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Termination of Pregnancy in Lothian A Health Needs Assessment Rosemary Cochrane Subspecialty trainee Chalmers Centre for Sexual and Reproductive Health.

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Presentation on theme: "Termination of Pregnancy in Lothian A Health Needs Assessment Rosemary Cochrane Subspecialty trainee Chalmers Centre for Sexual and Reproductive Health."— Presentation transcript:

1 Termination of Pregnancy in Lothian A Health Needs Assessment Rosemary Cochrane Subspecialty trainee Chalmers Centre for Sexual and Reproductive Health Edinburgh November 2011

2 Aims describe the population accessing termination of pregnancy services in Lothian describe the current service in Lothian identify areas where delay in service provision exists and to recommend ways to decrease delay identify areas of unnecessary complexity in the patient’s journey through the service

3 Aims elicit stakeholders views - patients, staff and management consider evidence of effective intervention to improve termination services recommend potential interventions to improve the service for patients and staff, and to eliminate waste. support planning for change from 2011 onwards.

4 Total in Scotland 2010 =12386 2254 were carried out in Lothian 12.1 women per 1000 aged 15-44 508 (25.2%) TOPs were in women <19 years 31.8% were repeat TOP (Scotland 28.4%) In Depcat 1 16.9/1000 women

5 Abortion mapping – over 20 years Terminations from Depcat 1-2: 22.3 / 1000 in 2007 16.9 / 1000 in 2010.

6 Current service in Lothian 2254 per year Royal Infirmary of Edinburgh - 80% St John’s Hospital, Livingston - 20% 37% of Gynaecology budget 70% before 9 weeks gestation 78% are medical procedures 55% of those at RIE are by EMD


8 Patient pathway primary care appointment → referral to hospital → hospital assessment clinic: counselled, ?DVD, ultrasound to establish gestation, consent, blood sample, urine for STI screen → plan made for next step → if medical, may get 1 st part same day → contraceptive plan approximately 2 hour visit

9 Patient pathway Key: REC = Reception D = Doctor’s room W/A = waiting area N1 = First nurse’s room T = toilet N2 = Second nurse’s room US = Ultrasound room CSW = Clinical support worker REC W/A US T N1 N2 D CSW N1 N2 DUS T CSW RECW/A

10 Service Standards HIS Standard 6: Termination of Pregnancy requires that women receive safe termination of pregnancy with minimal delay, followed by contraceptive advice and psychological support. 70% of TOP should be before 63 days gestation 60% of women should leave service with effective contraceptive plan

11 RCOG and FSRH Consensus Statement 2008 Delays in referral associated with a lack of awareness of the possibility of pregnancy delays in diagnosis access to and the availability of abortion services negative attitudes of some referring practitioners “In many services the patient journey from suspicion of pregnancy to completion of the procedure can be overly complex, particularly in the patients' perception. This is even more pertinent for vulnerable members of the community for whom particular support is needed to enable them to use the services more effectively.”

12 A large minority of patients accessing TOP services within Lothian are either young people(<19 years) or from the most deprived areas of the region, for whom the complexity of the TOP journey may well lead to delay, dissatisfaction with, or even avoidance of the service.

13 The patient experience Women’s choices pragmatic, related to finite household and psychosocial resources Positive responses to, and outcomes from TOP, are associated with:  rapid access to services  supportive non-judgemental staff  home TOP  good information and support Patients keep their experiences secret from family and friends - “The Silent Consumer” 1. Zapka et al 2001

14 Methodology Service users and service providers interviewed 17 staff members and 17 service users Staff –Doctors –Nurses –Receptionists –Sonographer –Clinical support workers –Managers

15 Results Service user interviews: 66 eligible patients 17 agreed to take part 17-34 years, mean age 24 6/17 repeat TOP (cf 32% for Lothian) 14 white UK 3 non-UK  1 student  1 married to Scottish man  1 travelling to UK solely for purpose of obtaining TOP

