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At the heart of general practice since 1960

Setting up a community gynaecology service

Dr William Tamkin, Dr Geeta Wadwha and Eve Donelon share lessons learned that could help ensure the success of any service redesign process

Dr William Tamkin, Dr Geeta Wadwha and Eve Donelon share lessons learned that could help ensure the success of any service redesign process

The origins of PBC in South Manchester go back more than two years when a number of GPs and their managers, disaffected by the slow implementation of the new contract and frustrated with trying to get good care for their patients, had a full and frank meeting with the PCT. This provoked a number of changes including the formation of a consortium that was given the freedom by the PCT to start reorganising clinical pathways. ‘Spend to save' became our working mantra.

First steps

We've now had more than a year of trying to make PBC a reality.

The first step was for our gynaecology GPSI to undertake a GP referral audit while the information team mapped existing services and compiled data including number of outpatient attendances, first to follow-up ratios, day-case activity and waiting times. It was estimated that about two-thirds of GP referrals could or should be managed in primary care.

Direct access diagnostics were highlighted as mandatory if more work was to be undertaken successfully in a primary care setting.

This set-up work required one session of clinician time a week for three months, paid at a rate of £180 per session. Other costs included £1,000 for a laptop and dial up token so that remote triage could take place.

A consortium meeting later concluded:

• more could be done within general practice, pre-empting the need for referral

• there was definite scope for an extended primary (tier 2) service

• links with the secondary care sector would be important for governance and future service development.

Engaging secondary care

Our GPSI was charged with setting up a pilot gynaecology service. The team, involving the GPSI, PCT modernisation manager and PCT service improvement manager, under the auspices of the PBC consortium, set about bringing together various stakeholders and giving shape to the tier 2 gynaecology service.

A gynaecology working party was organised and members of the local acute trust, consultants and managers, were invited to be part of this group.

We found it difficult to engage the secondary care sector in these talks initially as they seemed to consider this idea to be ‘poaching' on their turf. A potential loss of earnings also drove this attitude as gynaecology work has traditionally helped maintain the maternity service.

However, when the benefits of engagement were highlighted, namely better quality referrals, fully investigated patients, reduction in waiting times and the opportunity to increase capacity to see new patients and hence comply with the 18-week target, our consultant colleagues were eventually persuaded to come on board.

Protocols and feedback tools

A scoping visit was arranged to see another local site that had already been set up and was delivering high quality care.

Governance issues were identified. Robust data collection pathways to aid clinical audit were put in place. There were clear clinical protocols and pathways written by the GPSI in line with recommendations from NICE, RCOG and RCGP guidelines. A detailed triage protocol was formulated with clear inclusion/ exclusion criteria. It is the remit of the secondary care colleague to work with the GPSI to develop competency pathways within the accreditation framework contained in the recent Department of Health publication.

Patients were involved from the outset and a simple but effective anonymised questionnaire was devised in conjunction with the patient and public involvement lead who now feeds back the responses via a monthly report. Patients have indicated overwhelmingly their satisfaction with all aspects of the service. This has been extremely gratifying and a great morale booster.

The gynaecology team

The service is currently delivered from the local PCT-run state-of-the-art community hospital. The clinical team consists of the GPSI, a TAPS (trainee assistant practitioner) and a continence adviser. Excellent administrative support is provided. The GPSI is employed by the PCT on a sessional basis, working five sessions a week for the service. She is a partner at a local practice for another five sessions. This is extremely useful as she is very aware of local health needs, the services available and referral pathways.

Referrals we see

Referrals are received from all 27 GP practices as well as the primary care continence teams that are also based within the South Manchester Community Hospital. All referrals are assessed by the GPSI and those that need more input at the primary care level are triaged into the service.

Investigations and procedures we undertake

There is a dedicated ultrasound clinic and a number of scans are done prior to clinic appointment to aid discussion. Facilities are available for routine investigations and procedures like coil insertion, cervical polypectomies, insertion of pessaries and implants and so on. Currently the indications managed include menstrual disorders, urogynaecological conditions such as prolapse and incontinence, pelvic pain and PCOS.

Plans are in the pipeline to offer outpatient hysteroscopy, colposcopy and urodynamics studies and specialist physiotherapy in a one-stop clinic.

