NHS Hysteroscopy Treatment

Lyn Brown Excerpts

Tuesday 31st January 2023 Westminster Hall

[Ms Lyn Brown (West Ham) (Lab)]

I beg to move,

That this House has considered the matter of NHS hysteroscopy treatment.

It is an absolute pleasure to serve under your chairship, Sir Mark. I am particularly glad to be joined in this debate by hon. Friends and by the hon. Member for Thurrock (Jackie Doyle-Price). When she was responsible for women’s health, she took this issue seriously. We had a number of highly productive meetings about it, so it is welcome that we have the benefit of her ministerial experience in the debate.

This is the 10th time that I have spoken in this House about the completely unnecessary pain and trauma that women are subject to when they undergo hysteroscopies. Women who need pain relief are simply not being given it. They are being patronised, belittled and, frankly, betrayed. Effectively, they are bullied into accepting treatment so painful and damaging that they would never have agreed to it had they known what was coming.

I first spoke about how this issue needed to be resolved 10 years ago, at the behest of a constituent who came to my surgery to talk to me about her experience. Frankly, I am horrified that precious little seems to have changed since then. I will share a few of the recent stories that women have sent me since the last time I spoke about hysteroscopies in this place. I have had to choose very carefully: the number of women who have written to me is large, but my time this afternoon is short.

Julie had a hysteroscopy in July last year. She is 71 years old and wears hearing aids. Julie thought she was going in to see a gynaecologist and perhaps to have an ultrasound to investigate unexpected bleeding. She had been given no additional information, despite having waited for that emergency appointment for six long months. I can imagine how frightened she was. As expected, Julie’s appointment started with an ultrasound; unfortunately, the scan showed some thickening in the lining of her womb. Julie had removed her hearing aids to avoid losing them, which had happened before, so she could not clearly hear what was being suggested, but she was told that another procedure was necessary. A different nurse came in, and that was the very first time that Julie heard the word “hysteroscopy.”

Julie was, of course, a little confused about what was happening, because she could not hear properly, but she managed to make out that she might feel some mild cramping as the fluid and the scope were inserted. However, she describes the pain as utterly excruciating. The nurse tried to talk her through it and take her through breathing exercises, but they did no good—how could they? Julie was in a clammy sweat; she was worried that she would pass out. She was asked whether they could continue, and she was so worried about the ultrasound findings, and the last six months’ wait, that she said they could. A second attempt was made. Julie simply could not hold back her tears, or even breathe, through the terrible pain. Thankfully, the nurse asked again whether the procedure could stop, and Julie could say nothing but yes.

Afterwards, Julie was terribly woozy. She was wobbly, and scared that she would faint and fall. She was well cared for at that point—given pads for the bleeding and hot packs to help with the severe abdominal cramping. She lay in the recovery suite for about an hour, crying. Even after that, she was disassociated, trembling and struggling to walk. I remind hon. Members that she is 71 years old. She is truly lucky that she did not fall and break something.

Another woman who wrote to me was so overwhelmed by the pain of her hysteroscopy without pain relief that she fainted and fell from the full height of the operating bench to the floor. After that, she was left with not just serious bruises but lasting dizziness that has led to repeated falls and broken bones. It has physically affected her so badly that she has found it hard to stay in work for the very first time in her life.

In some ways, Julie was lucky, but the lasting impact on her was still significant. She vomited, and when she got home she continued to bleed for more than a week afterwards. She describes herself as stoic. She has had several surgeries before, and she lives with serious arthritis, so she is no stranger to pain. In her words, what she went through was “a brutal, torturous experience”.

The shameful truth is that at no point was Julie offered any form of pain relief at all. She only heard that a hysteroscopy was even a possibility while lying on the examination table with her legs up in stirrups. It is frankly a miracle that she was not so traumatised as to lose trust completely in the NHS, but she has since been back. She has had another hysteroscopy under general anaesthetic and found it an utterly different experience. All the procedures and risks were explained beforehand, and she had outstanding care throughout.

