55 days to go…Mass appeal…The UK two doctor model and abortion consent: How does it work? (part 3)

55 days to go to Ireland’s referendum on abortion on May 25th where voters decide whether to repeal / remove the pro-life 8th amendment to the constitution which gives equal protection to mother and child, or to keep it.

The UK two doctor model of abortion consent: How does it work ?

(part 3)

Review: In parts 1 and 2, we looked at how a scandal was reported in early May 2014 in the Telegraph newspaper  (1) over the pre-signing of abortion consent forms by 67 doctors during on the spot checks by the Care Quality Commission / C.Q.C. or health watchdog in 2012. How a cross-party group of M.P.s reported it to the Metropolitan Police and Earl Howe the Health minister in the House of Lords had said prosecutions should result.

However the General Medical Council / G.M.C.,  found no case against the medics in  question and stated the police had examined two sample cases and felt there was no ground for prosecution. The G.M.C. accepted that the practice was unacceptable and broke the law but refused to identify any doctors or their roles as it was so widespread, also stating that no woman had been harmed in the cases identified and because clinical practice had changed so much since the abortion act.

They stated they had warned the doctors in question not to do it again and stated that the C.Q.C. watchdog had since established that it was no longer happening. They didn’t explain what they meant by clinical practice having changed so much. It was not clear from the Telegraph report or the G.M.C. response if patients were just being seen after the forms had been pre-signed (which would possibly risk oversights due to a sense of complacency in any consultation with a woman) or if the women simply hadn’t been seen at all by the 67 doctors.

The reaction of Earl Howe in the house of Lords and M.P. s seemed to suggest the latter rather than the former and the statement by the G.M.C. suggesting that pre-signing had been stamped out in follow ups by the health watchdog / C.Q.C., suggested that women were now being seen in consultation and consented in proper order by abortionists as per the 1967 abortion act.

But within a fortnight the Telegraph reported a statement that the U.K. Dept. of Health issued, (2) that doctors could consult with a woman seeking an abortion by phone or Skype.

Most significantly, the Dept. stated that in fact under the 1967 act there was absolutely no obligation on doctors to see a woman prior to an abortion. That while it was good practice, it was not mandatory. The option to Skype a woman before an abortion no doubt to facilitate more interaction between doctor and patient did not suggest consultations in person were always happening if at all.

Just two weeks after the G.M.C.’s public reassurance that pre-signing had been stamped out, the statement by Dept. of Health, suggested the G.M.C. absolutely knew that the doctors were not seeing women before abortions, but that there no issue with that per se. So if there was no issue with the 67 doctors not seeing women prior to abortions, what does pre-signing of consent forms mean if not, failing to see a patient before a procedure? Wasn’t the furore because it was understood a woman should be seen by two medics or even by one and the second doctor approved the consent under the abortion act?

If this was the widespread practice that had changed radically since the 1967 act, the G.M.C. had adopted the position of not explaining this. It seems coy to read the initial Telegraph report. Surely the G.M.C. and possibly the Telegraph knew that if one believes the abortion act requires a woman to be assessed in good faith by at least one doctor, that the  G.M.C. intervention was open to the interpretation that women were now being seen by doctors if not before though of course they never directly said that. Just that there would be no censure because of changes in clinical practice without explanation. Perhaps this was rather than add fuel to the fire and escalate the scandal.

Probably under pressure from abortion providers, the D.O.H. decided to control the information flow, take the bull by the horns and effectively exonerate the practice of not seeing women prior to abortion as it was creating bad press for abortion providers and the industry.

There therefore appeared to be lack of clarity between the position of the G.M.C. who were insisting that consent forms not be pre-signed and the position of the D.O.H. which stated publicly, that there was no onus at all on abortionists to see a woman beforehand

Part 3:

The puzzle:

The timing, a fortnight after the negative publicity for abortion providers in the UK,  seemed to be a direct response to the pre-signing scandal though the G.M.C. findings were not mentioned directly by the D.O.H. in the article.

