Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 340-359)


24 OCTOBER 2007

  Q340  Dr Harris: This is also, like the last one, not a catch question, and it may be that it is one for you and Dr Adshead. When the Department advises you and when you put information into the domain for Parliament to come to a decision, do you count national surveys that are peer reviewed and published in medical literature differently from personal communications from individual hospitals which have not been published or peer reviewed about what their survival rates are? Do you see a difference in that? Do you qualify your advice based on those factors?

  Dr Adshead: Absolutely, yes, because, whenever we look at evidence in the Department we take the internationally accepted ways of doing that. We look at the quality of the studies. We look at complex issues, such as when the outcome was measured. Many of the studies look not just at how many children survived at birth but also, for example, what their quality of life was perhaps six years after delivery. We look at all those issues. The Committee member is right that it is absolutely the case that we look at information coming out of our hospital system but we very much base a higher factor on peer reviewed evidence that has been published and is thought to be by a range of academics more solid and more robust in its format. That is precisely why in the past, as a Department, we have proactively sought from the Royal College of Obstetricians and Gynaecologists peer reviews which balance all those factors in the quality of evidence as you are suggesting.

  Q341  Dr Harris: Have you seen any study from Hope Hospital? When I looked on the internet, all I could find was a comment on a blog,, from a commentator. I have not seen it in any journal. Are you aware of any published data from Hope Hospital?

  Dr Adshead: I have not seen any published data.

  Mrs Dorries: From Paul Clark.

  Chairman: That does not mean to say there is not any.

  Mrs Dorries: Exactly.

  Q342  Dr Iddon: I want to look now at the role that nurses play. The Act stipulates that abortions must be carried out by a "registered medical practitioner". There is considerable pressure for nurses to be allowed to conduct abortions. Would that need an amendment to the existing Act or a reinterpretation of the existing Act to allow nurses to perform abortions?

  Dawn Primarolo: I believe it requires an amendment to the current Act for that to happen, in that, although the role of nurses has change considerable since 1967, the ability for nurses to conduct the procedure would require an amendment.

  Ms Cohen: Obviously in the RCN case, which concerned the nurse's role in carrying out medical abortions, the court considered that, provided various safeguards were in place, nurses could, as it were, administer drugs to a woman. But there is a separate issue about the role of nurses in surgical abortions, where, having regard to a decision of Lord Roskill in the RCN case, we suggest that nurses cannot perform surgical abortions. One of the things that Lord Roskill said was that the registered medical practitioner should carry out any of the physical acts forming part of the treatment that it is accepted medical practice, are done only by registered medical practitioners. I understand that, as currently stands, surgical abortions can only be carried out by registered medical practitioners. If you applied the words of Lord Roskill to the question of whether nurses can carry out surgical abortions, I think you probably would not reach the conclusion that the law permitted it. The Act itself in section 1(1) is quite clear that the pregnancy is to be terminated by a registered medical practitioner, and in a way the interpretation by the House of Lords in the RCN case clarified what that means. That was in the context of a medical abortion.

  Q343  Dr Iddon: I think we are asking should that expression "registered medical practitioner" be defined in much more detail than it is in the original 1967 Act?

  Ms Cohen: I think that goes more to the policy of whether nurses should be able to carry out surgical abortions, which I think it is for the Minister rather than for me to say. As a matter of law, if one wanted nurses to be able to carry out surgical abortions, I think one would either be looking to amend the Act or, as in the RCN case, it would be for the court to give a ruling on section 1(1).

  Q344  Dr Iddon: Perhaps I could ask Dawn whether she considers that nurses should be allowed to perform abortions; for example, at both stages of a medical abortion. Should they be allowed to prescribe the drugs legally?

  Dawn Primarolo: Currently they have to be under medical supervision. That is within the Act and that is where the Government rests its case. It is difficult, but for it to be secure and to be sure that there was agreement of the House—because these are issues that are under the Act—I think any wider interpretation of "medical professional" would need to be an amendment to the Act. Whilst recognising that the skills of nurses have undoubtedly developed and they have a very important role to play through the whole process of a termination, the Government does not have any plans to broaden that at all and it would raise lots of issues that would need to be settled first in terms of appropriateness.

  Q345  Chairman: Minister, does it really require an alteration to the Act? Is it not a fact of redefining what in fact a medical practitioner is? Given the fact that the Royal College of Nursing, together with the Government, at the Government's instigation, is giving nurses a whole range of different duties, including surgical intervention, that would in fact just be a simple matter of changing the definition of medical practitioner.

  Dawn Primarolo: I think I would have to give the answer: "I do not think so" and I would need to do a note to the Committee. The procedure is also qualified by the General Medical Council, in terms of the regulation of the medical practitioner and the guidelines, and therefore the interaction between the Act and the rules of the General Medical Council—acting in good faith, et cetera—for the doctor. My view is that implies medical. I cannot answer beyond that at this point. I think I would need to take legal advice. I know time is of the essence, but perhaps I could get a note to the Committee by tomorrow. I think my view would still be that the Act means "medical", means "doctor", means "interaction with the GMC", and that means "not nurses".

  Ms Cohen: "Registered medical practitioner" is a defined term in the interpretation Act and it means someone who is fully registered under the Medical Act. You cannot alter the wording "registered medical practitioner"[2]. But of course the court has interpreted what role other healthcare professionals can have to assist a registered medical practitioner in terminating/abortion.

  Q346 Dr Iddon: Let us look at something slightly less contentious. Do you think that nurses should be allowed to sign the Department's authorisation forms for abortion?

