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House of Commons Hansard
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NHS: Hysteroscopies
11 December 2018
Volume 651

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I beg to move,

That this House has considered NHS treatment of patients requiring hysteroscopies.

It is an absolute pleasure to serve under your chairmanship, Mr Howarth. We know that hysteroscopies save lives, but all too often they cause excruciating pain and humiliation because some of the women who need them are not treated with the dignity, respect or even humanity that they deserve.

As hon. Members will know, a hysteroscopy involves the insertion of a camera into the womb, past the cervix, to look for abnormalities and potentially enable a surgeon to remove them. It can be used to rule out a diagnosis of cancer when women are experiencing heavy periods, unexplained bleeding, repeated miscarriages or difficulties in becoming pregnant, and it is a core part of the treatment for debilitating conditions such as fibroids and health risks such as polyps in the womb. However, for some women patients it causes severe pain, a sense of violation and lasting trauma.

The NHS website states:

“A hysteroscopy is not usually carried out under anaesthetic… Taking painkillers such as ibuprofen or paracetamol…can help reduce discomfort after the procedure.”

Unfortunately, many women experience severe pain during hysteroscopy. It is usually done with little or no anaesthetic, and many women are told nothing to prepare them for the agony that awaits. I have passed the Minister many dozens of anonymous cases from women who have experienced terrible pain at the hands of NHS surgeons and were ill-informed or misinformed about the pain risks and offered little or no pain relief. I am glad to say that she has always received those stories with sympathy, empathy and understanding, but I am receiving more and more of them all the time.

This is not an issue that gets huge acclaim or interest in the press. People are finding our campaign and Facebook page simply because they need to. I will put just two experiences on the record today.

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As my party’s health spokesperson, I am interested in all health issues, but particularly in this one, so I commend the hon. Lady for securing the debate. The National Institute for Health and Care Excellence guidelines published in March recommend that women should be offered an out-patient hysteroscopy if they have symptoms or risk factors associated with gynaecological conditions. Does she agree that that recommendation has not been translated into GP referrals? More must be done to ensure that those in need of the procedure, for the purpose of early diagnosis or the removal of issues, are referred and treated in an effective manner. It has to be done early, and that is where we fall down.

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I entirely agree, but the importance of early action is sometimes used to encourage or even force women to stay with a procedure that is causing them great pain because of the fear of what might happen afterwards. If the hon. Gentleman gives me a moment, I will illustrate that point.

In October, I heard from Jenny, who has undergone two hysteroscopies, both of which were traumatic. She told me:

“My first experience was shocking. I wasn’t prepared for it. The doctor didn’t warn me at all, and during the procedure I experienced the most unbearable pain ever and I almost fainted. I rose up from the bed that I was on and I shouted out. It felt like my insides were being ripped out. I wasn’t given the option to stop nor was I given any support.

The nurse was behind the doctor throughout the procedure and just watched as I suffered. After the procedure my legs were like jelly. I felt faint and in pain but I wasn’t even helped off the bed, I wasn’t even given a sanitary towel to help with the bleeding. I left the room and drove myself home in that state, I’m lucky I didn’t have an accident. I felt traumatised, in a state of disbelief and shock.”

What is even more shocking is that Jenny’s second hysteroscopy was also traumatising, even though she now knew the risks and had taken steps to ensure that the same thing would not happen again. She explained to her doctor what had happened and requested a female doctor the next time. Her doctor said that she would write that on the referral, and at her pre-hysteroscopy appointment Jenny was told that she could have an injection to numb the area. She was reassured and trusted the female doctor to be more careful, but the procedure was—again—horribly traumatising. Jenny said:

“My god it was shocking, I once again shouted out and raised from the chair this time. The nurse was trying to calm me down…while the doctor said she would stop at any time but she needed to go in again and take a biopsy. I was told that if she didn’t...the procedure would be incomplete and I would be left worrying that it could be cancerous. So I endured more excruciating pain.

I wasn’t given the option to come back and have the procedure done under general anaesthetic, which I have now found out could have been an option. I felt tricked into having the procedure.

I suffered with terrible pain for a week after. Mentally I was left traumatised and still am to this day.”

Understandably, Jenny is now scared about any gynaecological procedure—including smear tests, which she knows are essential for her health.

This autumn, Annie got in touch. Annie had had ultrasounds and smear tests before; like many others, she was given literature about her hysteroscopy that made her think that it would be no different. She was advised just to take paracetamol and ibuprofen before the appointment, and she felt confident. She told me:

“As the procedure began, I felt instant pain, so unexpected and intense that I began to cry and panic within seconds. I was asking the nurse if this was normal as I was so scared there was something wrong, and she nodded to reassure me. I couldn’t get my words out, I was panicking, going into shock. She offered me her hand to squeeze through the pain. I tried to be strong, but I couldn’t, I was yelling out in pain, shaking and crying.

