Transcript of VPS Podcast 6 - Vulval conditions and the new NHS: a presentation given by David Nunns

Very importantly, if you’ve got a long-term vulval problem, you need a multidisciplinary team and when you think about your health professional, the person looking after you, you have to think that we have all different backgrounds, all different levels of training, and in terms of our toolkit of skills, we’re all different. A woman with vulvodynia will be managed differently by, for example, a gynaecologist, compared to a psychosexual therapist, or compared to a physiotherapist. There will be overlap, but each of those health professionals will have different skills, different tools in their toolkit, as it were, this is a virtual toolkit, of how to manage that patient. The assessment will be slightly different of the patient depending on the eyes of the health professional. The length of time will be different, and the counselling and the therapy will be different. Unfortunately with vulval disease, there’s not one person out there that can sort all your problems out. You probably have to draw on the multidisciplinary team.

We want staff to be appropriately trained – absolutely. Unfortunately, there is no accreditation process for vulval disease. If you have an abnormal smear, and you need to go and see your doctor for a colposcopy to assess and treat the cervix, or if you have a cancer, you are managed by health professionals who’ve had that extra qualification to manage that problem. But in vulval disease, there isn’t an accreditation programme just yet. People who look after women with vulval problems generally have an interest in that area, because they think it’s an important part of healthcare.

Leadership: again, why did we put this into a document? It makes sense that if you’re running a vulval service, you need to have somebody leading the service, somebody who’s going to work with primary healthcare, work with all the different members of the team, somebody who’s going to develop guidelines, pathways and who’s going to take the service forward.

Governance: this means striving for clinical excellence – a real buzzword in the NHS – we need to audit the work we do, we need to reflect on what we’ve done and improve. Clinical governance is ingrained into the NHS, and why should a vulval service be any different?

And finally, patient and public involvement in the service development. Now, that can sound quite benign when it’s added to the end of the list, but if you look at every other document similar to our one, you’ve got at the bottom…

[Sudden loud vocal interruption. Laughter from the audience]

David Nunns: [Jokingly] A late arrival!

[Laughter]

David Nunns: You’ve got patient and public involvement as being absolutely crucial in development of service. What do I mean by that? Well, we need to know what your feelings are about our service. We need to know about your experience. We need to know about the outcomes of the care we give. Has the intervention worked? Has your experience been good? Have you waited too long? etc  - all that holistic aspect of the care that we’ve given you. We need to do surveys, we need to do questionnaires, we can even have focus groups, but the feedback from your experience will shape everything above, and that is a common theme throughout every standards document that’s ever been produced.

This is a busy slide that I’ve pulled from the document, but I’ve put it up just to give you an idea of what we’re planning. You have to remember that when you see a GP or a specialist in a vulval clinic, that we’re dealing with the majority of health professionals, not the super-duper GPs who are doing fantastic jobs managing women with vulval problems. Level 1 care is self-management, yes? Level 2 care: what’s the role of a GP in vulval disease, what do we expect a GP to do? We would expect that GP to take a history, examine the patient and take swabs, and perhaps make a proper assessment and diagnosis. So many GPs will not examine patients. Many women will go to a GP with a problem and there won’t be any examination whatsoever, which I don’t think is acceptable. But we would expect your average GP to manage common things like thrush, perhaps follow up women with lichen sclerosus. We’d expect then, if we were moving from this box to something a little more complicated, like if there’s a lump, or a lesion to see, and it needed a biopsy, that that patient would go up to the hospital, secondary level care, where this would be Level 3 care, and see a gynaecologist or a dermatologist. There’s a list here of different problems that we would want a GP, specialist and this supraspecialist clinic to manage. What we don’t want are women, for example with vulvodynia, or complicated lichen sclerosus, to languish in primary healthcare, being denied perhaps some of the teams that are further down the list, and that’s what’s happening at the moment.