4 days to go…. Mass appeal…From a two doctor model to Health Care Assistants: the UK slippery slope on abortion care

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4 days to go…. Mass appeal….Today’s Post: From a two doctor model to Health Care Assistants: the UK slippery slope on abortion care.

4 days to go to Ireland’s referendum on abortion and whether or not to retain or repeal our pro-life 8th amendment to the Irish constitution.

Mass appeal….please go to our home page for information on Sr. Briege McKenna’s appeal for Masses to be said for the Irish and protection of the 8th. We propose: reparation, conversions, protection of the 8th / dissolution of the repeal movement (bless them but block them Lord).

Today’s Post:

From a two doctor model of consent to Health Care assistants: the UK slippery slope:

In previous posts, we looked at how the UK system of the two-doctor model that was proposed in the original 1967 abortion act has morphed over time. The original framers of the act from parliamentary debates of the time clearly expected two doctors to determine if grounds for an abortion were met [1]. Now, other than performance of the abortion, all that is legally and practically required of the two medics, is that they sign the abortion forms and one doctor takes overall responsibility for the clinical chain of command in abortion clinics and hospitals.

The original law that required two doctors to form an opinion in good faith that a woman meets one of the five grounds of the 1967 abortion act, still stands, but its interpretation, no longer requires that even one of the said doctors physically sees or examines the woman before an abortion. The abortion forms, which still must be completed by both doctors, has an instruction to delete as appropriate if they did or didn’t see or did or didn’t examine the woman, which is now entirely optional. [2] Following a case in 1981 between the Royal College of Nursing and the then DHSS, Department for Health and Social Studies, when it was decided nurses could administer abortion pills, it was decided that doctors were not required to oversee every step of the process and that it could be delegated to other members of the clinical team.[3] It is now recommended or acceptable practice that a nurse sees the woman before the abortion.[4] However many people did not know this in the public domain. It emerged with the scandal of pre-signing of abortion forms….

How the original intentions of the original 1967 act has been abused:

When the UK government watchdog the Care Quality Commission or C.Q.C. which inspects all healthcare facilities in the UK did inspections back in 2012, they discovered illegal pre-signing of abortion forms.[5]

In the U.K., two doctors must sign that they agree in good faith that the woman meets one of the five grounds under which abortions may be performed under the ’67 Act. The C.Q.C. first discovered an isolated case in 2012, whereby the standard abortion form, known as HSA1 forms, had been pre-signed by a doctor. As a result, the Department of Health sent out a letter reminding all clinics / hospitals performing abortions in the U.K., of their duties under the act. A month later after sending this reminder, they did a series of on the spot inspections and still found 14 out of a total of 249 locations inspected were involved in pre-signing of abortion forms, all in NHS trusts with a total of 67 doctors involved. It emerged that HSA1 abortion forms with signatures were being photocopied or had been dated ahead of the patient setting foot in the hospital. Dept of Health guidelines are that medics can rely on information obtained by nurses, counsellors or midwives, but it is Dept.’s interpretation of the law that the medics should themselves review the information before reaching an opinion, for example by considering the paperwork or speaking to members of the team. This was not happening. A cross-party group of M.P.s in the U.K. parliament called for an investigation. Earl Howe, the Health minister in the House of Lords called for prosecutions.

30% of the roughly 180,000 or so annual abortions in England and Wales, tax-payer funded, are performed in NHS hospitals and 70% in private clinics, known as ‘NHS contract’, such as BPAS / British Pregnancy Advisory Service and Marie Stopes, the largest and second largest abortion providers in the UK respectively.[6] Of note, only NHS trusts were implicated. Whether the warning letter stamped out more widespread practice is of course speculative but comments by the U.K. General Medical Council tasked with maintaining clinical standards in the medical profession suggests this was the case.

An article in the Telegraph in [7] 2014, reported on the results of the official investigations in the scandal. It stated that 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, stating that this was because 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 1967 UK abortion act. If only 14 out of 249 clinics / hospitals were found to have breached the law by pre-signing, it’s surprising the GMC stated the practice was so widespread as grounds for not penalising anyone. Perhaps they knew that those who got caught hadn’t heard about the warning letter or were junior doctors.

