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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.
Rachael Maskell
I am grateful for the Minister’s response. Will she include women from ethnic minority groups? Their experience of the health system is very different, so it is really important that their voices are heard in this discussion.
Maria Caulfield
Absolutely. Dame Lesley has been very keen in some of her first work to ensure that we go out to women, rather than expecting women to come to us with their experiences. Often, if we wait for them to come to us, it is the usual voices that get heard. The people who have the greatest difficulties accessing healthcare are often the ones who get missed, so I can absolutely reassure the hon. Lady about that.
That is why we are setting up women’s health hubs, which are a particular priority of the women’s health ambassador. They are go-to one-stop shops that have experienced women’s healthcare professionals. If someone is going for a smear test, contraceptive advice or perhaps a hysteroscopy, there are experienced practitioners there who can support women’s health needs and perhaps give a better experience than many women have now. We hope to improve women’s experience in those areas.
I say to the hon. Member for West Ham that I absolutely recognise the significance of this issue. It is unacceptable that a test that is so important for women’s health is currently such a painful experience. We changed the tariff in the hope that it would encourage the use of general anaesthetics if that is what women want, because we felt that the previous tariff system worked against that. However, I am really keen that we deliver changes on the ground once we get the royal college guidelines and the roundtable with Professor Dame Lesley Regan and the Patient Safety Commissioner, who are there to advocate for women and patients. I hope that will be within the next few months, and I am happy to meet the hon. Member for West Ham, as I will be meeting the patient campaign groups too.
We can change this behaviour. A woman who is having a hysteroscopy should know in advance what is involved and what her choices are. She should feel confident that if she turns up for her appointment and finds it uncomfortable, which she was not expecting, the procedure can be halted and a separate appointment can be made swiftly to make sure that the procedure is as comfortable as possible. I hope that gives some reassurances that I absolutely take the seriousness of this issue on board, and that we want to make a change and a difference for women.