Early medical abortion at home - future arrangements: consultation analysis

Impact of the Current Arrangements

The consultation document asked a series of questions to illicit perceptions and feedback of the impact of the current arrangements, i.e. to allow eligible women to take both pills at home as a result of the COVID-19 restrictions. This included:

Q1. What impact do you think that the current arrangements for early medical abortion at home (put in place due to COVID-19), have had on women accessing abortion services? Please answer with regards to the following criteria:

a). Safety;

b). Accessibility and convenience of services; and

c). Waiting times.

Q2. What impact do you think that the current arrangements for early medical abortion at home (put in place due to COVID-19), have had for those involved in delivering abortion services? (For example, this could include impacts on workforce flexibility and service efficiency.)

Impact on Women's Safety

Q1a. What impact do you think that the current arrangements for early medical abortion at home (put in place due to COVID-19), have had on women accessing abortion services? Please answer with regards to the following criteria - Safety?

Impact of the current arrangements on women's safety

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
Positive Impact	1190	21%	1190	43%
No Impact	50	1%	50	2%
The Impacts are Mixed	130	2%	130	5%
Negative Impact	4,076[1]	74%	1296	47%
I Don't Know	57	1%	57	2%
Not Answered	34	1%	34	1%
Total	5537	100%	2757	100%

When considering responses from all respondents, 74% felt the impact of the current arrangements on women's safety was negative compared to 21% who felt they were positive. The proportions were much more balanced however, when the Right to Life standard campaign responses were excluded from the analysis, with 47% suggesting the impact was negative compared to 43% who felt they had a positive impact.

Respondents were also offered the opportunity to provide qualifying comments to support their response to the closed element of the question, with 4,408 providing further detail. Of these, 2,780 were Right to Life standard campaign responses who provided identical answers.

Positive Impacts

For those who felt the current arrangements for EMAH provided positive impacts for women's safety, the main reason cited was the timely access to medical intervention. It was noted that, without the delays of waiting for appointments, women were able to present and access the treatment quicker. As such, this was considered superior to the previous arrangements as it allowed termination earlier in the pregnancy, which results in lower risks to the woman and less chance of complications as a result of the procedure. Indeed, several organisations cited evidence that showed the average gestation period at which EMAs were carried out had reduced as a result of EMAH:

"Having had a service with long wait times for the Termination of Pregnancy Service pre Covid-19, this change has been positive as women can access the service speedily and this means that they can have treatment at an earlier gestation which in turn reduces the risks associated with a later gestation termination of pregnancy, this provides a safer set of circumstances." (Individual)

Many felt that the current arrangements provided greater comfort, safety and convenience as women were allowed to make the decision, undertake the consultation and take the pills all in their own home. This was considered to be less daunting and stressful than visiting a clinic. It was also seen to provide women with control and choice over who they had to support them during the process, as well as when to begin the medication. It was proposed that these amendments in practice provided more control over when and where they would pass their pregnancy which could improve both physical and mental safety:

"This gives women more choice of when and where to have the procedure. Women are able to make the choice of when and where they feel most comfortable which is a positive thing for their physical and mental health." (Individual)

Further, it was suggested that women will experience less judgement, stress and anxiety by being able to deal with the whole situation from home, and in particular allow them to avoid the "harassment" they may face from pro-life advocates/protesters when attending a clinic. As such, it was felt that the current arrangements better protected women's mental health. Individuals with experience of the previous arrangements suggested these were stigmatising and traumatic, with one indicating that the anxiety of attending a clinic had delayed them seeking the procedure. These respondents felt that the current arrangements were a significant improvement.

It was believed that the current arrangements had helped to keep women, their families/households and healthcare staff safe during the COVID-19 pandemic. As women didn't need to travel or attend a hospital or clinic it was assumed this supressed the transmission of the virus. This was seen as particularly helpful for women who had needed to shield (or had members of their household who were vulnerable or shielding) during the pandemic.

Both individuals and organisations felt that the EMAH arrangements improved safety for women in abusive relationships by making the process more discrete, private and confidential. This discretion was considered to be particularly beneficial for those in smaller/rural communities. In particular, it was noted that travelling to a clinic may be difficult for women with coercive and controlling partners or those who have to account for time spent out of the house/away from work and for travel expenses. As a result, it was suggested that the current arrangements allow women in such circumstances more control over their situation:

"With the spike in domestic abuse during lockdown, women may find this is the safest and less traumatic than being coerced into carrying an unwanted or unintended pregnancy and be able to bypass their abuser to access the safe medical procedure they require." (Individual)

Several respondents suggested that the current approach may also encourage the disclosure of abuse to a greater extent, with respondents citing evidence from providers in England which indicated that women were more likely to disclose abuse when it can be discussed outside of a clinic setting. Organisations highlighted that staff were trained to assess vulnerability during teleconsultation, with a few noting that identification of abuse by such service providers had risen during the COVID-19 lockdown demonstrating that this provided a useful support for women.

