- Email: [email protected]
Menorrhagia: The need for equity in treatment in Britain
Alison Chapple, Margaret Ling and Carl May Equity in health care is described as a key objective of the National Health Service (NHS) and the Department of Health in Britain.l There are various ways in which equity in health care may be detied,2 but for the purpose of this paper it is defined as ‘equally informed access’ to care. Using the example of treatment options for menorrhagia, this paper shows that gynaecological services available to women in two different geographical areas of northwest England vary considerably. As a result, some women are notbeing informed about the full range of alternative treatments and are therefore being denied access to up-to-date surgical procedures which have been shown to be effective in the treatment of menorrhagia. The data is drawn principally from interviews with 49 general practitioners and also from hospital managers in these two areas.
v
EN issues of equity in the British NHS are discussed in relevant journals,3 the emphasis often appears to be more on funding and resource allocation than on variations in medical practice and their effect on services.4 However, as Mooney observed:
‘One of the most fascinating and almost certainly inefficient and inequitable aspects of modern medicine is the extent and nature of variation in medical practice. It is a blight on the medical landscape. Yet the extent to which policy has moved to deal with variations is surprisingly small. Q This paper shows that treatment of menorrhagia is one instance where equity of care in medical practice is lacking between different geographical areas of Britain. The term ‘menorrhagia’ is used to describe regular menstrual blood loss that is excessive,5 usually defined clinically as blood loss of 80 ml or more per menstrual period, the level beyond which the incidence of anaemia increases significantly.6 Hormonal disturbance may be responsible for menorrhagia in adolescent girls or perimenopausal women, but this does not explain most cases of menorrhagia. Fibroids are sometimes said to be a cause of menorrhagia, but fibroids are often incidental to the excess bleeding rather than its cause.7 In 80 per cent of cases, there appears to be no obvious organic disease causing the heavy loss
of blood. In these cases, menorrhagia is sometimes referred to as ‘dysfunctional uterine bleeding’. Recent work suggests that menorrhagia may be the result of local endometrial factors, such as impaired haemostasis (constriction of small blood vessels).* The decision to seek medical help for menorrhagia may depend on the severity of the symptoms as well as the woman’s general attitude to menstruation and menstrual blood.g-12 Severe life events, such as bereavement and accompanying depression, may increase psychic reactivity to menstrual blood, triggering a consultation with a doctor.13 While some women do not want to consult a doctor for menorrhagia, in some cases perhaps due to the reported iatrogenic effects of medical treatment,14 other women clearly do want advice and help. One third of women in Britain will experience heavy menstrual bleeding sometime during their lives, and on average, a general practitioner (GP) can expect five per cent of women in the 30-40 age group to consult with this complaint each year.15 When women consult for menorrhagia, GPs may simply give information and advice or they may offer to start medical treatment. However, many GPs are unfamiliar with the latest research and may prescribe drugs which are often ineffective, such as the progestogen norethisterone.16 Perhaps partly as result of inappropriate treatment at primary care level, many women are eventually referred to consultant gynaecologists. 132
Reproductive
There are currently several effective medical and surgical forms of treatment available for women suffering from menorrhagia.5 If women are not told about these different treatments and offered a choice, they cannot be said to have equally informed access to care. There are some highly effective drugs, such as mefenamic acid (Ponstan) and tranexamic acid (Cyklokapron), which may reduce blood loss by as much as 54 per cent.17,*s There are also new intrauterine devices which release a progestogen, which are thought to reduce menstrual blood loss significantly.16 Many women (and some doctors) still believe that dilatation and curettage (D&C) can cure menorrhagia. While this procedure is still sometimes performed for diagnostic reasons, it has been shown that it does not cure menorrhagia. Indeed, some gynaecologists argue that the procedure is ‘diagnostically inaccurate and therapeutically ineffective’ and should not be done at all.lg Today, the most common surgical operation for menorrhagia in the UK is hysterectomy. Menorrhagia accounts for about half of the 90,000 hysterectomies performed every year.20 Over the past ten years there has been enormous debate about whether too few or too many hysterectomies are performed in the cour~try.*~-*~ Hysterectomy rates vary from country to country; there are also variations within countries and even between small areas. Sanders, Coulter and McPhersod4 suggest that the most important reason for the variation in the rate of hysterectomies is professional uncertainty and professional disagreement as to when hysterectomy is warranted. When menorrhagia is caused by small fibroids, myomectomy (removal of the f&oid, leaving the uterus intact) can be an option, although myomectomies are not as common in the UK as, for example, in France.22 In recent years, endometrial ablation has become an alternative treatment option for menorrhagia, particularly when there is no obvious cause. About 10,000 women with menorrhagia are treated per year by endometrial ablation in the lJK.l* Ablation may be achieved by transcervical resection, laser, radiofrequency or rollerball. Some studies have shown endometrial ablation to be highly successful,26 and numerous trials comparing the relative cost and effectiveness of endometrial ablation and hysterectomy show that the former leads to less morbidity and shorter stays in hospital than the latter.5,27,28However, endometrial
Health Matters, No 9, May 1997
ablation sometimes has to be repeated, and in one recent report up to 30 per cent of patients who had endometrial ablation later had to have a hysterectomy.2g The best treatment option for a woman with menorrhagia will depend on many factors, including whether she wants to avoid surgery and prefers medication, and whether or not she wishes to preserve her uterus or have more children. Endometrial ablation is a less invasive surgical procedure than hysterectomy, but hysterectomy is 100 per cent effective. There are many women who do not mind the idea of losing their uterus and are very satisfied after a hysterectomy.30,31 It is essential, however, that women are informed about the possible side effects and dangers of both medical and surgical treatments.32 Thus, to obtain optimal care, women with menorrhagia need doctors who are well informed and able to offer all of these treatments, or who are willing to cross-refer to others who can.
The study group and method This study explored referral decisions by GPs for women suffering from menorrhagia.33 The data is drawn principally from in-depth interviews in 1995 and 1996 with 73 GPs working in three areas of northwest England, and from information obtained from hospital managers. During the course of the study, a striking difference emerged between the gynaecological services available in a large town, which we have called Ashville, and a nearby city, which we have called Cenville.34 In Ashville 26 GPs were interviewed, and in Cenville 23 GPs. A qualitative approach was taken,35 employing a theoretical (or purposive) sample.36 This included GPs who had trained recently and those who had trained before 1980, and those working in both affluent and deprived areas. As the study progressed, extra efforts were made to include GPs with patients from ethnic minority groups. All the GPs in Ashville were asked to take part, and about 30 per cent agreed. In Cenville more GPs agreed to take part, over 50 per cent of those contacted. Some male GPs in both places declined because women with menorrhagia tended to consult their women partners, whom they suggested we contact instead. Interviews lasted approximately 30 minutes, and were audio-taped and transcribed with respondents’ permission.3” About half the GPs in both areas had the 133
w of the Royal College of Obstetricians and Gyna~ologists, a postgraduate gynaecology C@i6c&on. Also, almost all the GPs in both areas were on their local ‘obstetric list’. Thus, we Were COmPzkg the views of GPs with similar c@ifiCatiOnS.
