Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guideline Platform
  3. Gynaecology
  4. Back
  5. Gynaecology guidelines
  6. E-Vetting Guidance (907)
Announcements and latest updates

Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

E-Vetting Guidance (907)

Warning

Please report any inaccuracies or issues with this guideline using our online form

This guidance has been developed to assist the vetting process for GGC gynaecology referrals. The guidance aims to ensure there is appropriate and consistent access to gynaecology services in GGC.

General guidance

1. Downgrading of referrals from urgent to routine

All the following points must be completed:

  • GP must have examined patient, the examination must have been complete and normal
  • Outline reasons to the referrer for downgrading (e.g. normal smear, normal cervix, premenopausal with no risk factors so low risk for endometrial malignancy etc.)
  • Suggest interim treatment if appropriate
  • Advise GP to re-refer as urgent if symptoms persist or deteriorate

2. Suitability of referrals for a virtual appointment

  • GP has done a vaginal examination that is normal
  • Up to date with normal smear
  • Up to date BMI
  • No treatment or no failed treatment initiated by GP
  • If patient requires interpreter including BSL, consider suitability ( Attend Anywhere can facilitate remote interpreter)
  • Does not need USS or biopsy ( many patients will have been scanned prior to referral)
  • A virtual appointment can be offered even if an examination or scan is needed if it is felt that explanation and discussion virtually beforehand would significantly shorten the face-to face time.

3. Suitability for replying to referral with standardised advice

  • GP has examined patient and examination is normal
  • Normal smear where appropriate
  • No further investigation required before treatment/ management initiated
  • Standardised advice is available for HMB, PCOS, vulval itch, menopause/HRT, incontinence /prolapse, IMB/PCB

Vetting advice for specific conditions

  • PMB
    Has uterus/cervix- vet as USOC/URGENT- PMB/onestop North (clinic F)

    PMB- no uterus/cervix- GP has NOT examined or examination abnormal- vet as USOC/URGENT- general gynaecology

    PMB- no uterus/cervix- GP has examined and normal vault and vulva- Downgrade to ROUTINE, vet to general gynaecology and ask GP to check for haematuria

 

  • HMB 
    Women <40 can be vetted to a general clinic. Women ≥40 should be vetted to a one-stop clinic

    Women <45 with HMB with no risk factors for endometrial pathology / normal examination should be vetted as ROUTINE

    Women aged 40-44 with HMB AND persistent IMB or PCB, with no other risk factors for endometrial pathology should be vetted as ROUTINE

    Women aged 40-44 with HMB AND persistent IMB or PCB AND one or more additional risk factors for endometrial pathology should be vetted as URGENT

    Women ≥ 45 with no irregular bleeding, normal examination and no additional risk factors for endometrial pathology should be vetted as ROUTINE

    Women ≥45 with any additional risk factors for endometrial pathology OR persistent IMB / PCB OR treatment failure (continual use of hormonal treatment for 6 months) should be vetted as URGENT

 

  • IMB
    Women <40 with normal examination should be referred back to GP with advice to review hormonal contraception and exclude infection. If starting / changing hormonal contraception or treating infection is not successful, then vet as ROUTINE to general gynaecology.

    Women ≥ 40 with persistent IMB with normal examination, but who have risk factors for endometrial pathology (eg PCOS, BMI>40, current / past tamoxifen use) should be vetted as URGENT.

    Women ≥40 with no risk factors – vet as ROUTINE

 

  • PCB
    If appearance suspicious /consistent with cervical cancer vet as USOC to colposcopy.

    If abnormal cervical screening, vet to colposcopy as per usual protocol

    Women < 40 with normal smear / examination should be offered STI screen. Consider change of OCP / trial of Relactagel®. If ineffective, vet as ROUTINE to gynaecology or colposcopy as per local service provision.

    Women ≥40 – vet as URGENT 

 

  • PCOS
    Most referrals can be managed by sending standardised advice to GP- if an appointment is felt necessary this should be VIRTUAL unless there is significant menstrual disorder (e.g. requiring LNG-IUS etc)

 

  • CERVICAL POLYP
    Asymptomatic, normal smear- vet to ROUTINE general gynaecology appointment. If symptomatic (e.g. PCB/IMB), < 40 years vet as ROUTINE to general gynaecology, >40 years vet as ROUTINE to PMB/onestop North (clinic F)

 

  • VULVAL ITCH/DISCOMFORT
    If GP has examined and no focal abnormality (e.g. ulcer) and no treatment, send referral back to referrer with standardised vulval care advice.

    If examination by GP is abnormal or there has been treatment failure, vet to general gynaecology (vulva clinics are tertiary referral only). Grade depending on appearance of abnormality.

 

  • INCONTINENCE/PROLAPSE
    Current NICE guidance is for conservative management in the first instance- refer to SPHERE bladder and bowel service. OAB symptoms can be managed with medication (send GP standardised advice). Women with failed management or treatment should be vetted as routine to urogynaecology.

 

  • PELVIC PAIN/ QUERY ENDOMETRIOSIS
    If GP has examined and normal smear, vet as ROUTINE to virtual appointment

 

  • STERILISATION REQUEST
    Vet as routine to virtual appointment- send referral back to referrer if BMI >35 or no BMI recorded

 

  • MENOPAUSE/HRT
    Some referrals can be dealt with by sending standardised advice to GP. If appointment needed vet as routine to VIRTUAL appointment

 

  • ULTRASOUND
    Some referrals can be vetted directly to gynae USS ( e.g. asymptomatic simple cyst < 5cm, or radiology have suggested TVUSS) 

 

  • FINDING OF POSTMENOPAUSAL INCIDENTAL INCREASED ENDOMETRIAL THICKNESS/FLUID IN ENDOMETRIAL CAVITY
    In the absence of PMB vet as ROUTINE to PMB/onestop North (clinic F)

ADDENDUM December 2020

RE-GRADING OF USOC (URGENT SUSPICION OF CANCER) REFERRALS

  • It has been agreed that during COVID-19 pandemic Urgent Suspicion of Cancer (USOC) referrals can be re-prioritised at vetting to urgent or routine where a referral does not meet the Scottish Cancer Referral Guidelines
  • Scottish Cancer Referral Guidelines can be accessed at: http://www.cancerreferral.scot.nhs.uk/
  • An automated letter will be sent to Primary Care noting re-prioritisation. Thus ensuring clear communication back to GP whilst minimising impact on vetting clinician in dictating letter.
  • A 2 stage vetting process has been implemented in Trakcare:
    1. Select ‘downgrade of cancer’ in vetting outcomes, this will generate letter to GP; then
    2. Re-grade referral and assign appropriate vetting outcome

Editorial Information

Last reviewed: 01/02/2021

Next review date: 30/06/2024

Author(s): Claire Higgins.

Approved By: Gynaecology Clinical Governance Group

Document Id: 907