Several felt that this was a safe procedure, with a few noting it was physiologically comparable with early medical treatment for miscarriage, and so felt there was no reason it could not take place at home. It was considered that appropriate safety nets were in place to ensure a safe service. In particular, teleconsultation, the provision of instructions and advice, and contact numbers for advice or emergency situations were seen as appropriate, supportive measures of the current approach. Several noted that there was sufficient evidence to reassure respondents that the current approach was safe, and/or that there had been no increases in the safety risks or safeguarding concerns introduced by the current approach compared to in-person consultations. Evidence from the situation in England and Wales was cited, as well as data and recommendations from the World Health Organization (WHO).

A few noted that, for women who either could not or would not access a clinic for the treatment, the current arrangements were safer than trying to access abortion pills via unregulated channels (such as over the internet) or attempting 'homemade' abortion techniques. Organisations in particular, noted that since the introduction of the current arrangements the rate of women seeking abortion medication outside the formal healthcare setting had reduced significantly. These respondents highlighted that those previously too vulnerable to attend in-person had been able to access the necessary care and that a larger number of women were potentially benefiting from the wider care provided by regulated providers, e.g. safeguarding, counselling and contraceptive services.

A few who felt the impacts were positive overall, however, suggested that there should perhaps be increased follow-up care/consultation available/provided.

No Impact

Those who felt that making EMAH permanent would have no impact on women's safety generally highlighted that there had been no significant change in the statistics. They argued that complications would be a risk regardless of the arrangements and setting, but noted that the data showed these risks, or instances of these risks arising, had not increased since the introduction of the current arrangements.

Negative Impacts

With regards to the specific proposals, many of the main concerns focused on the lack of an in-person consultation. It was suggested that teleconsultations would not be as effective, and that various issues could not be confirmed or potential problems could be missed if the doctor or nurse does not see the woman in person. Potential issues identified included:

• assessing/confirming the patient's mental condition;
• identifying patients who are being abused or coerced, either in relation to the pregnancy or abortion, or more generally;
• assessing the true safety situation of the patient or where the pills will be taken;
• confirming the identity of the patient and whether the pills are for them or will be passed on to someone else;
• confirming the eligibility of the patient, including whether they are pregnant at all and if so, to accurately determine what gestational age they are at;
• assessing/identifying any underlying health concern and potential medical complications;
• assessing/identifying any trauma; and
• assessing the patient's understanding of the procedure, what to expect and the potential longer term emotional effects:

"I feel that consultation over a screen is by no means as effective as a face-to-face, where body language, facial expression and tone can be easier read. This allows for the healthcare practitioner to better deem whether the person may be being coerced into an abortion, be mentally stable enough to go through with an abortion and whether they really understand the possible side effects of these drugs and the weight of the decision to abort." (Individual)

A significant issue for respondents was that the teleconsultation was unlikely to be able to identify coercion and abuse, both in terms of those being victims of this generally or having an unwanted pregnancy due to sexual abuse, and to identify those women being coerced into an abortion. It was suggested that, while this risk had been identified in the consultation paper, no solutions or safeguards had been presented to mitigate this. It was also felt that the current arrangements made it too easy for people to obtain pills for others and/or for them to be obtained and given to women against their will or without their knowledge (e.g. in the case of abusive relationships, controlling family situations, child abuse or people traffickers). Further, it was suggested that those perpetrating abuse may withhold access to emergency medical support after the pills had been taken:

"If arranged by phone and drugs delivered home there is also the risk of a controlling partner arranging abortion on his/her partner without their knowledge/agreement and administering drugs via food." (Individual)

The lack of any in-person examination or need for medical supervision when taking the medication was also felt to increase the risk that the pills could be taken beyond the appropriate gestational period. This included concerns that women could be obtaining and taking the pills beyond the recommended or legal timescale, either by miscalculation or deliberately giving false information. Other concerns were that they could obtain the pills but not take them until much later, or that they might misunderstand or be unable to follow the instructions for taking the pills. It was noted that this carried risks to the physical health of the women as the risk of complications (such as haemorrhaging and incomplete abortion) increases with gestation period, which could require hospitalisation, surgery and other serious medical interventions as a consequence. Some respondents highlighted that there was evidence of abortion pills being taken later than advised in England,^[2] and so felt it would be inevitable that this would also happen in Scotland:

"The self-administration of abortion pills removes any control over who takes the pills, where they are taken, whether they are taken, when in the pregnancy they are taken, and in the case of underage patients, whether an adult is present. It is not clear how healthcare professional can ensure the pills are taken by the individual they are provided to and within the appropriate time frame." (Organisation, Pro-Life or Faith Group)

Many respondents also cited a number of adverse incidents in England following the introduction of the temporary approval in England in March 2020.

