In this blog, Patient Safety Learning reflects on a recent response from Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety, regarding concerns about painful hysteroscopy procedures in the NHS.
Towards the end of last year, Patient Safety Learning published a blog outlining five calls to action that could be taken to improve the safety of hysteroscopy procedures in the NHS. This has been an issue raised by patients, campaign groups and politicians in recent years, highlighting concerns that women having been suffering avoidable harm from hysteroscopies.
We wrote to several key stakeholders in healthcare across England, Northern Ireland, Scotland and Wales, to raise awareness of this issue and call for urgent action to prevent future harm.
While we welcome the Minister in her response supporting the general principles of informed consent and good practice guidance for hysteroscopy, we know that many women are still not being offered a choice of pain relief or given adequate information before consenting to the procedure. It remains unclear from her response whether the Government will take action to investigate the frequency of these experiences and respond to improve hysteroscopy safety.
Concerns about painful hysteroscopy
Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems, such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed into the womb, often with little or no anaesthesia. In a blog late last year, we reflected on some key patient safety concerns relating to these procedures in the NHS:
- Despite a significant number of women who undergo this procedure and experience high levels of pain, in many cases their remains little or no access to pain relief. Recent research, published in the British Journal of Anaesthesia, shows that 17.6% of women rate their pain during hysteroscopy as greater than 7/10, and only 7.8% report no pain at all.
- A growing number of women do not believe they were given sufficient information about this procedure beforehand and were therefore unable to provide informed consent.
- Patient experiences and concerns are not being adequately captured, recognised or listened to.
- Some women have been left traumatised by their experience of hysteroscopy, fearful to access further gynaecological investigations or screenings.
- There are reports that the good practice guidance available from the Royal College of Obstetricians and Gynaecologists (RCOG) is not being adhered to.
We wrote to several key stakeholders in healthcare across England, Northern Ireland, Scotland and Wales highlighting these issues, including Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety. Below, we reflect on the response we recently received from her on these issues, in the context of our five calls for action to improve hysteroscopy safety. We have also included our correspondence with her in full at the end of this blog.
Nadine Dorries’ response to our five calls to action
1) National guidance for outpatient hysteroscopy to be consistently applied
The Minister states her support for the NHS England and NHS Improvement position on this issue, specifically that the information leaflet produced by RCOG and the British Society for Gynaecological Endoscopy should be provided to all patients prior to their hysteroscopy.
While her support for the use of this guidance is welcome, she does not address the problem that, in many cases, this guidance is simply not followed. She also advises that RCOG are now in the process of developing a second edition of its patient leaflet. However, while there remains barriers which may prevent clinicians from using this guidance, or where clinicians may be reluctant to follow the guidance, women will continue to be susceptible to varied standards of NHS hysteroscopy care.
2) Women to be provided with information and advice to inform their consent
Nadine Dorries indicates her support that patients are provided with all the information they need prior to hysteroscopy procedures to help inform their consent.
As with the previous point regarding the consistent application of the guidance, however the issue remains that support for this in principle does not necessarily translate into the experience of patients undergoing this procedure. We are disappointed that the Minister fails to acknowledge that this remains a significant issue and does not provide any assurance that action will be taken to address a failure of informed consent.
3) Women to be offered and provided with pain relief
Her response notes support for women having the choice of a general or regional anaesthetic for the procedure. She also outlines forthcoming changes in the NHS that intend to remove the best practice tariff. This is important as this system has provided a financial incentive for hospital trusts to perform procedures, such as hysteroscopy, as outpatient services without a general anaesthetic, creating a perverse incentive against the use of pain relief.
4) Significant pain to be considered an adverse event and recorded and reported as such
5) Research to assess the scale of unsafe care and pain, the extent to which women are suffering, and to inform the implementation of national guidelines and the appropriateness of financial incentives without proper safeguards
Finally, on the issue of the pain experienced by a significant number of women who undergo a hysteroscopy procedure, in her response the Minister acknowledges that, in cases of severe pain, “it has become clear over the last few years that we can do better in terms of the services we provide for women”. However, on both this and the issue of further research, she does not make any specific commitments on hysteroscopy.
Patient Safety Learning believes that significant pain resulting from procedures such as hysteroscopy should be considered as an adverse event, being recorded, reported and responded to appropriately. We also believe that there needs to be specific research into the scale of unsafe care and pain of these procedures. We recently shared a blog on the hub by Dr Richard Harrison, a pain researcher at the University of Reading, reflecting on his recent research on this issue.
Improved guidance requires practical implementation
While the Department of Health and Social Care shows a clear recognition of concerns about hysteroscopy procedures in the NHS, the Minister’s response is focused on overarching principles and guidance, rather than how this is implemented in practice. We know that many women are still not being offered a choice of pain relief or given adequate information before consenting to the procedure. It remains unclear from this response whether any action will be taken to investigate the prevalence of these experiences and respond accordingly.
This is an example of the type of patient safety issue that we believe the recently announced Patient Safety Commissioner for England should investigate, and is something we intend to promote with them when this role is introduced.
Patient Safety Learning is working collaboratively with patients, researchers and clinicians to understand the barriers to safe hysteroscopy care. We continue to speak to and support patient groups to help raise awareness of safety concerns and amplify their voices. Our aim is that all patients have access to pain relief and the information they need to properly consent to treatments.
Read our initial email to Nadine Dorries MP (also attached)
Read Nadine Dorries' full response (also attached)
 Hughes, Helen, Early thoughts on a Patient Safety Commissioner for England (a blog by Helen Hughes, Chief Executive of Patient Safety Learning), Patient Safety Learning’s the hub, 23 December 2020.