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How our gynae service connects with Asian women



Dr Uma Marthi explains how an all-female staffed primary care gynaecology service is attracting many Asian patients and deflecting hundreds of others from hospital referral

Rochdale west has one of the highest levels of deprivation in the country and a high concentration of Asian patients. It’s a predominantly Muslim population, where many women are reluctant to consult male GPs about gynaecological problems. To compound matters, some practices are totally male dominated.

Research and consultation with all the practices in the area indicated that women, particularly those from Pakistani and Bangladeshi communities, have been embarrassed to present about gynaecological matters or sometimes even to talk to their own partners about symptoms. By providing an all-female staffed gynaecology and ultrasound service across the whole PBC cluster, we are reaching patients who might otherwise be missed and deflecting scores of others from secondary care – saving Heywood, Middleton and Rochdale PCT an estimated £64,000, after costs, over a 10-month period. A third of our patients have been Asian.

The service is based at my practice, the Castleton Health Centre in Rochdale, Greater Manchester – a seven-partner training practice with a list of nearly 11,000 patients. The service is available to GPs and nurses in the 10-practice Rochdale West GP Cluster PBC group, which covers 64,300 patients in total.

Beginnings

I have specialised in gynaecology for many years, up to fourth-year registrar level and I had a total of 16 years’ experience in the specialty in India and the UK before I became a GP. I’m also a member of the Royal College of Obstetricians and Gynaecologists (MRCOG).

41268654In 2008, the PBC group did an audit across the cluster that looked at GPs’ skills, premises, and practice referral rates for the previous three months, to pinpoint opportunities to provide services that might otherwise have been missed. They also looked at birth rates in the area, which were relatively high. It turned out that while referral rates were high for gynaecology, my own referral rates were low because of my background in gynaecology.

The ‘soft intelligence’ was that many women from ethnic minority groups weren’t presenting for gynaecological matters. It was also clear that my skill set could benefit the whole cluster by offering a dedicated clinic that would mean fewer cases would be referred to hospital.

Mark Brodigan, the PBC business manager, arranged a meeting with the other practices in the cluster at which I introduced myself and explained my background. Mark then contacted the Pennine Acute Hospitals Trust to ask for consultant and educational support. Meetings were held between the cluster and the head of gynaecology at the trust, consultant leads and trust managers.

The trust could see that with its help, we would be able to cut its workload by managing more cases within the cluster and agreed to support the service. A business case was then made to the PCT with costings for consultant time and educational development for staff. The first clinic was held in December 2008.

We recruited Dr Alka Kedia, a consultant in gynaecology and obstetrics at the Royal Oldham Hospital – part of the Pennine Trust – who works for us one and a half days a month. Dr Liz Tutton, one of my colleagues at the Castleton Health Centre, and Dr Shalini Gadiyar from the Ashworth Street Surgery in Rochdale both had gynaecological expertise and provide back-up for me. We also have a secretary for administration and bookings. That makes the team all female, which has had a big impact on getting women to present – especially those from Asian ethnic minorities.

How it works

Both GPs and practice nurses can refer to our service. We give practices a referral form with a reminder about what we can offer and referral criteria (find a copy on the online version of this article at practicalcommissioning.net).

We run the clinic over a full day every Tuesday, which I do in addition to my normal practice surgeries, and we alternate with a half-day the following Tuesday, done by myself or Dr Tutton. We also offer at least four appointments during the week to catch up and offer flexibility to working women. Family planning is currently done by Dr Gadiyar. We try to keep waits to a maximum of two weeks from referral.

Training

An education component has been built into the project. I am being funded to do my ultrasonography certificate at Salford University and should be qualified in September and Dr Gadiyar is being funded to do a gynaecology diploma at Bradford University. Pennine Acute Hospitals Trust is letting her work in clinics and giving mentoring support and being generally very supportive.

The business case also allows for some of my time to be freed up to go round to member practices and help them improve their gynaecology skills.

Costs

Start-up costs were around the £5,000 mark and covered improvements to the clinic rooms, including air conditioning and the purchase of a special bed.

At the end of March 2009, we bought two Toshiba ultrasound machines at a cost of about £25,000. One is specifically for the clinic and the other is based at the Ashworth Street Surgery.

Using ultrasound means we can handle a lot more cases wholly within primary care – for instance, a missing thread on an IUCD or difficult insertions. We’ve also had patients present with symptoms of bloating and have been able to eliminate ovarian cancer by doing an abdominal and pelvic scan.

The running costs, including my training course, specialist courses for Dr Gadiyar and Dr Tutton, plus the cost of a secretary and consumables total about £530 per session. Taking into account consultant costs, the overall cost comes to about £60,000 a year, according to PBC cluster figures.

The per-patient cost works out at £130 for first and follow-up appointment. This compares very well with another local provider of gynaecology services, which charges around £200 per patient.

We’ve seen about 190 patients in the first year who would have gone to secondary care. Over 10 months we saw 155 and only six of these were referred to hospital (around 4%). In addition, we’re seeing them closer to home and they are being medically rather than surgically managed. Quite a lot of women attend A&E early on in pregnancy and we have been able to offer our own patients a scan at the practice.

We estimate the saving over 10 months for the overall service to be around £64,000 and are anticipating a second-year saving of about the same order based on seeing 150 to 200 patients a year.

Outcomes

Apart from cutting admissions, one of our key targets is improving patient care. The cluster surveys patients every quarter, asking them to rate the service in terms of care, speed and communications.

Our latest questionnaire went to 40 patients and we got 27 replies (see table below). A typical quote was ‘wonderful in every way’– which is very nice to hear.

As well as benefitting patients and cutting admissions, the service ticks a lot of policy boxes including the guidance on service design. It’s evidence based, with clinical engagement all the way and is carried out in close consultation with secondary care.

Future plans

We plan to do outreach work to make hard-to-reach patients aware of the all-female service and to present via their GPs.

I’ve also put in a business plan to the North West Deanery to train a GP in primary care gynaecology. This has been accepted, so from this month we’ll have a trainee GP doing gynae with me instead of in hospital.

We want to offer hysteroscopy. At the moment this is done by a hospital-based consultant. We can offer it in house once I have done a course.

We also want to work with the trust to develop direct listing so that women who need specialist assessment can go straight to the consultant’s clinic rather than having to go to a general clinic first.

The demand is so great we could expand – perhaps to offer the service more widely or to take on more, perhaps employing more consultants if we have the money. We are hoping the vast majority of gynaecology will go through our service in the future.

Lessons

It’s hard work at first but it’s worth it. We needed to do a lot of research on things like infection control and clinical governance.

Given our time over again, we might have gone for a more expensive ultrasound machine, because we’d be able to do more with it – scanning elderly patients from nursing homes, for example.

But I would encourage any GP who has done gynaecology in the past to try a project like this. If they can offer ultrasound scanning as well, so much the better.

Dr Uma Marthi is a GP in Rochdale, Greater Manchester

41268655Buying an ultrasound machine has allowed a lot more patients to be handled in primary care Buying an ultrasound machine has allowed a lot more patients to be handled in primary care The all-female gynaecology team (from left): Dr Shalini Gadiyar, Dr Liz Tutton, Dr Alka Kedia and Dr Uma Marthi The all-female gynaecology team (from left): Dr Shalini Gadiyar, Dr Liz Tutton, Dr Alka Kedia and Dr Uma Marthi gynae pateint satisfaction results