It was also felt that EMAH reduced the safeguards for women's emotional wellbeing. It was suggested that they would feel isolated, that there was insufficient time or processes to ensure they had fully considered and discussed their choice, and that they were being left to go through with abortions by themselves without adequate or ongoing moral or medical support and advice. It was suggested this reduced access to support could be particularly acute for girls and young women who were perhaps trying to keep the pregnancy and abortion a secret from family and friends. Many felt it could be emotionally traumatic, and so there were implications for their longer-term mental health, with the risk of suicide being noted in extreme cases. A few respondents were also concerned that the lack of input from a clinical practitioner at the point of taking the pill(s) would leave women feeling more responsible for the abortion, resulting in greater emotional turmoil, with a few also querying the legality of this and whether the current arrangements meant that women were breaking the law:

"…women may be committing an offence under the Abortion Act 1967 if they are now taking both the early abortion drugs, mifepristone and then misoprostol at home. Indeed, it is the woman wanting an abortion who is basically terminating the pregnancy and not a registered medical practitioner as required by Section 1(1) of the Abortion Act 1967." (Organisation, Other)

It was felt that a greater level of moral support was required and potential for counselling following the procedure. It was also noted by several respondents that greater efforts should be made to signpost and discuss alternative options ahead of the procedure to ensure this truly is the right decision in each case - it was felt this could help to avoid some of the longer-term trauma and mental health impacts.

It was pointed out that the consultation document noted instances of risks to women's health, and referred to instances of significant complications in Scotland without providing details of these. As such, it was felt there was too little evidence to suggest these current arrangements were safe or improved patient safety.

Many felt that the lack of a scan would increase the risk of ectopic pregnancies not being detected and for pregnancies to be further along than estimated or disclosed by the woman via the teleconsultation. It should be noted however that several organisations who felt the impacts were positive stressed that there was no need for a scan or ultrasound in all cases and that there was no greater risk of ectopic pregnancies being missed.

Finally, some respondents were against all forms of medical abortions and/or abortions more generally, with qualitative comments focusing on the rights of the fetus or on the grounds of faith/religion. Others were against the 'at home' nature of the procedure and felt that abortions should only take place under medical supervision within a clinic or hospital setting. Where reasons were given, these often mirrored those outlined above or focused on concerns which would apply equally to the previous EMA arrangements and so were not generated by the move to the current arrangements (e.g. being alone during the process, experiencing complications, etc.). These concerns are outlined in the 'Other Comments' chapter.

Impact on Accessibility and Convenience of Services

Q1b. What impact do you think that the current arrangements for early medical abortion at home (put in place due to COVID-19), have had on women accessing abortion services? Please answer with regards to the following criteria - Accessibility and Convenience of Services?

Impact of the current arrangements on accessibility and convenience of services

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
Positive Impact	987	18%	987	36%
No Impact	28	1%	28	1%
The Impacts are Mixed	216	4%	216	8%
Negative Impact	3733	67%	953	34%
I Don't Know	239	4%	239	9%
Not Answered	334	6%	334	12%
Total	5537	100%	2757	100%

Just over two thirds (67%) of all respondents felt that the current arrangements had a negative impact on the accessibility and convenience of services. However, this was largely driven by the Right to Life standard campaigns, as the proportions who felt the arrangements had a positive (36%) or negative (34%) impact were similar when these responses were excluded from the analysis.

Again, respondents were provided with the opportunity to provide further details, with 3,869 respondents providing a qualitative answer (although it should be noted that some respondents also discussed accessibility and convenience in their response to Q1a - these responses have been included in the analysis below).

Positive Impacts

Those who felt that the current EMAH arrangements provided positive impacts in relation to the accessibility and convenience of services typically considered that it was easy and quick to access, as well as more convenient for women. This was seen as important during the COVID-19 pandemic in order to reduce the risk of catching the virus while ensuring the service remained available and accessible. Going forward, however, respondents felt that the current arrangements had improved access generally, as well as for particular categories of women, including those in rural areas (where long travel times and potentially overnight stays may be needed for each appointment), those with low-incomes or living in poverty, disabled women (who may find it difficult to travel or access the services), those who work, those who have childcare or other caring responsibilities, and those without access to private transport. In particular, the EMAH approach was considered to have removed both financial and accessibility barriers for women:

"All citizens do not experience equal access to healthcare. Some, particularly people from deprived or difficult personal circumstances, experience significant barriers to accessing healthcare, be that due to the inability to afford or organise travel, insufficient time to travel or even fears about having to account for time away from the home." (Organisation, Healthcare Provider)

Other comments made in relation to improved accessibility and convenience often mirrored or were linked to improvements discussed above about safety, with one often impacting the other. For example, it was felt that EMAH provided improved access to the procedure for women experiencing abuse who may not be able to attend a clinic in person or who would find it difficult to account for their time or travel. Similarly, it was again suggested that the ability to take both pills at home allowed women to control the timing of the procedure, to ensure it can be conducted when they are safest, and when their schedule and other responsibilities and commitments best allows for this:

"…they [women] have the flexibility to take their treatment at a time that suits them (e.g. over the weekend) and so minimise the disruption to their lives (e.g. jobs, childcare)." (Individual)

