Mystery Client Survey

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.

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.

During June and July 2020, our team of volunteers made calls to three independent sector abortion organisations, British Pregnancy Advisory Service (BPAS), Marie Stopes UK (MSUK), and National Unplanned Pregnancy Advisory Service (NUPAS). 26 sets of calls were completed for a variety of personas, client roles being acted by our volunteers. We received 26 treatment packs (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. The report below 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.
  • Safety concerns related to the provision of codeine phosphate.
  • The appendix includes an overview of the mystery shopper methodology and related ethics, and full transcripts for each of the calls made by two mystery clients, Eve and Saskia.

Key recommendations

  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.
  4. Service providers, particularly BPAS, should be asked to reconsider the prescribing and provision of codeine phosphate. The dosage provided should be reduced and the self-administration instructions clarified.