Commissioning a hysterectomy service

Hysterectomy is the surgical removal of the uterus, and has traditionally been regarded as the definitive surgical treatment for heavy menstrual bleeding (HMB). Hysterectomy is a major surgical procedure with significant physical and emotional complications and social and economic costs^[1]. It is one of the most commonly performed operations, with menstrual disorders being one of the leading indications^[2]. However, it is frequently performed for reasons other than HMB, including malignancy and genital prolapse.

Hysterectomy rates have been decreasing in recent years, but there remains large variation in population-based rates of hysterectomy across primary care organisations in England, from fewer than 10 per 100,000 to 100 per 100,000 female population^[3]. The Chief Medical Officer report in 2005 identified that ‘if the average rate of hysterectomy in England was reduced to that achieved in the 20% of the country with the lowest current rates, then 5,900 operations, costing £15 million, could be avoided per annum. Although the costs of alternative treatments would need to be taken into account financial savings would still be substantial'.

HMB, also known as menorrhagia, affects around one in three women^[4]. It is defined as excessive menstrual blood loss that interferes with the physical, emotional, social and material quality of a woman's life. HMB is a common reason for GP consultation, referral to secondary care and subsequent surgery^[5].

Pharmaceutical intervention, including the use of levonorgestrel-releasing intrauterine system (LNG-IUS), is usually the first-line treatment for women with HMB. Optimal medical management of HMB improves patient choice and provides an alternative to surgery. It also reduces the cost of HMB to health services and its detrimental effects on quality of life^[6]. Ineffective treatment of HMB is likely to lead to referral and a high chance of hysterectomy^[7].

Through effective commissioning of services for women with HMB based on NICE clinical guideline CG44 on heavy menstrual bleeding, it is anticipated that when women are given the choice of clinically appropriate treatment options, hysterectomy rates will be reduced further^[7].

Benefits

The potential benefits of robustly commissioning an appropriate hysterectomy service for the care of women with HMB based on an integrated care pathway include:

• Reducing the need for hysterectomy and the associated perioperative and postoperative complications by implementing the recommendations outlined in NICE clinical guideline CG44 on heavy menstrual bleeding.
• Improving patient-centred care and providing efficient clinical management of the care of women with HMB by optimising pharmaceutical management and reducing the need for referral onto specialist services^[5],^[7]. See also the commissioning guides on intrauterine devices and the intrauterine system and endometrial ablation.
• Reducing referrals to specialist services and offering less invasive treatment options - both may contribute to a reduction in the number of hysterectomies performed^[7]. They also provide the opportunity to reduce inpatient stays and patient waiting times.
• Improving clinical outcomes.
• Reducing inequalities, and improving patient access to services that provide pharmaceutical management, including levonorgestrel-releasing intrauterine system (LNG-IUS), endometrial ablation and non-hysterectomy surgery.
• Increasing patient choice and engagement in decisions about their care, and patient experience.
• Better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an appropriate hysterectomy service are:

• Ensuring that hysterectomy is not offered as a first-line treatment for women with HMB only.
• Accurately diagnosing all women presenting with HMB to support clinically appropriate care and ensuring there is access to, and sufficient capacity for, ultrasound, magnetic resonance imaging and hysteroscopy.
• Ensuring that women have access to information on clinically appropriate treatment options prior to their outpatient appointment. Women should have adequate time and support from healthcare professionals in the decision making process, and be made aware of the impact on fertility of any planned procedure.
• Ensuring that appropriate referral pathways are in place to support equity of access to LNG-IUS, endometrial ablation and other non-hysterectomy surgery. See also the commissioning guides on intrauterine devices and the intrauterine system and endometrial ablation.
• Ensuring that the service is integrated with other services for women with HMB to ensure continuity of care.
• Providing a quality assured service.

National priorities

National priorities and initiatives relevant to commissioning a hysterectomy service include:

• ‘World class commissioning'.
• ‘The NHS in England: The operating framework for 2009/10'.
• ‘Delivering the 18 week patient treatment pathway' and the heavy menstrual bleeding pathway.
• The ‘Care closer to home' initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• ‘Commissioning framework for health and well-being'.
• Considering the impact of patient choice.
• ‘A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services'.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health'.

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.

References

1. Lethaby A, Shepperd S, Cook I et al. (1999) Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database of Systematic Reviews. Issue 2.
2. Marjoribanks J, Lethaby A, Farquhar C (2006) Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database of Systematic Reviews. Issue 2.
3. Information from hospital episode statistics. The Information Centre for Health and Social Care 2007.
4. Kennedy ADM, Sculpher MJ, Coulter A et al. (2003) A multicentre randomised controlled trial assessing the costs and benefits of using structured information and analysis of women's preferences in the management of menorrhagia. Health Technology Assessment 7(8).
5. Grant C, Gallier L, Fahey T et al. (2000) Management of menhorrhagia in primary care - impact on referral and hysterectomy: data from the Somerset Morbidity Project. Journal of Epidemiology and Community Health 54: 709-13.
6. O'Leary JA, Tejura H (2005) Medical management of menorrhagia. Reviews in Gynaecological Practice 5: 159-65.
7. Nixon RM, Duffy SW, Fender GRK et al. (2001) Randomization at the level of primary care practice: use of pre-intervention data and random effects models. Statistics in Medicine 20: 1727-38.