Tales from the community menopause clinic

Introduction

Despite accounting for just over half the population, women continue to experience inequitable health care, which includes management of menopausal symptoms.

The vision of the British Menopause Society (BMS) ¹ is for every primary health care team to have at least one nominated clinician with a special interest in menopause. Primary care networks can support women from neighbouring practices to access more specialist menopause care. Future use of group consultations, with a shared consultation for 5–10 women, has the potential to further extend access, whilst group educational events provide a platform to improve patient understanding of menopause and potential management strategies.

The menopause marks the end of the reproductive life and can be associated with a wide variety of physical and psychological symptoms, the effects of which can impact quality of life and long-term health outcomes. The average age of the perimenopause in the UK is 46 years and the most common presenting symptom is heavy menstrual bleeding. Whilst fertility is reduced in this population, conception remains a possible consequence of unprotected sex and therefore continued use of contraception is recommended. Some of the new combined oral contraceptives (such as Qlaira®, Zoely® and Drovelis®) can manage the menopause transition, while also providing contraceptive cover, for medically eligible women, and can be a useful solution in this scenario.

At a population level, the effects of the menopause are felt more broadly and can impact public health outcomes, workplace productivity and societal wellbeing. This highlights the importance of prioritising equitable access to good quality menopause care, which is paramount to ensuring that all women are well supported through this life stage transition, to live more active, healthy and fulfilled lives, while enabling an ongoing contribution to the wider society.

The growing disparities in menopause care and women’s health is recognised by the Women’s Health Strategy for England, a comprehensive report on the current gender disparities seen in women’s health with key recommendations and ambitions to make changes. ² The strategy aims to improve the experience of menopause, by emphasising the importance of education and early intervention, with timely access to high-quality primary, intermediate and secondary care menopause services provided by experienced healthcare professionals in a variety of settings. Furthermore, it highlights the value of utilising women’s health hubs; specialist community services that bridge the gap between primary and secondary care and which have the potential to provide quicker access to local specialists. Better for Women, ³ published by the RCOG in 2017, highlighted the societal benefits associated with getting the best outcome for girls and women by, ‘avoiding them falling through the cracks in our health care systems’. Collaborative service delivery from Women’s Health Hubs take us one step further to realising this goal. In this tale, we describe an innovative funding model to improve menopause care in central Liverpool, the 3rd most deprived area in the UK, based on an index of multiple deprivation. ⁴

Background

In this paper, we outline the application of these ambitions to a busy tertiary menopause service in central Liverpool, which serves the majority Cheshire and Merseyside (C&M) with additional cross border referrals from Cumbria and the Midlands. Whilst referrals have steadily increased since the COVID-19 pandemic, capacity has remained relatively static, resulting in unacceptably long waiting times for first and follow-up appointments. Through collaboration with local primary care networks and specifically the Central Primary Care Network (PCN), this pilot project was developed to improve patient access to specialist menopause care, and to reduce waiting times for appointments, protecting the sustainability and quality of the regional service.

The Liverpool tale

One of the main drivers for this pilot project was the high number of non-complex cases seen in the secondary care menopause service.

The success of GP delivered community menopause care is built on a foundation of improved relationships between primary and secondary care, with existing community delivered services (community sexual and reproductive health) providing an essential link. In Liverpool, there was a 150% reduction in referrals to secondary care from 21/22 to 23/24, as a result of a focussed effort to make menopause training for local GPs a priority.

Women’s health hub

There are many different WHH models, and in this tale, we describe a novel pilot undertaken in central Liverpool to bridge the gap between primary and secondary care services. The aspiration is for a WHH in each integrated care board (ICB) in England with provision of eight core services:

• Management of menstrual disorders.

Larger ICB’s may need to consider more than one hub, particularly in areas where access to services is compromised for various reasons including transport systems, poverty and ethnic diversity.

Funding model

If additional funding is not available to establish new services, then alternative strategies need to be considered to ensure that the right care is available, in the right place at the right time.

This can be achieved in many different ways as per the pilots aims and objectives described below.

Pilot project overview

Objectives

• Identify suitable locations for community clinics, including use of existing community clinics. Locations that are local to the patients home will improve access and acceptability.

• Select a pilot partner for a new community menopause service delivery (in this example Central Liverpool Primary Care Network (CLPCN)).

• Secondary care provider to oversee administrative, governance, clinical support and supervision to the pilot partner organisation.

• Train community menopause care providers (GPs) to achieve the BMS Principles and Practice of Menopause Care (PPMC) certificate or the BMS Management of the Menopause certificate (exclusive online education, assessment and certification) and support appropriately trained primary care clinicians to deliver clinics locally, under an SLA.

• Organise funding of community service provision. LWH claims the appointment activity and tariff, and pays the PCN per appointment attended at a rate competitive with LARC. For the pilot service, this was £110 per new patient appointment. Aiming for 6 new patient appointments per clinic, that is, £660.00 per clinic (COST MODEL).

• Increase monthly appointments by 18, with an aspiration to increase overall appointments to 60 additional slots across Cheshire and Merseyside per month.

Clinic locations and secondary care support

There are nine locations or ‘places’ in Cheshire and Merseyside and the aspiration locally is to have a women’s health hub in every ‘place’. These will be selected based on the highest need for menopause services. In C&M, this includes Central Liverpool, South/Knowsley, Sefton and Wirral (pictured).

For our pilot project, CLPCN was selected. This PCN already have a lease in place for an identified location from which LARC services are delivered. The building was historically home to ‘Brook’ young person’s services (pictured) and is an ideal ‘hub’ as it is well known by the local community as a health resource. However, women’s health hubs can be delivered from different settings with variable models.

An identifiable independent setting was seen as a bonus and integration with the local community through neighbourhood engagement leads (NELs), helping bring women to services that they might otherwise fail to access was considered an additional benefit.

As the secondary care menopause provider to C&M, Liverpool Women’s Hospital (LWH) supervised the pilot’s implementation and clinical activity. LWH Consultants have maintained clinical oversight, governance and mentorship to support local GPs to deliver menopause care in the community, while the administrative team co-ordinate service appointments (see appendix).

Pilot promotion

Patient infographics were used to promote the new pilot clinic to clinicians and patients, explaining the aims and objectives of the pilot service.

Summary of the model

• Supports the NHS Long-Term Plan and NHSE Women’s Health Strategy.

Benefits

• Financially sustainable model for both Secondary Care Provider and Primary Care Collaborator without the need for additional commissioning agreements.

Project roadmap

Patient case

A 55-year-old patient was referred to the menopause service at LWH in January 2024. Her postcode meant that she was eligible for assessment and management within the community menopause clinic.

Conclusion

Current waiting times for secondary care menopause services have provided an incentive to look at alternative ways of working.

This pilot benefits from being cost neutral, with care provided within the existing budget, and the model is better for women and as a result society as a whole.

There have been teething problems relating to use of secondary care IT systems and ensuring availability of the necessary administrative support, but we are committed to continual evaluation, including responding to patient feedback, to ensuring ongoing success of the pilot service, with plans for roll out to other areas.

Patient feedback includes the following:

‘Staff are lovely, very caring and professional. Listened closely and considered the best treatment for me’