Specifying a hysterectomy service

Service components

The key components of a hysterectomy service are:

• ensuring appropriate care and onward referral for women with heavy menstrual bleeding (HMB)
• effective management of women who require a hysterectomy for reasons other than HMB
• developing a high-quality service for women who require a hysterectomy.

Appropriate care and onward referral for women with HMB

The diagnosis and general management of HMB is described in detail in NICE clinical guideline CG44 on heavy menstrual bleeding. It is clearly important to identify women with HMB to ensure delivery of care based on the best available evidence.

The relationship between medical management, referral and surgery is complex. There are wide variations in patterns of referral into secondary care and in the number of hysterectomy procedures carried out, despite clinically and cost effective alternatives. Some variation is likely to be due to symptom prevalence, the treatment preferences held by some women and clinical reasons. However, these are unlikely to account for all of the variation.

More effective management of HMB in primary care may reduce both the number of referrals into secondary care and surgery rates^[1],^[2]. Commissioners may wish to compare local GP referral rates and procedure rates for hysterectomy with hospital trusts to identify outliers. This will provide the opportunity to review current practice and develop an integrated care pathway with clinicians to inform local commissioning, optimise first-line medical management and identify thresholds for surgical treatments. However, commissioners will need to consider the age and ethnicity of their population, as this will have an impact on suitability for treatment options. Changing clinical practice in primary care is likely to require education and training.

Surgical treatment is usually offered to women with HMB who do not respond to pharmaceutical treatment. Because hysterectomy is associated with perioperative and postoperative complications, it is important to identify those women for whom hysterectomy is the most appropriate treatment option in order to prevent unnecessary invasive surgery and to manage service demand.

Another surgical procedure, uterine artery embolisation (UAE), is used to treat uterine fibroids, which sometimes causes HMB. The procedure is associated with shorter hospital stays than hysterectomy, and this is likely to contribute to reducing patient waiting times. The NICE interventional procedure guidance IP 94 ‘Uterine artery embolisation for the treatment of fibroids´ states that current evidence suggests that UAE is safe enough for routine use. The most commonly reported complications were the need for hysterectomy in 0.5% to 11.8% of women and the late expulsion of a fibroid in 2.2% to 7.7% of women.

The NICE clinical guideline CG44 on heavy menstrual bleeding recommends that:

• Pharmaceutical treatment should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity.
• Hysterectomy should not be used as a first-line treatment solely for HMB. Hysterectomy should be considered only when:
  • other treatment options have failed, are contraindicated or are declined by the woman
  • there is a wish for amenorrhoea
  • the woman (who has been fully informed) requests it
  • the woman no longer wishes to retain her uterus and fertility.
• When surgery for fibroid-related HMB is felt necessary then UAE, myomectomy and hysterectomy must all be considered, discussed and documented.

Women with HMB should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Although respect for autonomy and individual choice are important for the NHS and its users, they should not have the consequence of promoting the use of interventions that are not clinically and/or cost effective.

Management of patients who require hysterectomy for reasons other than HMB

NICE has not issued guidance on the management of patients who require hysterectomy for reasons other than HMB, such as malignancy and genital prolapse.

Useful sources of information may include the NHS Evidence, ‘Clinical knowledge summaries' and NICE CG27 ‘Referral for suspected cancer´.

Developing a high-quality hysterectomy service

Information on the detailed requirements of a hysterectomy service is available from the NICE clinical guideline CG44 on heavy menstrual bleeding, which recommends that:

• a woman with HMB referred to specialist care should be given information before her outpatient appointment (see Understanding NICE guidance)
• in women with HMB alone, with uterus no bigger than a 10-week pregnancy, endometrial ablation should be considered preferable to hysterectomy
• ultrasound is the first-line diagnostic tool for identifying structural abnormalities
• taking into account the need for individual assessment, the route of hysterectomy should be considered in the following order: first line vaginal, second line abdominal
• maintenance of surgical, imaging or radiological skills requires a robust clinical governance framework.

Commissioners may wish to consider delivering a hysterectomy service for the care of women with HMB in a number of different ways, and mixed models of provision may be appropriate across a local health economy. The Shifting care closer to home: care closer to home demonstration site - report of the speciality subgroups identifies innovative ways of delivering gynaecology services, whilst improving patient access. These include a primary care led model of integrated care, direct access to some procedures and consultant gynaecologists working in primary care. The use of integrated care pathways for HMB has been shown to reduce the need for outpatient attendance while improving patient experience and maintaining quality of care^[3]. The examples are offered in order to share local practice, but NICE makes no judgement on the compliance of these services with its guidance.

Local stakeholders, including service users, should be involved in determining what is needed from a hysterectomy service in order to meet local needs. The service should be patient-centred and integrated with other elements of care for women with HMB.

The service specification needs to consider:

• the required competencies of, and training for, staff responsible for providing the service
• the expected number of patients (this should take into account how quickly any changes in service provision are likely to take place)
• ease of access to all treatment options and service location within a geographical area; commissioners should engage with service users and other relevant individuals and organisations locally
• care and referral pathways to support patient choice of treatment and access
• information and audit requirements, including IT support and infrastructure
• planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks. See Choice of scan: guidance
• service monitoring criteria.

Useful sources of information may include:

• Delivering the 18 week patient pathway: 18 week commissioning pathways and the heavy menstrual bleeding pathway.
• The ‘NHS networks: learning from practice' database offers examples of innovative commissioning across the NHS and its partners.
• The Map of medicine provides an information resource that visually organises the latest evidence and best practice guidelines.
• The NICE shared learning database offers examples of how organisations have implemented NICE guidance locally, including services for the care of women with HMB, for example Bradford and Airedale tPCT.
• Implementation advice for NICE clinical guideline CG44 on heavy menstrual bleeding.

References

1. Grant C, Gallier L, Fahey T et al. (2000) Management of menorrhagia in primary care-impact on referral and hysterectomy: data from the Somerset Morbidity Project. Journal of Epidemiology and Community Health 54: 709-13.
2. 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.
3. Julian S, Nicholas J, Naftalin et al. (2007) An integrated care pathway for menorrhagia across the primary - secondary interface: patients' experience, clinical outcomes, and service utilisation. Quality and Safety in Health Care. 16: 110-5.