The nurses were telling me to relax my legs but it was impossible. When the Dr began the biopsy it was by far the worst pain I have ever suffered. I was hyperventilating and the nurse was telling me to breathe, but I couldn’t. I endured pain for 15-20 minutes.

I was asked to wait before I stood up, and I was so traumatised and sobbing, I just couldn’t move.

After a couple of minutes I got up and had to put on a sanitary towel and get dressed. It was hard—I was disoriented and shaking.

I sat with the Doctor who told me that due to it being too painful I have to have polyps removed under general anaesthetic. I could barely talk to him due to shock and tears. I wasn’t even offered water, and nobody asked me how I was getting home.

I cried from leaving the hospital at 2 until my wife arrived home at 6, at which point I broke down uncontrollably in her arms. I felt violated and abused, and the procedure felt very very wrong.”

As we know, women are still having these terrible experiences. I received another story in the past two weeks, but I do not have time to share them all. Women are still leaving NHS care feeling violated, and it ain’t going to stop unless we choose to stop it. I am very grateful to the Campaign Against Painful Hysteroscopy for providing support to those women and making sure that they are heard. The campaign group’s petition has received more than 47,000 signatures, which demonstrates that this is not an unusual, occasional thing.

We have four asks. First, if we are to stop patients from being violated or misled, all NHS trusts need to provide accurate information that enables women to give genuinely informed consent. I was pleased to hear from the Minister that her Department is developing tools to improve hysteroscopy care; I look forward to hearing her elaborate on those tools, but involving patients will be essential to making them work. The campaign wants to see a new patient information leaflet made available across the NHS. Campaigners have been working with the Royal College of Obstetricians and Gynaecologists and with specialists to create an appropriate leaflet that patients who have had negative experiences of hysteroscopy have helped to write, but it still needs to be rolled out.

The leaflet needs to be honest with patients. It needs to warn that there is a real risk of severe pain during out-patient hysteroscopy, and explain the risk factors that make pain more likely. They should tell patients that they have the right to ask for the procedure to be stopped at any time and for it to be rescheduled with a full anaesthetic. Hospitals should no longer have any excuse to hand out literature stating there will only be

“mild discomfort, just like a smear”.

After they have read through the leaflet, patients should be given an opportunity to discuss with a trained doctor what is going to happen during the procedure—whether a sample is going to be cut out for a biopsy, the risks involved, and the anaesthetic choices available. The campaign suggests that both patient and doctor should then sign a consent form to confirm the discussion has taken place and the choices the patient has made.

Our second ask is for improved training to enable better and more consistent care. We know that hysteroscopy can be a painless experience for women—some women will experience little pain from hysteroscopy even with minimal anaesthetic—but as we have heard, for others it will be like torture. There are some risk factors—older women and women who have never had children are far more likely to experience severe pain during hysteroscopy—but we cannot tell in advance what someone will experience, and that means we have to improve the guidelines and raise standards through training. The current national guidelines, produced by RCOG and the British Society for Gynaecological Endoscopy, do not recommend several forms of anaesthetic that I am told could be helpful. That has to be looked at, because, for some patients, stronger forms of anaesthetic might be the only way to have a hysteroscopy without experiencing severe pain.

Once we have changed the guidelines, investment in training will be needed to embed new best practice across the NHS. Hysteroscopy nurses should be routinely asking for patients’ pain scores during the procedure, so that informed decisions can be made about whether to continue or to stop. We need to audit pain scores and keep records of how comfortable the surgeon was with continuing, so that we can monitor whether more training is necessary. It should be a basic element of training that hysteroscopy teams should simply stop the procedure if a patient is suffering severe pain—not just hold them down—and reassure the patient that the procedure will be promptly rescheduled with more effective anaesthesia, rather than using the threat of possible undetected cancer to encourage her to continue.

Our third ask is for enough resources to enable all NHS bodies, everywhere in the country, to give women the choice between different anaesthetics when they need a hysteroscopy. The problem is not just flawed guidelines and inadequate training. Trusts may be loth to enable anaesthesia beyond over-the-counter painkillers or local anaesthetic simply because other methods are more expensive. Some are in-patient procedures, and some require clinicians to have specific training, and we all know that that comes with extra costs.

Our fourth, and possibly most important, ask is for a change to NHS incentives for hospitals. According to the information we have, the Department of Health’s quality, innovation, productivity and prevention tariff encourages trusts to promote hysteroscopy without anaesthetic, rather than offering an open choice to women. Annex F to the 2017 to 2019 national tariff payment system is explicit:

“For...diagnostic hysteroscopy...the aim is to shift activity into the outpatient setting.”

