This is a transcript of the soundtrack from VPS Podcast 6, which is an audio recording of a slide presentation given by Dr David Nunns at the VPS Super Workshop, 11 May 2013. You can listen to the podcast at Vulval conditions and the new NHS: a presentation given by David Nunns
Morning! Hello everyone – thanks for coming again!
I’m going to give a slightly different talk to what I’ve talked about previously, just to give you an update, my perspectives on what’s happening in the NHS and what’s happening with regards to vulval conditions. I say ‘vulval conditions’ not to just talk about vulvodynia, but lichen sclerosus, skin conditions, any sort of problem to do with the vulva, even infections, recurrent thrush etc. What we’ve seen in recent times is perhaps the biggest shakeup of the NHS ever. This coalition government is very keen that we become the best health system in the world and the fundamental changes to the current setup are that patients will have more of a say in their care, that we’ll really focus on the outcomes of care, and that health services will be bought by GP commissioning teams, so the leaders of this will be the GPs or the commissioners, and this has been a huge shift from what we’ve had in the past.
01:15 NHS aspirations
All of us who work in the NHS, we aspire to these following themes, and we obviously want in terms of healthcare for it to be of the highest quality: what we’d want for ourselves or our loved ones. We’d want that level of care to be equal for everybody. What one person gets, the next person gets as well. We don’t want this postcode lottery that you sometimes read about. And importantly, we want it to be effective; we want healthcare to help us to get better – we want it to work.
There’s a huge focus now on patients’ experience of healthcare and how satisfied they are with their healthcare and their experience of the service they get. Everything from waiting times to car parking to communication with doctors, information the patients get, even patients’ involvement in the decision-making process – this is all now hugely important for when we provide care to patients.
Cost-effectiveness – it sounds tainted, that phrase, doesn’t it, something that’s ‘cost-effective’? Because it sounds like you spend money on one thing and not on another. Perhaps a better term is ‘value for money’. We have to have healthcare that is value for money, basically – we can’t just pour pots of money into health interventions that don’t provide high quality equitable healthcare. So that’s very much a part of what we should aspire to in the NHS.
And to focus on outcomes – now this is really very much on the agenda health-wise. What’s the point of doing something, some operation or procedure to a patient if actually it makes no difference? What’s the point of investing huge amounts of money into a campaign, or into a building or into staff, if actually nothing’s changed? The most obvious part of healthcare that springs to mind is cancer care, and we have now in the public domain survival rates for treatment following cancer. They’re out there, we can easily access them, you can see how your hospital, your region does and you’ll see that some hospitals have good outcomes and some have poorer outcomes. This is probably the way forward really in terms of healthcare, to drive up the standard of those hospitals with poorer outcomes. It’s not just cancer care, it’s readmission rates to hospital, the number of patients, for example, who’ve had diarrhoea from antibiotics, the number of patients who report hospitals poorly on a patient satisfaction survey – there’s plenty of those national surveys around. But these outcomes are what are going to be examined very closely by what we call ‘commissioners’, or the GP leaders who are going to be buying up the services in our hospitals and communities.
And accountability – I’m sure you know with what’s been going on in the press with the Francis report [Robert Francis’s NHS report on whistleblowers], this is absolutely crucial – we have to be accountable for the care that we provide. So, these are the aspirations that we would have as health professionals.
05:17 NHS Outcomes Framework
The government has what’s called the NHS Outcomes Framework. This is the core of what we should be doing in the health service. These are the five main areas where the government want us to develop and improve. Obviously, Domain 1 is ‘prevent people from dying prematurely’. Yes, we want patients who’ve had cancer to have an early diagnosis and effective treatment and have a better five year survival rate than our colleagues who provide healthcare in Europe. We want to enhance quality of life for patients with long-term conditions such as dementia, help people recover from illness following injury, have a positive experience of care and treat and care for people in a safe environment, protecting them from avoidable harm. So, this is at the core of what we should be doing in the NHS, and it makes common sense, doesn’t it?
