Gynaecological Services: Waiting Lists

Emma Hardy Excerpts

Wednesday 6th July 2022 Westminster Hall

[Emma Hardy (Kingston upon Hull West and Hessle) (Lab)]

I beg to move,

That this House has considered waiting lists for gynaecological services.

It is a pleasure to serve under your chairship, Mr Robertson. I start by thanking the many women who have contacted me about this issue, whether in my role as co-chair of the all-party parliamentary group on endometriosis or as chair of the all-party parliamentary group on surgical mesh. The APPG on women’s health has been in contact, and we have also received testimony through the House services from so many women raising their concerns about gynaecological treatment. I thank the Minister for still being in his place to respond to me at the end of today’s debate—it is appreciated.

The debate will focus on the length of waiting lists for gynaecological treatment, and the amount of time people spend on those lists. It has been prompted by the findings of the Royal College of Obstetricians and Gynaecologists report, “Left for too long: understanding the scale and impact of gynaecology waiting lists”. However, I remind Members that when we talk about statistics, it is easy to forget the real people who lie behind them—those individual lives—who do not exist in isolation. When people’s health is impacted, it impacts their families, their friends, their communities and their work. As we will hear, the length of waiting lists is prolonging the suffering of tens of thousands of women, and that suffering has physical, economic and emotional costs.

Gynaecological waiting lists across the UK have now reached a combined figure of more than 610,000—a 69% increase on pre-pandemic levels. An observer might say, “Well, of course. There’s been covid, there’s been a pandemic—what do you expect?” The total pausing of elective care at the start of the covid pandemic has, of course, had an impact. That observer might add, “Our NHS has been chronically underfunded for the past 12 years. There was a steady increase in waiting lists even before the pandemic, and the 18-week waiting time standard for planned elective care has not been met since 2016, so why are you just having a debate on gynaecological treatments? Why not have a debate on waiting lists in general?”

The answer is that RCOG’s analysis shows that gynaecology waiting lists in England have seen the largest percentage growth of all elective specialities, and the largest percentage increase in patients waiting over 18 weeks from referral to treatment. The number of women waiting over a year for care has increased from just 66 in February 2020 to nearly 29,000 two years later, at the end of April 2022—the highest number ever recorded. Concerted efforts across the NHS to focus on longer waiters—that is, patients who have been waiting over a year—have resulted in a drop across all specialities combined from the peak in 2021. However, for gynaecology procedures, the numbers are going in the opposite direction: while we are seeing a reduction in waiting over a year for other treatments, we are not seeing the same for gynaecological treatment.

In addition, we have the prospect of even more cases in the pipeline. Analysis by Lane Clark and Peacock’s health analytics team on behalf of RCOG shows that between March 2020 and November 2021, more than 400,000 women who were expected to join the waiting list based on referrals in previous years did not do so. Therefore, those people are missing from the data I have just mentioned. The number of missing referrals tended to be higher in areas where the waiting lists were already larger. Perhaps that means that women in areas with longer waiting lists are, coincidentally, not going to their GPs, or perhaps it is because they are not able to see their GPs, or their GPs are not responding to those longer waiting lists. We are not quite sure what is going on, but what we do know is that lots of women are not getting the treatment they need.

As I mentioned at the beginning of my speech, I am co-chair of the all-party parliamentary group on endometriosis and chair of the APPG on surgical mesh. Both come under the heading of gynaecological conditions, and both are being impacted by increased waiting times. Endometriosis is the second most common gynaecological condition. It impacts around 1.5 million women—one in 10—in the UK and can affect all women and girls of childbearing age. It is caused by cells that usually form part of the womb lining growing elsewhere in the body, but they still react to the monthly cycle of hormones that regulate a woman’s period. That can create extreme pain and fatigue, because the cells are growing in completely the wrong place.

Part of the APPG’s role is to raise awareness of the condition and get people to talk about it. One in 10 women have it, but I am not sure that one in 10 people in the country know anything about the condition or the fact that it even exists. Many of the sufferers are facing increased waiting time for the procedures I am highlighting today. Even pre-pandemic, people were waiting on average seven and a half years for a diagnosis.

I want to quickly mention surgical mesh, because tomorrow is the second anniversary of the report “First Do No Harm”, which was commissioned by the then Secretary of State for Health and Social Care, the right hon. Member for South West Surrey (Jeremy Hunt), and undertaken by Baroness Cumberlege, to look at the condition. Surgical mesh was used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. It was promised to be simple and quick, but for some it has resulted in severe complications, including chronic pain, infections, reduced mobility, sexual difficulties and autoimmune issues. Lives have been shattered and the issue of mesh injury, along with the scandal surrounding hormone pregnancy, resulted in the “First Do No Harm” report.

