Examination of Witnesses (Questions 140-159)|
WEDNESDAY 10 JULY 2002
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
(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 recogniseorganisations like WHO recognisethis
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
141. What evidence do you have for saying public
(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.
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.
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.
(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
148. Has anybody done any assessment of the
quality of sex education in schools starting right in primary
(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
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
(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
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".
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.
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.
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?