Quality
of hospital gynaecology services
The GPs frequently made spontaneous comments about the gynaecology services generally, and those in Cenville were much more positive about their local hospital gynaecology services than those in Ashville. Twelve of the GPs from Cenville, a city with a teaching hospital, made very positive comments about their gynaecology services, while four made minor negative comments. In Ashville, on the other hand, there were 11 extremely negative comments about local services and six positive comments.37 One of those who thought the gynaecologists were good had had a great deal of contact with the Ashville consultant who was most likely to perform up-to-date procedures such as endometrial biopsy and endometrial ablation, which may partly explain his enthusiasm. Early on, even in the pilot study, we were alerted to the fact that treatment options might be much more limited in Ashville for women who were suffering from menorrhagia, as the GPs in the two places had strikingly contrasting views: The gynaecologists control menorrhagia very well.’ (Cenville GP 15) ‘Our service is not adequate for menorrhagia.... I am not blaming the consultants. I think the resources are verypoor.‘(Ashville GP 5)
This GP went on to complain about waiting lists and lack of bed space at the hospital. Another GP was less charitable about the consultants: ‘Some of the consultants don’t seem to have anyinterestataU,and theywill dotheD&Candsend them back and I am stuck with the same problem.. I am not getting any help from the consultants locally. ’(Ashville GP 11)
Another Ashville practice sometimes referred patients for private treatment but not to the local consultants: ? think we wanted to show partly a little bit of our displeasure at the service the gynaecologists were offering.‘(AshvilIe GP 9) 134
men asked if there was anyone in Ashville who would do a myomectomy for fibroids, one GP replied:
‘It for example, she has fibroids, Imight say, ‘You’ve got these, and the only way to control the bleeding is to perhaps consider, you know, would you consider a hysterectomy?” And if she said, “Well, definitely not’: then there is nopointin me referringher.... Not that I know of But I’ve only been here two and a half years, and I don’t know all the gynaecologists all that well.. Certainly in the time that I’ve been here I haven’t had a patient that has had a myomectomy.’ (AshviIle GP4, pilot study)
GPs’ perceptions of the availability of all treatment options In the city of Cenville almost all of the GPs seemed to be aware of the fact that endometrial ablation was an option for their patients. Cenville GPs also seemed to be aware of up-to-date diagnostic techniques offered at the hospital. While some thought that diagnostic D&C was still performed, others remarked: That - nobody does. You do a hysteroscopy to sample the tissue and have a look.‘(Cenville GP 10) ‘Fortunately they have actually audited the D&Cs and found that they serve no useful purpose at all.. . ‘(Cenville GP 8)
Again, in stark contrast, only the Ashville GP who knew the Ashvllle consultant who was most likely to perform up-to-date procedures, mentioned the existence of endometrial biopsy for diagnostic purposes. Others were uncertain or behind in their knowledge. ‘Our service is possibly not as up-to-date as it might be. ’(Ashville GP 81
The consultants usually do the scrape ID&Cl, you know, because [iUs] diagnostic as well as [curative] so they always do the scrape.. . Sometimes at?er the D&C the [women1 are cured for a while, maybe one or two years and then it will come back.’ (Ashville GP3, pilot study) Nine of the 26 Ashville GPs did not seem aware that two of their local consultants were able to perform endometrial ablation. We need to know more about developments like
Reproductive
endometial ablation, and that sort of thing. We would like to JUIOWwhat sort of hospitals are providing that sort of sen/ice, and where we are going to go from there.‘(Ashville GP 5) Most Asian women were very anxious to avoid hysterectomy. However, the one time that an Ashville GP suggested endometrial ablation to an Asian patient, assuming that endometrial ablation was available in Ashville, the situation proved to be otherwise: ‘After the outpatient appointment I had to sort of backtrack and eXprain that it wasn’t done. It was quite dif%uJt.‘(Ashville GP 11) Two Ashville GPs did not think the consultants were having much success with endometrial ablation, and another appeared to have a very negative attitude to this type of surgery: ‘1 think before my time someone tried it. I don’t think it was a terrific success.’ (Ashville GP 4, pilot study) ‘1 think it is an operation that can take sometimes as Jongas a hysterectomy so why on earth do that when you are stillJet? with the uterus?’Ashville GP 6) Yet this same commented:
GP,
later
in the
study,
Too many women have hysterectomies
also
at far too
earJyan age.‘(Ashville GP 6)
Communication between consultants and GPs Good communication between consultants and GPs, and between consultants themselves, is essential if GPs are to know what options are offered by different specialists, and so that consultants feel able to cross-refer if they themselves do not offer a particular service. In Cenville, communication between staff at all levels appeared to be good. One CenviIle GP pointed out that the consultants were very good at offering meetings and training. Almost all of the Cenville GPs had seen locally produced guidelines on the treatment of menorrhagia, which consultants had produced with the help of GPs. GPs could also obtain information sheets from the hospital to give to their patients, to help to explain alternative treatments. The situation in Ashville appeared to be quite different. When we asked the GPs in Ashville whether or not they had seen any local guidelines,
Health Matters,
No 9, May 1997
four of them indicated that there was some disagreement about treatment within the local gynaecology department. One explained: ‘I think the likelihood of getting our gynaecologists to agree on guidelines that could be put out in the name of the hospital is nil, so J think it is unlikely that we could ever get any....Some [consultants] probably haven’t talked to each other for years. 1 don’t think it is quite as bad as that, but they have certainly got very contrasting ideas about the way obstetrics and gynaecology is run.‘(Ashville GP 2) Another Ashville GP said that the consultants were still arguing over the protocol themselves and added: The obstetricians and gynaecologists are renowned for being at loggerheads with each other. ’ (Ashville GP 13)
Access to hysterectomy vs. endometrial ablation A hospital business manager and two hospital information officers provided details of the number of hysterectomies and endometrial ablations performed in the hospitals to which most GPs in this study referred their patients. In Ashville two consultants were technically considered able to perform endometrial laser ablation. However, while there were 262 women seen at the hospital in Ashville with a primary diagnosis of menorrhagia in 1995-96, there was only one endometrial ablation (and only one endometrial ablation the year before that as well). In Cenville, 541 women were given a primary diagnosis of menorrhagia in hospital, and 114 had endometrial resections. There were also 221 hysterectomies in Cenville in women with a primary diagnosis of menorrhagia. In fact, in Cenvllle surgeons were performing about twice as many endometrial ablations as the national average, when compared with hysterectomies. Thus, a woman with a primary diagnosis of menorrhagia had a 1 in 262 chance of having an endometrial ablation in Ashville, while in Cenville the chance was 1 in 5, indicating that in Ashville, endometrial ablation is a very rare event indeed.
