Gynaecology summit: 8 July 2024

In July 2022, Welsh Government published a quality statement for women’s and girls’ health. This set out that several pathways require significant attention including:

• menstrual disorders
• endometriosis
• menopause

The quality statement sets out a number of expectations of health boards including:

• the need to collaborate across health services to support equity of access for women and girls, consistency in standards of care, addressing unwarranted variation, and providing mutual aid when necessary
• ensure appropriate levels of diagnostic, therapeutic and surgical capacity to enable women who require interventions to receive care as close as possible to home without significant waits
• transform pathways in line with recognised care standards
• ensure that national, evidence-based pathways for women’s health services are fully embedded in local service delivery

The NHS requirements with regard to gynaecological cancer services had previously been set out in the quality statement for cancer. In particular, this had a focus on delivering nationally agreed pathways and tackling variation in quality of care.

A ministerial gynaecology summit was held in July 2024 to assess the current situation across the gynaecology pathways, understand the challenges within these pathways. This helped to:

• gain a better understanding of pathway transformation and how these can be accelerated across NHS Wales
• share best practice and any barriers to improvement
• consider sustainable models of care and how these can be implemented
• agree how improvements to performance can be implemented

The NHS Wales Executive’s National Director for Planned Care gave a presentation on the current position of gynaecology services across Wales, highlighting the variation between health boards. The key points included:

• In April 2024, gynaecology was one of the worst performing tumour sites against the suspected cancer pathway (SCP) standard at 30.6% across Wales, this position was consistent with previous months, improvements have not been noted since April 2021. Cardiff and Vale University Health Board performance has improved over recent months.
• Gynaecology emergency activity varies across Wales, with Aneurin Bevan University Health Board reporting much higher activity compared to other health boards.
• Total waiting lists have grown considerably from 26,138 in March 2020 to 49,400 in March 2024. There has been a growth in the number of patients waiting over 104 weeks for their treatment to commence.
• The service at an all-Wales level is not in balance, the total waiting list volume has increased by 89% since March 2020.
• The national Getting it Right First Time (GIRFT) review has set several areas that health boards need to focus on:
  • undertake review of tertiary complex gynae pathways across Wales to understand variance and inform on best practice model
  • understand assessment of services against GIRFT’s 'further faster' guidance
  • review the nurse hysteroscopy training and explore whether NHS Wales could provide in-house training to trainees
  • review current coding and develop recommendations to be used across NHS Wales
  • support and encourage adherence to ‘right procedure, right place’ principles (as per theatre optimisation work programme)
  • define procedures placed on see on symptoms (SoS) and patient initiated (PIFU) pathways and increase use of these pathways

The Cabinet Secretary for Health and Social Care confirmed the commitment to improving health services and outcomes for women and girls and the need to address the inequalities that exist in the healthcare system.

The following expectations of health boards were set out:

• the need for health boards to collaborate to support equity of access for women and girls, consistency in standards of care, addressing unwarranted variation, and providing mutual aid when necessary
• ensure appropriate levels of diagnostic, therapeutic and surgical capacity to enable women who require interventions to receive care as close as possible to home without significant waits
• transform pathways in line with recognised care standards
• ensure that national, evidence-based pathways for women’s health services are fully embedded in local service delivery

Current waiting times and variations in performance were highlighted. Addressing this is a key priority for this Government. To do this health boards will need to:

• implement the national optimal pathways
• ensure that the referral pathway is correct
• focus on improving the first contact with patients
• speed up diagnosis pathways
• invest in workforce capacity
• reconfigure fragile services

This will mean working across units, or across the health board, or across a region.

The Cabinet Secretary reinforced the need to use capacity appropriately to:

• take advantage of any technological and digital innovations to help us improve efficiency and implement the national optimal pathways locally
• ensure that the referral pathway is correct
• focus on improving the first contact with patients
• speed up diagnosis pathways
• invest in workforce capacity
• reconfigure fragile services

All available capacity must be used appropriately, as well as health boards ensuring that the most appropriate patients are referred to secondary care, improving the pathways by adopting national standards and approaches such as straight to test, and reducing the number of follow-up appointments by utilising approaches such as patient initiated follow-up and see on symptom. These must be supported by changes to service models to create more sustainable services.

The Cabinet Secretary asked those present to implement the national optimal pathways and reduce the pathway intervals through implementation of straight to test and same day follow on investigations.

