This Gynaecology Blog will keep track of all the activity undertaken by the Gynaecology Sub Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wished to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
Gynaecology workshop one: symptom profiling
The 15th May 2018 saw the first Scottish Access Collaborative workshop for the Gynaecology Sub Group team. In this first workshop, the gynaecology team, consisting of consultants, GPs, managers and other health care professionals, came together to work collaboratively with the Digital Health and care design team to map some of the most well-known current Gynaecological patient pathways, and find some of their common challenges. The Scottish Access Collaborative brings together representation from all the aspects of a health care pathway, from across the health boards in Scotland, to address the issues of waiting times for non-emergency care for people living in Scotland. Over a series of three design workshops, Sub Groups from different clinical areas will meet to lay out their most prevalent challenges, and work together to develop ways to address them, always with patient experience at the centre. In this workshop, the Gynaecology experts work collectively and in small ‘huddles’ to really scrutinize their current practices, share what is working, and importantly what they think are the big issues facing their field.
Focus on Symptoms
Mapping complex systems is a difficult task. They are multi-dimensional, non-linear, and have many variations. To map the whole national picture for gynaecology in a relatively short time would be too great and endeavour. Therefore, for this task we have elected to use individual symptoms as a unit of analysis in our approach to mapping the current state of gynaecology pathways. Developing symptom profiles for each clinical area helps the group to prioritise the areas of their practice that they would like to improve, and makes the mapping of current practice a manageable piece of work. To do this the group first listed the most common, troubling, or advantages symptoms presented in their experience. Following form this the group ranked and prioritised the list into four key symptom profiles.
Bleeding (pre-menopausal). Chosen because it is in general very common and presents in high volumes, it has a significant impact on the patient, it can be “very scary” and can be a cause of anxiety, there is variation in what is offered in primary care and this impacts on pathways leading to inconsistencies, it represents a large workload in outpatient clinics
Urinary symptoms. This profile combined incontinence, leakage, frequency and urgency of passing urine. When combined, this symptom was chosen for its frequency of presentation which is generally high (10 – 15%), there is an opportunity for primary care management but a variation in the support available in primary, and the symptom can have a significant impact on the patient quality of life
Prolapse. A medium frequency presentation chosen because of variation in the pathways, often inappropriate advice is given to patients, there is an opportunity for support in primary care, once in secondary care patients expectations are raised and can impact on anxiety levels for them
Pelvic Pain. Chosen because it can come from a variety of origins, it is a “non-specific” pain and is very difficult to manage, it is often referred as ‘urgent’, there is an imperative for investigation and it is resource heavy
Other symptom profiles that were defined by the group but were not chosen as the unit of analysis for the pathway mapping included: gynae-skins or, itches, lumps and bumps, that have a huge impact on the patient; anxiety which can lead to lots of referrals, for example a patient perception of their body shape is low volume in presentation but can be very heavy on resource if not managed appropriately; roots through general screening and infertility were disregarded at this stage as they have well established pathways and were felt not to be the focus of the group. Once the symptom profiles had been the decided the group broke away into four smaller groups to map the current common pathways for each, focussing on the various phases the symptom passes through, examples of best practice, variations and importantly the challenges.
Once the group had mapped out the various pathways for the selected symptom profiles, they came back together for a series of round-table discussions to share their findings.
The group talked about national specialist menopause clinics and the benefits of a national roll out.
There was also conversation around the potential for evidence based treatments that can be ‘done’ in primary care.
There is an issue around gynaecology expertise in primary care. Presentations of symptoms tend to be referred directly to gynaecology because of a lack of capacity in general practice. There is a ‘de-skilling’ happening around gynaecology
It was felt that the culture is to go straight to tests, a practice referred to as ‘defensive medicine’. There is a lack of clinical judgement, whether because of confidence or experience in primary care in general.
Many of the issues raised while discussing the pathway maps pointed towards the importance of the appropriate person doing the appropriate job. There is an opportunity to revise staff rolls and potentially innovate the current pathways, freeing up resources to do more appropriate work and to develop new definitions for roles with appropriate training.
The first workshop exposed some key issues for gynaecology pathways, and also some areas of best practice that could be replicated across services to improve patient and staff experiences. The DHI design team will collate the insights from the first workshop and bring them to workshop two where the group will further scrutinize the symptom based pathways and pull out some key challenges to take forward into workshop three.
Gynaecology workshop two: defining issues and opportunities
On the 12th June, the Scottish Access Collaborative Gynaecology Sub Group met for the second time with the design team from the Digital Health and Care Institute. This second workshop of three continued to work towards finding opportunities for improvements to Gynaecology services in the NHS in Scotland. The group are just one of many Sub Groups working towards NHS improvements for patients and staff, as part of the Scottish Access Collaborative program of work. The second workshop followed on from the group’s first meeting where they defined some key symptoms to focus on, and mapped out current symptom led pathways. In this workshop the group now aimed to take the next step and raise the key issues associated with current pathways, and suggest some opportunities for making service improvements.
