoscopy, this results in a considerable inconvenience to patients.

The service needs to commission, therefore, a radiographer to attend the community-based service, and a hospital-based radiologist to formally report the imaging. We are considering basing our service within a community hospital where we have the advantage of ultrasound and endoscopy facilities on site.

Which provider model is best?

A decision needs to be made on whether to organise the service through the PCT in the form of its provider arm, to go it alone, or to join with one of the ‘umbrella'GP companies that have sprung up around the country to capitalise on the opportunities presented by PBC.

All options have their pros and cons. The ideal scenario would be to retain control of the service, but the advantage of using the management and political skills of other organisations looks to outweigh the disadvantage of loss of autonomy.

Is it affordable?

The current tariff price for a referral to a hospital one-stop service is high – about £450 per patient – so a primary care service potentially offers considerable cost savings. Apart from staffing, the other main resource required is equipment. Our local League of Friends has previously funded purchase of endoscopes and may be a potential source of funding.

However, our PCT, like many others, faces considerable financial pressures. For many GPs, decisions on start-up funding and approval for new services are being stalled or are dependent on whether the Department of Health makes them a national priority that PCTs will invest in locally. We hope to find out soon whether our proposed service will see action in 2008.

Dr Jonathan Rees is a GP and urology GPSI in Nailsea, Bristol

Proposed pathway Proposed pathway Referring GPs would need to provide the results of dipstick tests Microscopic haematuria

As is often the case with PBC, deciding on the service you wish to provide is the first step on a long road

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say