Women have been left disabled by the mesh treatments. One of the key recommendations of the report, which, to the shame of this Government, are still not fully implemented two years on, was the establishment of specialist mesh treatment centres. Some of these have opened, but they are beset with problems over access, waiting times and cancellations. Through my involvement with these centres, I have heard at first hand the testimony of so many women whose lives have been blighted by what are currently referred to in the NHS as “benign” conditions. Yet, as we have heard, these conditions can be so painful and debilitating that they impact on every aspect of family, social and work life.

One lady, Kelly, said:

“The impact the long waiting lists have on my life is horrendous. I have endometriosis and adenomyosis and the daily pain these conditions cause me is terrible. Some days simple tasks like walking are unbearable. I have been on the waiting list for surgery for my endometriosis since 2019, and the length of time I am currently having to wait and the symptoms I am having to deal with daily are massively affecting every aspect of my life and having a profound effect on my mental health. I have been told that despite going on the waiting list for surgery in 2019 I will likely be waiting 4 years to get my surgery. Every day is a struggle.”

These conditions are not benign and cannot wait.

“Benign” suggests that there is no harm in delaying treatment, but that is emphatically not the case. For both endometriosis and mesh injury, longer waiting times can have a significant impact on progression. As time passes, options narrow, opportunities are lost and surgery becomes more lengthy and complex. Mental health deteriorates and depression, anxiety and suicidal thoughts become more common.

This is borne out by the most recent data from RCOG. Nearly three quarters of the members surveyed felt that they were seeing women with more complex care and treatment needs as a result of waiting longer for care, resulting in worsening and often extremely debilitating symptoms. Four fifths of the women surveyed reported that their mental health had been negatively impacted while waiting for care. So why are the waiting lists for gynaecological treatments growing? Is it the lack of priority they have been given simply because they are considered benign and not a threat to life? Or is it because gynaecological treatment is the only elective treatment unique to women?

There is undeniably a problem with the health service’s attitudes, in some places, to women’s health, where it involves reported symptoms and the voice of the patients themselves. I stress that I continue to give my wholehearted to the medical profession and everything it does, but there seems to be a concern particularly around the treatment of women’s health conditions.

“First Do No Harm” contains a section headed, “‘No-one is listening’—The patient voice dismissed”. In this case, “patient” is synonymous with “woman”. Although the following passage from the report refers to “mesh complications”, it applies equally to any other gynaecological condition. The report, published two years ago tomorrow, says:

“Women, in reporting to us their extensive mesh complications, have spoken of excruciating chronic pain feeling like razors inside their body, damage to organs, the loss of mobility and sex life and depression and suicidal thoughts. Some clinicians’ reactions ranged from ‘it’s all in your head’ to ‘these are women’s issues’ or ‘it’s that time of life’ wherein anything and everything women suffer is perceived as a natural precursor to, part of, or a post-symptomatic phase of, the menopause. For the women concerned this was tantamount to a complete denial of their concerns and being written off by a system that was supposed to care.”

Amatullah said:

“My GP actually laughed at me when I initially expressed concern that my condition was worsening despite my family history. I had to be hospitalised with suspected appendicitis before I was taken seriously enough to have more testing to see if my fibroids had grown. They had doubled in one year.”

Joanna said:

“As a newly qualified junior doctor, who hopes to specialise in gynaecology, I can’t stress enough how important this debate is. For too long, women’s pain has been ignored or dismissed. The topic is considered taboo despite it being something that a significant percentage of women experience.”

Do such attitudes reflect the prioritisation of gynaecological procedures? The facts certainly point to its neglect in comparison with other procedures. In the RCOG report, both the women and the RCOG members surveyed describe the way in which gynaecological conditions were perceived and prioritised as one of the biggest barriers to reducing the length of the wait time.

I want to quickly mention the data that I was sent from the APPG on women’s health. This is from its “Informed Choice” report of 2017. The APPG’s survey of 2,600 women showed that 42% were not treated with dignity and respect; 62% were not satisfied with the information that they received about treatment options; and nearly 50% of women with fibroids and endometriosis were not told about the short or long-term complications from their treatment. That information is from 2017, so we cannot put all that down to the pandemic. I hate to say this, but there is a problem with people’s attitudes to women’s health when it involves reported symptoms and the voice of patients.

