Optimising collaboration among pelvic floor specialists: the role of the MDT

Patients with PFDs have already had a difficult journey, often taking years to reach a specialist in secondary or tertiary care. It is of paramount importance that the patient feels looked after in a holistic manner and fragmented care and ‘silos’ should be avoided. Ownership of the problem, with a named responsible clinician in charge of care who liaises with colleagues, can help to avoid patients having to move unnecessarily between specialists.

Joined-up care is particularly essential for our most complex patients, who need a joint evaluation and possibly joint surgery. The optimal approach for these complex cases is the multidisciplinary team (MDT) meeting, featuring a range of specialists to ensure the full spectrum of factors is taken into account when deciding on treatment – an approach recommended by the recent Scottish Independent Review into mesh implants (Scottish Independent Review, 2017). Indeed, the MDT is no longer optional and is an essential resource in patient management, and as a minimum standard of care, all patients requiring surgery should be discussed before surgical treatment.

NICE guidelines for urinary incontinence recommend both regional and local MDT meetings (NICE guidelines, Urinary incontinence and pelvic organ prolapse in women: management, 2019) and state that local MDTs are appropriate to review proposed treatments for patients with primary stress urinary incontinence, overactive bladder or primary prolapse, whereas regional MDTs should review proposed treatments for patients with complex pelvic floor dysfunction and mesh-related problems. Currently, there are approximately 40 commissioned centres for complex pelvic floor problems (focused largely on urinary incontinence and pelvic organ prolapse) to be established under specialised commissioning. In its current iteration, the service specification relates largely to these symptoms and where they coincide with bowel symptoms, rather than for bowel symptoms alone, leaving people presenting with bowel issues alone uncatered for beyond the pelvic health services in primary and community care.

NICE recommends that local MDTs should feature as a minimum two consultants with expertise in managing urinary incontinence in women and/or pelvic organ prolapse, a urogynaecology, urology or continence specialist nurse and an accredited (POGP, 2020) pelvic floor specialist physiotherapist. Additional optional members listed in the guidelines are a member of the care of the elderly team, an occupational therapist and a colorectal surgeon. However, for regional MDT meetings, the colorectal surgeon is listed as a mandatory attendee, along with a pelvic floor specialist physiotherapist and a radiologist with expertise in pelvic floor imaging. Notably, the older (2007) guidelines for faecal incontinence do not yet include a recommendation for an MDT (NICE guidelines, Faecal incontinence in adults: management, 2007); given the evidence used for these guidelines is still current, the expected timeline for updating these is not yet known, although there is a guideline in progress from the European Society of Coloproctology (ESCP) and United European Gastroenterology (UEG). Further, a guideline on mesh in pelvic colorectal surgery has been submitted to Colorectal Disease at the time of writing. New and updated guidelines should include patient representatives to further improve the relevance and likely uptake of their recommendations.

Better MDT working will help to support the more complex patients, particularly those with multi-compartment disease. The development of MDTs has led in some centres to joint clinics, which are essential to evaluate (in one consultation) the most complex patients. However, since these are a limited and expensive resource, local teams should develop clear vetting procedures and establish strict referral criteria for access to this high-resource clinic. Guidelines in general for MDT referral will be necessary to ensure that all MDTs do not discuss inappropriate cases.

MDTs should be conducted as frequently as required in order to reduce patient waiting times (Balachandran et al., 2015), and should be attended by subspecialist functional colorectal, urogynaecology and urology team members. Ideally, two members of each specialist team should be on the MDT group so that one can attend if the other is unavailable (Balachandran et al., 2015). Online meeting technology may allow for more cost- and time-efficient MDT meetings and allow specialists to join and leave as required (see Chapter B).

The knowledge and training of specialist nurses is valuable for joined-up pelvic floor care, and the continence resources available from the RCN (RCN, 2016) provide a comprehensive overview and support for patient-centred care. One-stop clinics and use of patient navigators, with or without administrators or triage nurses, can help to triage patients according to local guidelines and thereby streamline investigations – these investigations should ideally be conducted prior to clinician review in order to enhance decision making.

Making use of available skills: the case of protocol-driven procedures for nurses

With growing demands on the service, it is time to reconsider which procedures require consultant expertise and which can be performed by appropriately trained nursing or allied healthcare professionals such as Assistant Practitioners. Often acting as leaders in the area of bladder and bowel care, specialist nurses are uniquely placed to step into many procedures in this area. Provision of clear protocols and formal governance arrangements ensures that procedures are standardised, minimising risk to the patient and providing an opportunity for the healthcare practitioner to work towards independent practice. Indeed, many experienced nursing staff can use their expertise and clinical judgement, with the appropriate governance, to conduct procedures. For higher-cost procedures, such as sacral neuromodulation (SNM) implants, procedures can be performed along with a consultant, but with appropriate training procedures under local anaesthetic could also be performed independently, freeing up specialist consultants to perform other procedures.