Health boards were asked to agree to reduce the volume of patients waiting over 62 days for their cancer treatment and implement efficiency measures designed to reduce the overall demand on the service, including the optimisation of referral processes through the use of e-referrals and access to guidance such as community health pathways.

The summit focused on the 3 pathways:

• suspected gynaecology cancer
• one stop gynaecology clinics and post-menopausal bleeding
• endometriosis

Suspected gynaecology cancer pathway

The presentation on the suspected gynaecology cancer pathway highlighted:

• Performance has been a challenge for a long time across all health boards in Wales.
• The number of patients referred onto the suspected gynaecology pathway has increased in the last 2 years, referrals are 30% higher each month compared to 2021 and 2022. Cwm Taf Morgannwg University Health Board have seen the largest growth in the last 2 years, whilst referrals have reduced for both Cardiff and Vale University Health Board and Swansea Bay University Health Board. This may reflect changes in demand managements and alternative pathways.
• Diagnosis rates continue to fall at all Wales level, by 4.4% for 12 months to April 2024.
• Treatment volumes have not increased to the same degree over the same time period, indicating a reduction in the diagnosis rate for gynaecology cancer. This may indicate that further work and investment is required within primary care and community services.
• Straight to test compliance has improved for several health boards in recent months.
• There have been improvements in performance at Cardiff and Vale University Health Board, in recent months, including an increase in the percentage of patients first seen by day 14 (89% of pathways closed in April 2024).
• Fragility of oncology services and workforce are major risks to this pathway.
• There are opportunities for health boards, including theatre optimisation programmes, straight to test, electronic referrals and rapid diagnostic centres.

The group discussion on the suspected cancer pathway raised the following:

• Pathway issues are predominantly at the beginning of the cancer pathway with low numbers first being seen within 14 days and receiving a decision to treat within 31 days. Minimal increase in the number of patients being treated year on year, partly due to a reduction in the diagnosis rate of cancer but clear growth in the volume of patients on waiting lists.
• Health Education Information Wales (HEIW) will focus on the following areas:
  • continuing education for GPs
  • gynaecological cancer workforce
  • workforce gaps
  • delivery of services
• That the cancer recovery programme should facilitate discussions around the development of regional services.
• That the NHS Wales Executive should lead on the generation of appropriate data and intelligence on gynaecological cancer.
• The cancer and clinical implementation networks lead on the implementation of a unified, all-Wales approach to managing unscheduled bleeding on hormone replacement therapy (HRT).
• That there are opportunities for other health boards to learn from the experiences at Cardiff and Vale University Health Board to review their pathways to include revised triage, front-end vetting and the allocation of additional capacity in theatres.
• The NHS Wales Executive to support health boards to implement various improvements such as improved coding, review of consultant job plans, implementing national guidance for HRT bleeding, and implementing patient-initiated-follow-up (PIFU) and see-on-symptom (SoS) initiatives.

One stop gynaecology clinics and post-menopausal bleeding

The presentation on one stop gynaecology clinics and post-menopausal bleeding highlighted:

• Three pathways have been developed at the all-Wales level for premenstrual syndrome, postmenopausal bleeding and heavy menstrual bleeding. However, these are not being implemented consistently across Wales with a variety of pathways in operation including one and two stop clinics.
• There is a need to review the one and two stop pathways to establish which option is most suitable for patient care and patient experience.
• GIRFT have recommended that Wales should focus on the development of women’s health hubs incorporating primary and secondary care.
• The HRT pathway is live on the Hywel Dda page and community health pathways page.

Key points from the group discussion included:

• Allowing consultants to scan would help address waiting lists and streamline pathways.
• Due to the constraint with diagnostic capacity, and the potential loss of hysteroscopy capacity resulting from a one stop model, may mean that a two-stop model with a very short turnaround is more effective.
• NHS Wales Executive to undertake detailed demand and capacity analysis to support a discussion on regional centres.
• The Endometriosis Cymru symptom checker is an effective tool to support early diagnosis and can support women to understand their symptoms.
• There are insufficient nurses in the service compared to other specialties.
• Community health pathways can support the quality improvement of referral letters.

Endometriosis pathway

The presentation on the endometriosis pathway covered:

• The gynaecology clinical implementation network needs to define and approve tertiary endometriosis pathways.
• A detailed toolkit to support women to understand their symptoms has been created. It is important that women are signposted to this and encouraged to use this toolkit.
• Primary care is the appropriate place to support and empower women.
• The gynaecology clinical implementation network needs to focus on establishing a two ways regional referral pathway.
• The NHS Wales Executive to focus on training and supporting primary care through the use of community health pathways for endometriosis and pelvic pain.
• Health boards should seek to raise awareness with the public and health care professionals with Endometriosis UK in their roadshow scheduled for Autumn 2024.

