Meeting documents

            Meeting: Health Scrutiny Sub-Committee (County Hall, Durham - Council Chamber - 02/07/2007 10:00:00 AM)

                  Item: A6 County Durham and Darlington Termination of Pregnancy Service (ToP) - Service Evaluation November 2005 - April 2006

         

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Report of the Head of Overview and Scrutiny

Purpose

1. To inform members of the findings of an evaluation that was conducted on the improved and reconfigured ToP service during November 2005 to April 2006.

Background

2. In January 2004 a working group of all key stakeholders involved with the ToP service within County Durham and Darlington, was formed following concerns raised by GPs relating to difficulties in accessing local termination of pregnancy services. Waiting times for assessment appointments were exceeding 2-3 weeks, resulting in women being referred, and having to travel, to other service providers within the North East of England. 3. The Working group agreed to investigate the accessibility and quality of services for women seeking a termination of pregnancy within County Durham and Darlington. Findings from this initial investigation included:
· Inequity in service provision existed across County Durham and Darlington Acute Hospitals (CDDAH) Trust. This was mainly due to the fact that the providers in the south of the county were working to provide a dedicated service whilst in the north there were difficulties in providing such a service due to lack of consultant capacity willing to perform termination procedures.

· There was a mismatch across the service providers within CDDAH Trust in terms of capacity and the demand that existed within each of the six PCTs for abortion procedures.

· Forty percent of referrals for termination of pregnancies from County Durham and Darlington were to ‘Out of Area’ providers.

It was clear from the above findings that service reconfiguration was needed.

4. The findings from this service evaluation predominantly show a greatly improved termination of pregnancy service that is meeting almost all national quality standards. Evaluation Report attached

Recommendation

5. Members are asked to note the key findings and recommendations from the evaluation report.

Contact: Feisal Jassat Tel: 0191 383 3506 feisal.jassat@durham.gov.uk

TO VIEW GRAPHS REFER TO PDF ATTACHMENT OR ALTERNATIVELY REFER TO HARD COPIES HELD IN THE COUNTY RECORD OFFICE OR CORPORATE SERVICES

1 Introduction

The County Durham and Darlington Termination of Pregnancy (ToP) service has undergone significant change over the last three years. This change has been driven by a desire to provide a higher quality service to women seeking ToP as well as a need to meet the evidence based recommendations as set down by the Royal College of Obstetricians and Gynaecologists in 2000.

The purpose of this paper is to present the findings of an evaluation that was conducted on the improved and reconfigured ToP service during November 2005 to April 2006. In order to put the findings into context an overview of the changes, which the service has undergone, has also been provided.


2 Background

2.1 Improving Access to Termination of Pregnancy Services Working Group

In January 2004 a working group of all key stakeholders involved with the ToP service within County Durham and Darlington, was formed following concerns raised by GPs relating to difficulties in accessing local termination of pregnancy services. Waiting times for assessment appointments were exceeding 2-3 weeks, resulting in women being referred, and having to travel, to other service providers within the North East of England.

The Working Group was chaired by the then Director of Public Health at Durham and Chester-le-Street Primary Care Trust (PCT), Dr. Tricia Cresswell, and set out to investigate the accessibility and quality of services for women seeking a termination of pregnancy within County Durham and Darlington. Findings from this initial investigation included:

· Inequity in service provision existed across County Durham and Darlington Acute Hospitals (CDDAH) Trust. This was mainly due to the fact that the providers in the south of the county were working to provide a dedicated service whilst in the north there were difficulties in providing such a service due to lack of consultant capacity willing to perform termination procedures.

· There was a mismatch across the service providers within CDDAH Trust in terms of capacity and the demand that existed within each of the six PCTs for abortion procedures.

· Forty percent of referrals for termination of pregnancies from County Durham and Darlignton were to ‘Out of Area’ providers.


It was clear from the above findings that service reconfiguration was needed. An option paper was produced by service leads, which contained five possible options to reconfigure the service. This paper was discussed at the working group meeting in June 2004, following which further work was undertaken to develop a detailed option appraisal of three of these options.

2.2 Reconfiguration of Termination of Pregnancy service - Option appraisal

The three options detailed in the option appraisal were:

Option 1: Service to remain the same with no re-configuration

Option 2: UHND adopts the service model being used at BAGH and DMH.

