Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 220-239)



  220. Absolutely.
  (Ms Weyman) The potential is there but whether it is actually going to happen I think is going to depend very much on what emphasis there is on looking from the centre at what is being delivered locally. The local area jumps still to the central targets.
  (Dr Randall) Could I just raise the issue that we are back again to this business of having an appropriate lead doctor. In fact, in your area in Swindon there is no lead for contraception.

Julia Drown

  221. Right.
  (Dr Randall) Therefore, who champions that side because there is nobody there to do that?

Jim Dowd

  222. Picking up the previous point on teenage pregnancy, in my part of South East London it is a key issue, it is the risk of it that concerns me. What I have heard from all of you is that PCTs are a new development but that the commissioners generally, whoever they have been, is this right or have I misunderstood, have never given this the priority or the commitment that it deserves?
  (Dr Guthrie) I think it is very variable from place to place. As it happens, where I am I have been very lucky but I know that is not true elsewhere.

  223. Is it the initiative of individual commissioners that dictates this or has it just been allowed to slip down the whole health agenda?
  (Dr Guthrie) A bit of both really.
  (Mr Jones) It has never been up the agenda.
  (Dr Guthrie) If you have got a local champion on the service delivery side they give it a high profile, that puts pressure on the commissioners and so you are likely to get more. It is also where the commissioners are coming from. Perhaps that is why we are thinking of the Strategic Health Authority because now with PCTs, who is going to make sure that the PCTs do not slip into the old habits which is one PCT really investing in this and another PCT not?
  (Ms Davies) There is also a huge frustration. Talking from the independent sector, when we are tendering for abortion services I am sure you have met the same problems that we have, that the whole tendering process and the whole commissioning process can take months and months and months because there are so many people in the decision making process and there is no real body that is given any real empowerment to make that decision. We get caught up in a lot of internal politics where some GPs may want the service to go out of house to the independent sector and others may disagree with that. Meanwhile, what is stuck in the middle—we seem to have ignored this so far—is the actual woman who is not able to access the service in the meantime while this whole internal politicking is going on. That is hugely frustrating for us and I am sure for the end user of the service.

  224. Thank you. Just coming back to a point that we touched on earlier briefly. This is the question of a lot of submissions we have received have highlighted the problems about lack of data. I want to know what specific data? Are we even trying to measure the right data or is it, as you said before, just not measuring it at all in a lot of areas related to sexual services?
  (Dr Randall) We are not measuring any data from the general practice. All they are collecting is the number of coils that they fit and everything else is just lumped together.

  225. So what else should we be collecting?
  (Dr Randall) The community clinics have collected what is called KT31 which has looked at methods by age for a very long time and that at least gives us a handle on what is going on out there. Whether it would be appropriate that—

  226. You would want GPs to do a similar exercise or you want similar information from GPs?
  (Dr Randall) They could probably do it fairly easily because they are computerised so it would not be that difficult for them to provide.
  (Ms Weyman) We need it right across sexual health. We need a cross-section, we need what GPs are doing around the treatment of STIs as well because GPs are involved in that area too. There is a group which is mentioned in the Action Plan for Sexual Health Strategy called the Sexual Health Services Data Group that is supposed to be reporting by next March. As I said earlier, we really feel that there should be this consistent data across all the service otherwise you cannot evaluate, you cannot monitor and we really just do not know enough about what is going on.
  (Dr Guthrie) Could I say, also, apart from number crunching, there is a need to gather information on waiting times, age distribution, social class distribution and users advice because until the users tell us what they are not getting we do not know what they need. We need all these things to then go away and design a more appropriate service. We had better watch that we do not get stuck in number crunching, which is very easy to gather at the end of the day, tell somebody to gather it and we will gather it; our need for information goes beyond that in terms of quality.

  227. Also the interpretation you put upon it.
  (Dr Guthrie) And standards.
  (Dr Randall) Standards could be targets.
  (Mr Jones) I think in the area of abortion there is perhaps a exception to this anxiety about data because the data reported from the national statistics are actually very clear in relation to abortion and the link to the Sexual Health Strategy and the target within there which identifies that there should be this commitment to provide NHS funded abortion. That quantum can be very easily calculable from within the ONS data. That is one exception, I agree entirely, from the need to collect consistent and appropriate data for abortion care, it is already there but what we need is the commitment to use it.[16]

  228. It is slightly paradoxical that abortion is actually in many cases the result of a failure of all the other things.
  (Dr Guthrie) Absolutely.
  (Mr Jones) There is a huge amount that needs to be reflected about why people end up in this situation. The Rowntree Foundation are currently doing some very interesting work on that about the variations in rate and why that should exist. I think from the health service management point of view, which is partly what this Sexual Health Strategy is aiming to address, this is one area that can be calculated very simply and put into the forward plans of all the PCTs.