As part of this approach, a national recruitment drive for specialist nurses is important to ensure sufficient manpower is available – this could ultimately bring about further cost savings.

The long-term view: training the pelvic floor workforce of the future

Currently there are around 100 unfilled urology posts in the UK, and the shortfall in pelvic floor expertise is expected to increase further. Specifically in surgery, there is a worrying trend of reduced applications for general surgery at Specialty Registrar level, as well as a paucity of people interested in taking up pelvic floor surgery: the recent negative media surrounding mesh may worsen this and create further issues in the future. Functional and incontinence work has always been something of a ‘Cinderella’ speciality, with cancer and inflammatory bowel disease (IBD) work seen as more challenging and rewarding. However, an improved understanding of pelvic floor conditions has created a pivot point with the perception of this field. Nursing is also under pressure: the previous provision of specialist continence training under the old English National Board (ENB) structure no longer exists and specialist post-graduate continence training is lacking. This reduces the opportunity to specialise in this area of care for adults and for children, and also reduces the visibility of any such career path.

Defining the workforce required to provide evidence-based care is a further stated aim of the NBBH project (NHS Supply Chain). It is essential to attract new trainees to the service – and abandoning the past approach of considering the three pelvic compartments entirely separately may help to do this. With many trainees struggling to meet the required number of procedures to qualify in their chosen specialty, and a large number of senior surgeons now on the brink of retirement, creating a new combined specialty can help to both make the best use of our available resource and attract the pelvic floor specialists of the future.

Colorectal, urology and urogynaecology functional subspecialists all need to be adequately trained in their individual specialties, and then ensure they are able to tackle the often-complex problems encountered in each compartment of the pelvic floor. However, specialist training across the different compartments is a desirable long-term goal to reduce siloed decision making. Equal emphasis in such specialist training should be placed on each aspect of the pelvic floor, with the ultimate aim of creating ‘three-compartment pelvic floor specialists’. This may involve, for example, a urogynaecologist training in colorectal for a period, with similar cross-compartmental training for urologists and colorectal specialists. Cross-specialty pelvic floor training fellowships should be encouraged.

Training and education are crucial to improving the quality and availability of pelvic floor services. Future specialists, nurses and allied healthcare professionals need access to structured training programmes and specialist fellowships, as well as modular courses. The hub-and-spoke approach outlined in Chapter B should result in a higher concentration of cases and expertise, thereby maximising training opportunities.

A further aspiration for the future could be a focus on ‘Pelvic Floor’ as a specialism rather than urology, urogynaecology and colorectal all being specialities in their own right (Beggs et al., 2014; Gash et al., 2015): this could help in recruiting and attracting talent to this speciality, securing a high quality of care for the future. Formal accreditation of units is currently offered by the British Society of Urogynaecology (BSUG) and includes a requirement for provision of training, and the Pelvic Floor Society also offers accreditation to pelvic floor MDTs (see Chapter C), but a greater emphasis on training standards and broad curricula by professional organisations like the BSUG and British Association of Urological Surgeons (BAUS) would be welcomed in order to help to build momentum for this cross-functional specialism.

Having nurses who can deliver treatment for both urinary and bowel symptoms, as already done by physiotherapists, could shorten the overall patient pathway and may allow some women to avoid surgery – for example, women with small posterior compartment prolapses and defaecatory symptoms who present to gynaecologists may be able to avoid surgery if they have access to appropriate conservative treatment. The protocol-driven procedures conducted by nurses, mentioned above, could also be performed across specialties where appropriate, to reduce duplication of effort and equipment and to maximise efficiencies. Specialist continence training, and a better-promoted career pathway, could also help to safeguard staffing levels in nursing for the future.

In the long run, guidelines should reflect this approach, providing guidance on an agreed, evidence-based national pathway for patients with complex pelvic floor disorders across the spectrum of disease. These guidelines would support primary care clinicians and specialists to ask all the right questions and conduct all appropriate investigations to ensure the best outcome for patients. The recent publication of the UK Clinical Guideline (POGP and UKCS, 2020) for best practice in the use of vaginal pessaries for pelvic organ prolapse provides a good example where the patient’s needs are potentially met by a range of clinicians with appropriate and shared training as part of the overall management of their pelvic floor condition. It is encouraging that overarching NICE guidelines for pelvic floor disorders in women are anticipated in 2021 (see box on previous page). It is also important that sufficient workforce is available for the approaches outlined above to ensure that services are not unnecessarily centralised and the travel burden for patients is not excessively high.