Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 140-159)



  140. Dr Guthrie?
  (Dr Guthrie) Pretty much the same again. I suppose I am concerned about monitoring and evaluation because as someone who has to provide sexual health services I appreciate I am competing within a limited funding pot because it is not an NSF. No money effectively has come with it. I am just anxious that at the end of the day family planning services in particular will be where they are just now, which is standing up against other services and competing for a limited pot of money. I am quite sorry that in this the whole funding issue has not been addressed in more depth.
  (Ms Thomas) I would agree with the statements made so far. It is important that it does focus around well-being and wider sexual well-being. I think it is limited on the specifics of how it is going to implement reduction in unintended pregnancy and also how it is going to measure that because that is actually quite a difficult thing to measure and perhaps not one of the things that we are able to measure currently. I think it is important it has put abortion on the public health agenda because I think it is important we recognise—organisations like WHO recognise—this is a public health issue. The RCOG has published a clinical guideline on quality of care. One of the ways of perhaps giving this Strategy more teeth would be to recommission that as a NICE guideline and ensure that those services are commissioned through the NHS.
  (Mr Jones) BPAS equally welcomes this Strategy and the inclusion of standards and targets for abortion in particular that for the first time positions this service as an accepted and necessary component of reproductive health care. We have some concerns over where the responsibility for delivering the Strategy will rest. Certainly from the area that I can speak from there appears to be some confusion between where the accountability will lie, whether it is with commissioners or whether it is public health to drive the stratefy for this service. I think that needs resolving. I think the other point I would make is that the historical reluctance to address the issue of abortion for all the factors which I am sure we would all be familiar with have led to deprioritising of this service in the past. I hope that now public opinion and the Government's acceptance in this Strategy that abortion is an integral component of sexual health care is both timely and welcome so we can move on to an exploration of how those services should be delivered and not whether they should be delivered. I hope this discussion and implementation of the Strategy will facilitate that.

  141. What evidence do you have for saying public acceptance?
  (Mr Jones) The most recent one I could point to of that is the MORI poll which was published in January of this year which was commissioned by BPAS. There was a presentation on that poll in the House earlier this year. That demonstrated a very clear acceptance that over 60 per cent of the public when polled believed that there should be a sensitive and sympathetic abortion law in this country.
  (Ms Davies) Like Ian, I think we should go one step further and look at the inequalities of service throughout the UK and why some women can access abortion much more quickly than others. That is a very important part of the Strategy and I would welcome more information on why that is happening and what is going to be done to address it. I think, also, that there is a glaring omission in the actual decision-making process and I do think we have got to look at a change in the law to allow a woman to make this decision herself without the need to go through two doctors to get their permission. I think that is a very important step which has to be taken. Our one concern, of course, is the actual abortion provision in terms of who is going to be doing these procedures. Fewer and fewer doctors are willing to perform abortion. I think we have to look again at the wording of the law to see if we can look to more mid level providers being allowed to carry out the terminations themselves.

  142. Why do you think more and more doctors are less willing to do it? What do you mean by mid level providers?
  (Ms Davies) There are a number of issues. One is that there are fewer and fewer doctors around now who were actually around pre-1967, so therefore they did not see the aftermath and deal with the aftermath of unsafe abortion. With early surgical termination of pregnancies it is a very low-tech, low-skill procedure and a lot of doctors are just not interested in doing that because they do not see it as a good career move. There are also, of course, moral issues which come into play and they may have a conscientious objection to abortions.

  143. Are you suggesting that one should widen the net of those people who should be allowed to perform abortions.
  (Ms Davies) That is right.

  144. Like who?
  (Ms Davies) First level nurses.
  (Ms Weyman) One of the issues is that abortion is in a completely different part of services generally from the other aspects of fertility control and contraception. It is part of obstetrics and gynaecology, which tends to have other interests. If it were much more part of contraception and abortion services then you could have a different range of professionals involved, which might include other doctors and also nurses as well. In a way, because of the law, abortion is over-medicalised and over-located in acute services rather than being seen as part of a broader service, as technology has changed and the types of techniques that there are are much simpler to use.

Sandra Gidley

  145. Putting the issue of making abortion easier aside, I am a little concerned that this appears to be locking the stable door after the horse has bolted, to use a very crude analogy. This picks up on something Anne Weyman said earlier. Is there not really a need to ensure that both men and women have access to good contraceptive services and advice in the first place so that we do not get to the stage of needing to make abortion easier? We seem to have got our priorities all mixed up.
  (Ms Weyman) Of course that is so, but we have to recognise that however good services are for contraception, and they could be a great deal better than at the moment if they were properly funded and adequate levels of training were provided to a full range of staff, there will always be circumstances where women need to seek abortion and we should ensure that those women who are in that position have early access and they have services for them. Certainly we are very concerned about the state of contraceptive services. They are over-loaded. We had a lot of discussion at the last session of the Committee about the problems that are facing other areas of the service, particularly the treatment of sexually-transmitted infections. Contraceptive services are in exactly the same position and under the same pressures. They are often the soft option for cutting expenditure when there is a need to cut expenditure at the local level. It is thought that clinics are not necessarily needed because GPs provide the service, but a lot of GPs only provide a very limited range of contraceptive choice and we know that women are not being offered very effective methods of contraception such as intra-uterine systems, implants and other long-acting methods because they are seen as being too expensive. This again is about fragmentation because they are seen as too expensive in the contraception budget, but if you then look at other services that have to come into play like abortion if the contraception the woman uses is not successful, then they are cost-effective. But people in the service are having to ration provision of effective, longer-acting methods.
  (Mr Jones) Could I just add a further point on that, which links back to the previous question about the reluctance of doctors to be involved in this work. I entirely agree that prevention is better than then dealing with the result, but the reality is there were still 175,000 abortions last year conducted in this country to residents of England and Wales and only 43 per cent of those were conducted within NHS trust hospitals which, as you well know, is the site where medical training takes place under the aegis of the medical schools, and therefore there are many junior doctors who will never have been exposed or had the opportunity for medical under-graduate

  training and post-graduate training in this area of expertise.

