Addressing the prolonged wait times and escalating complexity in gynaecological care

Abstract

In recent years, the landscape of gynaecological care has undergone a profound transformation, reflecting broader changes in healthcare delivery and patient expectations. A critical issue, with limited penetration into the general community, is the burgeoning wait list for non-urgent gynaecological consultations in public hospitals, particularly those related to persistent pelvic pain, and especially in Victoria.

Outpatient waiting times are a challenge in any country that seeks to provide universal access to health care. An informal survey of major tertiary referral hospitals across Australia reveals that wait times for non-urgent first visit public gynaecological referrals range from four months to two and a half years, with the longest wait in Victoria. New South Wales, the Australian Capital Territory, the Northern Territory and Western Australia do not currently publish these data.¹

Several factors have contributed to this increase. In general, wait lists across all Australian public outpatient domains has grown. This is due to many issues including the need for resource realignment in an increasing and aging demographic, issues of operational inefficiencies, and need for process improvements.²

Gynaecological outpatient clinics are a little different in that the patients' issues are frequently not related to aging. Historically, gynaecology was primarily a surgical specialty characterised by relatively swift consultations and procedures, with a rapid dispatch of patients back into the community. We had defined operative options and few medical options, so consultations were quick. We could also have been fairly accused of minimising women's experiences of pain.

In the last 20 years, the complexity of cases, especially those involving pelvic pain, has significantly expanded. Pelvic pain, for instance, is frequently associated with comorbid conditions such as irritable bowel syndrome, painful bladder syndrome, migraine, chronic fatigue syndrome, and central sensitisation. These complex, multifaceted cases require more time and expertise to address, further stretching the finite resources of gynaecological departments.

As options for managing these conditions have diversified, more information needs to be explained to each individual patient, and patients' expectations of the standard of care has increased, meaning that the time required for each individual consultation and the number of consultations for each patient has increased, leading to extended waitlists for those seeking to access gynaecological outpatient care in a public hospital.

The COVID-19 pandemic exacerbated the situation by shifting much of the outpatient care to telehealth consultations, particularly in Victoria. This transition, while necessary, has led to delays in patient management and increased the burden on outpatient services. The reduction and cancellation of many in-person clinics and postponed surgeries compounded the backlog, leaving many patients requiring multiple review appointments while waiting to proceed. As they remain on the wait list initially for their outpatient appointment and then for their surgical intervention, they deteriorate. In turn, their complexity increases, and they are further down a clinical trajectory, taking more time to see and solve and requiring more resources.

The government has been very reasonably focused on the wait times for theatre, which have blown out. The community can be readily galvanised to outrage over the wait times for elective surgery, but it does not seem to generate the same level of emotion when people languish on outpatient wait lists. This is interesting, when it has been reported that within the National Health Service in the United Kingdom the main increase in morbidity related to COVID-19 changes in medical care was the delay it created in diagnosis, not the ability to access care once the diagnosis was made, thus highlighting the importance of an initial assessment appointment.³

Our recent initiative at a major gynaecological tertiary referral centre in Victoria aimed to tackle this issue through a wait list management project. We proposed a randomised trial to assess whether active management of the wait list—offering a collaborative trial of hormonally induced amenorrhea in conjunction with the patient's general practitioner (GP) while waiting to be seen in the clinic—could mitigate symptoms and reduce emergency department presentations while patients waited for their gynaecological appointments. However, this trial faced significant hurdles.

GPs and patients were consented separately. Once we managed to contact these extremely busy practitioners, GPs thought it was a great idea. We had no real issues signing them up to participate. However, the patients were a different matter. Despite our efforts, only 12 patients out of 183 approached agreed to participate over an 18-month recruitment period. We initially approached those who had been on the wait list for under 180 days thinking they would be ready for an intervention, then moved from 180 to 365 days after which we tried 365–540 days. There was no change in the numbers consenting to the intervention. This shocked us, and our research nurse canvassed the reasons they were declining.

The primary reasons given for declining the trial were their reluctance to try hormonal treatments and their dissatisfaction with receiving this care from their GPs. Small numbers were already amenorrhoeic, some planning to conceive or breastfeeding so hormones were less suitable, and one was now post-menopausal on the wait list, which again can testify to the change in patient circumstance on a two and a half year outpatient wait. This unwillingness to take up an intervention, but rather wait on the list, even when they had been waiting for over two years in some cases, seemed inconceivable.

Despite these challenges, the reality remains that most patients eventually receive hormonal treatment from gynaecologists after their initial consultation, as that is a very effective way of managing pelvic pain. It seems that once they are seen by a specialist, there is more acceptance of hormones as a medical solution/ treatment.

The current state of prolonged wait times and increasing patient complexity in gynaecological care highlights a pressing need for systemic change. Patients facing long waits for care, especially those with persistent pelvic pain, are suffering from compounded distress and deteriorating conditions. By adopting innovative care models, enhancing GP education, and exploring new management strategies, we could work toward a more efficient and compassionate gynaecological care system that better meets the needs of our patients. Our patients deserve more than a prolonged holding pattern; they deserve timely, effective care that addresses their complex needs with empathy and expertise.