In any case, the G.M.C. warned the doctors in question not to do it again and said that the C.Q.C. watchdog had since established that the practice was no longer happening. The British public might now have supposed that a woman seeking an abortion was properly being seen by a doctor and consented in the context of a clinical history and examination in the normal way.

The Department of Health state no legal requirement for doctors to see women before abortions: 

But within a fortnight of the above article, a second article, again by the Telegraph blew open the myth that this was happening. It reported a public statement by the U.K. Dept. of Health / D.O.H.,[8] that doctors could consult with a woman seeking an abortion by phone or Skype. But most significantly of all, the D.O.H. stated that in fact under the 1967 act, there was absolutely no obligation on doctors legally to see a woman prior to an abortion. That while it was ‘good practice’, it was not mandatory.

The reactions of three women are quoted in the second Telegraph article on the current official interpretation of the 1967 law, that two doctors must form an opinion in good faith that a woman meets one of the grounds of the act, but currently there is no obligation on medics to see the woman unless one meets her when performing the abortion on her.

Ann Furedi the spokeswoman for BPAS, suggested doctors performing abortions had somehow now been exonerated even though pre-signing was and is still illegal. She further stated that while the law hadn’t changed, that it impeded practice as two doctors were not needed to sign off on abortions. Indeed. If the current interpretation of the law is a farce whereby doctors only need to sign forms at some point after someone else has seen a woman whom they do not see, then why bother at all with the two-doctor model? Of course, the current push to full decriminalisation of abortion to birth by Ann Furedi and others in the UK dispenses with this requirement.

The second woman quoted was the minister for public Health, Jane Ellison who said that: “This brings clarity to abortion care.”

The third woman quoted was Josephine Quintavalle of ‘Comment on Reproductive Ethics’. “A telephone consultation to ensure authorisation – presumably with a pro-choice doctor – completely ignores the life-taking nature of abortion, makes a complete mockery of the original Act and would surely not be tolerated in any other branch of medicine.”

At no point in the second article were the GMC findings mentioned directly even though they clearly referenced them which is odd. The GMC findings in no way clarified that the problem with pre-signing was because abortions were being signed off on by doctors prior to the woman setting foot in the clinic or a nurse seeing the woman. Post-signing of consent forms including batch signing after said nurse has seen the woman is acceptable.

Since then, the British Medical Association has clarified that pre-signing remains illegal though they suggest if one doctor is away that they can consent over the phone or some other means of communication.[9]

The Daily Mail sting: Health Care assistants do work up according to retired abortionist: 

Last year, an article appeared in the Daily Mail[10] of an interview with a retired consultant gynaecologist Dr. John Parsons who was the head of terminations in the public King’s College Hospital London. He separately worked for years in an unnamed Marie Stopes private London clinic and was also on the board of BPAS. He excoriated clinical practice in Marie Stopes. Interestingly while articulating the enormous time pressures and conveyor belt mentality at the clinic which appears to have been highly stressful for all concerned with managers harrying doctors to hurry up, he comments on how pre-operative care and work up was performed by Health Care Assistants. They had 20 minutes to do an ultrasound, bloods and take a history and he comments on how they would sometimes come into theatre to get the doctors to sign consent forms. Health Care Assistants are not nurses.

Official response of the UK health watchdog to Health Care Assistants seeing women before abortions:

The Care Quality Commission UK under Freedom of Information, on being asked if they had anything to say about Health Care Assistants doing work ups rather than nurses or doctors given that the different professional bodies including the Royal College Of Obstetricians and Gynaecologists and the UK Department of Health accept that a nurse only may see a woman before an abortion and consent her responded:[11]

“This would depend on what the role of the healthcare assistant and whether they are suitably qualified, competent, skilled and experienced to carry out that role. In the case of a staff member working in the role of a healthcare assistant and undertaking sonography (or indeed a radiographer carrying out sonography) the purpose of the ultrasound would be considered, for example is it solely to confirm a pregnancy rather than to assess gestation. CQC would seek information from the provider of how they can demonstrate that staff carrying out ultrasound are suitably qualified, competent, skilled and experienced to do so. This would include taking into account continuing development. It may also include taking into account professional published guidance on the subject. In every case the legal requirements of Regulation 18 and Regulation 19 (1)(b) of the Health and Social Care Act 2008 Regulated Activities Regulations 2014 must be complied. These regulations state that sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part. The staff must have the qualifications, competence, skills and experience which are necessary for the work to be performed by them. that under the Health Care Act, that all clinical organisations and institutions are required to ensure that staff are adequately trained in whatever area they are functioning in.”