Locating the issues and finding opportunities
Once the pathway maps had been discussed and some details added, each working group started to highlight the key insights and outline some potential opportunities for improvement. Initially working as two separate groups, and then combining later in the day to one group, the insights and opportunities associated with each particular symptom were recorded.
The four symptoms covered in the session were: heavy bleeding pre-menopause; pelvic pain; urinary symptoms; and prolapse. Overall the following points were raised in the groups discussions.
- The group highlighted the need for consistent agreed national referral guidelines. The NICE guidelines were cited as best practice.
- There are a relatively high number of presentations in secondary care that could be dealt with in primary. It was agreed that a vetting model currently adopted by Glasgow and Lothian, where dedicated time for Vetting is allocated, was a good example of best practice. If combined with phone support to GPs and patients, this had potential to reduce the number of patients presenting in secondary care when they could be better treated outside secondary care.
- There was much discussion around the first set of treatment options for patients presenting with certain symptoms, which included physio, specialist physio and continence clinics. Currently these treatment options are not always adopted effectively but they have potential to reduce appointments and secondary presentations.
- The group discussed the potential to align certain treatment options into one place. It was agreed that initial treatment could be provided in a specialist women’s health cluster which could be in primary or secondary care.
- It was also agreed that the group would benefit from understanding more about who provides these services now in primary care before any improvements to be feasibly suggested.
- The group discussed the crossover in some respects with Urology and proposed a specialist UroGynae clinic that could test, diagnose, and provide treatment in a ‘one stop shop’.
- With respect to patients who require physiotherapy, the group referred to the complexity and added difficulties in the process of planning and delivering this service. Quality of referral and quality vetting is critical to appropriate planning but currently referral is inconsistent and not always complete.
There were some other minor insights and opportunities flagged by the group that they will not want to lose, and these will be reviewed before the next Gynaecology workshop in July. At the July workshop, the group will meet for a final review of the insights and opportunities so far, deciding which opportunities they will ultimately recommend to take forward. Key to this will be to refine and prioritize what they have learned so far and decide where the most appropriate opportunities for service improvements lie.
Gynaecology workshop three: focussing opportunities
Earlier this month the Gynaecology Sub Group for the Scottish Access Collaborative met with the design team from the Digital Health and Care Institute for their third in a series of three design workshops. The aim of this series of workshops is to bring together a panel of gynaecology and health service experts, including GPs, consultants, managers, patients, nurses and physiotherapists, to discuss the future for gynaecology services in Scotland. Over the three workshop the Sub Group, in collaboration with the DHI design team, have worked together to scrutinize the current service ecology for gynaecology, taking on board patient and clinical perspectives, and make recommendations for future service improvements. These service innovations will align with the core principles of the Scottish Access Collaborative and other health care development ongoing in Scotland.
Having identified in workshops one and two some key areas for focus and some initial proposals for innovations in current gynaecology services, the group now came together in a third and final workshop to refine and prioritise their ideas for future recommendations. What follows here is a summary of the main proposals that will be put forward in an upcoming Gynaecology Report.
What was very clear from the discussions within the group was that the key to more efficient Dedicated vetting time. It is hugely important to get vetting right. Quality vetting can prevent unnecessary appointments, free up clinical time, and ultimately improve patient experience. Managing the quality of vetting means dedicated time as part of clinics for an experienced decision maker to scrutinize each referral and direct appropriately.
Sometimes, from a GP and a consultant perspective, the effective course of action for a patient can be determined by a conversation between primary and secondary. While advice referrals exist currently, what the group really wanted was some form of synchronous connection between GP and consultant. In an ideal world, there would be open access for GPs so that there can be a conversation between the clinic and the GP before referral is made.
High on the list of service improvements for the group was thinking about making things better from the patient perspective as well as from the clinical side. To reduce the number of miles travelled for patients the group proposed that telephone or some form of virtual appointments become part of gynaecology clinics for appropriate cases. In this scenario, a letter is created at the point of vetting for patients who could be ‘seen’ virtually, the letter is sent to the patient GP and to the patient informing them of the decision, an appointment is then made for a telephone consultation, and the call happens. The group thought this service would make sense for many scenarios, elderly patients and those who may have physical trouble travelling, remote patients and those who just need to speak to someone rather than be examined.
The general point made by the group is that it is the combination of primary secondary conversations, dedicated vetting, and options for virtual consultation that will be the most effective and could have a significant impact.
One big issue for gynaecology is the current capacity of specialist physiotherapists available for patient. Specialist Physiotherapy is often the best route for patients to take rather than forms of surgery or intervention, is a decision that can be made without secondary consultation, and direct access from GP would eliminate a potential 12 week additional and unnecessary wait. For bladder problems and prolapse, having more direct access to physiotherapy could make significant improvements evidence now shows how successful physiotherapy is with these symptoms. For this to be successful the capacity of specialist physiotherapists will need to increase to meet the demand, and the patient examination will need to be of a high quality so the referral has enough information to tailor the correct course of physiotherapy.
