Health and Care Bill

Written evidence submitted by the Royal College of Obstetricians and Gynaecologists (RCOG) (HCB49)

Submission to the Health and Care Bill Public Bill Committee

Introduction

The Royal College of Obstetricians and Gynaecologists (RCOG) works to improve the health and wellbeing of women everywhere, by setting standards for clinical practice, providing doctors with training and lifelong learning, and advocating for women’s health globally. Founded in 1929, the RCOG now has over 16,000 members worldwide and works with a range of partners both in the UK and globally to improve the standard of care delivered to women, encourage the study of obstetrics and gynaecology (O&G) and advance the science and practice of the specialties.

The Health and Care Bill presents the Government with a once-in-a-decade opportunity to shape and strengthen the UK’s health and care systems to match the demand and needs of those who use it. This includes 51% of the population who are women and use the UK’s O&G services everyday. Our submission includes recommendations as to how the Health and Care Bill should be strengthened to better reflect the health, care and wellbeing needs of women in the UK in the future.

Key points

- A ban on hymenoplasty surgery must be introduced into the Health and Care Bill alongside a ban on virginity testing as the two are inextricably linked. The RCOG supports the wording of New Clause 1 and New Clause 2 proposed by Richard Holden MP to criminalise virginity testing and hymenoplasty procedures.

- Workforce is the key limiting factor in the Government’s ambitions for health and social care and yet are essential for its future. The RCOG supports a cross-sector drafted amendment to Clause 33 which would require published assessments by the Secretary of State every two years of the workforce numbers required to deliver the work that the OBR estimates will be carried out in the future. This amendment will give the NHS the best foundations to take long-term decisions about workforce planning.

- The RCOG has been outspoken about the damaging impact that the lack of research and data has on women’s health in the UK. We are supporting cross-sector calls for the Health and Care Bill to mandate that Integrated Care Systems ensure that NHS organisations for which they are responsible, conduct and resource clinical research.

- Women's voices must be at the centre of their health and care and the Government should ensure that the Health and Care Bill reflects this by ensuring women’s health is represented in governance and leadership structures of ICSs.

- The current fragmentation of governance and commissioning responsibilities in England has created confusion and barriers for women when trying to access healthcare. The RCOG supports cross-sector calls for improvements to commissioning in the Health and Care Bill to better support women accessing sexual and reproductive health services.

- The safety and efficacy of folic acid intake immediately before pregnancy is well known and established and the RCOG recommends the introduction of mandatory fortification of flour with folic acid in the section on Food and Drink in Part 5 of the Health and Care Bill.

NC1 and NC2 - Virginity testing and hymenoplasty

New Clause 1 (NC1) and New Clause 2 (NC2), proposed by Richard Holden MP, are an unmissable opportunity to implement both a ban on virginity testing and on hymenoplasty procedures to protect women in the UK. We welcome the commitment from the UK Government in the Violence Against Women and Girls Strategy [1] to criminalise virginity testing, however we are concerned that this action will be severly compromised if an explicit ban on hymenoplasty surgery is not included within the Bill as the two practices are inextricably linked.

Virginity testing is an examination of the female genitalia which looks to determine whether a woman or a girl has had vaginal intercourse. The examination has no scientific merit or clinical indication as the appearance of a hymen is not a reliable indication of intercourse. There is no known examination that can prove a history of vaginal intercourse, therefore the sole perceived purpose of such a procedure is in itself obsolete.

Hymenoplasty (also known as hymen repair surgery) is a procedure undertaken to reconstruct a hymen, a thin piece of skin that partially covers the vagina. This procedure requires a surgeon to create scar tissue in the vagina, with the purpose of allowing a woman to bleed the next time she has intercourse, in order to give the impression that she has no history of vaginal intercourse.

Disturbingly, neither procedure has any medical benefit and both are harmful practices that create and exacerbate social, cultural and political beliefs that attach a false value to women and girls in relation to whether or not they have a sexual history.

