FEATURE BMJ: first published as 10.1136/bmj.n2156 on 9 September 2021. Downloaded from London, UK [email protected] BMJ Awards 2021: Women’s health team of the year Cite this as: BMJ 2021;374:n2156 Matt Limb finds out how the nominated teams are improving access to services and care http://dx.doi.org/10.1136/bmj.n2156 Published: 09 September 2021 Matt Limb freelance journalist Telemedicine care in the pandemic empowered to make an informed choice on their preferred contraception. In 2017, Rotherham sexual “As the covid-19 pandemic took hold, abortion health clinic’s local authority funding was cut by services in Britain were on the brink of collapse,” 10%, leading to a reduction in workforce. Despite says Michael Nevill, the British Advisory this, LARC provision was increased by two key Service (BPAS) director of nursing and quality. By interventions. Mandatory LARC education was law, abortion must be provided on licensed premises, embedded within the history taking template, and a but at BPAS large numbers of sick or self-isolating sustainable LARC training budget for sexual health staff meant a third of clinics had closed. With staff and allied healthcare professionals was lockdown, many women, including those shielding, generated. The income stream came from running living rurally, or in abusive relationships, found it Faculty of Sexual and Reproductive Healthcare virtually impossible to access care. “It was clear that contraception courses. Gupta says, “Subsequently, unless we could provide abortion without the need we achieved an almost 20% increase in LARC to travel, women would be forced to continue insertions, from 1469 in 2018 to 1746 in 2020. The unwanted or put themselves at risk,” increase was sustained, despite the covid pandemic.” says Nevill. The service became the “joint top sexual health clinic BPAS, which had experience of delivering early in England” for the proportion accessing LARC (NHS medical abortion through telemedicine in Northern Digital data). Waiting time for LARC appointments Ireland, led a campaign to urge the government to has fallen from three weeks to three days. The “did allow this model in England, and legal permission not attend” rate has halved, and was granted on 30 March 2020. The team supported rates in Rotherham have continued to fall. national guideline development and within nine days launched a pills-by-post service. “We built Women’s care project—NHS Lanarkshire infrastructure for clinician-led telephone or video Health inequalities are known to affect women consultations, removed unnecessary pre-abortion disproportionately, commonly leading to difficulties http://www.bmj.com/ interventions, posted to eligible women, accessing quality care, lack of information to aid and provided multimodal support for health choices, and ultimately poorer outcomes. This self-management,” says Nevill. Evaluations showed project tackled these deficiencies in women’s health better abortion access, equivalent outcomes to for NHS Lanarkshire’s diverse and vulnerable in-clinic care, and high client satisfaction. Refinement population. “What mattered to women was having of the service with client and staff input led to timely investigations leading to a diagnosis, and sustained uptake, with 66 000 telemedical having sufficient information with which to decide provided to date. on 29 September 2021 by guest. Protected copyright. on management options,” says Evelyn Ferguson, NHS Nevill says implementing telemedicine secured its Lanarkshire’s clinical role beyond the pandemic and the shortlisting was director, and . “a wonderful reward for everyone’s hard work and A package of measures was introduced, including dedication.” referral pathways for common gynaecological Helping women to make informed choice on conditions (shared with primary care through preferred contraception webinars and apps) and updated patient information leaflets and videos. The team also facilitated more Long acting reversible contraception (LARC) is the minor continence procedures being performed in gold standard method with respect to efficacy, but outpatients rather than in theatre and established a the pill, despite being less effective, is the most specialist menopause service. Among the key popular method used in the UK. outcomes were that 90% of hysteroscopies were done “This is perhaps not surprising, as clinicians require under local anaesthetic, equating to 6000 fewer specialised training to fit LARC (coils and implants), theatre procedures. See-and-treat operative which is costly and time consuming,” says Nadi hysteroscopy reduced the need for 300 repeat Gupta, consultant and clinical lead for the integrated procedures. sexual health service at Rotherham NHS Foundation Ferguson says the project improved both care quality Trust. LARC procedures take longer than writing a and women’s experiences, and also saved pill prescription. Women may not always be informed money—£732 762 (€850 000; $1m) in the first year. that, even with “perfect” pill taking, LARC is still “We were mindful that the unintended consequences more efficacious, adds Gupta. of the pandemic of cancer delays and worsening of A small team that is “passionate about women’s benign conditions may occur, therefore we health” sought to ensure that women were accelerated the project.” Cancer diagnosis and the bmj | BMJ 2021;374:n2156 | doi: 10.1136/bmj.n2156 1 FEATURE