The group discussion included:

• Health boards to collaborate with the joint commissioning committee to develop a specialist service using specifications from NHS England services.
• HEIW to consider how they can support the training of consultants and trainees in scanning for endometriosis.
• The gynaecology clinical implementation network to develop clear pathways for those with severe and superficial endometriosis.
• Health boards agreed to consider how they can establish local endometriosis centres.
• Health boards to complete the implementation of recommendations from the endometriosis task and finish group 2021 report, including formatting for diagnostic criteria and specifications.
• A review of the NICE guidance for endometriosis is underway.
• Health boards agreed to strengthen engagement with primary care and implement community care pathways to ensure early diagnosis and appropriate treatment for patients as well as help manage the increased demand for gynaecological services and provide high quality care closer to home wherever possible, with support for primary and community care services.

The Welsh Government’s Chief Nursing Officer acknowledged the deep desire and commitment from all of the teams working towards improving gynaecology services in Wales. She encouraged colleagues to share learning and look towards different ways of working both locally and regionally for a national direction of an all-Wales service.

She reiterated the need to develop and implement pathways for unscheduled bleeding on HRT and post-menopause care. Also, that the service will need to focus on bringing down the volume of waiting patients for gynaecology services through:

• straight-to-test programmes
• same-day follow-up
• e-referral systems
• scaling up of advanced and core training workforces

She encouraged services to continue strong engagement with primary care who can support referrals management and triaging of patients waiting for appointments and services.

The following commitments and actions were agreed and progress against these will be monitored:

• Health boards to strengthen engagement with primary care to ensure agreement of, and adherence to:
  • national optimal pathways
  • NICE guidance
  • efficient referral processes, including e-referrals
• Health boards to carry out an endometriosis benchmarking exercise against the NCEPOD recommendations, with clear and time-bound actions for improvement where required.
• Welsh Government, Women’s Health Network and the Gynaecology Clinical Implementation Network to discuss with the JCC potential funding options for commissioning of tertiary services in Wales.
• Health boards to focus on pathway improvements for: 
  • improved access to first outpatient appointment
  • implement PIFU/SoS pathways
  • post-menopausal bleeding and unscheduled bleeding on HRT
  • gynaecology community health pathways, to be used by all health boards
• Health boards to develop plans to include women in the delivery/design of gynaecology services.
• Value in health programme to focus on post-menopausal bleeding and define what good looks like with clear standards including PREM and core metrics.
• The NHS Wales Executive to:
  • develop plans to enhance patient experience including women’s voices / quality of care and Civica
  • lead on work to standardise coding and data capture processes across health boards to improve data intelligence and sharing
  • facilitate an audit of gynaecology referrals into services to understand variation across Wales
  • undertake an assessment of surgical demand and capacity to be completed, shared and understood to support a discussion on regional centres
  • facilitate an all-Wales pathway for unscheduled bleeding on HRT/PMB at the workshop on 27 September 2024
  • support health boards to implement various improvements such as review of consultant job plans, implementing national guidance for HRT bleeding, and implementing patient-initiated-follow-up (PIFU) and see-on-symptom (SoS) initiatives
  • develop clear pathways for those with severe and superficial endometriosis
• HEIW to lead on a workforce plan with actions to be taken around continuing education for GPs, surgical and diagnostic skills, AHP and nursing requirements.

Aneurin Bevan University Health Board

• Sara Garland, General Manager, Family and Therapies
• Louise Harvey, Service Manager, Obstetrics and Gynae
• Gareth Edwards, Consultant Obstetrics and Gynae
• Jayne Beasley, Head of Midwifery and Gynae
• Margeret Parrot, Cancer Services Manager

Betsi Cadwaladr University Health Board

• Angela Wood, Exec Director Nursing and Midwifery
• Fiona Giraud, Director Midwifery and Women’s Services
• Geeta Kumar, North Wales Clinical Lead Gynae
• Richard Peevor, North Wales Lead Gynae / Oncology
• Faye Pritchard, Business and Performance Lead
• Harriet Rees, Manager Cancer Services
• Joanne Hussein, Pathway Redesign Practitioner for Cancer Services

