The new NHS and what it will mean for the management of the menopause.

As we write this editorial, the publication of the Health and Social Care Bill (2011) proposes some of the biggest changes in the National Health Service (NHS) for decades. It is clear that all of us who provide health care in the UK will – to some extent – have to change the way in which we deliver that care. Whatever form the NHS takes in the future, it is clear that the running of a service will rely firmly on a clear and sensible dialogue between primary and secondary care. Providers should not see this time purely as a time of worry about the future; they should look upon the proposals as an opportunity to improve access to safe and high quality care for their patients. How will the proposed changes affect the care of women with menopausal problems? In England, the NHS Commissioning Board will be responsible for ensuring that the commissioning process is effective and transparent and achieves better quality care with improved outcomes. This, through use of evidencebased guidance from the National Institute of Health and Clinical Excellence (NICE), will steer primary care consortia to commission local service provision. Much of the work will continue to be supplied by the current providers; however, like-minded groups of general practitioners (GPs) and other health-care providers will be able to join together to deliver higher quality care in a more economical fashion with less bureaucracy. The ideology appears sound, but how will it work in our corner of medicine? As we have mentioned before, there has been a significant shift of the care of women with menopausal problems into primary care. This has been, for the most part, appropriate and many women have benefited from better access to care from well-trained primary care doctors and nurses. In developing menopause services within the proposed framework the temptation would be to try to manage problems in primary care and refer when necessary, as usual. However, as much of the management of the menopause should be focused on preventative health care that requires extensive counselling, for many a proactive approach to the commissioning of an integrated service makes more sense. Failure to engage may result in a temptation to delay primary management or onward referral of women, which may then miss important preventative health-care opportunities, in addition to issues of immediate symptom control. For example, a group of like-minded primary care practitioners could meet with local specialist providers to plan how best to deliver comprehensive health care for women with postmenopausal problems. What might such a service look like? At the outset, evidence-based care pathways for the common issues of the menopause should be designed. These will enable GPs and nurses in primary care to manage the vast majority of menopause problems to a high standard without the need for onward referral. Further development and education of primary care physicians and nurses, with additional specialist skill in menopause management, will mean that only in specific patient groups or in women whose primary care management does not meet their needs would then be referred for secondary care. One of the cornerstones of the health reforms is improvement of quality of care. What is uncertain is what represents high quality care. At this stage of consideration of future commissioning processes, it would be advantageous to identify areas of good practice and areas where quality could be improved. Identification of areas for improvement that can be measured will then provide evidence of good commissioning and can also be used to drive quality improvement where required. Will all primary care commissioning consortia plan their care pathways in the same ways and with the same providers of secondary care? This is unlikely for all areas of medicine, but it will then become important for commissioners to identify known high-quality providers at an early stage and possibly to encourage other groups to involve the same specialist primary or secondary care providers. This will undoubtedly assist in the development of a unified, economical approach to the complete management of our patients. In summary, what actions can we take now?