Results so far

Up to 28 new patients are seen per week. During the pilot, 40% of the referrals were triaged into the service. Nearly half of these were treated and discharged back to GPs. In addition there was a 15% DNA rate that was absorbed within the tier 2 service. It is envisaged that with expansion and more joined-up working the service would handle around 60% of the gynaecology workload.


It has not all been smooth sailing. Isolation, inadequate remuneration, lack of support and dysfunctional management have been the stumbling blocks. The lack of formal channels for feedback from practices and secondary care led to the GPSI feeling quite lonely and left wondering if the service made any difference at all to her colleagues!

There were too many managers involved which led to the service being pulled in different directions.

There was no adequate representation from primary care and although ostensibly commissioned by the practices, the ownership seemed to remain with the PCT.

Remuneration was an issue. The GPSI was paid the Manchester-wide ‘agreed' PCT rate but this did not reflect current market value nor the specialist qualification and work done by the GPSI, generating resentment as there was a comparative ‘financial loss' being borne by the GPSI.

Other lessons we learned are summarised at the end of this article. These have generic value and are being applied to new redesign work in urology, ENT, anticoagulant prescriptions and cardiology.

Questions that must be asked at the beginning of any service redesign include: are we doing the right things, are we doing them right and can we do them better? In addition, are we doing them in the right place and with the right people?

After this first year we can say we are doing them ‘rightish' but we plan to do better in 2007/8.

Dr William Tamkin is a GP in Withington and PBC chair of the South Manchester consortium

Dr Geeta Wadwha is the GPSI in the gynaecology service and a GP in Wythenshawe, Manchester

Eve Donelon is service improvement manager for Manchester PCT

60 second summary

Initiative A tier 2 community gynaecology clinic staffed by a GPSI, a trainee assistant practitioner and a continence adviser treating and triaging referrals from GPs and primary care continence teams. Includes in-house ultrasound clinic and doing procedures such as coil insertion, cervical polypectomies, insertion of pessaries and implants. Indications managed include menstrual disorders, urogynaecological conditions such as prolapse and incontinence, pelvic pain, PCOS.

Policy link Practice Based Commissioning: Promoting Clinical Engagement – Department of Health guidance, December 2004; white paper Our Health, Our Care, Our Say; 18-week referral to treatment target.

Preparation Three months to establish picture of current referral patterns and existing service needs and to create triage protocols and care pathways.

Costs of scheme Costs in set-up year about £115,000.

Outcomes High patient satisfaction rates. First year results show 40% of referrals were triaged into the service. Nearly half of these were treated and discharged back to GPs. In addition there was a 15% DNA rate that was absorbed within the tier 2 service.

Savings None as yet, but on course to break even next year and start saving money in year three.

Lessons for service redesign

• Consensus in the PBC consortium was important. It gave a mandate to the clinical lead and gave the steering group leverage with the local trust. It has taken a year to get a consultant fully on board!

• Challenging old ways of doing things is hard work but it's worth persevering. The challenges are both clinical – blurring the divide between primary and secondary care – and organisational. The old PCT seemed disconnected from clinical reality and this was a major reason for the initial stop-start progress of our gynae service.

• Service redesign must be linked with education. In particular, peer review of gynaecology referrals was built into the DES for practices, and the need of support for the GPSI was identified, particularly in being accredited for more procedures.

• Service redesign must also be linked with clear lines of responsibilities and accountabilities.

• The service cannot rely on one person providing it. It was anticipated the service would run throughout the year but lack of cover for the GPSI meant it was fully operational for 39 weeks only.

• Ensure patient involvement from the start. It will have greater utility than asking for a ‘rubber stamp' when it is already running.

• Saving money is unlikely to happen in

the first year. GPSI pay has to reflect as a minimum what it costs to free up the GP from the practice's everyday work.

• Practice managers are vital. They provide the link between the PCT world and the clinical world of shop floor general practice. Having a practice manager within the service liaising with the clinic manager, PCT manager and the clinician has been very effective in smoothing the way forward.

• GP ‘ownership' is important. Referring GPs understand more clearly, partly as a result of the gynaecology pilot, that every referral they make is a resource allocation decision. ‘Owning' the consortium budget prompts a more critical perspective on clinical behaviour and the best use of resources.

the stumbling blocks have been Isolation, remuneration, Lack of support, dysfunctional management the stumbling blocks have been Isolation, remuneration, lack of support, dysfunctional management Patients have indicated overwhelming satisfaction with the service – this is a great morale booster Patients have indicated overwhelming satisfaction with the service – this is a great morale booster

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