Cross-referral
options
In the city of Cenville eight out of ten of the 135
Chappie, L.ingand May
surgeons were performing endometrial ablation, so cross-referral was not so necessary. However, a GP in Cende remarked that the consultants did tend to cross-refer. Given that only two surgeons in Ashville were able to perform endometrial ablation, and indeed rarely performed the operation, we asked if direct referral from GPs to other hospitals was possible or if cross-referral between surgeons was common. A few Ashville GPs recalled that patients had occasionally been sent to a nearby city for endometrial ablations in the past. Others thought that it was difficult to refer directly to hospitals outside the area because of block contracts between the Health Authority and the hospital. Twelve Ashville GPs were asked whether crossreferral was a possibility within the hospital itself. None of them thought that cross-referral was likely between consultants in Ashville. ‘No, it’s very unlikely, so if I was against endometrial ablation and sent them [the women1 to a consultant who Iknew didn’t do it, then Iknowshe wouldn’t get that, but I would have talked her out of it anyway before she got there. GPs have great influence, haven’t they?’ (Ashville GP 6) Two other GPs thought that cross-referral would only take place at the instigation of the patient. As one doctor who was familiar with the hospital gynaecology department commented: ‘I think if the patient knew that she wanted an endomeirial resection, and was vociferous and coherent enough to voice an opinion, there is a chance that the consultant might do a lateral referral, and say, ‘Well, I’m sorry I don’t do that operation, but my colleague does”, but if she didn’t mention it, it wouldn’t be mentioned, I don’t think, with the consultants who don’t do it. As an option.‘(Ashville GP 14)
Discussion Although Britain and a number of other countries such as Sweden have a strong commitment to equity of access to health care,38 research indicates that wide geographic variations in admission rates for surgical procedures are universal.24 This paper reports on only two areas in Britain. While the lack of equity we uncovered does not necessarily apply to services in the rest of the country, the Endings do suggest that issues of equity need to be addressed. Many of the GPs in Ashville perceived that services were inadequate for their patients’ needs,
while the GPs in Cenville spoke with great enthusiasm about their local service. It is possible that GPs in Cenville were more enthusiastic about their local services than those in Ashville because they had seen the Cenvllle local guidelines for menorrhagia. However, the very fact that Cenville has local guidelines suggests that consultants and GPs communicate and that they work together, surely a positive feature of the Cenville gynaecology service. It is certainly clear from the hospital figures that women in Cenville had a real choice between medical treatment, endometrial ablation and hysterectomy, while women referred to the hospital in Ashville were very unlikely to be offered endometrial ablation. It is important that surgeons use skills regularly, yet the surgeons in Ashville had only performed endometrial ablation twice in a two-year period from mid-1994 to mid-1996. This could be considered inadequate for good performance, and may explain why GPs in Ashville believed that endometrial ablation had not been successful locally. Although women may on occasion have been referred outside the Ashville area for endometrial ablation, the GPs implied that this was unusual, and as one GP pointed out, many patients would not have been able to afford to travel outside the area for treatment anyway. As Lilford points out: ‘There is no “correct” hysterectomy rate, but “correct” practice is to make explicit the trade-offs between this operation and an increasing number of alternatives.‘2g Doctors in Britain are now actively being encouraged to practice evidence-based medicine.3g To do this successfulIy for menorrhagia, this study suggests that GPs and surgeons need to have their knowledge of medical methods and surgical procedures up-to-date, and surgeons need to be retrained to perform new techniques such as endometrial ablation or become more willing to ensure cross-referral. In every field of medicine uncertainties exist,@ and in the near future it is unlikely that gynaecologists will agree about the best choice of treatment for menorrhagia. However, women should be given as much information as possible, and thus be permitted to make an informed choice between those treatments which have been shown to be effective. If alternative treatments performed by competent surgeons are not easily available, and if consultants are not prepared to cross-refer, both
Reproductive Health Matters, No 9, May
1997
GPs and consultants may fail to tell their patients about the advantages and disadvantages of different options, and women may not have equitable access to a real choice of treatment.
in the study for their time and candour, and Dr Hermione Love1 for helpful comments on an earlier draft of this paper.
Acknowledgements
Alison Chapple, Institute for Health Research, Alexandra Square, Lancaster University, Lancaster, LA1 4YT. Tel: 44 1524-593 905.
Correspondence This study was funded by the North West Regional Health Authority, Britain. (Grant RF 95/12). We gratefully acknowledge this support. We should also like to thank those GPs and others who participated
References
and Notes
1. Variations in Health. What can the
2.
3.
4.
5.
Department ofHealth and the NHS do? Department of Health, London, 1995. Mooney G, 1994. Key Issues in Health Economics. Harvester Wheatsheaf, Hemel Hempstead. Whitehead M, 1994. Who cares about equity in the NHS? British Medical Journal. 308: 1284-87. FewtreIl C, Martin D and Layzell A, 1996. Fair ground reaction. Health Service Journal. 22 Feb. CouIter A, KeIIand J, Long A et al, 1995. The management of menorrhagia. Effective Health Care: A Bulletin on the Effectiveness ofHealth Service lnterventions for Decision Makers. 9:1-14.
6. HaIIberg L, HogdahI A, N&son L et al, 1966. Menstrual blood loss a population study. Acta Obstetrica et Gynecologica Scandinavica. 45320-51. 7. Coulter A, 1994. Prevalence and epidemiology of dysfunctional uterine bleeding. Dysfunctional Uterine BJeeding. SK Smith fed). Key Paper Conference, Series No 1. Royal Society of London Press, London. 8. Sheppard B, 1994. Pathophysiology of dysfunctional uterine bleeding. Dysfunctional Uterine Bleeding. S.K. Smith (ed). Key Paper Conference, Series No 1. Royal Society of Medicine Press, London. 9. Woods N, Dery G and Most E, 1982. Recollection of menarche, current menstrual attitudes and perimenstrual symptoms. Psychosomatic Medicine,
44(3):285-93.
