Streamlining women’s health – The case for change

The recently published Department of Health Strategy for Womens Health ¹ brings together many well-known unaddressed issues in the delivery of healthcare to women in England. For those of us working in primary care, sexual and reproductive health, fertility, menopause, community and hospital-based gynaecology amongst others, we are only too aware of the huge fragmentation that exists in the design and delivery of these services.

Over the years, the hugely popular ‘Tales from the clinic’ section of this journal has highlighted many of the real-world issues that we come across in the clinic and several of these cases have highlighted where care could have been improved by services that are more joined up.

Whilst we frequently get frustrated at work seeing patients in settings that represent a less efficient care pathway, we should not lose sight of the fact that as well as our frustration we may be looking after a patient who has been disadvantaged by an inefficient system. The problem here is that historically many of these pathways are not designed around the patient.

We all have experience of such pathways – where patients have to see a professional first to get referred onto someone who can deliver what they need. This is often in a different location, on a different day and may also be interspersed with investigations and tests, also on different occasions. Before you know it, some patients may have had 3–4 journeys before they get the treatment they need. At a time of a cost of living crisis and financial pressure on the NHS to deliver care more efficiently, it seems to us that our patients are taking time off work, paying more in bus fares, car parking, etc. to get to these appointments while the NHS is seeing them on several occasions to achieve the same aim. These are unnecessary visits and also introduce delays in care delivery. These inefficiencies also add patients to the ever-growing waiting lists, and these are patients that could so easily be managed quickly and safely in the community.

Let's consider one example, a typically frustrating situation of a woman who suffers at the hands of the current system. Usually in her 40s, she is often suffering from menstrual disturbance of some sort, is seen by her GP who examines her, and feels a slightly enlarged uterus and requests an ultrasound scan. These scans are typically normal with a thin endometrium and findings suggestive of mild adenomyosis. She has usually discussed the results with her GP who takes her through the options, including non-steroidal anti-inflammatory drugs (NSAIDs), antifibrinolytics, the Mirena IUS and hysterectomy which is often the point at which a gynaecology referral is triggered with interim measures of NSAIDs and antifibrinolytics or an IUS offered given the long waits for secondary care appointments at the moment.

A frequent outcome is that the bleeding problems worsen whilst waiting and patients need to take time off work. Women by this point have often asked their GP about an IUS, which sadly is not a service offered by all surgeries so she is usually signposted to her local sexual health service. The problem here is that most sexual health clinics will advise that they are only commissioned to insert intrauterine devices for contraceptive purposes, which means that many women cannot get one unless special arrangements are made.

For many women, this sounds like this is where the story ends – an over 6 month wait for a simple, yet effective treatment, sadly though many secondary care gynae clinics do not offer a see and treat IUS insertion service unless they are aware the patient is coming in for this procedure. It is not uncommon for the patient to have the expectation of insertion of an IUS on the day, but the clinic may be unable for various reasons such as skill mix or equipment to change tack to do something such as this.

The BMS vision for menopause care in the UK recommends that there is a specialist menopause service in every region/board to be able to offer advice for complex patients and provide support and education for primary care teams. Many BMS recognised menopause services are now in place, but for some, there are huge waiting lists, with some women waiting too long while continuing to experience menopausal symptoms. Changes are required to enable more menopause care to be provided confidently in the community and again in a joined up fashion such that other issues of women’s health can be managed under the same umbrella.

This series of predictable blocks to efficient and timely patient care and all the delays women experience is all too familiar across much of medicine at the moment. There are of course some beacons of light, some perfectly formed one-stop services where patients get the most efficient care. But, in women’s health, there are many such examples and similar stories to this that mean we should do more to help.

The best healthcare experiences are where the needs of patients and the abilities of the service are aligned: accessible, efficient, safe, effective, up to date and constantly improving. In other words, service is designed and delivered with the women very much at the centre. Designing such services in this way not only makes them more efficient for patients but also makes them more accessible.

Accessibility of healthcare is one of the key components of reducing inequalities of care provision which of course aims to reduce inequalities in the outcomes of care. All of us working in women’s health – in community, primary and secondary care – see daily examples of inefficiencies. We now have at hand the Womens Health Strategy and it is vital that we use it to its full effect.

Because some elements such as CSRH have been devolved to local government commissioning in England, this may require some negotiation around the commissioning elements but existing models of hubs in early set demonstrate that we don’t just see an improvement in the patient experience but in the overall efficiency of the services. The recent establishment and now operationalising of Integrated Care Services in England gives a great opportunity to reset functions and funding for this component of the relationship between Local Authorities and Healthcare.

Recently, £25m funding was announced to support the roll out of components of the strategy with a sharp focus on the formation of Women’s Health Hubs. A hub can take many forms – but the key philosophy is the organisation and delivery of care in as few steps for women with as few delays as possible. Generally, the best way to avoid delays is to avoid secondary care. For the vast majority of routine women’s health problems, secondary care is unnecessary. The role of the hub will be to design local pathways and efficient care that brings together existing skills in community and primary care and where necessary bring secondary care to the women rather than vice versa.

So, what’s not to like? The development of streamlined local healthcare provision designed around the needs of local women in a way that is not only efficient for the wider healthcare system but also for those of us who provide the care and the women that so desperately need it.