Examination of Witnesses (Questions 340-359)|
MP, DR FIONA
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
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, dorries.org.uk, 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
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
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
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
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 Housebecause these are issues that are under the
ActI 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
Councilacting in good faith, et ceterafor 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
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".
But of course the court has interpreted what role other healthcare
professionals can have to assist a registered medical practitioner
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,
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
Statesthey take it at home, instead of having to come in
and run the risk of completing the termination on the bus on the
way homecurrently 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
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
advicenot the opinion, because that is not normal practicecould
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