Option 3: Centralised medical termination of pregnancy service at BAGH with
satellite assessment and locally managed surgical abortion procedures. Table 2.1: Summary of improvements delivered by each option

	All services meeting RCOG recommendations	Equitable service across Trust	Trust capacity to cope with local demand	Improved waiting times and access	Dedicated service provision
Option 1	X	X	X	X	X
Option 2			X		X
Option 3

2.3 Patient and Public consultation exercise

Patient and Public Involvement (PPI) leads from five of the six PCTs (Durham Dales did not participate in the consultation as the proposals did not constitute a significant change of services for local residents) and from CDDAH Trust were consulted regarding a patient and public consultation programme around the proposed three service reconfiguration options. The working group and the PPI leads were aware of the difficulties in undertaking meaningful engagement with the public on this sensitive issue. Engagement retrospectively with women who have had a termination of pregnancy is both ethically questionable and severely restricted by the Abortion Act and Regulations. It was agreed that any direct engagement would be through clinical staff dealing with current patients. The agreed approach to patient and public involvement consisted of two strands of field work:


1. Distribution of questionnaires to women as they accessed the services at CDDAH Trust and focussed on respondents experiences of termination of pregnancy. 2. Focus groups co-ordinated and facilitated by each PCTs PPI lead and Sexual Health Outreach Worker, centred on where women would want to go for a termination, women’s views on a more centralised service and possible improvements to service provisions.


Key findings from field work:

Questionnaires - DMH/ BAGH/ UHND

· 49 out of 50 respondents to the questionnaire said that they would choose an earlier appointment over the choice of venue.
· The majority of women attending DMH/BAGH had not experienced problems getting to the hospital and the two main methods of travel were car (61%) and bus (33%)
· One third of respondents at UHND stated that they would have problems attending BAGH for a termination due to travel and transport.
· The three most important service delivery areas identified by respondents at UHND were confidentiality and privacy, information and explanations and caring, friendly staff.

Focus Groups

· Women still wanted the opportunity to go to a hospital of their choice.
· Women living in Easington would prefer to access services in North Tees and Hartlepool.
· The vast majority of young women would prefer to access both medical and surgical termination within their local hospitals.
· Main issues identified with centralisation of services at BAGH were expense associated with travelling longer distances, poor quality public transport and greater difficulty in justifying absence (these concerns were accentuated in Derwentside and Easington).
· Women within the focus groups who voluntarily identified themselves as having had a termination prioritised timely/quick access to quality services over other factor.
· Better access to quality information about services and transport to services.
· Staff should be empathetic and non judgemental towards patients.


2.4 Agreed service configuration


Following the patient and public consultation, an agreement was reached by members of the working group to reconfigure the ToP service to that outlined in option 3. The reasons for this were:

· Option 1 addressed none of the service quality issues. · Option 2 addressed some of the issues and maintained local access. This would best have met the concerns about geographical access expressed during consultation. However this option could not provide optimum facilities for medical termination in terms of privacy and dignity

· Option 3 delivered a service that met national standards. The major concern related to women who would have to travel to BAGH for medical management. However at the time of service improvement 40% of referrals from the six PCTS within County Durham and Darlington were travelling to “out of County” providers and the majority were travelling further than under this option. In national surveys, women who are referred for termination of pregnancy consistently rank immediacy of access above travelling distance as the key factor in relation to termination of pregnancy services. This was reinforced in the local surveys and consultation. 3 Evaluation of reconfigured ToP service in County Durham and
Darlington

3.1 Current service provision

The current ToP service within County Durham and Darlington consists of dedicated ToP clinics at Darlington Memorial Hospital (DMH), Bishop Auckland Hospital (BAGH), University Hospital of North Durham (UHND) and at Shotley Bridge Community Hospital (SBCH). Women attending these clinics are seen by a consultant gynaecologist, a family planning doctor and a nurse specialist who can provide or arrange for counselling sessions. Women are provided with information (both verbal and written) on their choices and if they choose to proceed with a termination they are given an appointment as well as detailed information on where and how to access the service.

Surgical terminations are provided as day cases at both DMH and UHND and medical terminations are provided on a dedicated ward by a dedicated team at BAGH.

3.2 Evaluation of ToP service framework

The evaluation was carried out for the six month period from 1st November 2005 to 30th April 2006. The format chosen to evaluate the current service was the Donabedian evaluation format - Structure, Process and Outcome, which is a commonly used framework when evaluating services.

Structure (service resources and inputs): The ToP service was compared against the service standards of the Royal College of Obstetricians and Gynaecologists.

Process (service activity): The number of patients being referred to out of ‘area providers’ were identified and compared to figures prior to service improvement.

