COMMUNITY GYNAECOLOGY IN THE UNITED KINGDOM COMPARED WITH SWEDEN
by Dr Babatunde A Gbolade

If you talk about community gynaecology to European specialists and trainees in obstetrics and gynaecology, you are likely to be met with blank stares. Not that this reaction will be any different from that of United Kingdom consultants and trainees in the specialty. The reason for this reaction is that community gynaecology is a new subspecialty within obstetrics and gynaecology, one of five recognised in the United Kingdom, but not yet recognised in other European countries.

The role of the United Kingdom consultant in community gynaecology

The National Health Service reforms have resulted in a shift in emphasis away from hospital care to community care. There is an increasing awareness of the lack of cohesion between those who provide the service for termination of pregnancy and general family planning on the one hand, and primary health care services on the other. This has led to the recognition of the need for the creation of posts to facilitate liaison between the different professional groups organising and providing these services.

In 1992, the Royal College of Obstetricians and Gynaecologists (RCOG) established a working party to advise on the needs of higher training in community gynaecology and define the r™le of the community gynaecologist. This arose out of the need for a consultant who would take responsibility for the organisation and direction of well woman care in the community, fertility services and gynaecology services. The job descriptions of consultants in community gynaecology vary according to the particular needs of the district and the services already provided there. The responsibilities of a consultant in this field include some or all of the following:

  1. The medical management of certain gynaecological problems, such as disorders of menstruation including dysmenorrhoea, premenstrual tension, menopause-related problems, primary and secondary amenorrhoea and pelvic pain.
  2. Supervision and integration of contraception services in hospital and the community, provision of training in family planning, screening for genito-urinary infection and pre-malignant disease, health promotion, youth advisory work, organisation and supervision of termination of pregnancy and sterilisation services.
  3. Interaction with social services and other agencies in matters pertaining to reproductive health.
  4. Responsibility for the management, audit and provision of services for women's health care together with training and research in the field.

The consultants in community gynaecology occupy new posts that do not replace traditional hospital-based obstetricians and gynaecologists. There are currently about 32 consultants in community gynaecology and family planning in the United Kingdom.

Some of these consultants have undertaken general professional training in obstetrics and gynaecology and obtained the Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), while others have general practice or family planning backgrounds. In some authorities, these posts are hospital-based, with the post holders having clinical responsibility for the local family planning services. Surgical competence in termination of pregnancy, laparoscopic sterilisation, vasectomy and minor gynaecological procedures may be required, but not all appointees have been required to be surgically competent. Where the holders of the posts undertake surgical procedures, they tend to be hospita l- based with outreach work in the community.

Higher training in community gynaecology in the United Kingdom

Following the RCOG working party report in 1993, two pilot training programmes in community gynaecology were set up in London and Manchester. Supervision of higher training in the subspecialty has been delegated to the RCOG subspecialty committee. The first two trainees have already been accredited in the subspecialty.

In 1994, the first two higher training programmes in Manchester and Edinburgh were recognised. There are currently three recognised training centres, including London. These posts provide training and experience in the clinical, administrative and management aspects of community family planning services, well woman care, psychosexual counselling, minor gynaecological surgical procedures, unplanned pregnancies, breast screening and genito-urinary medicine. The trainees also plan and participate in postgraduate training in family planning and related fields. They gain experience in all aspects of the administration of appropriate preventive health services for different population groups, and engage in clinical research and audit.

At the present time, only those with the MRCOG, and at least one year of experience in general obstetrics and gynaecology after passing the MRCOG, may undertake higher training in this subspecialty. Before the introduction of structured training, successful trainees were accredited in community gynaecology after satisfactory completion of the two-year higher training programme at senior registrar level. Since the introduction of structured training, there is only one Certificate of Completion of Specialist Training (CCST) in obstetrics and gynaecology. It is likely that in the future higher trainees will have a CCST in obstetrics and gynaecology and a certificate of subspecialist training in community gynaecology.

Community gynaecology in Sweden

Community Gynaecology is practised in a similar way in Sweden, but there is neither an established higher training programme, nor is it recognised as a subspecialty within obstetrics and gynaecology as in the United Kingdom.