10. Skultans V, 1988. Menstrual symbolism in South Wales. Blood Magic: An Anthropology of Menstruation. T Buckley and A GottIieb (eds). University of California Press, London. 11. Bransen E, 1992. Has menstruation been medicalised? Or wiII it never happen.... Sociology ofHealth and Illness. 14(1):98-109. 12. Scambler A and Scambler G, 1985. Menstrual symptoms, attitudes and consulting behaviour. Social Science and Medicine. 20(10):106568. 13. Harris T, 1989. Disorders of menstruation. Life Events and IJlness. G Brown and T Harris (eds). Unwin Hyman, London. 14. IIIich I, 1976. Limits to Medicine. Marion Boyars, London. 15. CouIter A, Peto V and DoII H, 1994. Patients’ preferences and general practitioners’ decisions in the treatment of menstrual disorders. FamilyPractice. 11(1):67-73. 16. CouIter A, KeIIand J, Peto V et al, 1995. Treating menorrhagia in primary care. An overview of drug trials and a survey of prescribing practice. International Journal of Technology Assessmentin Health Care. 11(3):456-71. 17. Preston J, Cameron I, Adams E et al, 1995. Comparative study of tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. British Journal of Obstetrics and Gynaecology. 102:401-06. 18. Bonnar J and Sheppard B, 1996.
Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. B&U. 313:579-82. 19. Lewis B, 1993. Diagnostic dilatation and curettage in young women. BhZI. 306:225-26. 20. Smith SK, 1994. Hysterectomywhy and when? Dysfunctional Uterine Bleeding. Key Paper Conference, Series No 1. Royal Society of Medicine Press, London. 21. CouIter A, McPherson K and Vessey M, 1988. Do British women undergo too many or too few hysterectomies? Social Science and Medicine. 27:987-94. 22. Payer L, 1988.Medicine and Culture: Varieties of Treatment in the United States, England, West Germany and France. Henry Holt, New York. 23. Studd J, 1995. Shifting indications for hysterectomy. Lancet. 345388. 24. Sanders D, CouIter A and McPherson K, 1989. Variations in Hospital Admission Rates: A Review of the Literature. King’s Fund Publishing Office, London. 25. Transcetical resection - a wire loop, fitted to a resectoscope is used to shave away the lining of the uterus. Rollerball - the lining of the uterus is destroyed by using a 2mm rollerball electrode, which is fitted to the resectoscope instead of a cutting loop. Laser ablation a saline solution is pumped into the uterus through a hysteroscope in order to distend the uterine cavity and create a visual field. A laser
fibre is then inserted (under video surveillance) and the uterine lining is completely destroyed. Radiofrequency (or high-frequency) endometrial ablation - an intrauterine probe, which emits radio-frequency energy, and creates localised heating which destroys the lining of the uterus. 26. O’Connor H and Magos A, 1996. Endometrial resection for the treatment of menorrhagia. New England Journal ofMedicine. 335(3):151-56. 27. Pinion S, Parkin D, Abramovich D et al, 1994. Randomised trial of hysterectomy, endometrial laser ablation and transcervical endometrial resection for dysfunctional uterine bleeding. BIW. 309:979-83. 28. Garry R, Shelly-Jones D, Mooney D et al, 1995. Six hundred endometrial laser ablations. Obstetrics and Gynecology. 85:2429. 29. Lilford R J, 1997. Hysterectomy: will it pay the biUs in 2007? BMJ.
314: 160-61. Coulter A, Peto V and Jenkinson C, 1994. Quality of life and patient satisfaction following treatment for menorrhagia. FamilyPractice. 11(1):67-73. 31. Sculpher MJ, Dwyer N, Byford S et al, 1996. Randomised trial comparing hysterectomy and transcervical endometrial resection. British Journal of Obstetics and Gynaecology. 103(2):142-49. 32. Hufnagel V, 1990. No More Hysterectomies. 2nd edition. Thorsons Publishing, Wellingborough. 33. This paper does not address the many factors affecting the referral decision, which will be reported elsewhere. 34. The names of these cities are pseudonyms. They are not identified in order to protect the identities of both the GPs and the consultant gynaecologists. 35. Britten N, Jones R, Murphy E et al, 1995. Qualitative research 30.
methods in general practice and primary care. Family Practice. 12:104-14. 36. Transcripts were analysed using a constant comparative or ‘grounded theory’ technique. See Strauss A and Corbin J, 1990. Basics of Qualitative Research. Grounded Theory, Procedures and Techniques. Sage, London. 37. Silverman D, 1994. Interpreting Qualitative Data. Sage, London. This author argues for the importance of mentioning the uncommon response in qualitative approaches. 38. Calltorp J, 1996. Health care with equity and cost containment. Lancet. 347:587-94. 39. Sackett D, Rosenberg W, Muir Gray J et al, 1996. Evidence based medicine: what it is and what it isn’t. B&U. 31271-72. 40. Fox R, 1957. Training for uncertainty. Dominant Issues in Medical Sociology. 2nd edition. H Schwartz (ed). Random House, New York, 1987.
R&umC
Resumen
En Grande-Bretagne, le Service National de la SantC aussi bien que le Dkpartement de la Santk ont fait un objectif essentiel de l’Cquit6 dans les soins. On peut la dkfinir de diffbrentes faqons, mais la d&i&ion retenue aux fins du present article sera ‘un accki &galement inform? aux soins. Prenant comme exemple les diverses possibilitks de traitement pour les mCnorrtigies, l’article montre qu’il y a de grandes diffkrences entre les services gynikologiques ouverts aux femmes dans deux zones gkographiques distinctes du Nord-Ouest de 1’Angleterre. De ce fait, certaines femmes ne sont pas informkes de toutes les possibilitks de traitement existantes, ce qui revient A ne pas leur donner acc&s g des procCdures chirurgicales rkentes qui ont fait leurs preuves dans le traitement des mbnorragies. Les donrkes sont essentiellement tirkes d’entretiens avec 49 m6decins g&kAistes et des administrateurs d’hspitaux dans ces deux zones.
El Servicio National de Salud y el Departamento de Salud de1 Reino Unido describen coma objetivo claro, la equidad en la atenci6n a la salud. La palabra equidad para el prop6sito de este ensayo se define coma el acceso a 10s servicios de salud de forma ‘equitativamente informada’. Usando coma ejemplo las distintas opciones de tratamiento de la menorragia, este ensayo muestra que 10s servicios ginecoldgicos a disposici6n de las mujeres, en dos diferentes areas geogr&ficas de1 nordeste de Inglaterra, varian considerablemente. Como consecuencia, a algunas mujeres no se les da informacibn sobre toda la gama de akernativas a la hora de1 tratamiento, y por lo tanto se les niega el acceso a procedimientos quirtigicos actualizados que han demo&ado ser efectivos en el tratamiento de la menorragia. Estos datos fueron obtenidos principalmente a travbs de entrevistas con 49 m&iicos/as de cabecera, asi coma con gestores de hospitales en las dos areas mencionadas.