Outcomes (what the service hoped to deliver):

1. Length of time between initial consultation with referring doctor and hospital clinic appointment was calculated
2. Patients’ experiences of and satisfaction with the service were gathered.
3. Total number of ToPs performed and the proportions that were performed as medical or surgical terminations was recorded.
4. Gestational age at time of procedure was also recorded.

Each patient attending the dedicated ward for medical ToPs at BAGH during the months of November and February were asked to complete a survey which ascertained their experiences along the termination of pregnancy care pathway i.e. at initial consultation with referring doctor, at hospital clinic and on the dedicated ward at BAGH.

Monthly audit forms were completed by the Fertility Control team in BAGH and DMH and by the head of midwifery at UHND. These audit forms recorded numbers treated, type of procedure and gestational age at time of procedure for both medical and surgical ToPs.

3.3 Evaluation results

3.3.1 Structure

In 2004 the termination of pregnancy service that was provided across County Durham and Darlington was compared against the nationally recommended standards for ToP services. In total the service was compared against 20 standards that were grouped under three headings; organisation of service, information for women and pre-abortion management, abortion procedures and after-care. This process was repeated following service reconfiguration (during evaluation period - November 05 - April 06) and the results of both comparisons are presented below.

Table 3.1: Results of comparison of ToP service against national standards in 2004 and 2006.

Standards	UHND	BAGH and DMH
	Standards achieved
	2004	200620042006
Organisation of service - 7 standards	1 out of 7	6 out of 76 out of 76 out of 7
Information for women and pre-abortion management - 5 standards	2 out of 5	5 out of 55 out of 55 out of 5
Abortion procedures and ‘aftercare’ - 8 standards	3 out of 8	8 out of 86 out of 88 out of 8

From table 3.1, it can be seen that improvements have taken place across each of the three standard groups with the most dramatic improvement occurring in UHND. Currently the ToP service being provided across County Durham and Darlington Foundation Trust is meeting 19 out of the 20 quality standards recommended by the RCOG.

3.3.2: Process

As highlighted earlier in the document prior to service re-configuration in October 2005, forty percent of referrals for termination of pregnancy were to ‘out of area’ providers. While it is accepted that some women will want to travel to such providers to maintain anonymity, the above figure also reflected the time delays in accessing services within County Durham and Darlington.

Data on referrals, during the evaluation period, from County Durham and Darlington to all termination of pregnancy service providers within the North East was requested.

Table 3.2: Referral patterns to Termination of Pregnancy services within the North East of England. November 05 - April 06.

Termination of Pregnancy service providers	Referrals from County Durham and Darlington
County Durham and Darlington Acute Hospitals NHS Trust	644 (67.6%)
City Hospitals Sunderland NHS FT	68 (7.1%)
Gateshead Health NHS FT	18 (1.9%)
North Tees and Hartlepool NHS Trust	183 (19.2%)
South Tees Hospitals NHS Trust	7 (0.7%)
The Newcastle upon Tyne Hospitals NHS FT	11 (1.2%)
Other	21 (2.2%)
Total	952 (100%)

Over sixty seven percent of referrals from County Durham and Darlington are to the ToP service provided by CDDAH Trust. Referrals to ‘out of area’ service providers have now fallen to thirty two percent. This suggests that as a result of improvements in the termination of pregnancy service provided by CDDAH, 76 fewer women had to travel outside of County Durham and Darlington for their termination procedure.


It can be assumed that referrals from Easington will continue to occur to service providers other than CDDAH trust because of the proximity of these other service providers. If we re-look at the data with Easington referrals excluded we find that just under 80% of referrals are to CDDAH trust with only 21% being referred to ‘out of area’ providers. (Table 3.3)







Table 3.3: Referrals from County Durham and Darlington (excluding Easington data) to termination of pregnancy service providers in the North East.

Out of area abortion service provider	Referrals from County Durham and Darlington
County Durham and Darlington Acute Hospitals NHS Trust	640 (79.4%)
City Hospitals Sunderland NHS FT	25 (3.1%)
Gateshead Health NHS FT	18 (2.2%)
North Tees and Hartlepool NHS Trust	85 (10.5%)
South Tees Hospitals NHS Trust	7 (0.9%)
The Newcastle upon Tyne Hospitals NHS FT	11 (1.4%)
Other	20 (2.5%)
Total	806(100%)

3.3.3 Outcomes

Four proposed outcomes were measured during the evaluation. Information on the first two outcomes was gathered from the surveys distributed to women attending the dedicated ward at BAGH. The last two outcomes were collated from data gathered from the monthly audit forms.

a. Length of time between initial consultation with referring doctor and hospital clinic appointment.