Again, some respondents argued that they felt the service was more accessible as women would not be put off going to a clinic and passing pro-life campaigners/protestors. Several highlighted that women can feel a sense of shame and can be reluctant to attend a clinic where they may be seen, whereas the current arrangements facilitated more discrete and private access:

"There is still a lot of shame associated with pregnancy termination. I believe not being scared of being seen or noticed in these places may allow women to really take this decision on their own terms." (Individual)

Several respondents cited research and customer surveys which showed that women who had experienced the current arrangements were happy with the approach, service, accessibility, etc. and noted that a systematic review of evidence by NICE had suggested telemedicine as a way of increasing accessibility of abortion services, especially for vulnerable groups. The perceived improvements to accessibility and convenience were also said to have benefits in reducing the number of women seeking access to abortion pills via unregulated methods (e.g. over the internet).

Despite their support for EMAH, several respondents (particularly, but not exclusively, organisations) did feel that there should be options available, with in-person and at-clinic services maintained for those who would prefer or need these. As such, they suggested that telemedicine approaches should be integrated into the in-person EMA service rather than fully replace the in-person component.

Negative Impact

While many respondents indicated that they felt the current arrangements had improved accessibility and convenience EMA, many felt this was not a positive impact.

Many believed that the ease of access and convenience of the current system had trivialised the practice. Some were concerned that women would not realise that a medical abortion was a major and traumatic procedure, and that they would not be given the full details of the levels of pain they might experience, possible complications, emotional trauma, and possible longer-term physical and emotional risks. Others felt that terminating a pregnancy needed to be given much more weight and gravitas than the current arrangements were considered to bestow:

"My concern is that by making this too easily accessible to a point where the person does not even have to leave the house, that the decision to go ahead with the procedure may be made rashly, with not enough thought or counselling." (Individual)

The speed and ease of obtaining the pills resulted in a few respondents being worried that this could be used as a form of contraception/birth control. With subsequent fears highlighted over possible increases in sexually transmitted diseases due to a lack of other precautions being taken.

There were also concerns that access to the pills was too quick and easy, and so women could make a rushed decision (which they may later regret), would not have time to fully explore or consider their options, or would not have had access to any support or advice from other services/supporters. A few respondents suggested that some women may make a different decision if they could access support and counselling ahead of taking the pills. Concerns were also raised over whether women could really be considered as providing informed consent via teleconsultation. They felt that a lot of information would be provided which the woman may not be able to fully comprehend via a teleconsultation:

"Accessibility at home means women may not be fully informed about the procedure and what impact it may have on them." (Individual)

Several suggested that EMAH had created barriers for some women. In particular, the deaf community, those not proficient in English, those experiencing homelessness, those with mental health issues, and some disabled people were mentioned specifically as being less likely to be able to use or fully engage with the online technology or teleconsultation process. It should be noted, however, that the Scottish Abortion Care Providers (SACP) guidelines already state that many of the women in these groups should be seen in person, for example if they are not able to fully understand the information given or if they cannot comply with the 'ordinarily resident' requirement.

Again, several highlighted that the ease of which pills could be obtained left the system open to abuse and misuse. It was felt that the current arrangements were not robust enough to verify the identity of the applicant and true gestation. In addition, the convenience of the arrangements were a concern in relation to perpetrating and covering up domestic abuse, violence and coercion:

"It will be very convenient for those who abuse women for their own gain to force her to abort her child against her wishes, because now she doesn't even need to come to a clinic to see anyone. It would be very difficult for her to call for help whilst on a virtual medical appointment if her abuser is there also." (Individual)

Many argued that convenience was not a key priority for such a procedure, but that other features should be paramount, such as safety, ensuring the woman is provided the appropriate and necessary medical and emotional care, being provided with all relevant information, having the opportunity to explore all options, and receiving the necessary support and ongoing counselling where required. Several respondents noted that polling had suggested that women wanted more safeguards, not fewer. It was felt that the increase in accessibility and convenience had come at the cost of quality and safety, with some highlighting that women would be left in unsafe situations if they experienced complications. Respondents suggested that the medical and psychological care that they considered should be provided with such a procedure had become less accessible under the current arrangements. This perceived decrease in accessibility was identified to be due to the lack of in-person contact ahead of the procedure and the risk that women would be reluctant to seek follow-up support:

"Services should be accessible but to say that abortions should be convenient is total disregard to the emotional, physical and mental turmoil which would be experienced by any woman." (Individual)

"Although the abortions themselves are more accessible the pastoral/medical care of health professionals is not." (Individual)

Several felt that continuing with EMAH after the COVID-19 restrictions had been lifted was simply a cost saving exercise which would put women at risk. A few others worried that permanently adopting the current arrangements would eventually lead to less in-person provision being available as services diminished in response to reduced demand.

Impact on Waiting Times

Q1c. What impact do you think that the current arrangements for early medical abortion at home (put in place due to COVID-19), have had on women accessing abortion services? Please answer with regards to the following criteria - Waiting Times?