When the Government finally publish their women’s health strategy—something the Labour party has been calling for since 2019—they should include an investigation into possible gender bias in the prioritisation of gynaecological services, and an end to the use of the term “benign gynaecology” to describe gynaecological conditions such as endometriosis, fibroids and polycystic ovary syndrome. There needs to be a shift in the way gynaecology is prioritised as a speciality across the health service. I understand that the RCOG is keen to engage on that with the NHS in all four regions.

I have given a few examples, but there are so many more. I really was inundated with testimonies from women ahead of this debate. There were so many cases and examples of the terrible effects that a prolonged wait for treatment can have. The prioritisation of care as part of NHS recovery must look beyond clinical need and consider the wider impacts on patients waiting for care. There must be a significant re-think in the development of a prioritisation framework for recovery that considers the impact of ongoing symptoms on an individual’s physical and mental health, their quality of life, their fertility, and their ability to participate in work, family and social life.

The RCOG has offered to work with stakeholders across all surgical specialties and the NHS to look at what the framework could look like in practice. We have an unequal growth of gynaecological waiting lists compared with other specialities, and that must be addressed as a matter of urgency. We have seen that there is in all likelihood a huge reservoir of unreferred cases, which will only worsen an already unacceptable situation. The RCOG is seeking a national ringfenced budget for recovery and long-term sustainability of elective gynaecology, with national funding to support local solutions. We obviously need to focus that funding on areas with the longest waiting lists and where disparities are greatest.

The NHS in each nation should commit to tracking and publishing progress on reducing disparities in elective waiting lists. The Government must use the women’s health strategy to commit to mandating co-commissioning of sexual and reproductive healthcare, removing the barriers for services outside of hospitals to support women in their communities.

Finally, Conservative Governments have presided over more than a decade of underfunding in our NHS, and that must be addressed. RCOG members were very clear that staffing is the biggest barrier to reducing waiting lists in outpatient settings and in theatre, and to increasing the number of beds. In March, unfilled posts across health services in England rose to more than 110,000, including nearly 40,000 nurses and over 8,000 doctors. Yet nearly 800 medical undergraduates who applied to start training as junior doctors at the start of August this year have been told that there are no places for them—that is the highest number ever. And despite an increase in applications for nursing degrees this year, the number of applicants remains below that of 2016, which incidentally was the last time that a bursary was available to financially support student nurses before it was scrapped.

The answers to gynaecological waiting lists lie in front of us. However, without the necessary action from Government and the funding to increase staff numbers, there will be no sustainable solution to reducing them. Instead, the Government are content to let the NHS limp along, understaffed, overstretched and with record waiting lists and the personal suffering and wider damage to society that they bring.

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[The Minister for Health (Edward Argar)]

I would just say that if I am still in post on Sunday, I will be the third-longest serving Minister of State for Health since 1970, but only time will tell. I congratulate the hon. Member for Kingston upon Hull West and Hessle (Emma Hardy) on securing this debate about waiting lists for gynaecological services. I know this is a very important subject for her, and I would like to take a moment to highlight her well-known focus in this House on women’s health matters and the work she has done in that space, which reflects the importance many of our constituents attach to these issues.

As has been alluded to, the hon. Member for Kingston upon Hull West and Hessle has done important work on the suspension of the use of vaginal surgical mesh. She has also worked to promote menstrual wellbeing and worked with Endometriosis UK. I congratulate her on that. It is always a pleasure to answer a debate of hers or to respond to her in the Chamber. It is also a great pleasure to be able to respond to the hon. Member for West Ham (Ms Brown), who as ever gave a typically powerful and forthright speech. She highlighted some harrowing examples—as the shadow Minister put it—that illustrate the broader issues around hysteroscopy and particularly the challenges around the NHS listening and acknowledging patients’ genuine concerns and requests. I will return to that in a moment. Normally at this point I would offer to meet with the hon. Member for West Ham to discuss this, but I will instead offer that the relevant Minister meet with her to discuss this matter further and the specific points she raised with her typical forthrightness and expertise.

The covid-19 pandemic has left a large backlog of people needing care. The latest figures show that 6.53 million people are waiting for NHS care, with 1.55 million of these waiting for diagnostic tests. As part of this, the waiting list for gynaecological services has over 28,800 people waiting longer than a year for care. We are working hard to reduce the number of people waiting for these vital services as swiftly as we can. It is promising that activity levels have reached 95% of their pre-pandemic levels in this area, but that is still 5% short of what normal activity would have been pre-pandemic. We recognise that more needs to be done in this space.

