Background.

On March 30th, 2020, the Secretary of State for Health and Social Care approved a pregnant woman’s home as a class of place where the treatment for termination of pregnancy (ToP) may be carried out. This approval enabled the implementation of a fully remote telemedicine service in which a woman no longer needs to make a clinic visit as part of the ToP process. Prior to this approval, it was necessary for a woman’s eligibility for early medical abortion (EMA) at-home to be assessed professionally by an authorised service provider (SP) during a clinic visit; this assessment routinely included the use of an ultrasound scan (USS) to confirm the gestational age (GA) of the pregnancy.

The approval of a woman’s home and the associated implementation of a fully remote telemedicine process mean that the assessment of GA is now solely dependent upon the woman’s accurate and honest recall of the first day of her last menstrual period (LMP). The prior use of an ultrasound scan was to overcome any lack of a service provider’s confidence in the woman’s recall.

Being certain of the gestational age is important because the new regulation limits early medical abortion at home to a maximum GA of 9 weeks and 6 days by the day on which the mifepristone is self-administered. Also, it is accepted that the efficacy of the medical abortion treatment reduces as GA increases, with a resulting increase in the potential side-effects experienced or adverse events arising.

In effect, the woman has been co-opted as an essential member of the multidisciplinary team (MDT) working for the registered medical practitioner (RMP), providing important clinical information necessary for the correct certification of the ToP by the RMP, to ensure compliance with the 1967 Abortion Act. When acting in good faith, the RMP is now solely relying on the woman’s accurate and honest disclosure and self-assessment.

Methodology.

We designed and implemented this mystery client survey to explore the reality of these concerns; to test the hypothesis that these new telemedicine regulations mean that service providers are now solely reliant on their clients’ accurate and honest recall of the first day of their last period and self-assessment of their medical history.

We recruited a small number of non-pregnant women aged 18-40 as unpaid volunteers for this survey. During June and July 2020, these volunteers made 85 calls to three independent sector abortion organisations, British Pregnancy Advisory Service (BPAS), Marie Stopes UK (MSUK), and National Unplanned Pregnancy Advisory Service (NUPAS).

Each volunteer was asked to take on a specific persona, the role which would be acted during the calls to a service provider. 26 sets of mystery client calls were completed for a variety of personas including:

  1. A woman who is already beyond the ten-week GA limit for early medical abortion and so she provides a false LMP to the service provider to present as being about seven weeks pregnant.
  2. A mother of a fifteen-year-old daughter who is pregnant. The mother does not want her daughter to go through the system and so she makes a call to the service provider, pretends to be seven weeks pregnant and asks for the abortion pills at-home. When received, she administers these to her daughter.
  3. A woman who first gives a date for her LMP which would indicate nine weeks GA, and then she changes this date on her next call to present as just seven weeks, thus remaining within the GA limit for the abortion pills at-home.

All calls were recorded, and the recordings have been transcribed; we have included full transcripts for two mystery clients, Eve and Saskia, at the end of the report.

Each of the mystery clients provided a false name, date of birth, and contact details. They provided false registration data when asked for details of their GP surgery, they were not registered with the NHS. They each mislead the service provider about their medical history and their gestational age, some even changed their gestational age mid-process. The only real data given was the address to which the abortion pills should be posted, so that the project could ensure the safe receipt, handling, and disposal of the treatment packs. After making 2 or 3 phone calls, taking no more than an hour in total, our 26 mystery clients received 26 abortion treatment packs at home (pills-by-post), for women who do not exist and are thus not registered by the NHS, and based on a set of false personal and medical data: BPAS 13, MSUK 11, and NUPAS 2.

Investigation Report.

The investigation report discusses our findings, which are based upon a detailed review and analysis of each of these calls. Findings are grouped together as follows:

  • Discussion of the move from comprehensive professional abortion care to self-managed abortion in which the woman manages her own self-referral, self-assessment, and self-administration.
  • Legal certification by the Registered Medical Practitioner of the termination of pregnancy under an approved ground.
  • The move to a fully remote telemedicine process.
  • The appendix includes an overview of the mystery shopper methodology and related ethics.

Key recommendations arising are:

  1. To correctly identify the client and to ensure correct use of NHS funding, the telemedicine process should be amended to collect and validate each client’s NHS number before proceeding with the consultation. It should be mandatory for inclusion of the NHS number on the HSA4 form and payments should be withheld if this is not completed correctly.
  2. The move to solely relying on telemedicine for the complete termination of pregnancy process means that it is not possible to prevent the regulatory and safety issues presented by self-assessment. These issues can only be avoided by mandating the return to the prior routine inclusion of a clinic-based assessment by an authorised service provider, as part of the overall process, which might then include the self-administration of the treatment by the woman at home.
  3. Service Providers should be asked to adopt video-calls as the default media for conducting these remote consultations. This would help to improve the quality of the care provided, compared to voice-only, and would be more consistent with the official guidance and best practice.

Our thanks to Christian Concern for commissioning this investigation and sharing the report – we appreciate this support.