138
v
EN issues of equity in the British NHS are discussed in relevant journals,3 the emphasis often appears to be more on funding and resource allocation than on variations in medical practice and their effect on services.4 However, as Mooney observed:
‘One of the most fascinating and almost certainly inefficient and inequitable aspects of modern medicine is the extent and nature of variation in medical practice. It is a blight on the medical landscape. Yet the extent to which policy has moved to deal with variations is surprisingly small. Q This paper shows that treatment of menorrhagia is one instance where equity of care in medical practice is lacking between different geographical areas of Britain. The term ‘menorrhagia’ is used to describe regular menstrual blood loss that is excessive,5 usually defined clinically as blood loss of 80 ml or more per menstrual period, the level beyond which the incidence of anaemia increases significantly.6 Hormonal disturbance may be responsible for menorrhagia in adolescent girls or perimenopausal women, but this does not explain most cases of menorrhagia. Fibroids are sometimes said to be a cause of menorrhagia, but fibroids are often incidental to the excess bleeding rather than its cause.7 In 80 per cent of cases, there appears to be no obvious organic disease causing the heavy loss
of blood. In these cases, menorrhagia is sometimes referred to as ‘dysfunctional uterine bleeding’. Recent work suggests that menorrhagia may be the result of local endometrial factors, such as impaired haemostasis (constriction of small blood vessels).* The decision to seek medical help for menorrhagia may depend on the severity of the symptoms as well as the woman’s general attitude to menstruation and menstrual blood.g-12 Severe life events, such as bereavement and accompanying depression, may increase psychic reactivity to menstrual blood, triggering a consultation with a doctor.13 While some women do not want to consult a doctor for menorrhagia, in some cases perhaps due to the reported iatrogenic effects of medical treatment,14 other women clearly do want advice and help. One third of women in Britain will experience heavy menstrual bleeding sometime during their lives, and on average, a general practitioner (GP) can expect five per cent of women in the 30-40 age group to consult with this complaint each year.15 When women consult for menorrhagia, GPs may simply give information and advice or they may offer to start medical treatment. However, many GPs are unfamiliar with the latest research and may prescribe drugs which are often ineffective, such as the progestogen norethisterone.16 Perhaps partly as result of inappropriate treatment at primary care level, many women are eventually referred to consultant gynaecologists. 132
Reproductive
There are currently several effective medical and surgical forms of treatment available for women suffering from menorrhagia.5 If women are not told about these different treatments and offered a choice, they cannot be said to have equally informed access to care. There are some highly effective drugs, such as mefenamic acid (Ponstan) and tranexamic acid (Cyklokapron), which may reduce blood loss by as much as 54 per cent.17,*s There are also new intrauterine devices which release a progestogen, which are thought to reduce menstrual blood loss significantly.16 Many women (and some doctors) still believe that dilatation and curettage (D&C) can cure menorrhagia. While this procedure is still sometimes performed for diagnostic reasons, it has been shown that it does not cure menorrhagia. Indeed, some gynaecologists argue that the procedure is ‘diagnostically inaccurate and therapeutically ineffective’ and should not be done at all.lg Today, the most common surgical operation for menorrhagia in the UK is hysterectomy. Menorrhagia accounts for about half of the 90,000 hysterectomies performed every year.20 Over the past ten years there has been enormous debate about whether too few or too many hysterectomies are performed in the cour~try.*~-*~ Hysterectomy rates vary from country to country; there are also variations within countries and even between small areas. Sanders, Coulter and McPhersod4 suggest that the most important reason for the variation in the rate of hysterectomies is professional uncertainty and professional disagreement as to when hysterectomy is warranted. When menorrhagia is caused by small fibroids, myomectomy (removal of the f&oid, leaving the uterus intact) can be an option, although myomectomies are not as common in the UK as, for example, in France.22 In recent years, endometrial ablation has become an alternative treatment option for menorrhagia, particularly when there is no obvious cause. About 10,000 women with menorrhagia are treated per year by endometrial ablation in the lJK.l* Ablation may be achieved by transcervical resection, laser, radiofrequency or rollerball. Some studies have shown endometrial ablation to be highly successful,26 and numerous trials comparing the relative cost and effectiveness of endometrial ablation and hysterectomy show that the former leads to less morbidity and shorter stays in hospital than the latter.5,27,28However, endometrial
Health Matters, No 9, May 1997
ablation sometimes has to be repeated, and in one recent report up to 30 per cent of patients who had endometrial ablation later had to have a hysterectomy.2g The best treatment option for a woman with menorrhagia will depend on many factors, including whether she wants to avoid surgery and prefers medication, and whether or not she wishes to preserve her uterus or have more children. Endometrial ablation is a less invasive surgical procedure than hysterectomy, but hysterectomy is 100 per cent effective. There are many women who do not mind the idea of losing their uterus and are very satisfied after a hysterectomy.30,31 It is essential, however, that women are informed about the possible side effects and dangers of both medical and surgical treatments.32 Thus, to obtain optimal care, women with menorrhagia need doctors who are well informed and able to offer all of these treatments, or who are willing to cross-refer to others who can.
The study group and method This study explored referral decisions by GPs for women suffering from menorrhagia.33 The data is drawn principally from in-depth interviews in 1995 and 1996 with 73 GPs working in three areas of northwest England, and from information obtained from hospital managers. During the course of the study, a striking difference emerged between the gynaecological services available in a large town, which we have called Ashville, and a nearby city, which we have called Cenville.34 In Ashville 26 GPs were interviewed, and in Cenville 23 GPs. A qualitative approach was taken,35 employing a theoretical (or purposive) sample.36 This included GPs who had trained recently and those who had trained before 1980, and those working in both affluent and deprived areas. As the study progressed, extra efforts were made to include GPs with patients from ethnic minority groups. All the GPs in Ashville were asked to take part, and about 30 per cent agreed. In Cenville more GPs agreed to take part, over 50 per cent of those contacted. Some male GPs in both places declined because women with menorrhagia tended to consult their women partners, whom they suggested we contact instead. Interviews lasted approximately 30 minutes, and were audio-taped and transcribed with respondents’ permission.3” About half the GPs in both areas had the 133
w of the Royal College of Obstetricians and Gyna~ologists, a postgraduate gynaecology C@i6c&on. Also, almost all the GPs in both areas were on their local ‘obstetric list’. Thus, we Were COmPzkg the views of GPs with similar c@ifiCatiOnS.