While Julie was in the waiting room for the second, successful hysteroscopy—this points to how commonplace this experience is—she met another woman whose experience was just like hers. The other patient was just as upset, but said she would not make a complaint because she felt she would just be ignored, and that would make her even more stressed. Sadly and understandably, most people who have had similar terrible experiences with the procedure are like the woman Julie met. We never hear their stories.

Let me offer some more testimonies to give voice to those whose pain and distress were completely ignored. Martha was seriously injured during her hysteroscopy last August. She went in for a check-up after she had bleeding for several days after starting hormone replacement therapy. Her GP referred her for the hysteroscopy, but although he explained some of what the procedure would involve, he was, in Martha’s words, “blasé”. He showed absolutely no understanding that Martha’s medical history and conditions made extreme pain and damage much more likely. When the procedure began, Martha described the pain as “excruciating”—exactly the same word that Julie used.

Martha screamed out, “No, no, stop,” repeatedly, yet when the doctor looked at her, he looked very unimpressed. He asked her whether she would rather he stopped so she could come back and have it under general anaesthetic. She said yes, but instead of listening, he insisted that he have more time—just 30 seconds. He went in again with a smaller scope, but again it caused searing pain.

After the procedure, Martha understandably felt violated, but sadly that was far from the end of her ordeal. She had burning pain for weeks, mixed with a loss of feeling in her groin. She developed repeated bladder infections and double incontinence, and her muscles started wasting. She had difficulty standing and walking. Eventually, Martha was told that she had post-operative nerve damage. To put the cherry on the cake, I understand that the doctor who did this to Martha recorded her pain score as just one out of 10. To me, this sounds very much like fraud—on top of sheer callousness, absolute incompetence and indifference.

Martha describes herself as a fiercely independent woman who does not suffer fools, but she told me she had the overwhelming feeling she had been duped and made a fool of. She says she has always trusted professionals, but never, ever again. She is reeling because the NHS that she supported for decades

“managed to injure me and cripple my life, take my self-respect and my confidence in under 15 minutes.”

Martha tells me—I think she might be right—that the next great women’s health scandal after mesh implants will be this.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

I am really appalled, and I want to raise a point with my hon. Friend. The situation Martha found herself in is happening up and down the country. A constituent who was due to have a hysteroscopy examination at our local hospital in Salford was told the same thing as in the stories my hon. Friend is telling: “Local anaesthesia can be given if necessary” and “Take paracetamol one hour before.” However, this constituent had a family member who had had a hysteroscopy in a private hospital and was offered a general anaesthetic because the procedure was “too painful” to be performed in any other way. So the NHS patient in a private hospital is offered a general anaesthetic, but the one in an NHS hospital is not. When I wrote to the hospital on my constituent’s behalf, I was told:

“a general anaesthetic can be requested, though the medical team advise against it.”

There is a key question that I want to put to my hon. Friend. It is all right to say that the procedure can be stopped or carried out later, but does she believe that the information given to patients is wrong and that that is not acceptable care?

[Sir Mark Hendrick (in the Chair)]

Order. Can I ask that, when hon. Members intervene, they make it short?

[Ms Brown]

I agree with my hon. Friend that there is a massive lack of information. I am sure there is a difference between private and public health in this area, but a friend of mine went to a London hospital and asked whether she could be given a general anaesthetic. The answer she got was, “Of course. Do you think we’re barbarians?” There is different practice in different NHS hospitals, and a different understanding of the kinds of issues we face.

I think we all know the upshot of these kinds of experiences: women will end up too afraid to get procedures that they need to have. It will impact on their long-term health prognosis. It will cost the NHS more in the future, as it has to play catch-up on diagnosis. As we know, hysteroscopies are really important. They can be used to rule in or out cancer and a host of other important conditions, so women have to be confident about having them. They need to have them, and they need to know that they will not experience what Julie, Martha and so many more women have experienced.

