The Minister for Patient Safety, Mental Health and Suicide Prevention (Ms Nadine Dorries)
Wow. That was certainly a moving Adjournment speech. I thank the hon. Member, who knows she has my respect. We have been here together for many years, and I have to say that I am truly moved—more than moved—by the accounts of Rebecca, Vidya and Alison. Those stories are incredibly impactful because we know they are real and because, as women, we understand exactly what they are relaying in their experiences in a way that—I am sorry—chaps just do not.
The hon. Member referred to being here eight times. I think I have some good news for her in my response, and that is because she has brought this issue back here eight times. What I am about to say is in no small part due to her persistence. We all know that, in this place, very little happens overnight. The only way we achieve change is by doggedly continuing to push until something happens. I think she will be pleased with what I am about to tell her, but there is also something we will need her and the campaign to do to continue the momentum.
I thank the hon. Member for her continued campaigning, and I am delighted to respond to the debate. A hysteroscopy can be an essential tool in the diagnosis and treatment of conditions. What she referred to in, I think, Rebecca’s experience was a biopsy that is taken to look at tissues, for various reasons. Hysteroscopies are most important in investigating unexplained and distressing problems—they are a timely diagnosis tool—and can be used as a process for dilation and curettage. There are many reasons why women need them.
I am almost loth to read out these words—the hon. Member can tell I am going off script here—but the answer always is, “It’s a very quick procedure, it takes 10 to 15 minutes. If someone is in pain, 15 minutes is a very long time. Who would want to be in labour for 15 minutes? It is a long, long time.
I am almost tempted to say, “Shall we put our hands up to show who in here has been through a hysteroscopy?”, but maybe it is not appropriate for me to say that. I think we all can understand what the experiences are like. Patient experience is significantly varied, so there will be patients who say they did not feel anything and there will be patients who have stories such as those of the people the hon. Member has spoken to.
The NHS does not collect data on the number of women who experience pain— surprise, surprise—during hysteroscopy. However, I am aware that the Campaign Against Painful Hysteroscopy estimates that between 5% and 25% of hysteroscopy patients have reported pain, and 25% is a considerable number. It is essential that women who are offered a hysteroscopy are given the information that they need to make that informed decision, which must include information about potential pain, options for pain management and alternative procedures that are available, such as a general anaesthetic.
I will address the points the hon. Member made regarding whether women are being offered appropriate pain relief and her concern that the national tariff—I completely agree with her here—creates an incentive for hysteroscopies to be carried out as an out-patient, without appropriate pain relief for those 25% of women. I will talk about three components to ensuring that women receive the care they deserve: evidence-based clinical guidelines, embedding the patient voice and monitoring implementation.
To minimise pain and promote best practice in hysteroscopy, it is essential that clinicians have access to guidelines. The Royal College of Obstetricians and Gynaecologists currently has a guideline, produced in 2011, which provides clinicians with evidence-based information regarding out-patient hysteroscopy. The guideline has an explicit focus on minimising pain and optimising the woman’s experience. It makes specific recommendations on practices that help to reduce pain.
I am told that the RCOG is now developing a second edition of those guidelines to ensure that the recommendations are based on the most up-to-date and robust evidence base. It is being developed jointly with the British Society for Gynaecological Endoscopy, and patient groups are represented on RCOG’s guidelines committee and the development group. Furthermore, a statement from the British Society for Gynaecological Endoscopy, which was published on RCOG’s website in 2018, also emphasises the importance of offering women from the outset the choice of having the procedure performed as a day-case procedure under general or regional anaesthetic as an alternative to an out-patient setting.
Alongside clinical guidance, I note the importance of patients’ voices, which are critical at every stage of the treatment pathway. Decisions on any treatment, including out-patient hysteroscopy with its benefits and risks, should always be discussed as part of the shared decision making between the clinician and patient. I understand that since the last parliamentary debate on this subject in December 2018, the NHS website, as the hon. Member noted, has been updated. I thank her for pointing it out and enabling that to happen. The website has been updated and RCOG has published a patient information leaflet regarding the procedure.
NHS England recommends that, as part of good practice, the Royal College of Obstetricians and Gynaecologists’ patient information leaflet, published in 2018, is provided to patients in advance, to assist with obtaining informed consent for the procedure. I imagine by that they mean that it is sent out with the appointment for the procedure or handed out at the clinic.
