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Ten steps to designing a gynaecology pathway

Ten crucial steps were taken by a London consortium as it designed a primary care pathway for gynaecological problems, writes Dr Ethie Kong

Ten crucial steps were taken by a London consortium as it designed a primary care pathway for gynaecological problems, writes Dr Ethie Kong

The Harness PBC consortium in Brent, north London, covers a diverse and deprived population of around 65,000 patients. We aim to provide equity of care across our patch; if we become more effective in our referrals, without compromising standards of care, we can make savings for investment.

Traditionally GPs had referred patients with gynaecological problems as they saw fit within the skills and experience they had. There were no localised agreed referral management guidelines.

We had a first outpatient attendance-to-follow-up ratio of 1:2 and local hospitals were not achieving 18-week targets. National pressure and our PCT's financial constraints, and GPs' wish to improve services, spurred us on to the road to redesigning the gynaecology pathway, as outlined in the 10 steps below.

1 Carry out a skills appraisal of the consortium's GPs

The consortium did a skills appraisal of its GP members and discovered there were a number of established GPs with previous hospital gynaecology experience and postgraduate qualifications. It made sense to tap into this resource.

Under the leadership of the consortium's clinical lead, we set up a clinical working group, bringing together these five GPs.

The group identified a GP – Dr Cyril Evbuomwan, who is a part-time associate specialist in gynaecology at an acute hospital – to be its clinical adviser. The group looked at existing NICE guidelines and communicated with other PBC groups outside the patch with a common interest in gynaecology pathways.

2 Perform a consortium-wide baseline audit

The working group commissioned a GP with public health experience to perform a consortium-wide audit, gathering practice-based data and also information held by Dr Foster, the national company that can crunch NHS data for local areas.

This took about five days and cost £2,500, which was paid for at the time out of pooled PBC DES (part 1) funding held by the consortium. In particular the audit examined:

• the number, type and source of referrals

• reasons for referrals

• number of days between referral date and first outpatient attendance

• number of follow-ups after first attendance

• primary care interventions prior to referral

• investigations carried out in secondary care

• management in secondary care

• final diagnoses

• outcomes – whether surgical, pharmaceutical or no intervention.

We found the top reasons for referral were menorrhagia, post-menopausal bleeding, colposcopy, fertility problems, urinary incontinence, fibroids, prolapse, antenatal care and abnormal pelvic scan findings. Using these results, the group produced its first draft pathway, on heavy menstrual bleeding.

3 Seek patient opinion

Most importantly, we needed to know from patients what they thought of services they received from GPs and hospitals and what should change. Under the leadership of the consortium's management lead, supported by the clinical lead and the working group's clinical adviser, a second group met, comprising of patients, a PCT non-executive director, a public health consultant and practice managers.

Patients described the good and bad encounters along their journeys.

In particular they called for changes to ensure they would not face duplication of blood tests by GPs and hospitals or long waits for ultrasound scans; that test results and/or notes would be ready and with doctors when they turned up at appointments; that they could see the same doctors; and that they could access services closer to home instead of having to travel to hospital.

We also shared results of the audit and the draft pathway with the patients. Their feedback gave an early sign of the pathway's user friendliness and allowed the clinical working group to redraft it.

4 Discuss the proposals with the PCT and secondary care

The pathway was discussed with a PCT commissioning directorate representative, who emphasised the need to tackle 18-week waits. To be transparent, we also shared the pathway with acute sector colleagues – consultant gynaecologists and nursing and service managers – and discussed when it might become operational. As a result, one of the gynaecologists volunteered to be a mentor to our clinical adviser.

5 Finalise the pathway for heavy menstrual bleeding

Under the final pathway, care will be provided as follows:

• The patient presents to her GP, who will take a history, examine, do a full blood count, coagulation screen and organise a pelvic USS. Persistent intermenstrual bleeding is referred to the consortium's gynaecology clinical adviser for consideration of endometrial biopsy or other intervention.