Impact of the current arrangements on waiting times

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
Positive Impact	905	16%	905	33%
No Impact	58	1%	58	2%
The Impacts are Mixed	203	4%	203	7%
Negative Impact	3522	64%	742	27%
I Don't Know	475	8%	475	17%
Not Answered	374	7%	374	14%
Total	5537	100%	2757	100%

Just under two thirds (64%) of all respondents felt that the current arrangements had had a negative impact on waiting times. However, when the Right to Life standard campaign responses were excluded from the analysis, one third (33%) felt they had a positive impact on waiting times compared to 27% who felt the impacts were negative.

Respondents were asked to provide further details to support their choice, with 3,673 providing qualitative comments.

Positive Impact

Specific elements of EMAH which were considered to impact positively on waiting times and speed up the process included:

• Self-referral by the woman herself was faster than requiring a referral from a GP (it should be noted, however, that the majority of women were already self-referring directly to abortion services prior to the pandemic);
• Teleconsultations were seen as quicker to arrange than face-to-face appointments;
• Not all women needed to wait for a scan;

"Waiting times have been dramatically reduced as clinical capacity was previously limited by availability of scanning. Allowing medical staff to triage women based on symptoms and history for a scan if they needed one has meant resources are used more appropriately, rather than forcing all women to have a scan, which is unnecessary in most cases and can cause distress to women." (Individual)

• Women not having to travel to appointments.

Some respondents cited examples of reduced waiting times associated with the current arrangements (both from published data and personal experience). For example, it was suggested that teleconsultations could be undertaken the same day or within days of the appointment being made, with access to the pills very quickly afterwards (with a few indicating this could be as quick as the same or next day following the teleconsultation). Some considered this to be a significant benefit as it reduced/removed the anxiety of waiting for appointments and barriers of attending in-person appointments. It was also felt to benefit those who found out later that they were pregnant, or made the decision to terminate later into the pregnancy and so there was little time left to access the procedure within the recommended gestation period - in such cases, time was of the essence.

Another positive impact identified was that women would not have to spend time waiting in clinics for their appointments. Removal of in-clinic waiting was considered less time consuming for women and also increased privacy as they could avoid spending time in waiting rooms (which was noted as being a stressful and unpleasant environment for women seeking abortions). Even where scans were required, it was suggested that the appointments and waiting times for these would be shorter as a result of the lower demand on this aspect of the service.

Similarly, several respondents highlighted that there would be a positive effect for those who wanted/needed in-person appointments as the health professionals' time would be freed up more to accommodate these - thus also reducing waiting times for this type of appointment:

"Telemedicine increases the availability of in-person appointments for those who really need them which reduces waiting times and allows doctors to see more patients." (Individual)

Several noted that the reduction in waiting times was a positive step, not just for accessibility and convenience, but also for the woman's safety. They highlighted that there were fewer complications the earlier the procedure could be carried out. A few noted that EMA was a better option than surgical abortion, which would be needed if women could not access the service efficiently.

Negative Impacts

The majority of those who felt that EMAH had a negative or mixed impact on waiting times proposed that waiting times provided a positive aspect of the service, as it allowed time for thought and reconsideration. Respondents highlighted that shorter/no waiting times meant there was a lack of time for the woman to fully consider and reflect on their decision, and that there was a lack of time for counselling prior to finalising their decision and for information to be sought/provided on alternative options. Again, it was suggested that women may develop mental health issues as a result of regretting their decision or feeling that there was no alternative:

"Having to wait is not a bad thing if it gives a pregnant woman the opportunity to consider the full range of options available to her and the risks involved." (Individual)

"The majority of women (who had abortions before the pandemic) I speak to feel rushed through the process, including by themselves, and say with hindsight that they should have given themselves more time or been less pressurised to make a decision and complete the procedure quickly. This would suggest there is a downside to shortening the timeframe." (Organisation, Women or Abortion Support)

Some advocated for the provision of independent psychological support, with one respondent suggesting that access to this and other support services may have been reduced or become challenging. A few suggested that teleconsultations often felt rushed, with little discussion of the woman's circumstances and no information provided about alternative options, which was again seen as adding pressure to the woman to continue with the abortion and a sense that the whole process was hurried:

"From what women have told me accessing support services for an unwanted pregnancy has been more difficult. With a number of women being offered abortion but not abortion counselling. It is important to remember that women accessing these services may be seeking support other than abortion, that they are not able to get in a timely manner… Women express the pain of an abortion they felt they were rushed in to, and live with the regret of a decision they were not well supported in making… Many women describe the telemedicine service as rushed and don't get the holistic care they should." (Individual)

In addition, some respondents (including a few who suggested the overall impact on waiting times were positive) cautioned that improvements in waiting times resulting from these arrangements did not necessarily equate to a better quality service. Again, concerns were raised over the risks and safety implications of the arrangements, such as the inability to confirm gestation and the associated complications that could arise from the medication being taken beyond the recommended 12 weeks, the inability to reliably check whether the woman has been coerced into having an abortion or has suffered from abuse more generally, and no in-person assessments or support being provided.