Quality
of hospital gynaecology services
The GPs frequently made spontaneous comments about the gynaecology services generally, and those in Cenville were much more positive about their local hospital gynaecology services than those in Ashville. Twelve of the GPs from Cenville, a city with a teaching hospital, made very positive comments about their gynaecology services, while four made minor negative comments. In Ashville, on the other hand, there were 11 extremely negative comments about local services and six positive comments.37 One of those who thought the gynaecologists were good had had a great deal of contact with the Ashville consultant who was most likely to perform up-to-date procedures such as endometrial biopsy and endometrial ablation, which may partly explain his enthusiasm. Early on, even in the pilot study, we were alerted to the fact that treatment options might be much more limited in Ashville for women who were suffering from menorrhagia, as the GPs in the two places had strikingly contrasting views: The gynaecologists control menorrhagia very well.’ (Cenville GP 15) ‘Our service is not adequate for menorrhagia.... I am not blaming the consultants. I think the resources are verypoor.‘(Ashville GP 5)
This GP went on to complain about waiting lists and lack of bed space at the hospital. Another GP was less charitable about the consultants: ‘Some of the consultants don’t seem to have anyinterestataU,and theywill dotheD&Candsend them back and I am stuck with the same problem.. I am not getting any help from the consultants locally. ’(Ashville GP 11)
Another Ashville practice sometimes referred patients for private treatment but not to the local consultants: ? think we wanted to show partly a little bit of our displeasure at the service the gynaecologists were offering.‘(AshvilIe GP 9) 134
men asked if there was anyone in Ashville who would do a myomectomy for fibroids, one GP replied:
‘It for example, she has fibroids, Imight say, ‘You’ve got these, and the only way to control the bleeding is to perhaps consider, you know, would you consider a hysterectomy?” And if she said, “Well, definitely not’: then there is nopointin me referringher.... Not that I know of But I’ve only been here two and a half years, and I don’t know all the gynaecologists all that well.. Certainly in the time that I’ve been here I haven’t had a patient that has had a myomectomy.’ (AshviIle GP4, pilot study)
GPs’ perceptions of the availability of all treatment options In the city of Cenville almost all of the GPs seemed to be aware of the fact that endometrial ablation was an option for their patients. Cenville GPs also seemed to be aware of up-to-date diagnostic techniques offered at the hospital. While some thought that diagnostic D&C was still performed, others remarked: That - nobody does. You do a hysteroscopy to sample the tissue and have a look.‘(Cenville GP 10) ‘Fortunately they have actually audited the D&Cs and found that they serve no useful purpose at all.. . ‘(Cenville GP 8)
Again, in stark contrast, only the Ashville GP who knew the Ashvllle consultant who was most likely to perform up-to-date procedures, mentioned the existence of endometrial biopsy for diagnostic purposes. Others were uncertain or behind in their knowledge. ‘Our service is possibly not as up-to-date as it might be. ’(Ashville GP 81
The consultants usually do the scrape ID&Cl, you know, because [iUs] diagnostic as well as [curative] so they always do the scrape.. . Sometimes at?er the D&C the [women1 are cured for a while, maybe one or two years and then it will come back.’ (Ashville GP3, pilot study) Nine of the 26 Ashville GPs did not seem aware that two of their local consultants were able to perform endometrial ablation. We need to know more about developments like
Reproductive
endometial ablation, and that sort of thing. We would like to JUIOWwhat sort of hospitals are providing that sort of sen/ice, and where we are going to go from there.‘(Ashville GP 5) Most Asian women were very anxious to avoid hysterectomy. However, the one time that an Ashville GP suggested endometrial ablation to an Asian patient, assuming that endometrial ablation was available in Ashville, the situation proved to be otherwise: ‘After the outpatient appointment I had to sort of backtrack and eXprain that it wasn’t done. It was quite dif%uJt.‘(Ashville GP 11) Two Ashville GPs did not think the consultants were having much success with endometrial ablation, and another appeared to have a very negative attitude to this type of surgery: ‘1 think before my time someone tried it. I don’t think it was a terrific success.’ (Ashville GP 4, pilot study) ‘1 think it is an operation that can take sometimes as Jongas a hysterectomy so why on earth do that when you are stillJet? with the uterus?’Ashville GP 6) Yet this same commented:
GP,
later
in the
study,
Too many women have hysterectomies
also
at far too
earJyan age.‘(Ashville GP 6)
Communication between consultants and GPs Good communication between consultants and GPs, and between consultants themselves, is essential if GPs are to know what options are offered by different specialists, and so that consultants feel able to cross-refer if they themselves do not offer a particular service. In Cenville, communication between staff at all levels appeared to be good. One CenviIle GP pointed out that the consultants were very good at offering meetings and training. Almost all of the Cenville GPs had seen locally produced guidelines on the treatment of menorrhagia, which consultants had produced with the help of GPs. GPs could also obtain information sheets from the hospital to give to their patients, to help to explain alternative treatments. The situation in Ashville appeared to be quite different. When we asked the GPs in Ashville whether or not they had seen any local guidelines,
Health Matters,
No 9, May 1997
four of them indicated that there was some disagreement about treatment within the local gynaecology department. One explained: ‘I think the likelihood of getting our gynaecologists to agree on guidelines that could be put out in the name of the hospital is nil, so J think it is unlikely that we could ever get any....Some [consultants] probably haven’t talked to each other for years. 1 don’t think it is quite as bad as that, but they have certainly got very contrasting ideas about the way obstetrics and gynaecology is run.‘(Ashville GP 2) Another Ashville GP said that the consultants were still arguing over the protocol themselves and added: The obstetricians and gynaecologists are renowned for being at loggerheads with each other. ’ (Ashville GP 13)
Access to hysterectomy vs. endometrial ablation A hospital business manager and two hospital information officers provided details of the number of hysterectomies and endometrial ablations performed in the hospitals to which most GPs in this study referred their patients. In Ashville two consultants were technically considered able to perform endometrial laser ablation. However, while there were 262 women seen at the hospital in Ashville with a primary diagnosis of menorrhagia in 1995-96, there was only one endometrial ablation (and only one endometrial ablation the year before that as well). In Cenville, 541 women were given a primary diagnosis of menorrhagia in hospital, and 114 had endometrial resections. There were also 221 hysterectomies in Cenville in women with a primary diagnosis of menorrhagia. In fact, in Cenvllle surgeons were performing about twice as many endometrial ablations as the national average, when compared with hysterectomies. Thus, a woman with a primary diagnosis of menorrhagia had a 1 in 262 chance of having an endometrial ablation in Ashville, while in Cenville the chance was 1 in 5, indicating that in Ashville, endometrial ablation is a very rare event indeed.