Patients being enabled to make decisions about their care, and to manage their symptoms themselves where appropriate is a key driver for gynaecology services. Good quality and timely patient advice and information is a vital goal for improved patient and clinical experience. There is currently variation in the front-end advice given to patients, that is advice given by GP at initial consultation about options, their symptoms, and their likely course of treatment. There is similar variation in the back-end advice, the advice given to patients on discharge about managing conditions and options to ‘come back’. Informing and empowering patients was seen as an imperative part of future services. A more informed patient is an easier consultation to have.
Linked to the idea of better informed and empowered patients, the group discussed the merits of an open return system, where patients can refer back to clinic themselves until their condition is resolved. There was some precedent for this already happening with some physiotherapy services, and the early evidence shows that return rates go down when patients are given the option to return rather than by default or through the GP. To enable further improvements in this area, combining the return appointment with virtual consultation could reduce more the number of unnecessary trips to clinic for patients. In this scenario when a patient calls to make a return, the call can be vetted and if appropriate directed for virtual services.
At the end of the workshop the group proposed the concept of bespoke education for GP clusters. The idea entails clinics collecting and analysing their referral data for consistent themes and issues, that could then be fed into area GP clusters to help them develop the joint services areas need and support their initial consultations. There was some discussion around how this could be implemented, whether through regular meet ups or online forums, but unanimously it was seen as a positive step gynaecology could take toward service improvements.
The next step is for the DHI team to compile the recommendations into the Gynaecology sub group report which will be published here on the Scottish Access Collaborative website.
Outpatient Services Update
Over the last year, visits have taken place to meet Gynaecology teams around Scotland, discussing outpatient services. At each visit, the patient pathway has been examined to look for any improvements that can be made to reduce referrals and ultimately the need for face to face consultations, while affording appropriate time without unnecessary delay for those patients who do need to be seen. This work is in line with the 1st founding principle from the Scottish Access Collaborative (SAC): Patients should not be asked to travel unless there is a clear clinical benefit and that any changes should not increase workload for primary, secondary or social care. Variation does exist yet common themes have been shown, the learning from which is applicable across specialties.
The following is a summary of where most action is required as concluded from visits, Modern Outpatient Programme, Scottish Access Collaborative and Regional planning.
1. Pathways—agreed national clinical pathways to facilitate self management, primary care management and appropriate referral. Workshops run by Digital Health and Care Institute team for Scottish Access Collaborative have confirmed this need across specialties. Gynaecology pathways to be promoted through Modern Outpatient Programme. (SAC founding principle 3: Referral and destination pathways, including patient self management options should be clear and published for all to see).
2. Referral triage--Investment in appropriate time for vetting of referrals- highlighted as of high importance across specialties (SAC founding principle 2: All referrals should either be vetted by a consultant/senior decision maker or processed via an agreed pathway/protocol). In Gynaecology, only 2 Boards currently provide dedicated time in job plans for vetting. For most others, and in many other specialties, vetting is part of on call duties and is not approached consistently. Programme supported by Scottish Access Collaborative
Active Clinical Referral Triage (ACRT)
- Senior clinical decision maker routinely reviews each referral to secondary care, fully utilising the available EPR (Electronic Patient Record)-including lab results/PACs etc.
- Each patient is then triaged to the optimal, locally-agreed pathway-which may include virtual clinics, supplying clinical information by return and allowing the patient to “opt-in”, ordering investigations or placing the patient directly on the waiting list for a procedure/surgery.
- A face-to-face attendance should only occur if there is a clinical need.
Examples of use of ACRT have shown up to 50% decrease in need for face to face consultations. Reducing face to face consultations not only offers reduction in inconvenience to patient, and often family/carers/work, allows time in clinics for patients who do need to be seen, but also affects patient expectations; patients attending hospital outpatients may expect instant treatment/procedure, rather than conservative management which may be more appropriate. Example would be management of pelvic organ prolapse, when conservative treatments including weight loss and pelvic floor exercises can reduce symptoms and avoid need for surgery. Attendance at hospital clinic without recommended initial treatments tends to lead to expectation of surgery and reluctance to engage with conservative measures. Indeed the variation of rates of procedures across Scotland such as hysterectomy for benign conditions, and prolapse repair may reflect variation in pathways.
Advice request option and easy process for sending back advice even if appointment has been requested is essential to facilitate this process, yet is not available throughout Scotland.
3. Reducing DNAs-Reminder systems are not in place throughout Scotland, and booking processes vary. It is likely that this is reflected in significant variation in DNA rates.
4. Reducing return appointments- Many specialties have ceased arranging routine reviews, especially post operative reviews for benign surgery. However the wide variations from benchmarking data seen within specialties suggests that not all return appointments are required and emphasis should continue to be on encouraging clinicians (including locums) to question the need, and, if a review is clearly required, to consider the type of review and option of virtual rather than face to face appointment.