We are increasing capacity for gynaecological surgery to tackle long waits in two key areas: first, through surgical hubs, which allow for higher volumes of care to be carried out in protected circumstances, reducing the risk of covid-19 infections; and secondly, through the high-volume, low-complexity programme, which allows increased volumes of surgical procedures to be carried out. To support services further, we have grown the workforce in gynaecology with the addition of 108 consultants this year, bringing the total number working in obstetrics and gynaecology to over 6,400, an increase of 681 since 2019.

The hon. Member for Kingston upon Hull West and Hessle rightly highlighted a number of key points, one being staffing and another being funding, which is also about facilities and their availability. That is why we increased funding by £33.9 billion in the legislation passed in early 2020 to reach a certain level by 2023-24, plus we provided additional funding throughout the pandemic. We recognise that there is a lot more to do.

The hon. Lady also talked about prioritisation and ringfencing. The only note of caution that I will set out about ringfencing particular parts of budgets is that often it is more effectively done by local clinical systems than by me or another Minister. Often those systems are best placed to work out what their priorities are, based on their waiting lists, population health and population need. I hope that integrated care systems will play an increasingly large role in understanding that, and adapting to the needs of local areas.

Turning to the women’s health strategy, which I know is a central element of the way the Government propose to move forward. Across women’s health we are working to deliver better care through the first women’s health strategy for England, which will reset the way in which the Government are looking at women’s health. That will correct the way in which the health system has in the past been set up—it is fair to say, although hon. Members may disagree—by men and for men. That is the historical evolution of our health service. Huge progress has been made, but there is more to do, which is why that focus is necessary.

Work on the strategy began in December 2021, when we published “Our Vision for the Women’s Health Strategy for England”. We announced in that vision that we are appointing the first ever women’s health ambassador for England. In June we announced the appointment of Dame Lesley Regan to that role. She will focus on raising the profile for women’s health, increasing awareness of taboo topics, and bringing in a range of collaborative voices to implement the women’s health strategy. To reassure the hon. Member for Kingston upon Hull West and Hessle, we do aim to publish the strategy before the summer recess. The relevant Minister will aim to do that.

[Emma Hardy]

When that is published, will it include the point I made about looking at whether there is a gender bias in the prioritisation of health treatment? That was something that the RCOG was really keen to emphasise. Everyone understands that covid meant waiting lists for everything. One of my key points was whether there is a gender bias? Is that partly why gynaecological treatment seems to be delayed more than others?

[Edward Argar]

I do not want to prejudge the specifics of that strategy. In broad terms, I hope that I can reassure the hon. Member that we are seeking to look at all the drivers of the challenges that she and other Members have highlighted, and seek to address improvements. Without prejudging, there are points made by hon. Members that I would expect to see included around information, engagement, guidance and empowerment. The importance of empowering women, believing them and engaging with them came through very clearly in the hon. Member for West Ham’s comments.

--- Later in debate ---

[Edward Argar]

The challenge that the hon. Lady poses is that if we are talking about, essentially, the multi-hospital trusts or similar, as they have grown up, they have often designed their services in x specialism in one hospital, and moved things around like that. In those cases, there are often only one or two hospitals within the trust that do it. We are seeking to try to create greater choice across the entire system, including regionally, which genuinely builds choice. That is a big challenge—Governments of both complexions have tried it with varying degrees of success—but that is what we are seeking to do here. However, there is a lot of work to do in that space. I hope that when she sees the strategy she will recognise the degree of underpinning research that has been done. It may not necessarily cover every point that she has focused on, but I hope she will recognise the amount of work that has been done.

[Emma Hardy]

I thank the Minister for again giving way. When we see the women’s health strategy, will it respond to all of the recommendations from the Cumberlege review? We had a bit of an interim response to the review, but I am sure the Minister will be aware that there is still a cross-party campaign to ensure that all of those recommendations are fulfilled. If he ever does happen to find himself on the Back Benches, he is more than welcome to join any of my APPGs, and any of those campaigns, from a different side. I would be keen to know whether he is aware of any plans to fully address the report and fulfil those recommendations.

--- Later in debate ---

[Emma Hardy]

I thank everyone who has taken part in the debate. In different circumstances this would have been a very full debate. I look forward to seeing the women’s health strategy as soon as possible. I feel I have been unable to give coverage to the number of women who have contacted me, but I say to them that I have read each and every one of their messages. The testimony that they give is incredibly moving, and clearly something needs to change.

Issues around women’s health appear to be disproport-ionately impacted, and that is not right. I am sure we will all raise this subject again and, in all sincerity, the Minister is always welcome to campaign with me on this issue from the Back Benches.

Question put and agreed to.

Resolved,

That this House has considered waiting lists for gynaecological services.