Mr Burns

  229. Can I move on to reactions to the Strategy. I would like to ask Liz Davies first, followed by Mr Jones and then Dr Guthrie, how do you think the current inequities in access and in quality of provision for termination of pregnancy services can be tackled?
  (Ms Davies) I think in a number of ways. Certainly there is a huge juggling act to balance questions of resources and also—I can only really talk about abortion services—the desire to provide those services. Certainly in some areas it is just not a high priority and it is not seen as a priority. I think there is a huge role for the independent sector here. The independent sector provides 33 per cent of all the abortions which are funded by the NHS. We have the expertise, we have the facilities, we have the resources, we have the management to be able to provide a very quick service and a lot of health authorities and PCTs do find this very cost-effective to actually contract out the services than to keep them in-house and it is not such a strain on their in-house resources as well.
  (Mr Jones) I think there are four areas and they mirror a lot of what has been said already today. I do think that the inequalities is one of the things that ought to be unacceptable in a National Health Service. I think that is one of the reasons why this is so important to address. The first one is commitment and adequate prioritising in this service because if that is then built into the performance assessment framework, or maybe even into an NSF, this will enable this to be monitored and the performance of PCTs will be able to be monitored to ensure that they do meet the targets contained within here. Then the inequalities ought to disappear. The funding is going to be one of the key priorities towards doing that in the sense that where there is enormous variation between different regions, but particularly down at PCT level, where we have some areas providing 96 per cent funded care and other areas providing less than 50 per cent, so the funding to make up that shortfall needs to be found and, as I said earlier, that is very easy quantify. The capacity issue: the NHS in the foreseeable future will not be able to double its capacity to meet this need within the NHS alone, so the independent sector is necessary to continue in partnership with the NHS in the way that it is doing now in providing over 60 per cent of the total care in this country. Then there is the point of capability. There is a need for the staff and skill base to be maintained in doctor's training and extending the role of nurses and also, within capability, looking at the way that services can actually be delivered. Particularly if the law were able to be implemented in a way that would allow early medical services in particular to be delivered from a greater variety of environments and perhaps in a variety of ways it would enable more women to access the service and it would relieve pressure elsewhere within the NHS, which would clearly help in both the capacity and the capability of running the services. I think those are the main areas I would see as having the potential to change.
  (Dr Guthrie) If we are going to address the disparities, which we acknowledge exist across the country, I think we have to get some way into monitoring and then addressing what is going on and to have a national framework to which everybody works. We can look at case loads, we can look at delays in presentation and we can look at how effective the information we give to the public enabling them to access to the services is and ask the public what they need so we can design something which is appropriate.

  230. Can I ask you another question, which in some ways you partially answered and give you the opportunity if you feel there are any areas you have missed or want to elaborate on. What changes would you like to see to modernise abortion services?
  (Ms Davies) Firstly a change in the law, allowing women to make their own decisions.

  231. I note that but—
  (Ms Davies) I know it is outside the framework of the Sexual Health Strategy but it is one of the most important issues facing women in abortion services today.

Jim Dowd

  232. Dispense with the two doctors, you mean?
  (Ms Davies) Yes.
  (Mr Jones) I think you are right, it would be unlikely to be a political winner at this stage to want to address wholescale changes within the law but there are matters within the Regulation that already exist that could make service delivery rather better. One of those is the one I just mentioned about extending the environments and the sites in which an early medical service can be delivered. There is already provision for that; it just needs approval. The other thing that I think would be the greatest benefit to future change, and I have said it a couple of times already, is sticking to what the Sexual Health Strategy aims are. If that has the commitment from the top level, it contains the sorts of things that we would need, and the biggest one is the funding. A point I would make, which is where my anxiety creeps in, is in the Sexual Health Strategy document itself it talks about NHS-funded abortions should be provided and from 2005 commissioners should then ensure that they meet the requirements of access. It specifically mentions NHS-funding of abortions. Within the implementation document the NHS-funding commitment disappears and it just talks about access to services. In the one it is explicit, in the other it is perhaps implicit and I think that should be made very clear because if that target is set and the funding there to deliver it, the rest of it can fall into place.
  (Ms Thomas) One of the big things here is that we have got a guideline which underpins part of the Sexual Health Strategy but the Strategy itself does not necessarily have the force of something like a NICE guideline and, therefore, if you really want commissioners to do something then tell them this is part of what the NHS should be providing. That is quite a simple thing to do. That guideline was produced in 2000 and it will be out of date in 2003-04. It needs to be re-done, so we say re-commission the guideline and give it NHS status. The Strategy highlights the fact that if you are poor you are probably more likely to end up with a pregnancy you do not want but you may also have more difficulty accessing services, and those are the very people who cannot access NHS services. If you do not address that you are not addressing inequality in care.