The survey being run by the Campaign Against Painful Hysteroscopy has had over 3,000 responses and counting. Despite that, and despite all the individual stories I receive and raise in Parliament, we simply do not know how widespread the problem is. I am afraid that the reason might be that the NHS really does not want to know, because knowing would strengthen our calls for change and for all women to be treated with respect, to have their pain taken seriously and to be given accurate information and genuine choice. For that to happen, I believe that the Minister has to engage with this issue personally and dig a bit deeper to ensure that accurate and appropriate data is being collected and analysed. We also need independent oversight. I beg the Minister not to be content when, inevitably, the medical profession says, “It’s fine” and “Action is being taken,” because, frankly, it has been 10 years, and we have heard it all before.

I am sure the Minister will remind us about some of the campaign successes, such as scrapping the best practice tariff, which until very recently financially rewarded NHS trusts for doing hysteroscopies in out-patient environments, where proper anaesthetic is not possible. Sadly, that drive for more cheap, quick hysteroscopies, regardless of the risk to women’s health and wellbeing, is still going strong. The target of 90% of hysteroscopies to happen within out-patient rooms has emerged again in a new NHS programme, which, ironically, is entitled “Getting It Right First Time”. I can tell the Minister that if women continue to be pushed into hysteroscopies without proper care, the NHS will not be getting it right first time at all. Instead, more women will endure pain for no reason at all during unsuccessful procedures, and they will then have to repeat those procedures under general anaesthetic.

It appears that the target of 90% is the brainchild and objective of the British Association of Day Surgery—well, I am sure there is no vested interest there. It is frankly alarming that we have a clinical lobby group advocating, effectively, against women having a genuine choice over the pain relief they need when they have a hysteroscopy. What is worse is that I understand that some private companies are promoting their no-anaesthetic out-patient procedures within the NHS by bragging that hospitals can save up to £1,000 per patient. You could not make it up. Clearly, there are some very influential people who do not want this campaign to succeed and who prioritise saving money—or making money—over women’s safety from pain and trauma.

I know how busy the Minister is, but we ain’t going to be successful in our campaign for pain-free hysteroscopies without Government leadership. I was pleased to hear last night that the Minister’s office has contacted the campaign group offering times for a meeting. That is good news. I strongly agree with some of the Minister’s words in response to one of the anonymous women whose cases I have raised today. Let me quote the Minister:

“It is clearly important that women are offered, from the outset and as part of the consent process, the choice of having the procedure performed…under general…anaesthetic.”

I ask the Minister to emphasise that point today, because women cannot give truly informed consent unless they have had a full discussion—including a discussion of their individual risk factors and a choice of anaesthetic—from the very start. In my view, that means that Julie, Martha and so many others have had a surgical procedure performed on them without consent. I am sure we would all agree that that is very serious indeed. When the Minister responds, I hope she will commit to treating this issue as a high priority for women’s health. We do not want women to be bullied when they go into the NHS for treatment.

We are eagerly awaiting the publication of the good practice paper from the Royal College of Obstetricians and Gynaecologists, and other new guidance—I had hoped to have it yesterday in order to inform this debate. I understand that the draft paper recognises that fully one third of women report pain scores of between seven and 10 out of 10. That clearly shows that we need a massive change. The need for real choice cannot just be in guidance; it also needs to be enforced.

Based on the recent stories of women that I have told today, in many cases we are seeing brutality instead of best practice. Women are being violated and betrayed. Their trust in the NHS and medical professions is completely undermined. Surely that cannot be a legacy that the Minister, or the Government, want to leave behind.

[Sir Mark Hendrick (in the Chair)]

Thank you. I remind Members to bob if they wish to speak.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Sir Mark. I congratulate the hon. Member for West Ham (Ms Brown) on securing this important debate. As Minister, I also responded to her debate on the subject last year and I recognise her campaigning on the issue.

