Examination of Witnesses (Questions 220-239)|
WEDNESDAY 10 JULY 2002
(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
(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
(Dr Randall) Therefore, who champions that side because
there is nobody there to do that?
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 middlewe
seem to have ignored this so faris 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
(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
(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.
228. It is slightly paradoxical that abortion
is actually in many cases the result of a failure of all the other
(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.
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 alsoI can only really talk about abortion servicesthe
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.
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.
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.
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 yearmen
too, not just womenand 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
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
238. Three weeks is an improvement on what is
happening in many parts of the country?
(Dr Guthrie) Absolutely, to achieve that would be
(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
(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