Without mentioning them directly, the 67 medics the C.Q.C. / health watchdog had found guilty of pre-signing consent forms, were effectively cleared of any implication that they’d failed in their duties as doctors.  Even if  on a technicality they’d breached the law because the law according to the article did not oblige doctors to see a woman pre-procedure. The D.O.H. were baldly stating women do not need to be seen under the law.

But how was the law technically broken if it did not mean failing to see a woman?  Also, accepting that the D.O.H. just considered it to be ‘good practice’ for a medic to see a woman before an abortion,  is this happening at any frequency now in the UK? What happens to the woman? 

This is important as a  two-doctor model is being proposed here in Ireland for abortions after 12 weeks, at least mid-trimester and depending on what the government are saying at any one time, final trimester of pregnancy.  (They haven’t got their story straight yet).

The two biggest private providers BPAS and Marie Stopes UK account for almost 7/10 of the 185,000 annual abortions in the UK paid for by the NHS, with the NHS accounting for almost 3/10, no doubt done through GP referrals (Only 2% are done privately).(3):

Often the first point of contact is a call to an abortion provider, usually a BPAS or Marie Stopes call agent, who as that first point of contact is trained to work to a script and need not have a  medical background. According to the NHS guide to abortion (4), a woman, if she wishes to, may see a trained counsellor.

If the decision for the abortion goes ahead, (with or without further counselling following that phonecall), then it appears that the woman is seen by a nurse or doctor and consent may be obtained at that time by one or other from NHS guidelines and the abortion can be done same day.

What is clear is that a nurse consents the patient but a doctor must sign-off on the consent form for the overall procedure without having to see the patient prior to the abortion. The 67 doctors in 2012 broke the law by signing the consent form before the nurses went through the form with the woman.

On reading the Quality Report for BPAS Slough (5) and others by the Care Quality Commission watchdog, in 2017, it’s clear that nurses or midwives consent the women. Equally a review of Marie Stopes’ practice (6) in February 2017 shows that: “A review of the provider’s abortion policy indicated that registered nurses could obtain consent providing they had attended consent training and had this competency signed off, by a clinical operations manager, a clinical team leader and/or a doctor”.

According to the BPAS report, paperwork would then be submitted to a doctor on site, who would assess the consent form and okay it / sign or be free to request more information. The ’67 act however stipulates that a second doctor must sign the consent form. The CQC report stated: “If a second doctor was available on site, they would review the  information and similarly authorise the HSA1 (government abortion form that must be filled in) as the second doctor or decline and request further information. If a second doctor was not available on site, BPAS used the electronic central authorisation system to ensure information and the HSA1 form was accessible and signed by doctors located at other BPAS units.”

The second doctor must agree that the ground for abortion is the same as the first even if they are off-site in another clinic from the information in the consent form the nurse sends through. If >1 or different grounds are found for the abortion by both doctors they must liase and agree which ground the abortion is being authorised under. Otherwise why would they liaise?

(7): BMA reference)

Ann Furedi for abortion provider BPAS in the second Telegraph article on Dept. of Health guidelines was quoted as saying: “Recently, doctors providing abortion services have felt under intense political scrutiny, and this document should give them the reassurance that neither the law nor regulations have changed to accommodate those who think their work is wrong.  The law impedes best practice.There is no clinical need for two doctors to certify a woman’s reasons for abortion, in addition to obtaining her consent, it simply causes delays. Bpas trusts women to make responsible choices and Bpas doctors comply with the law.”

Also in the same Telegraph article on the Dept of Health guidelines, came a somewhat surreal contribution from Public Health Minister Jane Ellison who said: “This brings clarity to abortion care. Throughout its development we’ve worked closely with medical professional bodies and consulted the Crown Prosecution Service to provide clear guidance to clinicians about their roles and responsibilities under the law so that they can continue to provide the best possible care for women.”