First and foremost, I recognise the pain suffered by women during the hysteroscopy procedure. Many women have contacted me to share their stories and distress. The testimony of the shadow Minister, the hon. Member for Enfield North (Feryal Clark), was powerful in explaining the distress the procedure can cause.

We have seen some progress around the tariff issue, which I will touch on later in my remarks. Last year, the tariff system financially rewarded out-patient settings that undertook hysteroscopies, but that has changed. However, I take the point made by the hon. Member for West Ham about getting it right first time. I may be doing the same with a new initiative, so I will certainly commit to looking at that.

We heard about patients such as Julie, and about how, right from the very start, an appointment letter is sent out that does not provide information about what to expect or the choices that are available. We heard about the procedure itself, including what pain relief is given, and the need to give women informed consent—they can have a general anaesthetic or ask for the procedure to stop. Another 30 seconds is not the answer to “stop”, and that would be my first concern.

My hon. Friend the Member for Thurrock (Jackie Doyle-Price) made a valid point about why the procedures are being done in the first place, and the testimony of Martha lends itself to that. Bleeding after HRT is very common for the first three to six months, and it is usually only after six months, or if there has been bleeding after long periods of non-bleeding, that perhaps an investigation could be considered. My hon. Friend pointed out that sometimes we carry out the procedure where there is not necessarily a clinical case for it. Both the procedure itself and the reason for it need to be justified in those cases.

As the shadow Minister said, hysteroscopy is an essential investigative tool. We do not want to put women off coming forward for diagnosis of their conditions or for investigations into distressing problems—whether it be heavy periods, miscarriages or difficulty getting pregnant—but it is true that women’s experiences of pain, and sharing those experiences with friends and family, can put women off or prevent someone from coming back for treatment or further investigation. Many women experience little or no pain, but the percentage that do experience pain is of significant concern.

The hon. Member for York Central (Rachael Maskell) highlighted the experience of Jan and the sheer scale of her pain. That was very powerful, and I reiterate to Jan’s husband, Steve, that her voice has been heard very powerfully in the debate. I am keen that we make progress on the issue, because we, like the hon. Member for West Ham, who comes on an annual basis, have been talking about it for far too long. I am keen to meet with the Campaign Against Painful Hysteroscopy group, and hope to do so fairly soon, to discuss how we can take the issues forward. A general anaesthetic can be used in some circumstances, but there are also a range of other anaesthetics—it does not have to be general anaesthetic—to make the procedure less painful.

For most women, the first issue is choice, having information about what to expect up front and being able to make a decision based on that. That needs to be done in advance of the procedure and not, as my hon. Friend the Member for Thurrock described, when your legs are in the stirrups. That is why the guidance is so important. The Royal College of Obstetricians and Gynaecologists provides evidence-based guidance. It is old, and it is being updated. My understanding is that RCOG is producing a good-practice paper on pain relief and informed decision making for out-patient hysteroscopy that will be published imminently— I understand in days rather than weeks or months. I committed in the debate last year to wait for that, and I hope that it will be through fairly soon. If we can get those good-practice guidelines, it is essential that they are rolled out in practice.

[Ms Lyn Brown]

I do not really know how to phrase this, but part of the problem is that, as we have heard, gynaecologists are basically being utterly insensitive to the needs of the women they are treating. My anxiety is that we will be told, yet again, that it is all okay, and that they have changed this or tweaked that. But the stories that we have heard today are from this year, so there has not been change. I am not sure whether we will be able to manage change unless the Minister is quite firm about the actions that she wants to see.

[Maria Caulfield]

I very much take the hon. Lady’s point. The change to RCOG guidance is not the only way we will change this. The hon. Member for Strangford (Jim Shannon) highlighted his wife’s experience, which also shows why this is so important. The royal college is important because it can bring clinical change on the ground, but it is not enough just to assume that its updated guidance will be enough to change what happens in practice. Its current guidance already sets out that a leaflet should be provided with information about what a hysteroscopy is, what happens, and what the possible risks and alternatives are, but that does not always happen. Women can choose whether to have their hysteroscopy in an outpatient setting or have a general anaesthetic and come in as a day case. They do not always get that leaflet now, so just changing the guidance does not necessarily mean that we change the practice, and that is the key.