Dr Taylor

  146. Can I go on trying to explore some of the omissions in the Strategy. We have recently had a visit to Brussels and I think all of us who went were absolutely staggered to learn the enormity of the difference for teenage pregnancies and abortions in England and Wales compared with the other EU countries. This Strategy does not appear to me to pick up adequately on education. I would love to know what other ways you think it does not pick up on addressing this tremendous problem that England and Wales have as opposed to all the other European countries. Really that is addressed to everybody.
  (Dr Guthrie) Of course, the Teenage Pregnancy Unit report came out before the national strategy did and I see the TPU report as being part of the Strategy. That report was very important. It is very much focused on the teenage issues of contraception, abortion, continuing with pregnancies, child care, parenting and education. One of the strengths of the Strategy was the provision of education and certainly the Teenage Pregnancy Unit is built around provision of education and how we deliver education from health into the general public. The British are very bad at sex altogether. You probably picked that up when you were in Europe. It is a number one problem.

  147. Absolutely.
  (Dr Guthrie) This reflects in what has become a medical problem, but it is only medical because we mop up. It is a cultural and attitudinal problem. As medical providers, we are left mopping up what has gone wrong. You are absolutely right, the fact that we have such a huge abortion need is an indication of failure. It is not just contraceptive failure, it goes back to education in primary schools, youth clubs, in the home, on television, and everything else.

  148. Has anybody done any assessment of the quality of sex education in schools starting right in primary schools?
  (Dr Guthrie) The focus is starting and we do know what works and what does not work. A lot of work has gone into this. Again, you must have picked up the public prejudice against sex education and so there is a lot of work to be done. We know what works and we know what does not work. This is coming out much more. In terms of research, it is very soft research so it is very difficult to give numbers. It is much more difficult to sell.

  149. When you say "we know what works and what does not work", is that sort of information widely available?
  (Dr Guthrie) Yes it is, if you know where to look for it. Perhaps what has not been done is marketing that information outside of the health arena.

  150. Do we know where to look because it is not something of which I am completely aware. (Dr Guthrie) If you start with the Teenage Pregnancy Unit, it will fan out from there.
  (Ms Weyman) I think there is a major issue about starting sex education at a young enough age and provision in primary schools. The guidance that was issued from the Department for Education focuses on the transition year so children between 10 and 11. By that age we know that children have picked up a great deal of information and misinformation about sex and about relationships. If you do not start early, you are losing the opportunity to get across appropriate messages to them in a way that is suitable for their age and experience. That is still enormously controversial. The moment you start talking about providing sex education to younger children you get a whole hysterical outburst in the media. That has its influence on professionals. Teachers do not go to teach in schools to be pilloried in their local press for providing education for children and it makes it very difficult for them. So we do need to do much more to support these schools. There needs to be much more acceptance publicly that this is the right way forward. Unfortunately the provision of services is very patchy and in primary schools they do not have to provide sex education necessarily.

  151. That goes right back to changing the culture.
  (Ms Weyman) Yes, it does.

  152. How do we do that?
  (Dr Guthrie) Good question.

  153. Have you got an answer?
  (Dr Guthrie) There is no one answer to that. I think we all agree—

  154. Can you throw out several ideas.
  (Ms Weyman) I think the comments you make in your report could be very important for helping to change the culture.

  155. Give us some pointers.
  (Ms Weyman) By saying that you agree with the provision of sex education, you do think it should start early, that it does need to be comprehensive and that it needs to address facts, information but also developing children's communication skills and their understanding of attitudes and values. That sort of sex education is the type which is shown to be the most effective.

  156. We have to get it out from under the taboo that we have all been brought up with.
  (Dr Randall) I think just covert advertising. If you go and try and advertise clinic services you will get an awful lot of people who say "Oh, no, we do not want that, thank you very much".

Mr Burns

  157. Advertise what?
  (Dr Randall) Contraceptive services, where you go for whatever it might be. There was a campaign some time ago about trying to advertise emergency contraception, a concept where you might have little stickers in public conveniences for that. An awful lot of district councils said "Oh, no, we cannot have that". It is all back to this business that we cannot talk about sex openly, sex does not happen.

Dr Taylor

  158. There is a huge lot of education, not only of primary children but of adults to bring it out into the open.
  (Dr Randall) Yes.

Julia Drown

  159. Yes, I want to provoke some more hysterical reaction. It is the same newspapers which have the reaction basically which uses sex to sell their papers half the time, which is very interesting. To get them even more hysterical, one of the things we picked up in Brussels was the idea that where we have got teenagers who do not engage in lessons because the lessons are stuffy, rather than just calling it sex education they should be called good lover lessons because that would be the hip and cool thing to attract people to. Being a good lover would mean being involved in a relationship, both partners taking the responsibility for contraception, both partners thinking about condoms and carrying them and so on. I would like your reaction to that? Then, just going back to the Sexual Health Strategy, I am just interested in the comments in the submission from the Family Planning Association. Can you say a bit more about your proposals for Chlamydia screening having a higher status in the Strategy and also about helplines needing to be all integrated with the NHS and others?
  (Ms Weyman) Shall I pick up those points first?

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