A few proposed that the evidence from service providers that EMAH had resulted in a reduction in the gestational age at which EMAs were taking place was unreliable as gestation was not verified. As such, they suggested the self-reported information from patients could be inaccurate, either unintentionally or intentionally.

No Impact

A few respondents who noted that the current arrangements had no impact on waiting times suggested this was because there was no significant waiting times created by the previous system/in-person appointments. It was felt that services had been accessible, provided in a timely manner, and that this had not been a limiting factor of the previous approach.

Impact on Service Providers

Q2. What impact do you think that the current arrangements for early medical abortion at home (put in place due to COVID-19), have had for those involved in delivering abortion services? (For example, this could include impacts on workforce flexibility and service efficiency.) - impact on those involved in delivering services

Impact on those delivering services

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
Positive Impact	825	15%	825	30%
No Impact	40	1%	40	2%
The Impacts are Mixed	216	4%	216	8%
Negative Impact	3645	66%	865	31%
I Don't Know	583	10%	583	21%
Not Answered	228	4%	228	8%
Total	5537	100%	2757	100%

Similar to the impact on accessibility and waiting times above, two thirds (66%) of all respondents felt that the impact on those delivering services had been negative. When the Right to Life standard campaign responses were excluded, the proportions of those who felt the impact of the current arrangements had been positive and negative were more equal, at 30% and 31% respectively.

Again, respondents were offered the opportunity to provide qualitative details to support their response, with 3,859 providing such comments.

Positive Impacts

Those who perceived a positive impact on the delivery of medical abortion services focused primarily on flexibility and efficiency. They felt that the current arrangements were more accessible, responsive and efficient, and thus enabled service providers to make time savings while still offering quality care to women seeking an abortion.

As discussed above, respondents felt that EMAH would be more efficient because the telemedicine approach was seen as less time intensive and would free up practitioners' time allowing them to focus on other patients, where appropriate. Several respondents commented that, to date, telemedicine had allowed NHS services to provide abortion services with fewer staff without compromising the quality of care, as well as to redeploy staff to deal with COVID-19 (i.e. optimising staff time usage). Overall, less time being spent on face-to-face consultations was seen as contributing greatly to increased efficiency allowing medical practitioners to plan and balance in-person and remote patient care effectively.

Indeed, a common theme was that EMAH had allowed abortion care providers to dedicate additional time to support service users and patients with more complex needs who attended clinics in-person:

"The availability of telemedicine EMAH has seen a greater number of women choose this option over hospital-based abortion care. This has reduced demand on acute gynaecology inpatient/day-care services, and has freed up staff capacity and facilities to provide care in a pressured service." (Organisation, Healthcare Provider)

Similarly, flexibility arguments focused on services being able to be more responsive to the needs of different women, allowing staff to undertake essential on-site clinics and counsel others via teleconsultation. This was felt to be of benefit to both patients and providers in making services client-centred:

"Staff report the advantage of being able to spend more time with those with more complex needs including those who do need to attend clinics in person." (Organisation, Healthcare Provider)

In addition, the introduction of self-referral for telemedicine was seen as reducing pressure and time-demands on GPs and local sexual and reproductive health services that sometimes refer patients for EMA.

Other positive impacts included the reported reduction in gestation at the time of treatment that the current arrangements had led to, as well as corresponding decreases in complication rates. This reduction in complications could increase doctors' and nurses' availability and therefore care opportunities for patients with more complex abortion and related sexual health care needs. Similarly, it may reduce the number of patients who attend for surgical abortions and therefore free up availability in abortion clinics. It was also suggested that the removal of routine scanning generated less distress, as it was noted that this can be invasive as well as physically and emotionally challenging for clients and service providers, by proxy. There were some views that more efficient access to early intervention may provide wellbeing benefits, i.e. by minimising complications, leading to safer practice and outcomes, with less distress for patients overall which would, in turn, reduce stress experienced by staff.

Other wellbeing benefits identified included reduced trauma and unnecessary stress to service providers linked to discomfort of face-to-face contact when discussing sensitive and often distressing personal circumstances. The telemedicine approach was also seen as beneficial as it could limit involvement for those professionals who are potentially uncomfortable with the process for religious or other reasons. Indeed, conversations were described by some as being easier for both patients and staff if transacted remotely or in the comfort of a patient's own home/practitioner's own workspace, potentially making consultations more patient-focused. It was stressed that, removing the need to attend in person would provide protection and reinforce confidentiality to all:

"Anecdotal evidence from those providing consultations suggests that many people have felt more free to talk and that there has not been a negative impact on the quality of consultations." (Organisation, Healthcare Provider)

Comments linked to efficiency again focused on the notion that telemedicine was more accessible to a wider selection of women who need it from a range of different situations and areas:

"The change has enabled services to provide safe and effective services that are more accessible than ever before." (Organisation, Healthcare Provider)

The easier scheduling and greater certainty of telephone appointments was seen as helping workforce management, in addition to providing more opportunities to schedule telephone appointments and potential for improved timetabling. The telemedicine approach was seen as being more reliable than in-person contact, having associated benefits for service providers insofar as it reduced uncertainties linked to missed appointments, late running appointments, etc. and was therefore less negatively impactful on waiting times i.e. smooth running and more efficient clinics.

