In this blog Patient Safety Learning reflects on responses received from Robin Swann MLA, Minister of Health (Northern Ireland), Jeane Freeman MSP, Cabinet Secretary for Health and Sport (Scotland) and Vaughan Gething MS, Minister for Health and Social Services (Wales), regarding concerns about painful hysteroscopy procedures in the NHS.
In November, Patient Safety Learning published a blog outlining five calls to action 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 have been suffering avoidable harm from hysteroscopies.
To raise awareness of this issue and call for urgent action to prevent future harm, we wrote to several key stakeholders in healthcare across the UK, including:
- Nadine Dorries MP, Minister of State for Mental Health, Suicide Prevention and Patient Safety (UK Government)
- Robin Swann MLA, Minister of Health (Northern Ireland Executive)
- Jeane Freeman MSP, Cabinet Secretary for Health and Sport (Scottish Government)
- Vaughan Gething MS, Minister for Health and Social Services (Welsh Government)
In January we published a blog reflecting on the response we received from Nadine Dorries on this issue. Here we will consider responses we’ve received from Robin Swann in Northern Ireland, Jeane Freeman in Scotland and Vaughan Gething in Wales. We have included our correspondence with the ministers in full at the end of this blog.
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.
Informed by insights from patients, researchers and clinicians, we have identified several key patient safety concerns relating to these procedures in the NHS around issues of informed consent, access to pain relief and the implementation of good practice guidance. When writing to healthcare stakeholders, we have been highlighting five calls for action to improve hysteroscopy safety:
1) National guidance for outpatient hysteroscopy to be consistently applied
2) Women to be provided with information and advice to inform their consent
3) Women to be offered and provided with pain relief
4) Significant pain to be consider 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
Response from the Northern Ireland Executive
In his response Robin Swann provided an overview of guidance currently followed in Northern Ireland for hysteroscopy procedures, referring to information provided by National Institute of Health and Care Excellence (NICE) and the professional guidance produced by the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Society for Gynaecological Endoscopy (BSGE).
He acknowledges concerns about the provision of pain relief for patients having hysteroscopy procedures, advising that his department will:
“write to the HSC Trusts in Northern Ireland to highlight this guidance and remind the service about the importance of the consistent application of the guidance”
While we welcome this step, we believe more robust action will be required, given the concerns we have seen in cases where good practice guidance is simply not followed.
We also reflect positively on the Minister’s comments, placing this issue within the wider context of his department’s response to the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review). He notes that this Review highlighted the wider importance of listening to patients’ voices and concerns, and advises that the issues we have raised on hysteroscopy procedures will be used to inform this work.
Response from the Scottish Government
We received a response on behalf of Jeane Freeman at the end of January which sets out the position of the Directorate for Healthcare Quality and Improvement. Their response initially focused on the importance of patient safety to the Scottish Government, emphasising they have put in place a number of policies to “promote the input of patients and the public to decisions about their care”. Their response notes their plans to establish a Patient Safety Commissioner for Scotland, with proposals to be published for consultation shortly.
On the issue of hysteroscopy procedures, the response refers to the guidance provided by NICE, RCOG and the BSGE, while noting that “ultimately decisions are for local clinicians, based on patients’ individual circumstances and clinical expertise”. It also acknowledges the importance of informed consent and shared decision-making, stating that:
“we would expect that prior to attending an outpatient hysteroscopy appointment, women should be provided with patient information resources, such as the BSOG and BSGE ‘Information for you – Outpatient Hysteroscopy’ leaflet”
While we welcome the Scottish Government’s stated support for the use of patient information resources, the issue remains that support at a policy level does not necessarily translate into the experience of patients undergoing this procedure.
Response from the Welsh Government
At the end of January, we also received a formal response from a representative from the Department of Health and Social Services on behalf of Vaughan Gething. The response gave a brief overview of the guidance form NICE and RCOG currently followed for hysteroscopy procedures in Wales, but disappointingly did not engage with any of the five calls to action we set out in November.
While the response notes the Minister has been receiving an unprecedented amount of correspondence as a result of the pandemic, in our view this is not an adequate response when serious patient safety concerns relating to a healthcare procedure have been highlighted.
More work is needed to ensure that patients’ voices are heard
There are many examples of hysteroscopies being performed without women being fully informed beforehand. The high levels of pain experienced by a significant number of these women, coupled with the realisation they were not given the information to make a decision that was right for them, has left some feeling traumatised and violated. Recent testimonials from women show this is still happening today, highlighting that guidance is not being followed in practice.
Considering responses we have now received from UK, Northern Irish, Scottish and Welsh ministers, it appears clear that, at a departmental level, concerns around the safety of hysteroscopy procedures remain focused on overarching principles and guidance. Although most ministers accept that there is a significant safety concern, we believe that they do not look closely enough at the difference between the guidance and its practical implementation, which for many women results in severe pain and avoidable harm.
There is also still much more work needed to make patients’ voices heard on hysteroscopy. Data needs to be collected through patient reported outcomes in order to understand the scale of harm, identify the barriers to safe care and to hear from those with lived experience. The cursory response received from the Welsh Government appears to suggest that patient safety concerns around hysteroscopy are not yet recognised as a significant issue by all healthcare leaders at a devolved level.
Collaboration between clinicians and patients
In addition to highlighting patients’ voices with politicians on painful hysteroscopies, we’re also seeking to work with healthcare professionals to further explore patient safety concerns, raise awareness and encourage best practice. At the end of last month, we published an interview with a Obstetrics and Gynaecology consultant, Dr Saira Sundar, who provided her clinical insight and highlighted some of the challenges involved when it comes to managing pain during hysteroscopies. We will continue to work collaboratively with patients, researchers and clinicians to campaign for safer hysteroscopy care.
If you have insights you would like to share around hysteroscopy procedures, please get in touch with the Patient Safety Learning team at firstname.lastname@example.org or share your thoughts with us on the hub here.