  Dawn Primarolo: Although the involvement of the nurse is critical, I suppose it is possible in principle that it is not an issue that I would want to recommend. I think that it raises the same issues again with regard to the fact that the certificates must be by a certified medical practitioner. Therefore, it does not get around that, it just puts in another level of compliance, if you like, if it was a nurse. There would need to be clarification, an amendment to the Act, because of the requirement of "certified medical practitioner" and the inability to broaden that in our view to a nurse. We come back to the same point. I think it is also understanding the roles of those who are involved with the medical practitioner, nurses, for example, in the procedures. Yes, it is possible, but the Department is not attracted to that unless there was a redefining of the "certified medical practitioner", which we are not recommending.

  Q347  Dr Iddon: The Department is funding two pilot studies to run early medical abortion services in non-traditional settings. What is a "non traditional setting"? What are the pilots intended to evaluate exactly?

  Dawn Primarolo: The pilots are considering the setting as being not in a hospital, in the sense of the medical wards. The two pilots are set within hospitals, but less formally a hospital setting. That is St Mary's, and Chilterns and South Bucks. The evaluation obviously needs to look at all of the issues around safety, acceptability, how we produce protocols, criteria beyond ... This is about "class of place". I can say to the Committee that the response from those two pilots will be published early next year, raising all of those issues. We are trying to move beyond the more ward/hospital setting but still within a medical setting.

  Q348  Dr Iddon: How many women will be involved before the publication of the results? Do we know roughly the numbers?

  Dawn Primarolo: I do not know the number involved in the pilot. I am happy to get that figure to the Committee. That would all be subject to the analysis and the publication of the evidence early next year.

  Q349  Dr Iddon: The medical abortions, of course, are being carried out by a registered medical practitioner, and you have already defined such a person.

  Dr Adshead: All the services are supervised by registered medical practitioners.

  Q350  Dr Iddon: Supervised or carried out by? Are nurses being involved here or not?

  Dr Adshead: Nurses are involved, yes.

  Dawn Primarolo: Nurses are involved but they are supervised by a medical practitioner.

  Q351  Mrs Dorries: In terms of being strictly true on supervision, what is happened is that they are taking the medication in the approved place or building and actually going home to abort on their own. Does the Minister think it is appropriate for a 15-year old girl to be at home, alone, in pain, while she is aborting?

  Dr Adshead: The key thing here—

  Q352  Mrs Dorries: The question was to the Minister for the Minister's opinion.

  Dawn Primarolo: I think it is very difficult in these areas to do that. We have a pilot. Absolutely correct, there is an issue with regard to "class of place"—which is already permitted in the Act. The Government is seeking to assess these very carefully. It has been criticised that the pilots that have been chosen are taking rather a long time and excessively medical perhaps are not in the right setting, but nonetheless it is to settle exactly the protocols around these potentially sensible arrangements. And the women make the choice with regard to those pilots. I know it is always very difficult, Mr Willis, but we have to stay on the practice of the evidence.

  Q353  Chairman: Minister, I do not want to get into individual cases, so I am trying to keep away from being highly emotive on the Committee, but, in terms of the medical abortions and taking Misoprostol, the second dose, will you concede that a significant number of women are in fact taking the Misoprostol in a registered place but then going home to abort?

  Dawn Primarolo: They are encouraged to stay. In the pilots, they are encouraged to stay.

  Chairman: No, forget the pilots. Outside the pilots, in an ordinary hospital setting, they are taking Misoprostol and then going home.

  Q354  Mrs Dorries: There are reports of women aborting on the bus.

  Dawn Primarolo: If supported unaccompanied, yes. That is the advice to me, yes.

  Q355  Chairman: The question was: In terms of your opinion, is that acceptable? Is it acceptable practice? That is all.

  Dawn Primarolo: In terms of the work that is being done now with regard to the pilots, exactly those are the issues needed to look at protocols that are settled, and it is currently permissible, yes.

  Q356  Dr Harris: My understanding is that is what happens to hundreds of thousands of women in America. It is standard practice in America. It has been going on here for about five years in the independent sector and there have been studies of the safety, effectiveness and acceptability of women having the choice to complete the treatment at home if that is their wish. Is that your understanding, Dr Adshead?

  Dr Adshead: Yes, it is.

  Q357  Dr Harris: In order to go home with the Misoprostol, which is what they also do in the United States—they take it at home, instead of having to come in and run the risk of completing the termination on the bus on the way home—currently the legal advice is that that is not possible in this country under the terminology and the interpretation of the Act. Is that your understanding also?

  Dr Adshead: Yes, the second stage of a medical abortion needs to be done in an approved premise, so they do need to go into the medical premise at that moment in time.

  Q358  Dr Harris: That has not been legally tested but you have a view. Are you willing to share the essence of the legal advice you have had with us?

  Dr Adshead: I do have a view on that. Under the Act, women need to have the second part of a medical abortion in approved premises at the moment, under the supervision of a medical practitioner.

  Q359  Dr Harris: Forgive me, as I understand it, I think there is. This has been questioned on two occasions, to my knowledge, about whether it is lawful, about whether the Misoprostol is an abortion for the purposes of having to take place in an approved place. My understanding is that it certainly was being conducted and was asked to stop by the Department of Health because it said legally it was not clear that that was lawful. I am asking whether the essence, the basis for that legal advice—not the opinion, because that is not normal practice—could be shared with the Committee so that we can understand that.

  Dr Adshead: Yes, we could do that.

  Ms Cohen: Yes.

2   Note from the Witness: To clarify, rather, it is necessary to add to those words, so the Act would say for example "registered medical practitioner or a registered nurse". Back

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