So where does ‘vulval disease’ or ‘vulval conditions’ sit amongst all that? Well, you could say it falls in between Domain 2, ‘enhance the quality of life for people with long-term conditions’, and also perhaps Domain 4 ‘a positive experience of care’. Now, we know that that doesn’t happen, and that the current model of care for women with a vulval problem is flawed. We know that when women finally get, if they do get, to a vulval service, a vulval clinic, dedicated to vulval disease, this is a team of health professionals, that many of them have no diagnosis, they have incomplete treatment, or there may be even wrong treatment. And a lot of women who end up in vulval clinics have what we might consider fairly straightforward problems to manage. The care around the country’s quite patchy. Some women remain within primary healthcare; some women are seen in fantastic vulval clinics, but those services are not uniform around the country. A lot of women don’t get access to the extended team that we feel is important in managing vulval problems.
07:58 Standards of care for women with vulval conditions
This document has been published this month and what it is, is I think quite an important document that we helped write. It’s a framework for the future. It’s available on the internet on the BSSVD website, which is the specialist society dedicated to vulval problems, a medical society. It’s a document for two groups of people. One is the providers, the health professionals, and it’s a document for the purchasers of healthcare, the commissioners. I get emails now and then from people asking me ‘What is a vulval clinic? You’ve got a vulval clinic in Nottingham – what does that mean?’ Up till now, we were never able to define a vulval service or vulval clinic, and so this document, which has included a whole host of specialist societies, from the British Association of Dermatology, the Faculty of Sexual and Reproductive Health, the British Association of Sexual Health and HIV, this is the Physiotherapy College, the BSSVD is the vulval medical college, the Worldwide Lichen Sclerosus is Fabia’s group [Fabia Brackenbury], the Royal College of GPs, Lichen Planus group and the VPS. This group, together with an expert panel, came up and defined what a woman with a vulval problem, what level of care she should have access to. I hope that this will be a reference document for both providers of care and also one that the buyers of healthcare will go to, to provide women with a comprehensive level of vulval care, depending on her needs.
10:08 Standards of care
What are the standards? Well, I’m afraid you might think that this is all pretty much common sense, but what we’ve said in this document is that there are different levels of healthcare that you need as patients. Level 1 might be self-management; Level 2 might be your GP; Level 3 might be your hospital specialist clinic and Level 4 would be a vulval specialist clinic. Now, not everybody needs to be seen in the vulval clinic that is the Level 4 service, and a lot of women prefer to self-manage rather than being in a hospital system. So, the individual needs of the patient are going to determine which health professional sees that patient – the right health professional at the right time.
We’ve outlined the fact in this document that patients should receive the right information on their condition; that you should be treated in facilities conducive to a vulval examination – privacy, a chaperone, curtains, it’s as basic as that, but that needs to be defined. And time: we’ve agreed that 30 minutes is an adequate length of time for a new patient to be seen in a specialist vulval clinic. 30 minutes in healthcare terms is quite a long time – your average GP might see you in about seven to ten minutes, so 30 minutes is, we feel, an adequate length of time within a vulval service, and 15 minutes for a follow-up.
12:06 Toolkit of skills
Very importantly, if you’ve got a long-term vulval problem, you need a multidisciplinary team and when you think about your health professional, the person looking after you, you have to think that we have all different backgrounds, all different levels of training, and in terms of our toolkit of skills, we’re all different. A woman with vulvodynia will be managed differently by, for example, a gynaecologist, compared to a psychosexual therapist, or compared to a physiotherapist. There will be overlap, but each of those health professionals will have different skills, different tools in their toolkit, as it were, this is a virtual toolkit, of how to manage that patient. The assessment will be slightly different of the patient depending on the eyes of the health professional. The length of time will be different, and the counselling and the therapy will be different. Unfortunately with vulval disease, there’s not one person out there that can sort all your problems out. We probably have to draw on the multidisciplinary team.
13:27 Standards of care
We want staff to be appropriately trained – absolutely. Unfortunately, there is no accreditation process for vulval disease. If you have an abnormal smear, and you need to go and see your doctor for a colposcopy to assess and treat the cervix, or if you have a cancer, you are managed by health professionals who’ve had that extra qualification to manage that problem. But in vulval disease, there isn’t an accreditation programme just yet. People who look after women with vulval problems generally have an interest in that area, because they think it’s an important part of healthcare.
Leadership: again, why did we put this into a document? It makes sense that if you’re running a vulval service, you need to have somebody leading the service, somebody who’s going to work with primary healthcare, work with all the different members of the team, somebody who’s going to develop guidelines, pathways and who’s going to take the service forward.
Governance: this means striving for clinical excellence – a real buzzword in the NHS – we need to audit the work we do, we need to reflect on what we’ve done and improve. Clinical governance is ingrained into the NHS, and why should a vulval service be any different?