I visited Sweden as a participant in the European ÒHOPEÓ exchange programme for hospital professionals between May and June 1996. This exchange programme was designed to increase understanding of the functioning of health care and hospital systems within the European Community and in Central and Eastern European countries with the intention of facilitating interchange, co-operation and free movement of health professionals.

I spent my time in the Department of Obstetrics and Gynaecology at the county hospital of Angelholm in the south, where I obtained first hand experience of the Swedish system for the provision of obstetric, gynaecological, family planning and reproductive health care services within hospital and community settings, as well as the provision of adolescent and youth advisory services. I was able to observe how these services have evolved to meet the needs of the population.

The County Hospital of Angelholm serves a population of about 100,000 people who live in the six north-western rural districts, including the provincial town, in the county of Skane. There were twelve consultants in obstetrics and gynaecology, one senior resident and two residents. Each consultant had undertaken specialist training in obstetrics and gynaecology lasting five years. The department had three sections: Gynaecology, Obstetrics and Preventive Obstetrics & Gynaecology, each headed by one of the consultants.

The head of the section for preventive obstetrics and gynaecology was the designated consultant for the supervision and provision of services encompassing family planning and reproductive health care, adolescent and youth advisory work, counselling for termination of pregnancy, termination of pregnancy services, screening and primary care for urogenital infections and pre-malignant disease, as well as antenatal care. She held the budget for contraception services and also had the responsibility for the administration, management and audit of services in the field and for continued training and development. There was close liaison with general practitioners, schools, parent groups and social services.

In essence, the Swedish equivalent of the United Kingdom consultant community gynaecologist is usually a hospital-based obstetrician and gynaecologist, who also has responsibility for the organisation and supervision of the provision of family planning and reproductive health care services, as well as management, administrative and audit, functions. In most parts of Sweden, the organisation of community gynaecology services is similar to that described above but in some places, not all the spheres of activity are covered as in Angelholm. Some organisations include antenatal care in the services provided while others do not. I visited similar departments in Stockholm and Lund where the services were organised along different lines. Hospitals are not involved in some districts, but everywhere the head of the organisation, who has responsibility for medical supervision, is a specialist gynaecologist with many years experience of hospital- based obstetrics and gynaecology. Special interest groups within obstetrics and gynaecology meet twice a year to review current practice and recent advances in the different fields and produce guidelines for future practice.

Training in community gynaecology in Sweden

At the present time, there is no training programme in Sweden equivalent to that in the United Kingdom. Generally, Swedish trained doctors would have had experience in the different areas in this field during undergraduate and postgraduate training in obstetrics and gynaecology. Residents must attend courses that include theoretical aspects of community gynaecology and undergo several weeks of practical training in the different components. The final examinations for residents include questions covering community care.

Those interested in specialising and leading the Swedish equivalent of this specialty must also have many years experience in hospital-based obstetric and gynaecological practice. Special training courses are organised every year under the supervision of the Swedish Society for Obstetrics and Gynaecology and the National Board of Health and Welfare. Many training courses are also organised at local level. I observed the training of junior doctors for specialist practice and compared it with the British system. These experiences were very valuable for me as they served to highlight the similarities and differences between the Swedish and British systems. Both systems have evolved in response to the medical, political, social and cultural environment of each country.

Acknowledgements

I wish to thank Dr Ingrid Emgard, head of Preventive Obstetrics & Gynaecology, and Dr Sven Montan, Head of the Department of Obstetrics and Gynaecology, Sjukhuset i Angelhom Sweden, for organising my exchange programme and providing some of the information relating to Swedish practice.

Dr Babatunde Gbolade graduated from University of Ibadan, Nigeria. He came to UK in 1988 to train in Obstetrics & Gynaecology. Currently Clinical Lecturer in Family Planning & Reproductive Healthcare, he is also an Honorary Senior Registrar in Community Gynaecology in Manchester. Ed.

Return to the Table of Contents

 {FILE "e:\platform\iis\wwwroot\oblive\eago\_footers\footer.txt"}