16 Results: service users In general, women were very satisfied with the service they received Theme/commentNo. of replies/times mentioned No questions unanswered and certain about next step 17 Friendly clinic staff17 Positive attitude from GP/CY/FPC11 Time to clinic quick or about right8 Discreet pleasant helpful reception staff8 Non-judgemental staff8 Mix of patients in waiting area lends anonymity 5 Female staff in clinic2 Staff professional and helpful, pt not made to feel bad or hurried 4 Military efficiency, gathering all info good idea 2 Lots of written information1 Hospital easy to find1 “They (Dean Terrace) were really nice, the doctor was great, really understanding. You feel bad enough yourself, you don’t want anyone making you feel worse. It was very clear and quick.” “All very private, discreet and non-judgemental”

17 Results: service users Not all views of assessment clinic were positive Theme/commentNo of replies/times mentioned Would have preferred shorter wait from GP/FP to assessment clinic 9 Assessment clinic very long and complicated 8 Communal waiting area viewed negatively 5 Name being called on several occasions4 Not enough information available in primary care 4 Negative attitude from GP or wrong info from GP 3 Distant/unfriendly/intimidating staff3 Repetition of tests at GP and hospital2 Excluding partner from clinical area1 Getting through to family planning clinic on phone 1 “the doctor I spoke to said he didn’t deal with that so he would have to get someone else to speak to me -I didn’t like that” “My name was called at least 4 times across the waiting room. Four times I was sent back out there!”

18 Results: service users follow up Positive comments reflect those prior to procedure Negative comments despite extensive written information given to every patient Theme/commentNo. of replies/times mentioned Supportive friendly staff9 Information before was accurate about what happened 6 Non- judgemental attitude of staff 3 Efficiency and speed of visit4 Pain worse than expected7 Lack of accuracy about procedure3 Poor signposting and information within hospital 2 Perception of coercion into MTOP3

19 Results: providers Positive responses Description of issueWho is affected? No of times mentioned Reduced waiting times due to EMD/reorganisation of clinics Patient7 Integrated service means staff better informed re TOP, contraception etc Patient/staff4 Increased nurse-led services felt to be an advantage Patient/staff4 1st part of TOP given at assessment streamlines process for patient Patient3 Good private facilities for patients Patient3 Enjoyable supportive service to work in Staff2 Good relationship with primary care Staff/patient1 Reduced waiting times have made a huge difference; can make the difference between STOP and MTOP, or even having the termination at all Nurse CY

20 Results: providers Negative responses Theme/commentWho is affected? No of times raised Complexity and timing of assessment clinic (Both sites) Patient11 Difficulty dealing with TOP emotionallyStaff7 Waiting area (Both sites)Patient6 Capacity at assessment clinic - rooms, staff Staff/Patient5 Fear of judgment– anonymityPatient5 Delays due to capacity i.e. beds available within wards Patient5 Challenges providing effective follow-up contraception Staff/Patient5 Amount of information given to patientsPatient4 Privacy for procedurePatient4 IT/paperworkStaff4 Number of repeat abortionsStaff/Patient3 Difficulty accessing servicePatient3 Distance to Bruntsfield Suite from clinicStaff3 Implementation of multiple changes to service Staff3 Staff cover for clinicians not wishing to be involved in TOP Staff2 Patients not attending – wasted resources Staff1 That whole waiting area needs to be looked at. That’s where we really fall down. The women might as well have a sign round their necks. Feel that its common knowledge that Bruntsfield is for TOP – ‘people know’. Research Nurse

21 Results: suggestions for improvement From service users: Increased information about pain Written info about other patients in waiting areas e.g. pregnant women Shorter, less complex assessment clinic Weekend appointments Encourage surgical methods Publicise EMD

22 Results: suggestions for improvement From service providers: Self referral Assessment/first medication in primary care Nurse-led service Move all EMD to new community SRH facility Weekend service Streamlined service, one practitioner performing scan, bloods, consent, counselling and arranging onward care Lean

23 Conclusion: Large busy TOP service Meets HIS and RCOG Standards Ascertaining the needs of women using the TOP service is a difficult process Flaws in system in general are minor Improvements are feasible and many are planned/in progress Service users in general very pleased with current pathway

24 Acknowledgements: Dona Milne, Specialist in Public Health, Edinburgh Sheila Wilson, Senior health Policy Officer, Edinburgh Staff at St John’s Hospital Livingston Staff at The Royal Infirmary of Edinburgh Women attending the TOP service in Lothian Thank you

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