Select Committee on Health Appendices to the Minutes of Evidence


APPENDIX 58

Memorandum by Birth Control Trust (SR 33)

SUMMARY

  1.  The provision of abortion by the NHS is complicated by the statutory right of medical and nursing staff to conscientious objection.

  2.  Women requesting abortion are a major part of the gynaecological case load. They should be assessed and treated only by medical and nursing staff who consider legal abortion morally acceptable and who have the experience and resources to provide an adequate service. This is difficult to achieve within a block contract for general gynaecological services.

  3.  Satisfactory provision can be achieved either by the creation of dedicated services associated with the gynaecological units of NHS trusts, or by contracts between NHS health authorities and private-sector providers.

  4.   Health Service Guideline HSG(94)39 Appointment of doctors to hospital posts: termination of pregnancy ensures that medical staff applying for gynaecological appointments are protected from discrimination because of their conscientious objection. It does not give enough priority to the need in many gynaecological units for a majority of medical staff to be willing to provide legal abortion. It also gives excessive protection to gynaecologists in the training grades. This is resulting in a significant proportion of junior doctors feeling able to opt out of abortion provision, so that they are receiving no training in this work, and an undue burden of routine abortion care is being placed on consultant staff. This has serious implications for the future consultant staffing of abortion services.

Introduction

  Birth Control Trust has been concerned for many years about the inadequate provision of abortion services by the NHS. There are several reasons for this, among which are the methods of recruitment of medical and nursing staff for the gynaecological units of NHS Trusts and the organisation of the services they provide.

The right of conscientious objection

  Health professionals with a conscientious objection to legal abortion can invoke Section 4 of the Abortion Act and opt out of personal involvement in the practical aspects of termination of pregnancy. This can create considerable difficulty when legal abortion is one of many items in a block contract for gynaecological or anaesthetic services. Numerically, abortion is a major part of the gynaecological case load and is difficult to provide efficiently if more than a small minority of staff are unwilling to do this work. Staff who are unwilling vary from a few with strong religious beliefs to a rather larger group who are ambivalent, or who consider abortion work distasteful and tedious. This can result in the staff who are willing to terminate pregnancy providing an inadequate service because of their need to balance the priorities of women requesting abortion with other urgent gynaecological problems.

  Birth Control Trust strongly supports the right of health professionals with a conscientious objection not to be involved in abortion work but equally strongly, maintains that women seeking help with unwanted pregnancies must have access to adequate NHS services. The NHS is already evolving solutions to this dilemma but beneficial change is slow and patchy. The staffing and organisation of NHS abortion services requires review, and the adoption nationally of the best local practice. There is also a need to consider changes in national guidance on the recruitment of gynaecological and anaesthetic medical staff.

Suggestions for the improvement of abortion provision by the NHS

  1.  NHS abortion services should be separate from those for general gynaecology. This allows the appointment of staff who are willing to do this work. Most can be employed less than full-time. Consultant medical staff can have other gynaecological or obstetric sessions, or can be specialist community gynaecologists with responsibility for contraceptive services. Nursing staff can either be part time or have other gynaecological duties. Gynaecologists in the training grades can be offered experience in such units or, with a change in NHS guidance, fill posts in which experience in abortion provision is part of the job description. There are already examples of specialised NHS abortion services—particularly in districts with a consistently high level of provision by NHS staff.

  2.  NHS abortion services can be contracted out to a private provider. The contract can be designed to meet an appropriate proportion of the historic local abortion case load. Birth Control Trust suggests that the proportion should be 90 per cent (NHS provision in Scotland has been 99 per cent for many years). Contracts of this type ensure that women have prompt access to assessment for termination of pregnancy, and that they are cared for by health professionals who are specifically appointed for this work. Such "agency arrangements" between the NHS and the private sector currently provide about 20 per cent of all abortions and are an option that can be developed when there is local resistance to the creation of specialised local services with NHS staffing, or when the local case load is too small to make such a specialised service cost-effective. A disadvantage of "agency arrangements" is that NHS gynaecologists are deprived of experience of abortion work. This could be remedied by the inclusion in the contract of training by the contractor for junior gynaecologists employed by the contracting health authority.

  3.  Consideration should be given to revising Health Service Guideline HSG(94)39 Appointment of doctors to hospital posts: termination of pregnancy.

    (a) The guideline states that advertisements for consultant posts should not mention the need to provide abortion and that abortion should be included in the job description only if "adequate services for termination of pregnancy within the NHS/trust would not otherwise be available." Candidates may be asked questions about abortion provision only if abortion is mentioned in the job description. Much depends on the local view of what is an "adequate service". Unless there are special arrangements for the provision of the type outlined above in (1) or (2), the size of the abortion case load makes it desirable that most NHS gynaecologists should be willing to terminate pregnancies. It is also important that the level of staffing allows for absences for study leave, illness and holidays. The guideline gives necessary protection to the minority of candidates who have deeply held objections to this work but gives too much scope to trusts that are reluctant to give sufficient priority to the needs of local women for termination of pregnancy.

    (b) The guideline also states that it is not considered obligatory for medical staff in the training grades to undertake duties involving the termination of pregnancy. Such duties may not be included in the job description and candidates should not be questioned about their attitude to this topic prior to their appointment. In practice, all general gynaecological units providing legal abortion depend heavily on the day to day clinical work done by gynaecologists in training. The refusal of one or more juniors to take part in abortion work leads to an overload of routine work for the consultants and a deterioration in the service that can be provided. In addition, such trainees do not obtain the experience of listening to women describing their need for abortion, or acquire practical skill in evacuating the uterus. There is a danger that an increasing proportion of consultant candidates will have had no experience of abortion provision and may lack the ability to deal effectively with women admitted urgently with abortion complications. A majority of training posts should include the provision of abortion in the job description—the proportion depending on the local case load and the way in which the service is provided.


 
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