It is important that women are in control when it comes to hysteroscopies, which we are talking about today, and many other issues that we have debated. That is the fundamental principle behind the women’s health strategy, which we introduced because women are very often not listened to in all aspects of their healthcare.

The hon. Member for Enfield North touched on the top priorities for the first year of the women’s health strategy. The reason that hysteroscopy did not make that list is that we want to wait for the guidance before we act, but it will be a high priority, and work is starting this year.

One of the key priorities is to provide better information to women and girls about their health. We are setting up a space on the NHS website for women’s health so that women who are going for a procedure have go-to information. If they are thinking, “I don’t know what a hysteroscopy is. I don’t know what sort of tests I need. I am going for an ultrasound, but what else might they suggest to me while I am there?” they can go to that site and get reliable information that will help them make that decision. If they are not sent a leaflet and the procedure is not discussed in the clinic, they will be able to know in advance what to expect. We want that to happen this year so that women have more power when making decisions about their healthcare needs.

Waiting times for gynae procedures have not come up much today, but we know that the covid pandemic has had an impact on them. Gynae procedures are part of the elective recovery plan, which is why we are investing in community diagnostic centres to get those waiting lists down as quickly as possible. It is hoped that by having specialist centres such as community diagnostic centres, which are specialists in doing diagnostic tests, we may be able to improve women’s experience.

One of the things that will make the greatest difference is the appointment of Professor Dame Lesley Regan as the first women’s health ambassador—my hon. Friend the Member for Thurrock mentioned her. She is a female gynaecologist, and she completely gets the issues facing women. We also now have the patient safety commissioner, Dr Henrietta Hughes, who was appointed last year. She is a female GP. Dame Lesley has been passionate about this issue for many years and has been working with women’s groups on it. I have asked her and Dr Hughes to discuss hysteroscopies. They are planning a roundtable on the issue to get stakeholders round the table to discuss how we can make things happen in practice. If guidance is issued, how do we make sure that is what is happening on the ground? The roundtable will be chaired by Dame Lesley, and the patient safety commissioner will be attending. I will update Members on their recommendations, which I will take extremely seriously, and I will want to implement them as quickly as possible.

--- Later in debate ---

[Ms Brown]

We have had a really good debate this afternoon about the serious harms to women, the lack of respect and the lack of regard in this area of healthcare. I am really grateful to all the contributors, including the hon. Member for Thurrock (Jackie Doyle-Price)—we will march on with this one, I am sure. The hon. Member for Strangford (Jim Shannon), who has been at many of these debates, offered his support. My hon. Friend the Member for York Central (Rachael Maskell) shared a story that I recognise, which was tragic and sad. My hon. Friend the Member for Enfield North (Feryal Clark) did not tell me about her personal experiences before the debate—how brave and amazing that she stood up and told us all. I am genuinely grateful for that.

I think we all agree that we need informed consent, individual risk assessments and compassionate care in our health service. We need proper and independent research into the actions that are being taken, and we need action. We do not need to be back here in a year’s time, with me reading out people’s stories again, and we certainly do not need to be led in this debate by those who seek to profit from women’s pain.

I say to the Minister that the gynaecologist who saw my hon. Friend the Member for Enfield North was a woman. A few years ago, the gynaecologist who tried to talk me—a childless woman with a frozen cervix—into a hysteroscopy without an anaesthetic was a woman, and I worry that the idea that this is a pain-free procedure is somehow baked into the gynaecological community. However, I express my gratitude to the Minister for offering to stay in touch on this issue. Hopefully, we can get some resolution to the betterment of women’s health generally in the country.

Question put and agreed to.

Resolved,

That this House has considered the matter of NHS hysteroscopy treatment.