The current availability of these procedures is contributing to entrenching the myths around virginity that are compelling individuals to seek virginity testing and hymenoplasty in the first place. By removing the availability of these procedures, through NC1 and NC2 to the Health and Care Bill, the ability for those currently seeking to infringe on the bodily autonomy and sexual freedoms of women and girls will be significantly limited.

Clause 33 - Report on assessing and meeting workforce needs

The workforce are the lifeblood of the NHS and every day provide world-class expertise and services to women in obstetrics and gynaecology across the country. However O&G has changed significantly in the past twenty years, both in terms of staffing and patients. Patient care has become increasingly complex as fewer than half of women giving birth have a normal BMI and fewer than half are categorised as ‘low risk’. This requires greater cover by consultants due to the fact that junior and middle grade staff do not yet have the appropriate level of skill and experience to manage patient care independently.

However, staffing numbers have not kept pace with demand. Research conducted by the RCOG found that there were gaps in middle-grade rotas in nine out of ten obstetrics units and 100% of trainees reported rota gaps at their level in their current unit. Understaffing has a direct impact on safety, with nearly 70% of NHS litigation costs in 2019/20 related to maternity. [2]

We urgently need to identify the current and future needs of the O&G workforce to ensure the future safety of women and children within the UK. The RCOG is supporting the cross-sector amendment to Clause 33 of the Health and Care Bill. This would require biennial published assessments of the workforce numbers required to deliver the work that the Office for Budget Responsibility estimates will be carried out in future, based on projected demographic changes, the growing prevalence of certain health conditions and likely impact of technology.

The Bill currently places a duty on the Secretary of State to describe the system in place for assessing and meeting workforce needs. While this will bring welcome clarity to a system that has long been opaque and convoluted, it means we still will not know whether the system is training and retaining enough people to deliver health and care services now and in the future. The non-legislative approach to workforce planning that has been taken so far has not been sufficient to ensure that health and social care services can keep pace with changing and growing demand.

Workforce is the key limiting factor in the Government’s ambitions for health and social care. Regular, independent and public workforce projection data will not solve the NHS workforce crisis, but it will provide the best foundations to take long-term decisions about workforce planning, regional shortages and the skill mix to help the system keep up with service user need.

Embedding clinical research in the NHS

The RCOG is supporting a cross-sector submission to the Health and Care Bill Committee calling for it to be mandatory for Integrated Care Systems to ensure that NHS organisations for which they are responsible conduct and resource clinical research.

Existing legislation (the Health and Social Care Act 2012) includes only a duty for Clinical Commissioning Groups (CCGs) to ‘promote’ research. The NHS’s ability to prioritise the resourcing and delivery of research has been a major impediment to improving the UK’s clinical research environment over the last decade. This has contributed to a significant variability of opportunities for patients to engage in research, with disparities in participation reported for women [3] , as well as due to geographic location [4] , socioeconomic background [5] and ethnic origin [6] .

The Health and Care Bill is a major opportunity to embed a research-active culture within the NHS, building upon the response to COVID-19 which has seen more NHS sites, staff and patients engage in research than ever before. Combined with effective resourcing and support for NHS staff to engage in research opportunities, a strengthened research mandate will help to deliver a number of well evidenced benefits including: improved patient outcomes, improved staff satisfaction, and delivering economic benefits for the NHS and broader economy.

Within ‘The Future of UK clinical research delivery vision’ [7] , the Government set an ambition for the UK to become the destination of choice for clinical research and that the "NHS will be encouraged to put delivery of research at the heart of everything they do, making it an essential and rewarding part of effective patient care." We join the Government in its calls and urge them to put this ambition on a statutory footing within the Health and Care Bill.