treatment targets have continued to be met. “Continuing to treat BMJ: first published as 10.1136/bmj.n2156 on 9 September 2021. Downloaded from women and develop our services despite covid-19 pressures has been very rewarding for the team,” says Ferguson. Remote monitoring of diabetes in pregnant women Diabetes in pregnancy is increasing in prevalence worldwide, affecting 20% of women in the UK alone. If left untreated it can cause serious complications including preterm birth, pre-eclampsia, and increased risk of caesarean section, and it raises the chances of developing type 2 diabetes later in life. Consistent blood glucose control and regular clinic visits can reduce the chances of developing these complications. This requires women to self-monitor and record their blood glucose levels up to six times a day. But the conventional paper diary method, which requires in-person review by a clinician every one to two weeks, can lead to delays in identifying women in need of immediate treatment. GDm-Health, initially developed by Oxford University Hospitals NHS Foundation Trust and the University of Oxford’s Institute of Biomedical Engineering, allows pregnant women to log blood glucose readings on their mobile devices and digitally share these results with their care provider. This reduces clinic visits, allows clinicians to review readings in near real time, and prioritises women most in need. In February 2017, GDm-Health was licensed to Sensyne Health. Since its commercial launch in 2018, 56 NHS trusts have implemented it, helping to care for 28 338 pregnancies. Stephanie Kwok, account director, says this has made a “tangible difference” to the lives of pregnant women, adding, “With diabetes in pregnancy becoming more prevalent, digital technologies can help women and their clinicians better manage this condition.” NHS Lothian Choices service

Changes in legislation brought by covid-19 allowed home use of the http://www.bmj.com/ abortion mifepristone and misoprostol. The Choices service, which provides abortion care to women in NHS Lothian, introduced a telemedicine service on 1 April 2020. Women had a telephone consultation and, if less than 12 weeks pregnant, could choose to receive medication abortion at home. An ultrasound was not required unless clinically indicated (uncertain gestation or risk

of ectopic pregnancy). A medication pack was prepared for on 29 September 2021 by guest. Protected copyright. collection or delivery the same day, including contraceptive supplies and a pregnancy test to confirm the success of the procedure. Ongoing telephone support was provided from the clinic and 24 hour telephone advice. John Reynolds-Wright, clinical research fellow at the MRC Centre for , University of Edinburgh, says, “We evaluated this service in its first three months (663 women) to determine treatment effectiveness and acceptability to women, using the regional electronic patient record and database, a two part telephone questionnaire, and qualitative interviews with 20 women.Nine out of 10 women chose telemedicine medication abortion at home. Rates of complete abortion were high (98%), with very low rates of serious complications—no different to those in previous cohort studies from the service.Most women (98%) were highly satisfied or satisfied with care, and interviews showed they valued this enhanced care quality in relation to access, comfort, and flexibility. “This model delivered safe, effective, patient centred abortion care, and legislation should remain in place for it to continue,” says Reynolds-Wright.

The winners of the women’s health team of the year award will be announced at The BMJ Awards virtual ceremony on Wednesday 29 September 2021. For more information see https://thebm- jawards.bmj.com.

2 the bmj | BMJ 2021;374:n2156 | doi: 10.1136/bmj.n2156