Cross-referral
options
In the city of Cenville eight out of ten of the 135
Chappie, L.ingand May
surgeons were performing endometrial ablation, so cross-referral was not so necessary. However, a GP in Cende remarked that the consultants did tend to cross-refer. Given that only two surgeons in Ashville were able to perform endometrial ablation, and indeed rarely performed the operation, we asked if direct referral from GPs to other hospitals was possible or if cross-referral between surgeons was common. A few Ashville GPs recalled that patients had occasionally been sent to a nearby city for endometrial ablations in the past. Others thought that it was difficult to refer directly to hospitals outside the area because of block contracts between the Health Authority and the hospital. Twelve Ashville GPs were asked whether crossreferral was a possibility within the hospital itself. None of them thought that cross-referral was likely between consultants in Ashville. ‘No, it’s very unlikely, so if I was against endometrial ablation and sent them [the women1 to a consultant who Iknew didn’t do it, then Iknowshe wouldn’t get that, but I would have talked her out of it anyway before she got there. GPs have great influence, haven’t they?’ (Ashville GP 6) Two other GPs thought that cross-referral would only take place at the instigation of the patient. As one doctor who was familiar with the hospital gynaecology department commented: ‘I think if the patient knew that she wanted an endomeirial resection, and was vociferous and coherent enough to voice an opinion, there is a chance that the consultant might do a lateral referral, and say, ‘Well, I’m sorry I don’t do that operation, but my colleague does”, but if she didn’t mention it, it wouldn’t be mentioned, I don’t think, with the consultants who don’t do it. As an option.‘(Ashville GP 14)
Discussion Although Britain and a number of other countries such as Sweden have a strong commitment to equity of access to health care,38 research indicates that wide geographic variations in admission rates for surgical procedures are universal.24 This paper reports on only two areas in Britain. While the lack of equity we uncovered does not necessarily apply to services in the rest of the country, the Endings do suggest that issues of equity need to be addressed. Many of the GPs in Ashville perceived that services were inadequate for their patients’ needs,
while the GPs in Cenville spoke with great enthusiasm about their local service. It is possible that GPs in Cenville were more enthusiastic about their local services than those in Ashville because they had seen the Cenvllle local guidelines for menorrhagia. However, the very fact that Cenville has local guidelines suggests that consultants and GPs communicate and that they work together, surely a positive feature of the Cenville gynaecology service. It is certainly clear from the hospital figures that women in Cenville had a real choice between medical treatment, endometrial ablation and hysterectomy, while women referred to the hospital in Ashville were very unlikely to be offered endometrial ablation. It is important that surgeons use skills regularly, yet the surgeons in Ashville had only performed endometrial ablation twice in a two-year period from mid-1994 to mid-1996. This could be considered inadequate for good performance, and may explain why GPs in Ashville believed that endometrial ablation had not been successful locally. Although women may on occasion have been referred outside the Ashville area for endometrial ablation, the GPs implied that this was unusual, and as one GP pointed out, many patients would not have been able to afford to travel outside the area for treatment anyway. As Lilford points out: ‘There is no “correct” hysterectomy rate, but “correct” practice is to make explicit the trade-offs between this operation and an increasing number of alternatives.‘2g Doctors in Britain are now actively being encouraged to practice evidence-based medicine.3g To do this successfulIy for menorrhagia, this study suggests that GPs and surgeons need to have their knowledge of medical methods and surgical procedures up-to-date, and surgeons need to be retrained to perform new techniques such as endometrial ablation or become more willing to ensure cross-referral. In every field of medicine uncertainties exist,@ and in the near future it is unlikely that gynaecologists will agree about the best choice of treatment for menorrhagia. However, women should be given as much information as possible, and thus be permitted to make an informed choice between those treatments which have been shown to be effective. If alternative treatments performed by competent surgeons are not easily available, and if consultants are not prepared to cross-refer, both
Reproductive Health Matters, No 9, May
1997
GPs and consultants may fail to tell their patients about the advantages and disadvantages of different options, and women may not have equitable access to a real choice of treatment.
in the study for their time and candour, and Dr Hermione Love1 for helpful comments on an earlier draft of this paper.
Acknowledgements
Alison Chapple, Institute for Health Research, Alexandra Square, Lancaster University, Lancaster, LA1 4YT. Tel: 44 1524-593 905.
Correspondence This study was funded by the North West Regional Health Authority, Britain. (Grant RF 95/12). We gratefully acknowledge this support. We should also like to thank those GPs and others who participated
References
and Notes
1. Variations in Health. What can the
2.
3.
4.
5.
Department ofHealth and the NHS do? Department of Health, London, 1995. Mooney G, 1994. Key Issues in Health Economics. Harvester Wheatsheaf, Hemel Hempstead. Whitehead M, 1994. Who cares about equity in the NHS? British Medical Journal. 308: 1284-87. FewtreIl C, Martin D and Layzell A, 1996. Fair ground reaction. Health Service Journal. 22 Feb. CouIter A, KeIIand J, Long A et al, 1995. The management of menorrhagia. Effective Health Care: A Bulletin on the Effectiveness ofHealth Service lnterventions for Decision Makers. 9:1-14.
6. HaIIberg L, HogdahI A, N&son L et al, 1966. Menstrual blood loss a population study. Acta Obstetrica et Gynecologica Scandinavica. 45320-51. 7. Coulter A, 1994. Prevalence and epidemiology of dysfunctional uterine bleeding. Dysfunctional Uterine BJeeding. SK Smith fed). Key Paper Conference, Series No 1. Royal Society of London Press, London. 8. Sheppard B, 1994. Pathophysiology of dysfunctional uterine bleeding. Dysfunctional Uterine Bleeding. S.K. Smith (ed). Key Paper Conference, Series No 1. Royal Society of Medicine Press, London. 9. Woods N, Dery G and Most E, 1982. Recollection of menarche, current menstrual attitudes and perimenstrual symptoms. Psychosomatic Medicine,
44(3):285-93.