The RCOG strongly believes that there must be a renewed effort to tackle the gender data gap by funding more studies which focus on women’s health and responses to treatment to eliminate the gender bias evidence in diagnosis, treatment and medical research. Currently, less than 3% of the overall medical research funding is focused on women’s specific diseases, such as endometriosis, which is holding back women’s health outcomes and experiences. [8]

Research shows that women are less likely to be invited to, or to participate in, medical trials and research. [9] For example, diagnostic techniques and treatments for cardiovascular diseases have been based upon research conducted predominantly on men meaning that there is a possibility that treatments could be less effective in women than men. [10]

A legislative requirement, with improved accountability for ICS leadership teams, and a more inclusive research workforce, will play a key role in ensuring all patients have the opportunity to take part in clinical research, regardless of where they live, their gender or their ethnicity and will help to overcome the intersecting inequalities that many women face across the lifecourse.

Women’s voices in governance and leadership structures of ICSs

Without professionals listening to and empowering women, a barrier between women and good health will always exist. They will not be able to access the care and support they need, and they will not trust professionals to support them to make decisions about their future health, leading to worse health outcomes through their lives. Professionals are a key enabler to ensuring women are at the centre, and feel in control of, their own health.

In order to ensure women’s voices are at the centre of their health and care, their voices must be at the centre of the systems and services that are there to support them. Women’s health must be represented wherever decisions are made that will impact their health and care. Furthermore these voices must represent the diversity of women seeking access to and using these services.

Part 1 of the Health and Care Bill presents a great opportunity to strengthen the role of women’s health in leadership positions, including in Integrated Care System Boards and Partnership Boards, and within the governance and leadership of Primary Care Networks.

Improving Governance and Commissioning

The current fragmentation in the way our healthcare services are designed and delivered means that many women are struggling to access basic services including contraception, abortion care and cancer screening. The consequences of this include, but are not limited to, an increase in the number of unplanned pregnancies (resulting in poorer outcomes for women and their babies), a rise in requests for abortion, especially among women in older age groups, and later diagnosis of cervical cancer, which can adversely impact on survival rates.

The current fragmentation of governance and commissioning responsibilities in England has created confusion and barriers for women when trying to access healthcare. This is most acutely seen in sexual and reproductive health (SRH) services, the commissioning of which is currently split between CCGs, Local Authorities and NHS England. This means there is no single body invested in providing women’s basic healthcare needs.

This lack of accountability and ownership has led to variations in access to services and quality of care. It has also created a system where there are few incentives to prevent health problems developing. Resultant poorer health outcomes are invariably more expensive to resolve than preventing the problem in the first place. [11]

It is arguable that the 2012 Health and Social Care Act reinforced the fragmentation of the health and social care service by, for example, splitting health commissioning responsibilities amongst a range of different organisations, most of which were newly created in 2013. This meant that there were, and still are, multiple providers in competition with each another. [12]

The RCOG supports cross-sector calls for better joined up thinking in governance and commissioning in Part 1 of the Health and Care Bill to improve the levels of local collaboration and joint working.

Mandatory fortification of folic acid in flour

The safety and efficacy of folic acid intake immediately before pregnancy is well known and established. In 1991 The Medical Research Council recommended the fortification of flour with folic acid in order to reduce the occurrence of neural tube defects. [13] The Scientific Advisory Committee on Nutrition recommended mandatory supplementation in 2006 and in 2017. The measure has also been backed by the Welsh and Scottish Governments, and the UK Government has the opportunity to introduce the mandatory fortification of flour with folic acid in Part 5 of the Health and Care Bill.

Over 80 countries around the world already benefit from mandatory fortification and higher intake of folic acid among their population. This helps to prevent neural tube defects and instances of spina bifida, anencephaly and encephalocele, and provides other health benefits. It is particularly beneficial for those who have poor diet and low socioeconomic status, as well as women who may not have planned their pregnancy.

While women are encouraged to take folic acid supplements, the evidence shows that this has not been as effective as intended and the delay to introducing mandatory fortification as a public health measure is contributing to the continued occurrence of neural tube defects and other health problems for both mother and child.

Part 5 of the Health and Care Bill includes a subsection on food and drink and we would urge the Government to use this to introduce mandatory fortification of all flours and other non-wheat products, such as those which are gluten free, with folic acid to ensure that nobody is disadvantaged.

For further information, please contact Zoe Russell, Public Affairs Manager, z.russell@rcog.org.uk.

September 2021