Cardiff and Vale University Health Board

• Suzanne Rankin, Chief Executive Officer
• Paul Bostock, Chief Operating Officer
• Richard Skone, Interim Medical Director
• Marie Davies, Interim Executive Director of Strategy and Planning
• Sandeep Hemmadi, Clinical Board Director Children and Women
• Anju Kumar, Director Obstetrics and Gynae
• Anju Sinha, Clinical Lead Gynae
• Andy Jones, Director of Nursing
• Sam Barrett, Deputy Director Operations Children and Women
• Ken Lim, South East Wales Clinical Lead Cancer / Consultant Gynae Surgeon
• Catherine Wood, Director Operations, Children and Women’s Services Clinical Board

Cwm Taf Morgannwg University Health Board

• Gethin Hughes, Chief Operating Officer
• Mohamed Elnasharty, Clinical Lead Gynae
• Carl Verrecchia, Director Operations
• Hannah Lloyd, Director Manager Obs Gynae and ISH
• Caleb Igbenehi, Clinical Director Gynae and ISH

Hywel Dda University Health Board

• Lisa Humphrey, Interim General Manager
• Debra Bennett, Cancer Services Delivery Manager
• Islam Abdelrahman, Consultant Gynaecologist, Cancer and Laparoscopic Lead
• Lyndon Freeman, Service Delivery Manager Gynae and Sexual Health
• Lauren Davies, Service Manager Obstetrics, Gynae and Sexual Health
• Samantha Robinson, Senior Nurse Manager, Gynae

Powys Teaching Health Board

• Zoe Ashman, Assistant Director Quality and Safety
• Claire Madsen, Executive Director Allied Health Professionals, Health Sciences and Digital

Swansea Bay University Health Board

• Deb Lewis, Chief Operating Officer
• Abigail Morris, Directorate Manager
• Michelle Mason-Gawne, Associate Group Director

Velindre NHS Trust

• Louise Hanna, Consultant Clinical Oncologist
• Rachel Hennessy, Interim Director Velindre Cancer Service
• Annie Evans, Deputy Director Nursing
• Sarah Burton, Macmillan CNS Gynaecological Cancers
• Jane Powell, Medical Physics, Velindre Cancer Centre
• Erin McMonnies, Superintendent Radiographer Brachytherapy

Third sector

Debbie Shaffer    Founder, Fair Treatment for the Women of Wales
Lowri Griffiths    Chair of Wales Cancer Alliance, Tenovus Cancer Care

NHS Wales Executive

• Meinir Jones, National Clinical Director
• Andrew Sallows, Director National Planned Care Programme
• Alex Hicks, Network Manager Womens Health and Children’s Health
• Tom Crosby, National Clinical Lead Cancer
• Gareth Lee, Deputy Director Delivery and Assurance
• Roxanne Green, Assistant Director Partnership and Integration
• Ihab Abbasi, Clinical Lead Gynaecology Clinical Implementation Network
• Helen Munro, Strategic Network for Women’s Health Clinical Lead
• Jeff Turner, Clinical Lead Cancer Recovery Programme
• Heather Wilkes, Clinical Lead Cancer Recovery Programme
• Gillian Day, Principal Programme Manager
• Jenna Goldsworthy, Principal Programme Manager
• Alastair Roeves, National Clinical Lead Primary and Community Care / National Clinical Lead Health and Care Pathways
• Chiquita Cusens, National Lead Nurse Primary and Community Care
• Andrew Jones, Quality and Performance Improvement Manager
• Alun Matthews, Demand and Capacity Improvement Manager 
• Alana Fowler Browne, Senior Improvement Manager
• Ellis Owen, Project Manager
• Bethan Hawkes, Lead Cancer Nurse

Welsh Government

• Sue Tranka, Chief Nursing Officer
• Anthony Davies, Clinical Pathways and Major Conditions Policy
• Janine Hale, Head of Women’s Health
• Olivia Shorrocks, NHS Performance, Escalation and Intervention
• Caroline Lewis, NHS Performance, Escalation and Intervention
• Pushpinder Mangat, Deputy Chief Medical Officer
• Martyn Rees, NHS Performance, Escalation and Intervention
• Luke Solomon, NHS Performance, Escalation and Intervention
• Sarah Jones, NHS Performance, Escalation and Intervention
• Kate O’Neill, NHS Performance, Escalation and Intervention

Ministerial

• Eluned Morgan, Cabinet Secretary for Health and Social Care
• Catherine Cleaton, Cabinet Secretary’s Private Office
• Madeleine Brindley, Cabinet Secretary’s Private Office