And finally, patient and public involvement in the service development. Now, that can sound quite benign when it’s added to the end of the list, but if you look at every other document similar to our one, you’ve got at the bottom patient and public involvement as being absolutely crucial in development of service. What do I mean by that? Well, we need to know what your feelings are about our service. We need to know about your experience. We need to know about the outcomes of the care we give. Has the intervention worked? Has your experience been good? Have you waited too long? etc – all that holistic aspect of the care that we’ve given you. We need to do surveys, we need to do questionnaires, we can even have focus groups, but the feedback from your experience will shape everything above, and that is a common theme throughout every standards document that’s been produced.
16:19 Standards of care for women with vulval conditions: levels of care
This is a busy slide that I’ve pulled from the document, but I’ve put it up just to give you an idea of what we’re planning. You have to remember that when you see a GP or a specialist in a vulval clinic, that we’re dealing with the majority of health professionals, not the super-duper GPs who are doing fantastic jobs managing women with vulval problems. Level 1 care is self-management, yes? Level 2 care: the GP – what’s the role of a GP in vulval disease, what do we expect a GP to do? We would expect that GP to take a history, examine the patient and take swabs, and perhaps make a proper assessment and diagnosis. So many GPs will not examine patients. Many women will go to a GP with a problem and there won’t be any examination whatsoever, which I don’t think is acceptable. But we would expect perhaps your average GP to manage common things like thrush, perhaps follow up women with lichen sclerosus. We’d perhaps expect then, if we were moving from this box to something a little more complicated, like if there’s a lump, or a lesion to see, and it needed a biopsy, that that patient would go up to the hospital, secondary level care, where this would be Level 3 care, and see a gynaecologist or a dermatologist. There’s a list here of different problems that we would want a GP, specialist and this supraspecialist clinic to manage. What we don’t want are women, for example with vulvodynia, or complicated lichen sclerosus, to languish in primary healthcare, being denied perhaps some of the teams that are further down the list, and that’s what’s happening at the moment.
18:30 Pathways of care for women with vulval conditions
Pathways are very important. Every patient with a health problem should be on some sort of pathway. They’re very well established in cancer care. If you’ve got a suspected cancer, you’ve developed symptoms, you see your GP, you get a referral to the hospital, you get tests, you get a diagnosis, you get treatment, you get discharged, and you follow that pathway – it’s very well defined. Does that pathway exist for vulval conditions? The answer is that it’s very poorly developed in the UK, but this is perhaps what we would want to happen in the future. The blue arrow is a consultation, perhaps the onset of symptoms – soreness, burning, itching – a problem, and so the woman would go to see her GP as the first port of call. At that first visit, we’d want assessment, take a history, maybe a swab, certainly a close examination, maybe a diagnosis being made and then some form of treatment. It might be an emollient; it might be a Canesten pessary if it’s thrush; it might be a steroid ointment. Often a follow-up visit’s necessary, or if things don’t subside, then a return visit to see the GP. But after a period of time, if there’s repeated visits, that GP would refer on, thinking that this wasn’t straightforward. He or she would send that patient to the hospital – secondary level healthcare. So, that’s a referral. Now, usually that is going to be a specialist within Gynaecology or Dermatology, depending on the local services. Dermatology are skin specialists; gynaecologists are women’s health specialists. Gynaecologists are surgeons; dermatologists don’t usually do surgery on the vulva. I can tell you now that the gynaecologists have very little training (and dermatologists) in vulval problems – it’s a real fraction of their overall training. Your Obs & Gynae consultant, and I am one – basically the majority of the work is obstetrics, and there is gynaecology attached to it, of which vulval disease forms a very small part of the training. So new consultants don’t have a huge exposure to vulval problems. It’s the same for Dermatology: vulval dermatology forms a very small part. Anyway, you go to these clinics, but new consultants should know about all the basics I’ve talked about – history, assessment, examination. So you might be seen in this service here – history, examination, diagnosis, treatment, perhaps a follow-up visit. If things are fine, great – you might be returned to general practice. If things aren’t fine after a series of visits, then that’s their next level, this vulval service that I’ve talked about, this multidisciplinary team, and it’s at this service that you might then access the bigger team – the specialist physiotherapy for pelvic floor rehabilitation, sexual therapy for psychosexual problems – low libido, vaginismus, arousal disorders – we’re going to hear about all these problems later on today. Pain management I’ll come onto in a sec – CBT, cognitive-behavioural therapy, for the bigger picture. I’ve said to you before, I think often patients get stuck here in general practice, or they’ve dipped into the hospital and they’re back into general practice.