Being able to work remotely (rather than in dedicated clinics) was also seen as beneficial for medical staff to meet their own needs for flexible working arrangements both during the COVID-19 pandemic and longer-term. Several respondents suggested that the current arrangements should/could be extended to routinely offer video-consultation as standard practice to optimise engagement.

Finally, several respondents again noted that home facilitation and removal of the need for face-to-face contact had been essential in protecting medical staff from risks associated with COVID-19 (i.e. reduced transmission with healthcare workers not contracting COVID-19). It was felt this was one of the main positive impacts of the change for service providers. The reduction in on-site clinic appointments also offered added protection for patients who still need to attend in person:

"Reducing in-person appointments also acts as an additional safeguarding measure for staff and patients during the pandemic as foot fall in healthcare settings has reduced, and social contact has therefore minimised." (Organisation, Professional Bodies)

Negative Impacts

The main view offered by those who felt there would be negative impacts on those involved in delivering abortion services was that removing the need for in-person consultation may be damaging to service providers if it depleted the relationship between the patient and the healthcare provider. One potential negative impact on the doctor-patient dynamic included not being able to ascertain sufficiently accurate information on which to help patients make their decisions. Another was not being able to provide sufficient psychological and other support once decisions have been made. It was suggested that removing in-person consultation would fundamentally alter the relationship between patient and physician to the detriment of both.

Specific common concerns included that service providers would not have the same confidence about consent and intentions of the patient compared to in-person contact, as remote consultations lacked the exchange of important non-verbal communication cues and were therefore less 'informative'. This was seen as particularly important where the patient did not have a good level of English or where other communication barriers existed (although it should be noted that the SACP guidelines make clear that such patients should be seen in person if they are unable to easily understand what is being explained).

Concerns were raised that it would be less clear to practitioners if a patient was fully informed before making their decision (and able to offer fully informed consent) or if they were being coerced into an abortion (including in cases where women were living in abusive or exploitative relationships). It was felt that staff would not be able to guarantee remotely if the patient was being given the opportunity/freedom to speak with their medical practitioner in private. Indeed, this was the most frequently cited concern as it was seen as having potentially negative impacts on whether practitioners could do their jobs with confidence:

"It is not known who else is in the room at the time of the call and if the woman is being coerced… This puts healthcare workers in a very difficult position. Firstly, legally as we have safeguarding obligations and a duty of care that cannot be safely provided through a telemedicine service. Secondly, this has huge moral complications, and healthcare workers may have to live with the guilt of being involved in a forced abortion or not stopping abuse." (Individual)

It was suggested that patients may not communicate any questions or concerns as openly via teleconsultation and this may be hard for a nurse or doctor to assess without seeing body language. Similarly, it was suggested that healthcare providers may experience decreased confidence as the lack of personal consultation would hinder informed health and risk assessments (i.e. making it challenging for medical personnel to do their job thoroughly). Duty of care should not be compromised, it was stressed, and NHS staff should not feel disempowered by virtual approaches.

Potential for deskilling was also raised by a minority, with suggestions that the current arrangements undermined the skill and expertise required to ensure that abortion decisions were appropriately facilitated:

"The loss of independent medical advice shows a lack of understanding of the efficacy of trained, skilled involvement in the process. It has given rise to anxiety on the behalf of staff where complications and thus recriminations against them have arisen." (Organisation, Pro-Life and/or Faith Groups)

Concerns were also raised about the risks, stress and anxiety for healthcare professionals (including potential for litigation) linked to being held accountable for the safety of patients in cases where:

• Medication is not taken appropriately or as directed;
• Medications are taken by someone other than for whom they are intended (including being given to very young women/girls);
• Positive pregnancy tests resulting from non-intra-uterine pregnancy/ectopic pregnancy being missed and associated (potentially fatal) consequences;
• Gestational age being inaccurately estimated/falsely disclosed, and associated negative consequences if the fetus is more developed; and
• Medical complications arise and/or a patient death is linked to the current arrangements (fatalities, in particular, could negatively impact the mental health of individual service providers, it was suggested):

"Lack of definite control over the process must be stressful for medical practitioners with the risk of complications and subsequent litigation against the professionals involved." (Individual)

Concerns about negative outcomes for patients may be augmented when using remote communication approaches where providers must rely more heavily on the word of the patient, and this may undermine the providers confidence in issuing EMA medications, it was stressed. Medical professionals remain responsible for their patients' welfare, although at a distance, and it was suggested that the current arrangements may not lend themselves to good patient care, or protection of workers' mental health, thus eroding professional standards of care.