Further mandating of the zero doctor model masquerading as a two doctor model then came from the British Medical Association B.M.A. representing the medical profession itself which months later, in November 2014 issued its ‘Law and ethics of Abortion’ guide (8). In its introduction it states:

“The BMA has longstanding policy dating back to the 1970s and 80s supporting the Abortion Act 1967 as a practical and humane piece of legislation.” They outline the abortion act as follows:

Under the Act, a pregnancy can be lawfully terminated by a registered medical practitioner, in an NHS hospital or premises approved for this purpose, if two medical practitioners are of the opinion, formed in good faith etc etc etc.

It continues, “there is no legal requirement for the doctor to personally examine a woman seeking termination. Indeed, there is the option on the HSA1 (abortion) form for one or both of the doctors to certify that they have not seen or examined the woman. In 1981 the courts confirmed that abortion was a procedure carried out by a multi-disciplinary team, and that whilst the doctor should accept overall responsibility for all treatment with regard to a termination of pregnancy, they do not need to personally conduct every stage of the procedure, and can rely on information gathered by other members of their team in forming their opinion. Nevertheless, doctors must be satisfied that the conditions of the Abortion Act have been met.

They cite the D.O.H. guidelines: “Guidance from the Department of Health asserts that it considers pre-signing of forms “without subsequent consideration of any information relating to the woman” to be incompatible with the requirements of the Abortion Act.23”

So there it is. The consent forms may not be pre signed, but they must be post-signed where usually a nurse has consented the woman and they sign the form afterwards. At least by having the doctor have the responsibility of examining the completed consent form it opens the possiblity of dialogue with the nurse about any issues or even the woman herself though there be no requirement to see her. In fact, one imagines that the first line of defense for those who pre-signed the consent forms, was the fact that the abortion forms give abortionists the option to document that they did or didn’t see the woman. If the culture is so loose that it’s optional on the official documentation to say if one has or hasn’t seen the patient before an abortion, it must have been tempting or thought implicitly okay, to just cut to the chase in a busy clinic and  pre-sign the form, trusting a nurse will flag them if something comes up.

One potential consequence of that is sooner or later something can go wrong somewhere and it risks a nurse taking the flak  and the whole practice is then brought into question. To ensure the buck stops with the doctor ensures that if something does go wrong, it is an individual case and the whole practice can continue.

Did Earl Howe who called for prosecution in the House of  Lords and the cross-party M.P.s who went to the Metropolitan Police know that the pre-signing of consent form scandal was not problematic because of doctors not seeing patients but only because at stake was overseeing issues by medics and chain of command, or were they just uninformed? The careful wording of a response by the GMC would not debunk any misunderstanding. Only the Dept of Health statement did so.

Care Quality Commission (CQC) (2012). Findings of termination of pregnancy inspections published. Press release, 12 Jul

(1): https://www.telegraph.co.uk/news/uknews/law-and-order/10807990/Pre-signing-abortion-forms-is-illegal-General-Medical-Council-admits.html

(2): https://www.telegraph.co.uk/news/health/news/10851574/Abortion-doctors-can-consult-women-on-phone-or-via-Skype-guidance.html

(3): https://www.gov.uk/government/statistics/report-on-abortion-statistics-in-england-and-wales-for-2016

(4): https://www.nhs.uk/conditions/abortion/what-happens/

(5)http://www.cqc.org.uk/sites/default/files/new_reports/AAAF9125.pdf / BPAS Slough Quality Report pg. 19, 23-24.

(6): https://www.cqc.org.uk/sites/default/files/new_reports/AAAG6589.pdfhttps://www.cqc.org.uk/sites/default/files/new_reports/AAAG6589.pdf   / Marie Stopes Interantional UK Quality Report 

(7): The law_and_ethics_of_abortion_BMA Views Nov 2014

 

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