The outcomes that matter most

The Committee decided that ‘change in management decisions’ and ‘health-related quality of life’ (specific to urinary incontinence or pelvic organ prolapse) were critical outcomes. Patient satisfaction was considered an important outcome.

The quality of the evidence

No clinical evidence on effectiveness of multidisciplinary teams for the assessment and management of urinary incontinence or pelvic organ prolapse, including mesh complications was found for this review.

Benefits and harms

In the absence of evidence the committee made all recommendations relevant to this evidence review based on their expertise and experience and by consensus. They agreed that it was important to make these recommendations because women with UI often have complex coexisting conditions such as POP and bowel symptoms, and therefore may benefit from a MDT assessment and management approach. In addition, women with mesh complications after UI and/or POP surgery using mesh may present with a variety of symptoms and management of these women may be complex. The decision on how to treat these women requires a team of expert health professionals within a region to ensure that all suitable options have been considered and offered.

The committee discussed the importance of outlining what an MDT is and setting out the composition of the various MDT teams. There is currently no definition of what comprises an effective MDT for the assessment and management of simple and complex cases of UI or POP, including mesh complications. Also there is currently no evidence to suggest when simple and/or complex UI or POP cases, including mesh complications, should be referred to an MDT. The committee decided that women with these complex conditions require more specialised care and input from a wider specialist team and they also agreed the different levels of MDT involvement. The committee agreed on two levels of MDT:

• Local (for women with primary SUI, OAB or primary prolapse);
• Regional (for women with recurrent UI and/or POP surgery, for those who require surgery that is not available locally or for those with complex pelvic floor dysfunction and mesh related problems).

The committee noted that some interventions may be offered for UI and/or POP which are not available locally. If local MDTs work within a regional clinical network with a regional MDT, women can be referred elsewhere in that network for treatment. Women with mesh complications may benefit from a MDT approach to future care planning.

The committee noted that it might be difficult to state exactly who should be in an MDT, as this will not only depend on the condition (UI or POP) but also on the resources available at local and regional levels. The committee wanted to be clear that more than one consultant with expertise in the management of urinary incontinence and pelvic organ prolapse are needed to ensure that full discussion of care takes place. The committee wish to remove the risk of one individual making decisions without full consideration from other specialists with similar knowledge. The committee also agreed that Occupational therapists would not be needed as core members of the MTDT. Pelvic floor physiotherapy is directly involved in primary treatment of urinary incontinence and prolapse, and occupational therapists are there to advise on patients with co-morbidities who may have other considerations to take into account. As there are fewer women in this latter group, an occupational therapists would not be needed as a core member of the MDT.

The committee agreed that the recommendation on local MDT composition reflects the current arrangements throughout England and Wales because different trusts have different availability of MDT members.. They also noted that there may be circumstances in which continence services are provided by urologists rather than urogynaecologists and therefore the local MDT needs to reflect local arrangements. They agreed that all members of the local MDT should attend all local MDT meetings. They agreed that the regional teams are more likely to include more specialist members. The specific composition of the regional MDT meetings may vary depending on required expertise and case mix and therefore, and the committee noted that for regional MDTs members should attend when their specific expertise is needed.

When drafting the recommendations for this guideline, the committee highlighted the potential overlap with the recommendations in the commissioning review (NHS England’s Complex Gynaecology Specialised Commissioning Team - https://www.engage.england.nhs.uk/consultation/gynaecology-surgery-and-complex-urogynecology/). The committee agreed that at a minimum, these two levels of MDT (local and regional) are required; however, the committee discussed the possibility of three levels of care, with a third level specialising in the care for women with complex pelvic floor dysfunction and mesh related complications (Supra regional). The committee are aware of the current NHS England consultation on specialised gynaecology surgery and complex urogynaecology conditions service specifications, which was launched in August 2018, and runs until November 2018. The committee are clear that women with complex pelvic floor dysfunction and mesh related complications require expert clinical teams at specialist centres, but the final distribution and definition of these centres may change after this NHS consultation period.

Cost effectiveness and resource use

There was no evidence on the cost effectiveness of multidisciplinary teams for the assessment and management of urinary incontinence or pelvic organ prolapse, including mesh complications.

The committee thought that women with mesh complications appear to be badly served by the current service configuration and that delays and inappropriate treatment may make symptoms that may need expensive secondary care management worse. The committee expressed the view that, in principle, if specialist mesh service MDTs improve their assessment and monitoring and this leads to the timely identification and appropriate treatment of mesh complications, then the additional costs associated with such a service configuration would probably be outweighed by the longer term improvements in health outcomes and the potential future cost savings to the healthcare system,.

The committee also noted that increasingly women cannot obtain care they want locally. For example, women who do not want the procedure they are offered locally (e.g. TVT), may need to be referred to another centre where they can have procedure they would prefer.

The committee discussed the benefits of different compositions of MDT services and agreed that having a tiered approach to MDTs (i.e. local, and regional, service MDTs) may result in substantial savings to the NHS. For example, the MDT would not require every single specialist (e.g. pain specialist, colorectal surgeon or neurologist) for every with prolapse being discussed. By more closely defining the composition of the various MDTs (e.g. only regional MDTs would need to include pain specialists) scarce and expensive consultant time might be freed up. Given the large number of procedures undertaken, such a tiered approach could result in a significant overall cost saving to the NHS.