Julia Drown

  233. Would there be any disagreement from any of our panel today that women should be given abortion on request in the first trimester? Would there be any disagreement that nurses should be allowed to perform abortions? Is there any disagreement that abortions should be performed, as Mr Jones said, in a wider variety of clinics?
  (Mr Jones) No.
  (Dr Randall) We welcome that.
  (Ms Thomas) Can I just say one thing. I would not disagree but you do not need to wait for a change in the law or a change in those circumstance to improve the quality of care that women receive. The College's stance would be there are huge inequities already and you can improve the quality of care people yet without resorting to legislation and you should not hold up that improvement because you get entangled in legislation.

  234. Not only nurses being able to do abortions but to, say, sign certificates and do more of those things as well if there is a will?
  (Ms Davies) They already take quite a large part in a lot of the services, but there is then that gap of them not being able to take that one stage further.
  (Ms Weyman) Can I make a comment. When I started looking at some of these issues around abortion when I first came to FPA, I thought making service delivery better would solve the problems, and I agree we should go ahead and try and change the service provision, but they will not do what is needed in the end totally because unless you change law you cannot allow nurses to go beyond their present role, and they need to be properly trained and supported to do that. If you do not change the law I do not think we will ever overcome some of these delay issues because they are structurally there. It is unnecessarily bureaucratic and very expensive to run the service the way we do now. Why do we have doctors' time wasted signing the forms. The majority of abortions happen before the end of the first trimester. That is much better for women without those barriers and it would cost less.

Jim Dowd

  235. One of the objectives of the Strategy is to ensure the national standards for three weeks from first appointment to receiving a termination and you alluded to that. Is that a realistic target? Is it achievable? Is it appropriate? Is there a better way?
  (Ms Weyman) There is an issue before that which is asking for referral. Some women experience long delays in getting a referral. This is where they start to meet some of the barriers in the system. They have a GP that does not tell them that they do not refer, he just tells them that they are not eligible. Doctors are not supposed to do that, although we know a minority do, and there are other doctors who are not necessarily against abortion in all circumstances but will decide for that woman they are against it. Our Helpline deals with 80,000 enquiries from women a year—men too, not just women—and a lot of the enquiries are from women who have been put in that position. It may be three weeks before they get to see somebody who can refer them on. So then if you are counting three weeks you actually are talking about six weeks.

  236. We are aiming at the wrong targets?
  (Ms Weyman) This is about these barriers which there are. I think it is right there should be a restriction about how long it takes to get from your referral to having the abortion, but we should not ignore there is a problem for many women before you get to that stage. You can see it in the figures because if you look at the percentage of women who pay for their own abortions and go directly to the independent service who have their abortion before nine weeks, there are 64 per cent of those compared with 36 per cent of women who have NHS-funded abortions before nine weeks, whether in NHS services or in the independent sector. So you are seeing considerable delays that are arising with women having to go through the system. Some of those are coming before referral and some of them are coming after referral.

  237. Even then it is not a perfect measure but are you confident that the action plan has the elements in this to achieve even this limited objective?
  (Dr Guthrie) Right now it is not achievable; it will need resource to achieve it. Nationally in some places you can wait six weeks which immediately puts you too late for medical termination, the low-tech and definitely safer method of termination. Some resource will have to go into some services around the country to bring them anything like hitting a three-week target. Three weeks has been put down as a maximum; ideally it should be less. There are many services in this country that could not hope to achieve that.

  238. Three weeks is an improvement on what is happening in many parts of the country?
  (Dr Guthrie) Absolutely, to achieve that would be an improvement.
  (Mr Jones) I think it is an entirely appropriate target and I think it is achievable as long as the Strategy encourages a partnership with the independent sector (which meets that standard already) and provides the funding to enable commissioners to buy that service, because the target just says "access to an abortion", it does not say where it has to be, and certainly the independent sector is working to a quality standard of less than three weeks now. So it can be achieved as long as it is funded and there is a commitment there to do it.

  239. You mentioned it in outline earlier but is there anything further you or Ms Davies would like to say about the role of the specialist independent sector in achieving the Strategy?
  (Mr Jones) I think it has been referred to several times. We already provide within the independent sector the higher number of procedures that are conducted in this country already, so as long as that relationship exists and is encouraged then the independent sector will continue to work in partnership with the NHS. It has the expertise and it has got the advantage that we are largely a single subject speciality. We do choose to work in that area and the staff who work with us do so for that reason. We are not having the problems that many NHS units would have in trying to slot this service into what might be a difficult environment within an NHS Trust. In many areas it is not and I hope that it will continue to be so, but in some areas it is. The other advantage of being specialists in this particular area is that it enables us to focus all of our management and our resources on delivering that service in a way that meets the needs of the woman and that local community and we can do that cost-effectively. I think the Committee has got some evidence that I submitted which demonstrates the cost-effectiveness of that. That can help the NHS meet these targets by an appropriate partnership with the independent sector certainly.

16   Note by witness: Unlike many other areas of the Strategy, the abortion target is clear, definitive and readily quantified. Back

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