If you’re in this setup, you can’t stay here forever – these slots are usually quite precious, so it’s back to general practice for follow-up. It’s a pyramid structure, and at the bottom of the pyramid, very important, you’ve got self-management. You’re all self-managing because you’ve come to days like today, you’re reading, you’re looking on the internet, you’re watching the webinars, you’re listening to the podcasts, you’re joining support groups, you’re networking with other women with vulval pain and you’re actively self-managing, and that’s throughout the whole process, really – understanding your condition, becoming the expert patient, that’s absolutely crucial.
One more part to this slide that I’ve put together is GU Medicine clinics. I’m not sure if you’re aware of this service, but GU Medicine clinics offer an excellent service to women with vulval problems. I know we’ve got some GU Medicine people here – they might want to chip in at the end with questions. They offer a free – well, everything’s free – a confidential, anonymous service to patients, and women do dip into these clinics for flare-ups, for exclusion of thrush, for STI checkups and sometimes they just go because of problems at this level here. Every hospital has a service. There are more community services now, but they fall outside any sort of referral pattern from GPs to hospital, hospital to vulval service. But they are integrated very much into vulval services in the UK.
24:42 Toolkit of skills
Back to Toolkit of Skills – well, this may be pretty basic, but just to open up your minds to some other people that might be involved with your vulval problem, and this is quite honest, and again, we can have a discussion about this afterwards, but I think there is a role for pain management teams, specialist hospital or community-based teams. You get there via a GP referral. If a GP has seven minutes per patient, they generally have 20 – 30 minutes per patient for a new patient. Their role is advanced pain management: nerve blocks, spinals, epidurals, advanced pain-modifying drugs; they have a whole different toolkit of options they can offer to women with vulvodynia. However, many of these health professionals will not examine the vulva. They’re pain management consultants and nurses, they often have an anaesthetic background, so they probably won’t be looking at your vulva for them to check you out.
Specialist physiotherapy for pelvic floor muscle rehabilitation – that is their role. We know that in vulvodynia there is a hypertonicity, an excess tightness in the pelvic floor muscles, and these very skilled non-medical staff, they’re physiotherapists by training, will work on pelvic floor rehabilitation. This is of benefit in women with unprovoked vulvodynia. Referral by a GP – but look at that, you usually get 45 minutes for consultation, a much longer period of time, and again, they may not be that happy looking at your vulva to look for skin problems.
CBT we’ll come onto this afternoon – I think there is a lot to be said for this type of therapy. For chronic pain, there are lots of benefits. I think you can access it via various routes – referral by a GP, you can even self-refer, I think. I have a bit of an information gap around referral into that, but I know that that’s the focus of today, so perhaps we can touch on that later on. The principles are there, but again, you probably won’t be examined if you’ve got a vulval problem in that setting.
Sexual therapy: again, a key part of the management of vestibulodynia. Lots of benefits there – the one I’ve put here is vaginismus management. Again, you’d get referred by your GP or by the hospital as a part of the extended team, but you’re generally getting 60 minutes of history and counselling and treatment. Again, many sexual therapists will not examine you, but some will.
And acupuncture: again, self-referral usually. You often have to pay for this service because this is what has been withdrawn in the modern NHS, but it’s an established treatment, it has a role in chronic pain management and I put it in there because many women have benefitted from it.
My point really is to show you this extended team, as it were, when it comes to vulval problems.
So that’s a bit about where we’d like to go with this problem with vulval conditions, and I’m optimistic in the future that this will improve.
28:52 Working with health professionals: some tips
Just some bits and pieces, really, to take home in terms of working with health professionals. I’m very mindful of the fact that when you come to the hospital, you have driven a long way, you’re in pain when you come to the hospital, you’re sitting in the waiting room for an hour, parking’s a problem, there’s a great deal of anxiety around coming to see the hospital specialist, and we know that people just don’t take the information in when they’re seen by their doctor. What a waste of time! It might feel like a waste of a consultation – you didn’t get your words out, you didn’t understand what the doctor said, he gave you a prescription and you didn’t understand the side-effects, and it’s all over and done with within about 20 minutes, or if you’re lucky, half an hour. That’s half an hour’s snapshot time in your life with pain, so you get half an hour of the hospital experience, the specialist’s experience. Which isn’t long. So you’ve got to optimise that time, you’ve got to make the most of that time.