10. Skultans V, 1988. Menstrual symbolism in South Wales. Blood Magic: An Anthropology of Menstruation. T Buckley and A GottIieb (eds). University of California Press, London. 11. Bransen E, 1992. Has menstruation been medicalised? Or wiII it never happen.... Sociology ofHealth and Illness. 14(1):98-109. 12. Scambler A and Scambler G, 1985. Menstrual symptoms, attitudes and consulting behaviour. Social Science and Medicine. 20(10):106568. 13. Harris T, 1989. Disorders of menstruation. Life Events and IJlness. G Brown and T Harris (eds). Unwin Hyman, London. 14. IIIich I, 1976. Limits to Medicine. Marion Boyars, London. 15. CouIter A, Peto V and DoII H, 1994. Patients’ preferences and general practitioners’ decisions in the treatment of menstrual disorders. FamilyPractice. 11(1):67-73. 16. CouIter A, KeIIand J, Peto V et al, 1995. Treating menorrhagia in primary care. An overview of drug trials and a survey of prescribing practice. International Journal of Technology Assessmentin Health Care. 11(3):456-71. 17. Preston J, Cameron I, Adams E et al, 1995. Comparative study of tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. British Journal of Obstetrics and Gynaecology. 102:401-06. 18. Bonnar J and Sheppard B, 1996.
Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. B&U. 313:579-82. 19. Lewis B, 1993. Diagnostic dilatation and curettage in young women. BhZI. 306:225-26. 20. Smith SK, 1994. Hysterectomywhy and when? Dysfunctional Uterine Bleeding. Key Paper Conference, Series No 1. Royal Society of Medicine Press, London. 21. CouIter A, McPherson K and Vessey M, 1988. Do British women undergo too many or too few hysterectomies? Social Science and Medicine. 27:987-94. 22. Payer L, 1988.Medicine and Culture: Varieties of Treatment in the United States, England, West Germany and France. Henry Holt, New York. 23. Studd J, 1995. Shifting indications for hysterectomy. Lancet. 345388. 24. Sanders D, CouIter A and McPherson K, 1989. Variations in Hospital Admission Rates: A Review of the Literature. King’s Fund Publishing Office, London. 25. Transcetical resection - a wire loop, fitted to a resectoscope is used to shave away the lining of the uterus. Rollerball - the lining of the uterus is destroyed by using a 2mm rollerball electrode, which is fitted to the resectoscope instead of a cutting loop. Laser ablation a saline solution is pumped into the uterus through a hysteroscope in order to distend the uterine cavity and create a visual field. A laser
fibre is then inserted (under video surveillance) and the uterine lining is completely destroyed. Radiofrequency (or high-frequency) endometrial ablation - an intrauterine probe, which emits radio-frequency energy, and creates localised heating which destroys the lining of the uterus. 26. O’Connor H and Magos A, 1996. Endometrial resection for the treatment of menorrhagia. New England Journal ofMedicine. 335(3):151-56. 27. Pinion S, Parkin D, Abramovich D et al, 1994. Randomised trial of hysterectomy, endometrial laser ablation and transcervical endometrial resection for dysfunctional uterine bleeding. BIW. 309:979-83. 28. Garry R, Shelly-Jones D, Mooney D et al, 1995. Six hundred endometrial laser ablations. Obstetrics and Gynecology. 85:2429. 29. Lilford R J, 1997. Hysterectomy: will it pay the biUs in 2007? BMJ.
314: 160-61. Coulter A, Peto V and Jenkinson C, 1994. Quality of life and patient satisfaction following treatment for menorrhagia. FamilyPractice. 11(1):67-73. 31. Sculpher MJ, Dwyer N, Byford S et al, 1996. Randomised trial comparing hysterectomy and transcervical endometrial resection. British Journal of Obstetics and Gynaecology. 103(2):142-49. 32. Hufnagel V, 1990. No More Hysterectomies. 2nd edition. Thorsons Publishing, Wellingborough. 33. This paper does not address the many factors affecting the referral decision, which will be reported elsewhere. 34. The names of these cities are pseudonyms. They are not identified in order to protect the identities of both the GPs and the consultant gynaecologists. 35. Britten N, Jones R, Murphy E et al, 1995. Qualitative research 30.
methods in general practice and primary care. Family Practice. 12:104-14. 36. Transcripts were analysed using a constant comparative or ‘grounded theory’ technique. See Strauss A and Corbin J, 1990. Basics of Qualitative Research. Grounded Theory, Procedures and Techniques. Sage, London. 37. Silverman D, 1994. Interpreting Qualitative Data. Sage, London. This author argues for the importance of mentioning the uncommon response in qualitative approaches. 38. Calltorp J, 1996. Health care with equity and cost containment. Lancet. 347:587-94. 39. Sackett D, Rosenberg W, Muir Gray J et al, 1996. Evidence based medicine: what it is and what it isn’t. B&U. 31271-72. 40. Fox R, 1957. Training for uncertainty. Dominant Issues in Medical Sociology. 2nd edition. H Schwartz (ed). Random House, New York, 1987.
R&umC
Resumen
En Grande-Bretagne, le Service National de la SantC aussi bien que le Dkpartement de la Santk ont fait un objectif essentiel de l’Cquit6 dans les soins. On peut la dkfinir de diffbrentes faqons, mais la d&i&ion retenue aux fins du present article sera ‘un accki &galement inform? aux soins. Prenant comme exemple les diverses possibilitks de traitement pour les mCnorrtigies, l’article montre qu’il y a de grandes diffkrences entre les services gynikologiques ouverts aux femmes dans deux zones gkographiques distinctes du Nord-Ouest de 1’Angleterre. De ce fait, certaines femmes ne sont pas informkes de toutes les possibilitks de traitement existantes, ce qui revient A ne pas leur donner acc&s g des procCdures chirurgicales rkentes qui ont fait leurs preuves dans le traitement des mbnorragies. Les donrkes sont essentiellement tirkes d’entretiens avec 49 m6decins g&kAistes et des administrateurs d’hspitaux dans ces deux zones.
El Servicio National de Salud y el Departamento de Salud de1 Reino Unido describen coma objetivo claro, la equidad en la atenci6n a la salud. La palabra equidad para el prop6sito de este ensayo se define coma el acceso a 10s servicios de salud de forma ‘equitativamente informada’. Usando coma ejemplo las distintas opciones de tratamiento de la menorragia, este ensayo muestra que 10s servicios ginecoldgicos a disposici6n de las mujeres, en dos diferentes areas geogr&ficas de1 nordeste de Inglaterra, varian considerablemente. Como consecuencia, a algunas mujeres no se les da informacibn sobre toda la gama de akernativas a la hora de1 tratamiento, y por lo tanto se les niega el acceso a procedimientos quirtigicos actualizados que han demo&ado ser efectivos en el tratamiento de la menorragia. Estos datos fueron obtenidos principalmente a travbs de entrevistas con 49 m&iicos/as de cabecera, asi coma con gestores de hospitales en las dos areas mencionadas.
138