History and Rationale for the BSGE Ambulatory Care Network 

Several years ago Mamta Pathak, an old trainee of mine and consultant gynaecologist in Worcester, were talking about the need to set up a meeting for outpatient hysteroscopy and ambulatory interventions. As with many of my good intentions, it remained ‘on ice’ (!) for too long but eventually, with my research fellow Dr Preth de Silva, I finally set about developing what was to become the Ambulatory Care Network or ‘ACN’.

The reason I used the term ‘network’ was because I wanted the meetings to be educational but importantly interactive allowing us to share best practice, keep up to date and set the agenda for research / guidelines / audit / political aspects (NHS). I had initially conceptualised the idea from my observation when attending and speaking, at mainly industry sponsored meetings covering new hysteroscopic technologies, the most interesting parts were usually the discussion. There never seemed enough time for these open forums. In addition, it was becoming clear that more and more clinicians; gynaecologists, GPs and nurses, were undertaking outpatient interventions, especially hysteroscopy, as part of their day to day jobs. It was therefore apparent that we needed a specific meeting to allow us to interact and learn from each other and help each other solve problems, share materials (protocols, information, consents, ‘SOPs’ etc.) and experiences, help others set up and expand their services, improve training, keep up to date with the relevant publications and collaborate on quality improvement projects as well as research studies.

I submitted a proposal to the BSGE Council in August 2018 (“Proposal to establish a BSGE Ambulatory Gynaecology Network”) and they approved the development of the BSGE Ambulatory Care Network at our next Council meeting in November 2018. It then came down to practicalities to realise the project. We were (and remain) indebted to industry for supporting this endeavour, which has allowed the meetings to be heavily subsidised, incentivising all interested clinicians to attend. Without our industry partners help, the ACN would not have ‘got off the ground’ and have become the success it has.

I must also mention a small group of local colleagues, primarily young clinicians, mainly my past and present trainees  / research fellows, for helping organise and run the meetings (Paul, Siobhan, Zahid, Ayesha, Helen, Oga, Zeyah); these have to date all been in Birmingham (28-29 March 2019; 27-28 February 2020) apart from the 2021 meeting that was run virtually from the Birmingham Women’s Hospital (18 June 2021). We had 140 attendees at our inaugural ACN and 170 at our second CAN. We had over 180 attendees (200 registrations) at our most recent virtual ACN.

Atia Khan has as always has been hugely important and without her experience of organising and running meetings, this would not have been possible. The biggest ‘shout out’ however, needs to go to Dr Preth de Silva for putting so much effort, persistence and expertise into sourcing and arranging venues and helping develop the programmes amongst a myriad of other things. He has driven the endeavour and should take the major credit for its success.

Finally, I am truly grateful to my BSGE colleagues for attending and contributing, making the meetings fun and worthwhile, many of whom have stepped up to participate as faculty to get our discussions going.

We look forward to many further fruitful meetings in the years to come to improve the care of women undergoing ambulatory interventions.

T Justin Clark
BSGE Past President

Proposal to establish a BSGE Ambulatory Gynaecology Network

Background and Rationale 

Many diagnostic and therapeutic interventions can now be undertaken in an ‘outpatient’ or ‘ambulatory care’ setting within self-contained hospital or community facilities. Procedures are carried out without general anaesthesia (and for the most part without the presence of an anaesthetist) such that the use of precious operating theatre capacity is unnecessary and admission to a hospital bed avoided. These facets make ambulatory management of common gynaecological conditions attractive to patients, health care professionals and health service managers namely because care delivered in this way is safe, convenient, associated with rapid recovery and return to normal functioning and cost-efficient.

However, managing women who are awake in an ambulatory care setting presents challenges: (i) from the patients perspective these relate primarily to controlling pain, optimising patient experience and ensuring good levels of patient acceptability; (ii) from the health care provider’s perspective these centre around achieving high levels of procedural success in a conscious patient where perceived discomfort and the ability to tolerate prolonged interventions may compromise feasibility; (iii) from a health service manager’s perspective ensuring a viable service – where the infrastructure, human resource and health technologies needed to undertake such interventions are invested in and appropriate revenue generated.

Ambulatory gynaecology in its broadest sense incorporates most areas of gynaecological practice:

• Diagnostic and operative endoscopy (hysteroscopy, colposcopy, cystoscopy);
• Diagnostic and therapeutic imaging (e.g. 2D/ 3D +/- contrast, egg collections, fibroid ablation);
• General interventions (e.g. manual vacuum aspiration, Bartholin’s cyst/abscess incision)

Such procedures are utilised across most gynaecological specialties including: (i) functional gynaecology (e.g. menstrual disorders and abnormal uterine bleeding); (ii) reproductive health (e.g. infertility and recurrent miscarriage, fertility control), (iii) urogynaecology (e.g. urinary incontinence and prolapse); (iv) acute gynaecology and early pregnancy complications (e.g. miscarriage, lower genital tract abscesses / cysts) and (v) oncology (abnormal cervical cytology, post-menopausal bleeding, vulval lesions).