If Marie Stopes, trained up Health Care Assistants to do the pre-operative assessment and investigations on a woman pre-abortion, the C.Q.C. government watchdog are okay with that even if guidelines are not.

So the UK has ‘progressed’ from a situation, where in 1967 those who framed the abortion act, alleged or genuinely envisaged that two doctors would determine if a woman was eligible for an abortion under the five grounds of the Act, so as to avoid completely unrestricted on demand abortions right through to birth. To delegating pre-operative assessments to a nurse, midwife or counsellor put on a legal footing in 1981. To a situation where apparently Health Care Assistants if they get in house training on establishing gestation through ultrasound, taking bloods and filling in details on in house forms / clinical notes is acceptable to the watchdog authority responsible for maintaining the accepted clinical and legal framework. The C.Q.C. appear to have no interest whatsoever in checking out if the practice is ongoing in the unidentified London clinic.

Why Ireland will likely also slide down this slippery slope…

The Irish government proposes mid-trimester abortions from 12 to 24 weeks, if there is a serious risk or risk of serious harm to the mental or physical health of the woman to be assessed by two government nominated doctors: one, an obstetrician (at consultant or registrar level) and another a medical practitioner but not a psychiatrist.  This two-doctor model is supposed to allay fears and reassure us. However Ailbhe Smyth of the Repeal campaign complained that mid-trimester abortions would be too restrictive on the grounds of the word ‘serious’. Dr Boylan’s response?

“I don’t really have a problem with them saying ‘serious risk’ because if the woman regards it as serious then it is. It should be the woman’s assessment of the risk that counts.” [12] . 

While guidelines will be published by the Institute of Obstetricians and Gynaecologists it will be done under Boylan’s chairing.

Taoiseach  Prime Minister Leo Varadkar stated:

“After 12 weeks’ gestation, abortion will only be allowed in exceptional circumstances such as a serious risk to the life or health of the woman or in the event of a fatal foetal abnormality. Ultimately, it will be a decision based on the wishes of the woman concerned and the best available medical evidence.” There again he also borrowed Hilary Clinton’s statement about U.S. abortions that they would be “safe, legal and rare”. After 60 million of them.

Finally, we noted how in Germany, 9/10 Down’s syndrome babies diagnosed mid-trimester were aborted on the ubiquitous mental health ground. [13] This despite there being no specific ground for such abortions there. Exactly like proposals here. The absence of a specific ban has been routinely exploited there to permit abortions of Down’s babies at the same rate as the UK which has a specific ground (E) on the abortion form. The perfect storm is:

No ground + mental health risk + no ban + medics open to okaying abortions of Down’s babies = eugenics of disabled babies in Germany in the 21st century. And that’s before the fetal DNA or NIPT / Non-invasive pre-natal test is rolled out which increases screening uptake and predicts Down’s from 9 or 10 weeks with a 99% accuracy. It’s being rolled out in the NHS and is already available in a number of European countries. It’s only a question of time.



[1] 23 October 1967 original debate on two doctor model of consent

[2] HSA1-form HSA4-form

[3] http://www.e-lawresources.co.uk/Royal-College-of-Nursing-v-DHSS.php

[4]  https://www.nhs.uk/conditions/abortion/what-happens/

[5] http://www.cqc.org.uk/news/releases/findings-termination-pregnancy-inspections-published

[6] Abortions_stats_England_Wales_2016

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

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

[9]  BMA law_and_ethics_of_abortion_nov2014 pg 7 consent issues

[10] http://www.dailymail.co.uk/news/article-4284290/Marie-Stopes-abortions-signed-just-phonecall.html#ixzz5BYycYUiL (scroll down to The Abortion conveyor belt: Bullying, cost-cutting and a relentless pressure to perform terminations – a former Marie Stopes doctor reveals how women were pushed through system

[11] CQC response to FOI query on Health Care Assistants:

[12] https://www.thetimes.co.uk/article/repeal-campaigners-fear-implications-of-serious-risk-proviso-6df3ndsbh

[13] https://www.irishtimes.com/news/world/europe/shadow-of-history-hangs-over-germany-s-abortion-debate-1.3381181


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