• If blood tests are normal and there is no structural abnormality, the patient is offered pharmaceutical treatment by her GP from the following options: IUS, tranexamic acid/NSAIDs/COCP, oral/injected progestogen and GnRH analogue

• If the patient's GP does not offer IUS or GnRH analogue, the clinical adviser will see and offer such treatment.

• The patient is followed up and reviewed at three to six months.

• If pharmaceutical treatment is not successful and the patient is over 45, she is referred to the clinical adviser for endometrial biopsy from community premises. If indicated, she is offered surgical treatment options. If she accepts, she is referred to secondary care.

• If pharmaceutical treatment is unsuccessful and patient is under 45, discussion on surgical/radiological treatment options are offered and if she accepts she is referred to secondary care.

• If there is structural abnormality with fibroid less than 3cm, the patient is offered pharmaceutical treatment as listed above.

• If the fibroid is more than 3cm, surgical treatment options are discussed. If accepted, patient is referred to secondary care.

• All referral letters to secondary care by GPs are peer reviewed by the clinical adviser, who makes suggestions to the GP as required.

6 Build in a pathway audit tool

We proposed that an administrator would need to collect data weekly from GPs to inform the consortium of the pathway's effectiveness and compliance with it. This would help us plan education and feedback sessions with GPs and to consider ongoing workforce requirements. Data would include:

• number of referrals to clinical adviser (including new and follow-up appointments)

• referrals to secondary care (including new and follow-up appointments)

• number of contacts with GPs regarding tests required

• number of non-surgical and surgical outcomes

• number of patients discharged to GP.

7 Cost the pathway

We established that the financial implications of the new pathway were:

The role of pathway clinical adviser – to spend one session a week reviewing GP referrals and act according to the pathway by bouncing referrals back to the GPs if primary care investigations needed to be done first; advise on clinical management that can be initiated by the GPs; or see patients to offer further advice, investigations and treatments such as endometrial biopsy and cervical cautery and so on. We called him a clinical adviser, not a GPSI in gynaecology, as his skills are more advanced than those of a GPSI.

Educational support – to be provided by the gynaecology mentor to the clinical adviser and in a regular forum with GPs.

Administrative staff member – to collect referrals from practices, type letters, deal with queries and support the clinical gynaecological team.

Audit clerk – to collect data for analysis.

Premises – an equipped consultation room from which the clinical adviser would perform procedures.

Consumables and disposables.

Investment in diagnostics – ultrasound scanning equipment to be based in primary care with the clinical adviser. In total, we would need £60,000-£65,000 start-up funding.

8 Identify potential savings

Our audit showed 24% of referrals needed surgical intervention at secondary care.

This meant, potentially, 76% of our referrals could be managed within the primary care pathway.

We estimated £100,000 could be saved, by reducing secondary referrals from GPs, consultant-to-consultant, and follow-up. These funds would be reinvested back into primary care, with practices and patients jointly deciding how it would be spent.

9 Deal with resistance

‘Territorial invasion' was felt in some quarters of secondary care, which thought provision of specialty services ought to be provided by hospitals and that primary care did not have the skills to redesign or provide them.

Some PCT officers found it a problem to ‘let go' of the commissioning agenda and did not believe PBC would work. Some also wanted to continue with top-down redesign and provision. Through regular dialogue between the consortium and PCT, and emphasis from the Department of Health on PBC, better understanding ensued and a close working relationship was achieved.

10 Secure investment from PCT

By the time we finished our pathway, our PCT had gone further into deficit and was subject to ‘turnaround' measures, so no investment was made and it had to be shelved. But our efforts were not in vain.

This year the PCT has a healthier financial status and proactive new executive leadership. In line with the world-class commissioning agenda and working towards provider separation, the PCT is very keen on PBC groups taking forward service redesign.

Gynaecology remains among the top five high referral rates so the pathway is now back on the table.

Dr Ethie Kong is a GP in Willesden, London, and clinical lead of Harness GP PBC consortium

Dr Ethie Kong: spurred on the road to redesign

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