Evidence and Implementation 

The evidence base to support ambulatory gynaecology is expanding and demonstrates in a number of areas, particularly that of outpatient hysteroscopy, feasibility, effectiveness, cost-effectiveness and supportive qualitative data pertaining to patient experience and acceptability (REFs). However, these evidence-based findings are often not uniformly introduced into contemporary gynaecological practice leading to inequitable care (REF). For example, in relation to diagnostic outpatient hysteroscopy, despite the production of BSGE/RCOG ‘best practice guidelines’ (REF) a significant minority of women report poor experiences and unacceptable levels of pain (REFs) and clinical outcomes particularly in regards to procedural success (feasibility) and complication in this setting are either unknown or vary between centres. Reasons for these variations are unclear but may in part relate to not complying with best-practice guidance and issues relating to staff training and proficiency. A similar picture is seen in therapeutic interventions because despite evidence to support the use of ambulatory Bartholin’s cyst incision using Word catheters and outpatient hysteroscopic polypectomy (REF) using hysteroscopic tissue removal systems (REF), many women do not have access to such services in their local hospitals.

As outlined above, although ambulatory interventions are widespread and applicable to many areas of contemporary gynaecological practice, the overall evidence-base to inform practice and patient choice is lacking. This means that the most effective management is unknown e.g. what is the optimal diagnostic work up of heavy menstrual bleeding / post-menopausal bleeding?; what are the best health technologies to treat focal uterine lesions (polyps / fibroids)?; how best can we optimally control pain and enhance experience during hysteroscopic interventions such as polypectomy and endometrial ablation)?; what are the optimal pathways for managing miscarriage?

In the absence of data to inform clinical practice we rely upon our experience and those of others. Most of us have either had the chance to research and prepare talks or deliver training classes / programmes or participate in expert groups / committees or attend training / educational programmes as a participant and these are valuable opportunities to debate best practice and share experiences. Units may have particular areas of strength and success where others may have struggled to introduce a similar service or deliver one of a comparable standard. Understanding why this may have occurred and sharing knowledge is of key importance to optimise the availability and quality of ambulatory care provided. This is especially true in a rapidly developing area of practice, like ambulatory care, where new health technologies become available and new ways of designing care and care pathways  are introduced (in the absence of an informative evidence base). 

Opportunities

Establishing on behalf of the British Society of Gynaecological Endoscopy (BSGE) an ‘Ambulatory Care Network (ACN)’ will provide a forum to debate and discuss relevant aspects of management, standardise the quality and availability of ambulatory care through improving awareness of the evidence, best-practice guidelines and sharing experience (e.g. successful services, pathways, staffing, training, business cases, establishing services) and provide a setting to design and implement audits and research projects on a national basis. 

BSGE

• Reputational benefits – e.g. demonstrative commitment to enhancing the quality of endoscopic care, data collection for audit and scientific research +/- obtain significant research funding
• Membership – potentially expand our membership through increasing relevance to a wider population of practitioners; multi-disciplinary arena 

Clinicians (Doctors / Nurses)

• Share best practice – aid the implementation of viable and quality services (not having to ‘reinvent the wheel’)
• Participate in research and audit
• Shape future practice

Patients (Service Users)

• Standardise the quality and provision of care

Health Service Managers

• Development, implementation and funding of services through sharing experiences and business cases / models of care

Industry

• Liaison with clinicians – awareness and promotion; develop and refine new health technologies

Threats

• Attendance – costs of, and need for, travel, accommodation and time off work may limit attendance
• Viability – need to gain sponsorship in the form of educational grants from industry and potentially some financial support from the BSGE
• Compromise other BSGE events – attendance / funding (from industry)
• Utilisation of BSGE resources – organisational aspects will place an additional burden on the BSGE secretariat

See the following sections (‘proposed meeting design’ and ‘business model’) to see how these ‘threats’ will be offset. 

Proposed Meeting Design 

The broader the ACN the better but initially, in order to establish this BSGE supported forum, the focus will be on outpatient hysteroscopy and related interventions.

The meeting will run over two days but will essentially be a one day interactive meeting with the agenda in time set by prospective attendees / participants in the ACN. The reason to stretch the meeting over two days is to allow delegates to travel (afternoon start) and return the next day easily and in good time (finish at lunchtime). In addition this model allows the incorporation of an ACN meal where attendees can network / discuss ambulatory care and a collegiate feel will be engendered, hopefully ensuring ‘buy in’ such that subsequent meetings will be well attended and successful.

Photos from ACN 2024

1 2 Next »