1. Downgrading of referrals from urgent to routine

All the following points must be completed:

• GP must have examined patient, the examination must have been complete and normal
• Outline reasons to the referrer for downgrading (e.g. normal smear, normal cervix, premenopausal with no risk factors so low risk for endometrial malignancy etc.)
• Suggest interim treatment if appropriate
• Advise GP to re-refer as urgent if symptoms persist or deteriorate

2. Suitability of referrals for a virtual appointment

• GP has done a vaginal examination that is normal
• Up to date with normal smear
• Up to date BMI
• No treatment or no failed treatment initiated by GP
• If patient requires interpreter including BSL, consider suitability ( Attend Anywhere can facilitate remote interpreter)
• Does not need USS or biopsy ( many patients will have been scanned prior to referral)
• A virtual appointment can be offered even if an examination or scan is needed if it is felt that explanation and discussion virtually beforehand would significantly shorten the face-to face time.

3. Suitability for replying to referral with standardised advice

• GP has examined patient and examination is normal
• Normal smear where appropriate
• No further investigation required before treatment/ management initiated
• Standardised advice is available for HMB, PCOS, vulval itch, menopause/HRT, incontinence /prolapse, IMB/PCB

• PMB
  Has uterus/cervix- vet as USOC/URGENT- PMB/onestop North (clinic F)
  
  PMB- no uterus/cervix- GP has NOT examined or examination abnormal- vet as USOC/URGENT- general gynaecology
  
  PMB- no uterus/cervix- GP has examined and normal vault and vulva- Downgrade to ROUTINE, vet to general gynaecology and ask GP to check for haematuria

• HMB 
  Women <40 can be vetted to a general clinic. Women ≥40 should be vetted to a one-stop clinic
  
  Women <45 with HMB with no risk factors for endometrial pathology / normal examination should be vetted as ROUTINE
  
  Women aged 40-44 with HMB AND persistent IMB or PCB, with no other risk factors for endometrial pathology should be vetted as ROUTINE
  
  Women aged 40-44 with HMB AND persistent IMB or PCB AND one or more additional risk factors for endometrial pathology should be vetted as URGENT
  
  Women ≥ 45 with no irregular bleeding, normal examination and no additional risk factors for endometrial pathology should be vetted as ROUTINE
  
  Women ≥45 with any additional risk factors for endometrial pathology OR persistent IMB / PCB OR treatment failure (continual use of hormonal treatment for 6 months) should be vetted as URGENT

• IMB
  Women <40 with normal examination should be referred back to GP with advice to review hormonal contraception and exclude infection. If starting / changing hormonal contraception or treating infection is not successful, then vet as ROUTINE to general gynaecology.
  
  Women ≥ 40 with persistent IMB with normal examination, but who have risk factors for endometrial pathology (eg PCOS, BMI>40, current / past tamoxifen use) should be vetted as URGENT.
  
  Women ≥40 with no risk factors – vet as ROUTINE

• PCB
  If appearance suspicious /consistent with cervical cancer vet as USOC to colposcopy.
  
  If abnormal cervical screening, vet to colposcopy as per usual protocol
  
  Women < 40 with normal smear / examination should be offered STI screen. Consider change of OCP / trial of Relactagel®. If ineffective, vet as ROUTINE to gynaecology or colposcopy as per local service provision.
  
  Women ≥40 – vet as URGENT 

• PCOS
  Most referrals can be managed by sending standardised advice to GP- if an appointment is felt necessary this should be VIRTUAL unless there is significant menstrual disorder (e.g. requiring LNG-IUS etc)

• CERVICAL POLYP
  Asymptomatic, normal smear- vet to ROUTINE general gynaecology appointment. If symptomatic (e.g. PCB/IMB), < 40 years vet as ROUTINE to general gynaecology, >40 years vet as ROUTINE to PMB/onestop North (clinic F)

• VULVAL ITCH/DISCOMFORT
  If GP has examined and no focal abnormality (e.g. ulcer) and no treatment, send referral back to referrer with standardised vulval care advice.
  
  If examination by GP is abnormal or there has been treatment failure, vet to general gynaecology (vulva clinics are tertiary referral only). Grade depending on appearance of abnormality.

• INCONTINENCE/PROLAPSE
  Current NICE guidance is for conservative management in the first instance- refer to SPHERE bladder and bowel service. OAB symptoms can be managed with medication (send GP standardised advice). Women with failed management or treatment should be vetted as routine to urogynaecology.

• PELVIC PAIN/ QUERY ENDOMETRIOSIS
  If GP has examined and normal smear, vet as ROUTINE to virtual appointment

• STERILISATION REQUEST
  Vet as routine to virtual appointment- send referral back to referrer if BMI >35 or no BMI recorded

• MENOPAUSE/HRT
  Some referrals can be dealt with by sending standardised advice to GP. If appointment needed vet as routine to VIRTUAL appointment

• ULTRASOUND
  Some referrals can be vetted directly to gynae USS ( e.g. asymptomatic simple cyst < 5cm, or radiology have suggested TVUSS) 

• FINDING OF POSTMENOPAUSAL INCIDENTAL INCREASED ENDOMETRIAL THICKNESS/FLUID IN ENDOMETRIAL CAVITY
  In the absence of PMB vet as ROUTINE to PMB/onestop North (clinic F)

RE-GRADING OF USOC (URGENT SUSPICION OF CANCER) REFERRALS

• It has been agreed that during COVID-19 pandemic Urgent Suspicion of Cancer (USOC) referrals can be re-prioritised at vetting to urgent or routine where a referral does not meet the Scottish Cancer Referral Guidelines
• Scottish Cancer Referral Guidelines can be accessed at: http://www.cancerreferral.scot.nhs.uk/
• An automated letter will be sent to Primary Care noting re-prioritisation. Thus ensuring clear communication back to GP whilst minimising impact on vetting clinician in dictating letter.
• A 2 stage vetting process has been implemented in Trakcare:
  1. Select ‘downgrade of cancer’ in vetting outcomes, this will generate letter to GP; then
  2. Re-grade referral and assign appropriate vetting outcome