Telford and Wrekin Clinical Commissioning Group
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1 Telford and Wrekin Clinical Commissioning Group Agenda Item 9.2 CLINICAL COMMISSIONING GROUP GOVERNANCE BOARD EXECUTIVE SUMMARY DATE: 9 th April 2013 TITLE OF PAPER: Continence pathway and Referral letter EXECUTIVE Fran Beck, Executive Lead Commissioning RESPONSIBLE: Contact Details: Ext: fran.beck@telfordpct.nhs.uk AUTHOR (if different from above) Nicky Wilde, Head of Commissioning Planned and Primary Care Liz Cartwright - Primary Care Development and Liaison Lead Contact Details: Ext: liz.cartwright@telfordpct.nhs.uk CCG OBJECTIVE: To improve quality and service transformation For Information X For decision For performance monitoring At least one box must be ticked EXECUTIVE SUMMARY As part of the service redesign programme, the continence (Key points in report) pathway has been developed to refine Gynaecology referrals. The continence pathway has been developed using current NICE and best practice guidelines. It has been developed by 11 Telford and Wrekin GPs in conjunction with the local Continence team and Dr R Foon, Consultant Obstetrician & Gynaecologist. (Urogynaecological), SaTH. The pathway is to offer guidance to primary care clinicians to manage female patients presenting with incontinence within General practice and the community continence team. The continence team will then refer, where appropriate, patients on to secondary care through TRAQS using the referral pathway letter template. This will ensure a seamless pathway of care without the need of referring patients back to GPs for onward referral. The GPs at the March 2103 Practice Forum agreed the clinical elements of the pathway and the onwards referral letter. The programme is now presented to Board. FINANCIAL IMPLICATIONS: The continence pathway is part of the Planned care QIPP plan. The resulting cost efficiency would equal a saving of circa 16,000 in the first year and savings of 32,000 in subsequent years EQUALITY & DIVERSITY The continence pathway will allow more timely access to incontinence management and investigations, with advice and guidance for onward management in Primary Care from the continence team. There would be a reduced demand for face to face appointments to ensure the more complex gynaecology
2 patients are able to be seen within appropriate timescales. PATIENT & PUBLIC ENGAGEMENT None undertaken LEGAL IMPACT: N/A RECOMMENDATIONS: Is there a need to consider inclusion in the Corporate or Executive Risk Registers? The Board is recommended to: To support the recommendation of the GP Forum to implement the continence pathway and the onward referral letter. N/A
3 1. Title Agenda Item 9.2 CLINICAL COMMISSIONING GROUP GOVERNANCE BOARD REPORT Continence pathway and Referral Letter 2. Substance of the Report Data gathered on GP gynaecological referrals for 1 st outpatient attendances for the period April-June 2012 demonstrate approximately 20 referrals were made for urinary incontinence across 11 practices. It has been identified that this group of patients could have been diverted from secondary care through management in the community by the Shropshire Community Trust Continence Service. This pathway is the result of the QP work and it has GP support from the 11 practices that took part in the review. The pathway is to be implemented in the 22 practices. As part of the service redesign programme, the continence pathway has been developed to refine Gynaecology referrals. The outcomes of the project will assist the CCG to improve commissioning of effective, safe and sustainable services, which deliver the best possible outcomes, based upon best available evidence. Current pathway A number of GPs refer patients for incontinence to secondary care for investigation and further management New pathway Telford and Wrekin GPs have developed a continence pathway, following NICE guidelines, where they follow the pathway where appropriate and/or refer to the continence team to continue the management of their patient within primary care. This new pathway will allow patients to be managed within Primary Care with direct access to specialist tests and advice and guidance from the continence team without the patient attending hospital resulting in hospital capacity being prioritised for complex patients who require a face to face consultation with a secondary care Consultant. Measure and monitor The success of the service redesign will be via monthly monitoring of SUS and RTT data. Planned Start Date & Review Date Planned start April 2013 for new referral process review October The GPs at the March 2013 Practice Forum agreed to take this pathway and referral letter forward subject to approval from Board.