The National Strategy for Sexual Health and HIV, in 2001, set as a national standard that ‘no woman need wait longer than three weeks from her initial referral to the time of her abortion’. This standard had a number of benefits in terms of reducing women’s anxiety by ensuring that they did not have undue waits for a termination procedure. The standard also aimed for quicker access to a termination of pregnancy so that women could present earlier in the first trimester, resulting in better outcomes following the procedure.

A Darlington GP conducted a study at BAGH and DMH in 2003, to estimate the proportion of women meeting the three-week standard for access to an abortion procedure. The study found that the national standard of a three-week timeframe was achieved for only 28% of the women included in the study. Similar anecdotal evidence concerning patients attending UHND was shared with the working group in 2004.

Information on waiting times for hospital assessment appointments and admission for procedures has not previously been available because of the difficulty in recording and collating such data. The distribution of questionnaires as part of this evaluation provided us with an opportunity to gather this type of information.


Table 3.4: Waiting time information for initial hospital visit and the procedure itself.

	Time from 1st visit with referrer to dedicated clinic appointment	Time from clinic appointment to procedure
November 2005	15 days	3 days
February 2006	18 days	3 days
Average	16.5 days	3 days

The average wait for an appointment to be seen at a dedicated ToP clinic during the months of November 2005 and February 2006 was sixteen and a half days. Women had to wait a further three days to have the termination procedure performed, resulting in a total wait of 19 and a half days. This implies that the new re-configured termination of pregnancy service in County Durham and Darlington is meeting the national standard as set down by the sexual health strategy.


b. Patients experience and satisfaction with the service

In total one hundred and seven (107) patients returned the patient experience and satisfaction questionnaire during the months of November 2005 and February 2006. Not all questionnaires were fully completed. Information extracted from the responses received, is detailed below and is presented under three headings; the referral process, experience at dedicated clinic, experience during hospital admission.

Referral process:


The majority of women were referred for their ToP by a GP (76.6%), while a family planning doctor referred 19.6 %. For 11% of women, the initial doctor consulted for referral was unable or not prepared to refer them for a termination procedure. The following statement from one respondent provides insight into her experience with her GP.


“I first saw my own GP who refused to refer me, told me all babies deserved a chance to live and because I was at no harm I could not terminate my pregnancy but then I saw a doctor at the Family Planning Clinic who referred me”


National studies of GPs have shown that overall 82% were pro-choice and therefore happy to arrange a termination of pregnancy referral.


The majority of women (75%) received their hospital appointment either at the time of their initial consultation, later the same day or the next working day. Just over a fifth of women received their appointment two or more days after their initial consultation. This type of delay can lead to increased anxiety for women with the potential of also delaying their procedure.

Graph 3.1: Receipt of hospital appointment - Time and place



Experience at dedicated hospital clinic:

Ninety eight percent of women attending the dedicated clinic felt that enough information had been provided and a similar percent found it easy to understand. In relation to communication and history taking at the clinic the majority of women felt that there had not been too much emotional talk (70%) nor medical talk (72%). Eight two percent of the women felt that the staff were not afraid to discuss emotional issues. Over 95% of women felt that the staff treated them with respect and were professional and thorough towards them. Ninety three percent (93%) felt that they were treated as a whole person.


Experience while admitted onto dedicated hospital ward:

Similar to experiences at the clinic, the vast majority of women were happy with the information provided (98%). Again women felt that they were treated with respect (99%), that staff were professional and thorough (99%) and that they were treated as a whole person (97%).

“Just like to say the staff on ward 10 were excellent. Dealt with the emotional and physical sides brilliantly”.


“I was treated with a lot of respect today the staff were so friendly and understanding towards me I would like to say thank you to everyone”.

With regard to care on the ward 11% of women felt that there were some things about their medical care that could have been better but that over all clinical care received was excellent (99%).


“I can’t thank Trudy and the team enough for looking after me today. I was not made to feel bad or at fault for my decision and the care and advice I received has been first class thanks for everything”.


“I found the staff on the ward fantastic and enabled me to make a very difficult time a bit easier”.

“All of the nurses have been lovely. Thank you very much. They have made a horrible day not so bad”.

“My mother and I have been in this ward today, where I have been treated. From the minute I came in everybody has been marvellous, I have been treated with kindness and respect by everyone”.