The best practice tariff

“is made up of a pair of prices...one applied to outpatient settings, the other to...elective admissions. By paying a higher price for procedures in the outpatient setting, the BPT creates a financial incentive for providers to treat patients there.”

The national target is for the risky out-patient hysteroscopies to increase to 70% of the total, up from 59%. The Department for Health is not working to reduce pain and trauma for women—it is incentivising hysteroscopies without effective pain relief and is taking our choices away. It has to stop, and I hope the Minister will look at how she is going to stop it.

Those are our four asks of the Government, and I think the Minister will agree with me that they are entirely reasonable. I do not believe they would be massively expensive to implement, and we should also consider that current NHS practices may not be cost-effective. Women who have undergone a painful hysteroscopy may not return for other gynaecological tests and procedures. If they do not have those early preventive interventions, more costly interventions will be needed later.

Some action has already been taken. The issue has been raised with the national medical director of NHS England. I thank the Minister for that, and for launching her women’s health taskforce, which I would be interested to hear more about today.

I would like to say something about the history of the hysteroscopy campaign and the amazing women who have led it—I am delighted to see some of them in the Gallery today. With their support, I have regularly been raising this issue in the House for four years now. I cannot say progress has been easy or swift. At times I—we—have been ignored by the Government, despite strong cross-party support every time I have raised the issue. I have been left concerned that officials at the Department of Health, and some senior NHS managers, have not been willing to engage with the problem of women’s pain when the NHS is under financial stress.

However, this last year has been more hopeful. The Minister met me and a core group of campaigners last year, and listened with compassion to their stories. I believe she has taken this cause as her own. I am waiting with bated breath to hear what she is going to say today, and to hear about the rapid and dramatic progress we are going to be able to make on this issue over the coming year.

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It is a pleasure to serve under your chairmanship, Mr Howarth. It is an even bigger pleasure to respond to the hon. Member for West Ham (Lyn Brown). I pay tribute to the work she has done to highlight this issue, which has affected many women over many years who have been left to suffer in silence.

As the hon. Lady said, there were 47,000 signatures on the campaign petition, which is an indication of just how many women have been badly affected by what is actually a common procedure. It does not matter that it is only one in four, which is probably the most generous estimate. It could be as low as one in 10; it does not matter. We are talking about individuals who have been badly affected and who have been traumatised to the point where it effects their ability to look after themselves in the future. Frankly, it is no value to the NHS to leave those women suffering in silence, and I am very grateful to the hon. Lady for sharing the experiences of the women who have been brave enough to come forward.

The hon. Lady set me a challenge. She is quite right to demand swift action, because this has been going on for many years. She had four asks. On the first two, I will work with her and the campaign to make sure we can deliver them. They are extremely reasonable, to be brutally frank. On her third ask, we need to make sure that we have sufficient resource to enable women to exercise genuine, informed choice about how they take this procedure. On the fourth ask, about the tariff, notwithstanding the guidance about what might be best practice in most cases, we need to make sure that the tariff does not encourage perverse incentives that will disadvantage women. At the heart of all this, we need to ensure that running through every piece of treatment for women with gynaecological conditions is the ability to make informed and empowered choices—genuine choices. In that respect, I see the hon. Lady as a strong ally in working towards far better treatment for all women at the hands of the NHS.

The hon. Lady has given a great voice to people who have been through such terrible experiences. She again shared some of the distressing accounts of women for whom current practice has not been good enough. She is right that in the past not enough attention has been paid to a common procedure that generates harm to far too many women. I hope that the very fact of our debate today will shine a light on the situation, because the more we can do to spread awareness, the more women are empowered to look after themselves when facing treatment in the NHS. I hope that she will take some reassurance from the fact that I will continue to work with her to improve women’s health outcomes.

I also want to put something else on the record: the hon. Lady talked about a complete lack of humanity in how those women were treated. I would not be the first to say this—I have spoken to many female colleagues across the House as well—but we often feel that, when our reproductive organs are not being used for the purpose of having children, they are just an inconvenience. The NHS needs to do better. She mentioned my women’s health taskforce, and it is very much at the heart of that. As we go through life, the virtue of having our reproductive organs brings morbidities which are not always treated well in the NHS. We need to do better.

Hysteroscopy, as the hon. Lady explained, is a useful tool in the diagnosis and treatment of a number of conditions, such as the investigation of heavy menstrual bleeding, which affects as many as one in four women between the ages of 15 and 50. That gives some indication of just how many women might consider the procedure. Hysteroscopy is also used to treat fibroids and polyps, which are conditions that can cause long-term symptoms of pain and discomfort. The procedure is without doubt useful in treating women, so hysteroscopies have a role, but as she illustrated beautifully, they can be invasive and traumatic. We need only think about what the procedure involves to understand how traumatic it can be when it becomes painful.