Take a friend; take somebody who’s going to ask questions on your behalf. It’s perfectly reasonable to have somebody in the room with you. These are things that I would find helpful.
Take a list of your medications. I give pain-modifying drugs out to patients with vulvodynia. It’s always good to know what you’ve tried before, how long you tried it for, what dose you got to, and whether you could tolerate it, yes or no, and did you get side-effects. In effect, just a summary sheet of what’s happened. Why do we do this? Because it avoids me giving you the prescription that you’ve already had before, and you end up duplicating a treatment that gave you a problem. That’s very helpful. Plus, certain drugs interact with each other, so we’ve got to be careful what we prescribe.
The VPS have got a questionnaire that you can download from the internet. You can print it off, and you can hand that to your doctor. It’s fine. It’s a bit long – some doctors might be put off by it – it’s comprehensive, but you might just want to put at least one side of paper together with the drugs you’ve taken.
Make notes. I’ve had relatives of patients record me in the consultation because they’ve wanted to pick up every word I’ve said and make notes afterwards, which is fine by me, but some health professionals would find that difficult. But just scribbling notes down is absolutely fine, I think – make your notes as you need to.
And then, obviously, ask about things you don’t understand. I think the biggest failing that we have is to talk about pain modifying drugs without clear explanation. I think I’ve said at previous talks about the central nervous system, the role of the pain centre in the brain being overly sensitised in chronic pain, and how these drugs, the nortriptyline, the gabapentin reduce that sensitivity in the pain centre. Very often we just hand the drug out without giving an explanation. So, if you don’t understand it, ask.
Side-effects – yes. Are there any alternatives to the drug you’ve been offered? That’s a valid question. I do mainly oncology in Nottingham, and when we’ve got somebody with cancer, we spend an incredible amount of time talking about the alternatives. Your options are surgery, radiotherapy, chemotherapy, we talk about the pros and cons of each. We can do all that within half an hour for a new patient. Why should vulval problems be any different? We should be talking about the alternatives, we should talk about the options. Amitriptyline is the classical drug, where a lot of women won’t take it because the side-effects outweigh potential benefits. The tiredness, the drowsiness, the initial feeling of feeling a bit hung over, outweigh the benefit of pain relief. That’s for many women. The reality is many women on amitriptyline function quite well and actually side-effects usually subside after a few weeks. So, there’s that encouragement that we need to give patients. If you’re just given a script, you’ve got an information gap on whether it’s going to work or not. You have to say to yourself: what do I want from this consultation? I’ll come on to that in a sec. You can be very specific about what you want from your doctor, which will help, particularly in general practice, where the slots are very tight.
34:15 Working with your GP
If you turn up to your GP in the surgery, you’re more likely to be seen than if you phone, because when you ring a GP surgery you get those automatic answer machines, call queuing, and you eventually get through. It’s generally better if you turn up at the surgery – you’re more likely to be seen. I gather from those automatic, what do you call them, when you ring up and you’re put in a call queue – that they can only take so many calls, and obviously, people do ring up for appointments, and it’s sometimes difficult to get through. Turning up is better. Mondays are always busy for GPs. They’re days to avoid.
When you’re working with your GP, I think it’s not unreasonable to take some research. So many women have said to me: ‘I had to suggest vulvodynia to my doctor’. I think it’s not unreasonable if you’ve got a short printout from the VPS website or if it’s lichen sclerosus, something you’ve read about, to take that to the GP. Not a whole thesis, but just a front sheet of paper. GPs are busy people – seven minutes per patient. I’ve got friends who are GPs. They are incredibly stretched and I think that they work very much to pathways and guidelines, and they really want to provide equitable care. Some GPs are going to know a lot about vulval disease because that’s their area of interest, but many GPs are going to have a very minimal understanding, and I think if you suspect you have a problem – it may be lichen sclerosus, it may be pain syndrome – it’s not unreasonable to suggest that to the doctor. Easier said than done!