Four women stated that transport had been difficult for them, especially arrival at the hospital early in the morning. Two women commented on the expensiveness of getting a taxi to Bishop Auckland.

“I had some transport difficulties. I had to get a taxi costing £45”.

“With the treatment being at Bishop Auckland. I had difficulty with transport. I had to pay £25 for a taxi. But apart from that, everything was fine”.




c. Number of terminations performed

A monthly audit form was completed for each of the six months of the evaluation. This form collected data on the number of terminations performed, whether they were medical or surgical terminations and the gestational age at time of the procedure.

Table 3.5: Medical and surgical procedures: November 05 - April 06.

	Medical	Surgical	Total
UHND	0	30	30
BAGH	432	3	435
DMH	0	18	18
Total	432 (89%)	51 (11%)	483

In total 483 termination procedures were carried out with 89% being performed as medical procedures. The advantages of medical termination procedures include:

· Increased patient control - woman awake
· Non-invasive procedure
· Fewer complications
· Avoidance of a general anaesthetic
· Safer in terms of long term risk
· Can be accompanied by partner or friend
· More individualised care

The 2005 Abortion Statistics for England and Wales showed that there had been a continuing upward trend in medical abortions since 1991 but that they still just accounted for 24% of the total number of abortions in 2005. The percentage of medical terminations being performed in County Durham and Darlington (89%) compares favourably against the national figure.

d. Gestation and termination procedures

The percent of terminations performed less than 10 weeks gestation is a reasonable indicator of service accessibility. If women can access services before 10 weeks gestation they can have the choice of an early medical or surgical abortion.

During the initial review of the termination of pregnancy service in County Durham and Darlington in 2004, data available at that time showed that just over 57% of termination referrals were being performed at less than 10 weeks gestation.

Graph 3.2 shows the breakdown of terminations into gestational bands for data collected during the evaluation period. Sixty five percent (65%) of terminations were being performed at less than 10 weeks gestation with 87% being performed at less than 13 weeks. This is a significant improvement when compared to what was being achieved prior to service reconfiguration.

Graph 3.2: Gestational age and termination of pregnancy: November 05 - April 06


4 Key findings from the evaluation


· The County Durham and Darlington Foundation Trust is meeting 19 out of the 20 evidenced based standards as set down by the RCOG

· Referrals to out of area service providers has fallen with 76 fewer women having to travel outside of County Durham and Darlington for their procedures.

· Waiting times for women accessing the termination of pregnancy service have improved with women being seen within the national standard of three weeks from initial appointment with referrer to having the termination procedure.

· Overall patient experience throughout the termination of pregnancy care pathway was very positive.

· Eleven percent of women required a second appointment with a referring doctor as the first doctor was unable or not prepared to refer them for a termination procedure.

· Over 95% of women at the dedicated ToP clinic felt that the staff treated them with respect and were professional and thorough towards them.

· While admitted for the termination procedure 97% of women felt that they were treated as a whole person.

· Transport issues and its costs were a problem for six out of a total of 107 respondents.
· Eighty nine percent (89%) of terminations are being performed medically, which is a less invasive procedure with fewer risks.

· Sixty five percent (67%) of terminations are being performed at less than 10 weeks, which has the associated benefits of providing women with more choice with regard to termination procedure and reducing the risk of complications.


5 Recommendations


1. Formulation of pathways of care for women seeking induced abortion from first contact with a health professional to follow-up post procedure. This will promote efficiency and help reduce the waiting time from initial referral to attendance at dedicated clinic.

2. Development and implementation of a system to measure the waiting time from first appointment with the referring healthcare professional to the abortion procedure to ensure that women are not waiting excessively for their procedure.

3. Development and distribution of a local information strategy for the ToP service within County Durham and Darlington. This strategy should include all points of contact along the termination of pregnancy care pathway, contact details and transport links to the different services.


6 Conclusion


The findings from this service evaluation predominantly show a greatly improved termination of pregnancy service that is meeting almost all national quality standards. This improvement is a result of the combined efforts of the key service stakeholders throughout County Durham and Darlington but in particular the efforts of the Fertility Control Teams in the north and south of the county. The patient and public consultation, while difficult to conduct because of the sensitive nature of the issue, did provide valuable help in agreeing service reconfiguration. The task facing the service now is to use the findings from this evaluation to address any gaps in service provision and to continue to provide a high quality service.



Dr. Mary Browne
Public Health Specialist Registrar
County Durham PCT
July 2007



Attachments

 appendixfor item6.pdf;
 item6.pdf