Women’s least expectation of going through the procedure—this is crucial—is that they should be treated with sympathy and respect. They should also have full understanding before undertaking such an experience. As the hon. Lady explained, however, often women find themselves in profound shock at what is happening, and it does not always take place in the most appropriate setting. We clearly need to do better. Information is crucial in that regard: we need to ensure that nothing comes as a surprise.

I encourage women to access the NHS webpage on hysteroscopy, which includes information on what the procedure involves, the likely recovery period and the alternative procedures available. It notes that experiences of pain during a hysteroscopy can vary considerably from one woman to another but—the hon. Lady highlighted this point—I do not think that it properly reflects that, for women who have never had children, the pain can be particularly acute. We should consider the question whether it is ever appropriate for women who have not had children to have the procedure. Clearly, from the evidence she has presented to me, that is where the highest risk is.

I also feel strongly that merely giving information is not enough. Not only is this about providing clarity about what will happen and whether there are decision points for patients—some women will experience little or no pain, but for others it can be severe. We should also remember that for some women the hysteroscopy might be a first encounter with gynaecological services and that some might need to confront past pain or trauma. The hon. Lady has illustrated that well today. It is concerning when medical professionals do not prepare patients for the treatment in a sensitive way.

I fully agree with the hon. Lady that when a woman is clearly suffering during the procedure, it should be stopped. In any case, consent means that at any point people should be able to request that a procedure is stopped. It horrified me to read some of the accounts that she shared, such as women being held down and told, in essence, “You’ve got to continue this treatment or it will be worse for you.” That sort of conversation does not belong in 21st-century Britain in our fantastic NHS. I think we would all agree, women need to be treated better in that regard.

I also agree that we need better training on pain relief and managing women who are to have what can be a traumatic procedure. For practitioners, gynaecological procedures might be an everyday thing, but us women who present ourselves for such a procedure might have to have an out-of-body experience to go through it, because it is not comfortable—[Interruption]—excuse me—to have people engaged in that. We need more sensitivity—[Interruption.] Excuse me, Chair, I have a terrible cold.

The Royal College of Obstetricians and Gynaecologists has produced a guideline to provide clinicians with evidence-based information regarding outpatient hysteroscopy—[Interruption.] Excuse me—[Interruption.]

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Order. The Minister is clearly in some distress. She must feel that she has more to say, but it would be perfectly in order if she wished to conclude the debate at this point. How can I put this? In these troubled times, it is really nice to see the amount of co-operation taking place across the Chamber. We have established that there is a consensus, so if she feels that she is still in some distress, it is perfectly acceptable if she wishes me to put the question, or we can continue—it is her choice.

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I give way to the hon. Member for West Ham.

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I am really grateful to the Minister for her response thus far. I have found her, to be honest, to be the only Minister I have been able to have proper conversations with about such issues who has understood them. I am grateful. However, I honestly believe that we need to do something about the fourth ask. I am a fairly strong woman, but even I was in such a position: I had requested a hysteroscopy with general anaesthetic, but the hospital spent an hour of its time trying to talk me into having one without anaesthetic. I am in a high-risk category of being an older woman and of not having had a child, but I had to beat off the medic who was trying to use every piece of emotional blackmail that she could to get me to agree—the cost to the NHS, taking up resources, the possibility that I had cancer or of a long wait, and so on. It was an uncomfortable conversation. If we do not get rid of the perverse financial incentives, even women as strong as me will be browbeaten.

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I thank you, Mr Howarth, and the hon. Lady for the generosity of allowing me to recover myself. We can tell it is December, because we all have colds—thank you very much.

In the short time I have left, I will address the specific issue of the tariff and the possible incentives, which I know the hon. Lady is particularly concerned about. She is right that there is a best practice tariff that incentivises care in a day-case setting with no anaesthetic, just pain relief. That tariff is agreed with the Royal College of Obstetricians and Gynaecologists, but it is revising its guidance. I want to engage the hon. Lady and the campaign group in that process through the women’s health taskforce, so that we can all satisfy ourselves that the guidance is appropriate. She is absolutely right: if someone such as her or me—women Members of Parliament—cannot look after ourselves, neither can anyone else, and I have heard many tales of people often feeling diminished at the hands of the NHS. She and I have the opportunity to use our voices to ensure that women get a better deal.

I again thank the hon. Lady for all her work. I look forward to continuing to work with her to ensure that all women who face that procedure can do so with sensitive treatment and appropriate pain relief.

Question put and agreed to.

Sitting suspended.