If you’ve got lots of problems to raise, then that generally is a problem. Generally, if there are a few things you want to discuss, in an ideal world, you’d make a double appointment. I’m not exactly sure how easy it is with GPs in general practice, but a double appointment might be better than a single. Another thing is if there’s going to be a major change in your treatment plan, a GP might be reluctant to instigate that, because he or she might say: ‘Well, you’re under the hospital care, and I can’t change what Mr Nunns has said because this is a big shift from what he’s just said. What I can do is the minor things. I can adjust a drug dosage, for example, or I can switch from one drug to another, because it’s a similar drug, it’s got fewer side-effects.’ You might find that the major changes in your management plan are something you have to take up with the hospital rather than with your GP. Generally the GPs will work with you if it’s in a letter. If it’s in a letter from the hospital that says: ‘If drug X doesn’t work, try drug Y or drug Z’, you have that green light for the GP to change things, and that’s very important.
37:35 Working with your specialist
Working with a specialist – now, obviously you go into a hospital, usually. It’s less easy, isn’t it? You’ve got to drive to the hospital, or get transport, you’ve got to park, it’s a busy place, it’s less personal, perhaps, than your surgery down the road. Everything else applies – write your questions down. I think it’s very important to tell, perhaps what exactly the main problem is, because I think there is a perception in health professionals that with vulval problems, with vulvodynia, with lichen sclerosus, there are perhaps too many balls going up in the air. There may be pain issues, sexual problems, anxiety, worry, concern, worry about infection, fertility issues. It’s very difficult to articulate that in a consultation of 20 minutes, but I suppose you’ve got to think before you walk through the door: what is my main concern here? What is my main problem that I want this doctor to help me with? That will really focus the consultation.
What’s the follow-up plan? This is a very common problem. You see the specialist, you’re given a prescription, you leave the clinic, the next appointment’s in four months’ time, or there may be an open appointment, or you may be discharged back to general practice. It’s not unreasonable to have a follow-up appointment, so you should ask for that, and make sure that’s arranged.
What if that drug you’ve given me doesn’t suit me, or I have a problem? What’s Plan B? If I have a problem, can I get in contact? Can I have a copy of your letter? I think that’s very important. You are all entitled to letters that your GP receives from the hospital, so you should ask for that. There are good letters, and there are bad letters. A good letter, you’ll be copied in, and it will have a clear plan of action. Poorer letters will have very patchy information. We’re all individuals, and I think we all dictate according to habit.
Access to a specialist… Where are these specialists? We don’t have a national database that’s comprehensive, but the best you’ll find is on the British Society for the Study of Vulval Disease’s website. A few years ago, we approached all the vulval clinics in the country, and we said: ‘Would you be happy to be included on a database that patients could access?’ With the exception of one clinic, they all said ‘yes’. This database of clinics includes a number of health professionals who want to help you and pretty much most of the country’s covered. It’s comprehensive, but it doesn’t go into that much detail, and we can’t validate who the health professionals are. All we know is that they’re usually senior health professional-led services by either gynaecologists, GU medicine doctors or dermatologists who have an interest in vulval problems.
Ask the GP about vulval service, yes? There may be one in your area. It’s a vulval clinic or a vulval service. Are there any other tests I could have that only a specialist could perform, or do I have unusual symptoms that a specialist might help with? That might be a question that you could ask your GP if you need to see a specialist. That’s not unreasonable, particularly if you’re not progressing with the treatment they’re offering you. Private healthcare – we know very little about vulval problems in private healthcare. There’s no national data collection on the outcomes of private healthcare, but many women do in desperation pay to go and see a private consultant. Many of the consultants who work within the BSSVD would see patients privately, but you’d have to do your own homework on that.
42:17 What is the problem?
I suppose the big question is: what do you want from your GP? There’s a whole host of things that you might want from your GP, or even your specialist. One thing that we are acknowledging more and more now as doctors and health professionals is the unmet needs of the patient and sometimes we’re just not aware of what the needs are when you come in for a short consultation.
All these issues on this slide cover vulval disease, like vulvodynia, lichen sclerosus. It may be something very simple like you need a sick note, you might want something like a new prescription, it might be that this is the main problem – anxiety management, you might want help with that, it may be sexual therapy referral, it may be that you’ve found a lump, and you’re concerned, and you just want reassurance. But all I’d say to you is yes, these issues, you can discuss with your GP or a specialist and try and be very focused on what the main problem is, but some of these other options here – sexual therapy, anxiety management, can be instigated by yourself, and our VPS website’s got many links that you can tap into, where you can almost bypass the hospital specialists and go directly yourself. The physiotherapists, for example, have a very good website where you tap in your postcode and you can find a physiotherapist who’s local to you.