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Clinical referrals to Colposcopy

National Women and Infant Health Programme and the Cervical Check programme Joint Statement on the Management of women with intermenstrual bleeding, postcoital bleeding or a "suspicious cervix".

Over the past few years, there has been a significant increase in clinical referrals to the colposcopy service. Because one third of all referrals are now due to clinical reasons, it has become difficult for clinics to fulfil the programme standards and see all women referred within the recommended 8 week timeframe. The introduction of primary HPV screening is anticipated to lead to, at least a 40% increase in the number of new referrals to colposcopy from years 2 to 5 of the new programme.

Historically there has been sufficient capacity at CervicalCheck funded colposcopy clinics to allow patients with clinical symptoms (both urgent and non-urgent) and those with a suspicious or an unusual appearing cervix to be seen and investigated there. Whilst this was not strictly within the remit of a cervical screening programme, it was accepted that any spare capacity could be used to look after women from the symptomatic services.

In order to ensure that colposcopy clinics will be able to cope with the anticipated number of referrals in the near future, urgent steps are required to maximise capacity at colposcopy clinics. It is essential that women who screen positive are seen within the programme standard waiting times (i.e. all women should be seen within 8 weeks). This issue has been recognised by both CervicalCheck and the National Women and Infants Health Programme. Creating new capacity at colposcopy clinics by investing in additional trained colposcopists will take a considerable amount of time and will not be finalised prior to year 2 of the HPV programme.

A joint decision has been made by the senior management teams at NWIHP and Cervical Check to redirect clinical referrals to the gynaecology service from 1/3/2021. Additional funds have been identified and distributed to hospital groups to provide rapid access gynaecology clinics to deal more appropriately with these clinical referrals. We believe that this will result in more holistic, women-centred care which will ensure that women will see the right person with the appropriate expertise, at the right time in the right clinical setting.

CervicalCheck in collaboration with NWIHP are taking the following steps which should enhance this process

    A. The CervicalCheck laboratory referral form issued to primary care will no longer have a tick box for suspicious cervix referrals. If a GP is genuinely very concerned about a possible cervical cancer, they should contact senior clinical staff in their local clinic.

    B. The CervicalCheck programme will facilitate electronic referral from primary care to Colposcopy for screen-positive referrals. This has been completed and awaits implementation by HSE.

    C. From 1/3/2021, all clinical referrals should be referred primarily to gynaecology clinics and not to colposcopy clinics. Any referrals that are sent to colposcopy clinics will be triaged and forwarded to the local gynaecology service for management.

    D. CervicalCheck are engaging with primary care sample takers to improve education regarding recognition and management of clinical symptoms and the recognition of a clinically 'suspicious cervix'.

    E. A new electronic referral, specifically for gynaecology, is currently being developed by Primary Care, NWIHP and The Institute of Obstetrics. This new form includes specific conditions that warrant urgent referral, including the suspicion of cancer.

Although we recognise that different Hospital Groups will deal with this in different ways, it is essential that several steps are taken by each Colposcopy Clinic to ensure that whilst patients are not seen in colposcopy, they are still are seen promptly and appropriately assessed to ensure their safety.

CervicalCheck and NWIHP recommend the following steps are taken by Colposcopy Leads to ensure timely patient-centred care

  1. Lead Colposcopists should engage with their local management team to determine that the funds devolved to them have been utilised to provide rapid access gynaecology clinics, which are staffed appropriately and capable of managing women with clinical symptoms or a 'suspicious cervix'.
  2. Local guidelines should be developed with primary care to ensure referrals are appropriate and a policy for the management of inappropriate referrals should be in place.
  3. A local policy should be drawn up to adequately deal with clinical referrals in conjunction with Gynaecology colleagues including a pathway to ensure letters are triaged in a single place by a suitably qualified clinician who will act on behalf of the colposcopy and gynae teams. Triage should include time frames for urgent and non-urgent gynaecology referrals to be seen.
  4. There should be agreement between colposcopy and gynaecology services to ensure patients are seen in the right place by the right person in a timely manner. There should be suitable training in place if anyone other than consultant grade physician is seeing these patients.

Monitoring and audit of referrals should be put in place to ensure the quality and safety of this process. Our key objective is to provide high quality care for women with appropriate assessment, investigation and treatment of symptoms such as post-coital bleeding, intermenstrual bleeding and a finding of a clinically suspicious cervix.

Dr Peter McKenna
Dr Noirin Russell
Dr John Price
Ms Grainne Gleeson



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