The patient information leaflet contains a lot of helpful information for patients. It explains what the procedure is and what is involved, what the patient should do beforehand and the questions they should ask health care professionals, the risks and alternatives, after-effects and what will happen following the procedure. The leaflet also recommends that patients take pain relief one to two hours before the procedure. After a hysteroscopy, I encourage any woman to read these valuable resources, along with the additional resources provided by their clinician. First, before the procedure, women must be able to speak to their doctor or nurse about what to expect and about pain relief options, including local or general anaesthetic, but, as we know and as the Cumberlege report has recently shown us, women’s voices are very often not listened to.
Ms Dorries
That is distressing to hear.
Women should also be advised that the procedure can be stopped at any time— but, although they are aware of that, that is an incredibly difficult decision to make. When we are in pain, we do not think rationally. It is important to put this on the record as women must be informed of their rights and have their voices heard. Finally, after the procedure, if the woman believes that there have been issues with the treatment that should be raised with the trust.
I want to talk about progress. NHS England advises that progress is being made through the implementation of clinical guidance. Within that, commissioners, and providers should advise service user feedback to be monitored to identify where the guidance is not being followed. As the hon. Member may be aware, women’s health is a personal priority of mine, and I have been looking at improving the experiences of women in the healthcare system since I arrived in the Department. As I recently set out in my statement to the House on the Independent Medicines and Medical Devices Safety Review, we cannot accept the status quo whereby it takes women so long to have their voices heard and for their concerns to be taken seriously. Whether we are talking about the Shipman or Paterson inquiries or the Cumberlege review or another maternity incident, it is sobering to reflect on the amount of inquiries that we have taking place that are about women-only issues. As I work with the team to evaluate every recommendation and every aspect of the Cumberlege review, I want to assure the hon. Member and the House that it remains an absolute priority of mine to tackle these issues.
I understand that the hon. Member has ongoing concerns with the best practice tariff. The aim of the best practice tariff is to encourage procedures in an out-patient setting where clinically appropriate. Out-patient procedures provide the patient with a quicker recovery, as well as allowing them to recuperate at home. I understand that NHS England and NHS Improvement will shortly be engaging with the sector on policy proposals for the 2021-22 national tariff. The tariff engagement document due for October publication will lay out NHS England and NHS Improvement’s initial proposals for the 2021-22 national tariff and will be followed by a statutory consultation. I understand, drawing on the momentum created by changes in the payments system this year due to covid-19, NHS England and NHS Improvement expect to propose an accelerated shift towards the use of a blended payment approach. This proposal would include the majority of services providing hysteroscopy. Blended payment would not differentiate between in-patient and out-patient procedures and, as such, the out-patient procedure’s best practice tariff would no longer be necessary. NHS England and NHS Improvement are currently planning to propose the removal of the best practice tariff from April 2021.
I hope the hon. Member will be pleased to hear this update, and I encourage her and patient groups to comment and contribute to NHS England and NHS Improvement’s proposals both in the tariff engagement document and the subsequent statutory consultation. I myself will be contributing to that consultation.
Once again, I thank the hon. Member for raising this important matter for discussion. She raised the issue of what was the women’s taskforce. I am not aware of any work that has taken place so far on hysteroscopies, but I will look into that. What I will say is that we have established something called the women’s health agenda, which has met this year. Sadly, it had to be stopped because of covid. We are already looking at restarting that agenda now and hysteroscopies will very definitely be on the table, as with all women’s procedures, when we are discussing the women’s health agenda. I really feel strongly that there is more we can do to ensure that we empower women to talk about their health, and I hope that we enjoy better outcomes as a result. Women are not listened to. They are not listened to in so many areas within health as a whole, and we have to change that. We have to ensure that a woman’s voice is heard throughout all the settings in the NHS.
Madam Deputy Speaker (Dame Eleanor Laing)
I have heard this debate before, and I am very, very glad to hear that progress is being made. Fifteen minutes is the time that the Minister took to speak, not two minutes. [Interruption.] No, I am not criticising the Minister. I am pointing out that being in pain for the whole of the Minister’s speech would not have been amusing.
Madam Deputy Speaker
We were not in pain for that time.
Question put and agreed to.