Other common responses included suggestions that medical professionals may feel that they have been unable to fully support the patient in their care when making significant life decisions, staff being concerned about being able to provide consistency and continuity of care, and apprehension about being able to offer sufficiently compassionate and patient-focused responses overall when using remote communications. Some felt that health professionals cannot perform their duty of care when separated from their patients:

"Without an in-person appointment, there is no relationship between patient and caregiver, making clinical decision making harder. This is a dangerous precedent and puts an unfair weight of responsibility on the caregiver." (Individual)

Having facilities to allow nurses or doctors to routinely follow-up on remote consultations was suggested as a means of improving the service and mitigating against concerns for service providers that appropriate care is being given.

A lack of support for staff who morally, religiously or conscientiously object to abortions was suggested by a minority as something which would be potentially compounded by the current approach. It was highlighted that it was not clear whether medical professionals who have issues with the morality of abortion were able to have their freedom of conscience protected. Staff should have the option to decline participation, it was suggested, to avoid potentially negative impacts on individual service providers.

Other wider concerns for service providers considered capacity-related issues, specifically:

• Potential for increased demand on counselling and other care providers who manage post-abortion care for women using EMAH;
• Potential for increased attendance at A&E or other medical services in cases where EMAH has resulted in medical complications; and
• Potential for loss of jobs in abortion services if demand for in-person appointments decreases and the EMAH arrangement results in significant efficiencies.

A very small number mentioned job dissatisfaction as a potential negative consequence, e.g. if a reconfiguration of services results in changes to working practices it may have a negative impact on staff morale in some circumstances. This, in turn, may lead to high levels of staff turnover and present a challenge to the service provider workforce stability.

Mixed Impacts

Among those who felt that there would be mixed impacts, several highlighted what they perceived to be a process of making the system quicker and cheaper to the detriment of patients and providers (i.e. although improved efficiency, time and cost savings might benefit service provision, it was not necessarily positive since care was potentially being sacrificed). An assessment of efficiency would differ significantly, it was felt, based on the perspective from which it was viewed:

"If efficiency is only to be regarded as how many pregnancies were ended, they have been efficient. But if quality of patient care is considered efficient, then the lack of person-to-person interaction and provision of pre- and post-abortion counselling means the current policy is seriously inefficient and negative from the receivers' point of view." (Individual)

Others highlighted that while the change may benefit service providers, employers or organisations (in terms of efficiency and potential staff and cost savings), this may be to the detriment of individual care practitioners who may find telemedicine approaches less comfortable, or more stressful, again due to lack of face-to-face interaction with their patients. It was felt that staff would need to be adequately supported to make a transition to virtual approaches:

"While I imagine it allows for greater flexibility, efficiency and potentially reliability, I can imagine there are some delivering the service who find it hard to connect or support people adequately through a digital platform and maybe be resistant or require additional support in delivering the same level of care." (Individual)

The teleconsultation approach may be more emotionally draining, it was suggested, and more challenging as it places more demands on the professional to be alert to very subtle cues in the spoken word which might indicate if women are being coerced, etc. It was also suggested that additional resources for training (e.g. in teleconsultation and identification of gender based violence) may be required if remote approaches were to become embedded, which could counteract efficiencies achieved elsewhere.

Indeed, several medical practitioners highlighted that they had mixed views on the proposal. While recognising that it could be more efficient, several highlighted that they preferred, or felt more comfortable, meeting patients face-to-face in appointments to discuss abortions. They considered in-person consultations to be of greater benefit to both themselves and the patient:

"As a nurse myself I would feel that a telephone appointment may well save me time but that I would not be providing holistic, patient centred care. I think a patient may feel less like they had other options than they would in a face-to-face appointment." (Individual)

A small number suggested that teleconsultation approaches may, in fact, not be quicker than face-to-face, as practitioners may spend longer discussing patients' histories and trying to reassure themselves that they are fully informed of all relevant background and context data to inform their remote assessment. Others highlighted that efficiency benefits may be outweighed by more time being needed to manage cases where the procedure does not go to plan.

While several felt that the current arrangements were appropriate in the short-term to counter the risks associated with COVID-19 transmission, they felt that it was not suitable as a permanent or long-term plan (usually on the grounds that the remote approach was inferior to face-to-face contact).

Other Perspectives

A small number of respondents indicated that they perceived there would be no impact. Among these, the main argument was that teleconsultations and face-to-face consultations should, in principle, entail the same planning, time and quality of care, making any impacts neutral.

Others suggested that questions focused on 'service efficiency' were inappropriate given the sensitivity of the consultation subject matter. Several others commented that they were not knowledgeable enough, or that there was insufficient information in the consultation paper, to provide an informed response on this matter.

Overall, while a notable number of respondents acknowledged that the current arrangements were probably more convenient for service providers, and would lead to efficiencies, there was consensus that the needs of service users should always be prioritised, both short- and long-term.