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GPs taking on ring pessary service under QIPP

Dr Anita Sharma explains the dynamics of shifting this service from hospital to less costly primary care.

Dr Sharma: without primary care service in situ to meet demand, patients faced the prospect of seeking a GP referral each time they needed their pessary changed
Dr Sharma: without primary care service in situ to meet demand, patients faced the prospect of seeking a GP referral each time they needed their pessary changed

One of the key aims of our local Quality, Innovation, Productivity and Prevention (QIPP) programme is to minimise hospital follow-up appointments and treat patients more cost-effectively wherever possible.

Key performance indicators (KPIs) applied to provider contracts to reduce variation in follow-up activity levels led to acute trusts in the Greater Manchester area rethinking these processes.

One consequence was our trust's decision in Oldham to discharge, rather than arrange follow-ups for, patients needing regular ring pessary changes, a service that can and should be delivered in primary care.

However, without primary care services in situ to meet demand, patients faced the prospect of seeking a GP referral each time they needed their pessary changed, and the PCT faced a bill for hundreds of 'first' appointments, at more than double the cost of follow-ups.

NHS Oldham commissions gynaecology outpatient services from the Greater Manchester Clinical Assessment Service (GMCATS), a Care UK service provided from mobile units at multiple locations.

However, because referral exclusion criteria apply (BMI, comorbidities and so on), it cannot treat everyone requiring this service. As a consultant-led service, this may also not represent the best use of resources.

Another important factor was the guaranteed financial value or prepaid level of the GMCATS contract: the PCT has a strong incentive to ensure that the service is used up to a certain level of activity.

Patient leaflet

This includes answers to the questions that patients commonly ask about ring pessaries:

  • What a ring pessary is.
  • Reasons why you need it.
  • What will happen during an appointment for removal and replacement.
  • About the doctor (GP specially trained to do the procedure).
  • Risks and possible side-effects.
  • Normal sex life is possible.
  • It will not interfere with bowel movements.
  • What to do if the pessary falls out or you have concerns.
  • Frequency of replacement.
  • Follow-up appointments.
  • Name of doctor and surgery contact details.

 

Solution found
Three strategic priorities needed to be taken into account:

  • Patient choice.
  • Care closer to home.
  • Primary care capacity and capabilities.

Oldham's clinical commissiong group (CCG) supported a proposal to move towards an any qualified provider (AQP) model. This initially takes the form of a local enhanced service, enabling practices to become accredited to offer pessary services to patients registered with other practices in Oldham.

The medium-term intention is to allow non GP practice providers - sexual health service providers and district nursing services, for example - to apply to become accredited pessary service providers through an open AQP tender process.

Intrapractice referral
This service is the first in Oldham to involve a formal intrapractice referral system that systematically builds in patient choice (and will soon also apply to minor surgery services).

The CCG is keen to realise the benefits and learning from these initiatives to help it plan the release of expertise residing in primary care, through intrapractice referral systems that ensure best value for money.

Chaperone policy
  • The patient's need for privacy and dignity must be respected at all times.
  • This, together with the healthcare professional and examination required, will dictate the chaperone's role.
  • Examination details including presence/absence/availability of chaperone and information provided to be included in the patient's case notes.
  • The chaperone should ideally be a clinical health professional or trained non-clinical staff member.
  • The chaperone should be sensitive to, and respectful of, the patient's dignity and confidentiality; prepared to reassure if the patient shows signs of distress or discomfort; familiar with the procedure(s) and prepared to raise concerns about the healthcare professional's conduct if necessary.
  • If possible, they should be the same sex and speak the same language as the patient.

Better for patients
Women who need a change of pessary for vaginal prolapse will soon be able to choose from a number of practice-based services across Oldham and from GMCATS (if appropriate), if their GP practice does not already provide the service.

This will allow more women to be seen in the community, avoiding unnecessary hospital trips. We expect this to improve access and patient experience, while empowering primary care clinicians to provide pessary fitting and changes.

Trained and competent GPs, and in future, other suitably qualified clinicians, will carry out procedures in suitable clinical facilities.

Policies and procedures
Practices providing the service will be required to have appropriate protocols and procedures in place, including infection control, consent policy, chaperone policy, patient leaflet, patient satisfaction feedback and proper record-keeping.

They will also need to ensure the patient's GP receives timely information, including details of any significant events.

Provider activity levels and KPIs will be monitored through an elective care performance 'dashboard', generated by an in-house automated data collection and analysis system.

  • Dr Sharma is a GP and clinical director for elective and vascular care in Oldham
  • Michael Dearden, NHS Oldham senior project manager, commissioning and system reform, was the lead in developing the pessary service

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