4 3. Financial Implications Anticipated recurrent annual cost: Year 1 cost 13,500 Year 2 and beyond cost 27,000 Cost efficiencies will be released by treating these patients in a community setting minimum recurrent savings will be 8,000 in the first year increasing to circa 20,000 in subsequent years. 4. Equality & Diversity impact assessment The continence pathway will allow more timely access to incontinence investigations, and advice and guidance for onward management in Primary Care. There would be a reduced demand for face to face appointments to ensure the more complex patients are able to be seen within appropriate timescales. 5. Process by which the document has been developed, including consultation and engagement of patients and clinicians As part of the service redesign pathway work, there have been ongoing discussions around improving the gynaecology pathways. The work has been undertaken in conjunction with Shropcomm Continence team and Mr Foon, Consultant Urogynaecologist. An outline of the pathway and letter was discussed at the Telford and Wrekin Practice Forum in March 2013 and approved for implementation dependant on approval from the CCG Board, quality improvement being assured and financial efficiencies being delivered. 6. Legal Impact N/A 7. Risks identified N/A 8. Recommendations To approve the Continence pathway and referral letter
5 Female incontinence pathway Refer under 2 WR Painless macroscopic haematuria Unexplained microscopic haematuria if 50 or over Recurrent or persistent UTI with haematuria if 40 or over Pelvic mass not obviously fibroidal Refer to Urologist if: Palpable bladder post voiding Consider referral to Secondary care if: Persisting bladder or urethral pain Voiding difficulty especially if post voiding volume>100 ml at bladder scan Clinically benign pelvic masses Associated faecal incontinence Suspected urogenital fistulae Suspected neurological disease Previous continence/pelvic cancer surgery Previous pelvic radiation therapy History Urinalysis treat UTI if present Pelvic examination 3 days bladder diary Atrophic vaginitis treat with topical estrogens (ie Vagifem 10 mcg vaginal tab one daily for 2 weeks then one twice weekly ) Prolapse fit ring pessary if associated uterine prolapse refer to Uro Gynaecologist if symptomatic prolapse visible at or below introitus Voiding difficulty or recurrent UTI refer to CAS for bladder scan and uroflowmetry Stress incontinence (leakage on effort/ exercise) Overactive bladder (Urgency and/ or urge Incontinence, nocturia, frequency 8 times per day) Mixed incontinence Pelvic floor muscle exercises (see leaflet) Lifestyle advice fluid, weight reduction Refer to women s health physio if unable to contract pelvic floor Bladder training (see leaflet) Lifestyle advice fluid, caffeine, weight reduction Review at 6 weeks Treat most bothersome aspect first or Refer to CAS if unable to identify underlying aetiology Refer to CAS if patient needs added support with pelvic floor exercises particularly if they are lacking in motivation or understanding Antimuscarinics if still symptomatic. Refer to CCG Medicines Management guideline Drug treatment algorithm for urinary incontinence Review at 12 weeks Refer to CAS if still bothersome Review at 6 weeks Increase dose/change antimuscarinic Or Refer to CAS if patient distressed/too many side effects Review at 6 weeks Refer to CAS if no improvement. Community based patients with cognitive impairment/mobility issues/housebound refer to District Nurses
6 *CAS = Continence Advisory Service INCONTINENCE PATHWAY LETTER BMI Table Height Table Weight Table Smoking Status Table Parity Table No of complicated vaginal deliveries Dear Colleague Thank you for seeing the above named lady who is suffering with urine incontinence. Symptoms present for Main Problem Urge Incontinence Stress Incontinence Mixed Incontinence Unidentifiable Atrophic Vaginitis present/treated Lifestyle and fluid advice given Pelvic floor exercises for 12 weeks Bladder training for 6 weeks Antimuscarinics tried with doses and duration of use: Seen by Women s Health Physiotherapist Any other Comments Yes Yes Yes Yes No No No No
7 Please see attached a summary printout. Please see for ongoing management options, Thank you Yours sincerely Dr. Onward referral to secondary care if appropriate. Yes No Suitable for surgical consideration Yes No Refer back to GP once treatment complete Yes No
8 Onward referral letter from Continence Advisory Service Dear Colleague Thank you for seeing the above named lady who is suffering from urinary incontinence. Details to be merged as above. This patient has been referred, seen and treated by Continence advisory service and in view of the following findings:- e.g. Poor response to medical treatment and ongoing stress symptoms Details of investigations and management performed to-date e.g. specialist physiotherapy, bladder training, and medical treatment. Please see and advise for further ongoing management. Yours sincerely Dr.
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