abortion rules in a generation. The amendments, tabled by the Conservative MP Nadine Dorries, would ensure that all women who are seeking an abortion are offered "independent counselling", defined as counselling offered by either a statutory body (the NHS) or a private body that does not itself provide the termination of pregnancies.The Commons will tomorrow debate whether to enact the biggest shake-up of the
Dorries argues that the non-NHS organisations – Marie Stopes and the British Pregnancy Advisory Service - that currently provide around half of terminations are conflicted because they both advise women and provide terminations, which they are paid for.
But much of the basic facts in this debate are contested fiercely by the huge lobbying operations on either side of the debate. We want to find out whether the basic premise of Dorries' claim is right.
Is abortion counselling independent?
There will be other questions that arise out of this:
Are abortion services motivated by profit?
What is the current process for women seeking an abortion via the private groups that offer abortion processes?
What exactly do the Dorries amendments propose?
Who would carry out independent counselling if the amendment passes?
Are abortion services motivated by profit?
Dorries' argument for the changes is set out in this Daily Mail article.
Under present legislation, doctors or pregnancy advisory services have no duty to offer professional, impartial help to women considering an abortion. Moreover, most counselling is offered by the big abortion providers themselves, like the British Pregnancy Advisory Service or the Marie Stopes clinics, which are paid millions by the NHS to carry out terminations — and so profit from the process.
BPAS and Marie Stopes provide around half of the 200,000 abortions carried out every year and are paid £60m by the NHS for the services they provide. They are registered as charities (Marie Stopes hereand Bpas here) and reinvest any profit they make into the service. They dispute the idea that their motivation is for profit.
Ann Furedi, the chief executive of BPAS, told me last week:
The thing I find most frustrating about this discussion is the assumption behind it that we want to encourage women towards the abortion option, rather than the option of continuing the pregnancy. Nothing could be further from the truth. I can say with hands on heart that the last thing that anyone involved in abortion wants is for a woman to be having treatment that they are not sure about. Everybody wants people to walk away feeling that the right thing has been done.
The Dorries campaign cites a job advert for a business development manager at BPAS as proof that they are profit motivated. The Right to Know campaign, which is backing the Dorries amendment and is known to be supported by religious anti-abortion groups raises the advert in this document setting out their case for reform. They don't appear to have similar evidence to substantiate their argument against Marie Stopes.
Regarding the advert, Bpas say:
Bpas was set up to provide the highest standards of abortion care to women when the NHS was either unable or unwilling to offer that care. That remains the same today – we try to increase the proportion of women who can access our services, rather than having to go to another provider, because we believe women deserve the best possible treatment. So for instance in much of the NHS there may be little in the way of choice of method, particularly at later gestations when women may only be offered medical methods (ie induction/delivery of the foetus) which we know is not what women choose when they have the choice. Abortion is not something any woman aspires to, but we think if she needs one she is likely to receive the most compassionate care at Bpas.
Right to know also cites harrowing examples of women who felt they were railroaded into abortions at the clinics. This video on their website is of an interview with one woman who felt this way.
However, Frank Field, the Labour MP who is a signatory to the Dorries amendment, has admitted that there is no evidence of a problem, though he argues that the principle should be to separate advice and services.
He told me last week:
It is a general principle that advice and services should be separate. I have no evidence of that [biased advice]. But we had no evidence of mis-selling of pensions until people investigated.
Field has kept a fairly low profile in this debate, but there is a good interview with him today in the Liverpool Echo here
The private abortion services are charities that reinvest their profits into their services. There is no evidence that they are motivated to encourage women to have abortions because they will financially benefit.
Next, I'm going to look at the current counselling processes.
What are the rules governing abortion counselling?
The Royal College of Obstetricians and Gynaecologists publishes guidance on the clinical aspects of abortion, which says that women should be given counselling according to their need – including post-abortion if she needs it. All women should be offered standalone counselling under the current procedures.
The guidance says that counselling may include:
Implications counselling: Aims to enable the person concerned to understand the implications of the proposed course of action for themselves and for their family.
Support counselling: Aims to give emotional support at times of particular stress.
Therapeutic counselling: Aims to help people with the consequences of their decision and to help them resolve problems which may arise as a result.
The Department of Health (DH) regulations state that:
Counselling must be offered to women who request or who appear to need help in deciding on the management of pregnancy or who are having difficulty in coping emotionally', and that it should also be offered 'to women under 16 and to those with a history of psychiatric illness, who lack social or emotional support or whom their partner, family or employer is possibly coercing into having an abortion.'
What does this means in practice?
At Marie Stopes a woman normally contacts by a call centre first, which is staffed by "health advisers" who have been trained by Marie Stopes and follow a script to discuss a woman's options. They are offered standalone counselling and around 11-12% of women opt for this. Across their services in England there are 30 half hour appointments available a day for face-to-face or over the phone counselling. Women can return for as many sessions until she has made her decision. Counsellors are all members of the British Association of Counselling and Psychotherapy (BACP) and access to follow-up counselling is usually within 24 hours by phone or 48 face-to-face.
At Bpas women have an initial consultation which can last up to 50 minutes with an adviser who has been trained to offer both counselling and medical advice. Bpas, including their training, is accredited by the BACP. They are also offered further counselling if they need it and this can be 24 hours later or a week later depending on the woman's need. Its protocol states:
Many clients will have already made a decision to have an abortion, but may still need a supportive listener who will advocate for their needs while they access our services. Some clients will be uncertain as to whether or not they will continue their pregnancy, and may need to spend more time discussing their situation and feelings. A small number of clients will need structured counselling to address more complex issues. These clients should be recognised and referred appropriately.
The Today programme on Radio 4 this morning had a fascinating debate between Dr Paula Franklin from Marie Stopes and Jenny Baines from Care Confidential, a private clinic that does not refer women to abortion and whose affiliated centres are often linked to religious organisations.
I've just been speaking with Franklin who raises an interesting point about inspection. She says that all abortion services are inspected by the Care Quality Commission, which includes an examination of the counselling they provide.
She tells me:
CQC looks at whether we are fair and impartial, treat people as individuals, give information and respond to their needs. For organisations that are not service providers they are not regulated. The concern for me would be that if organisations are providing counselling and not other services they ought to be regulated. There should be some method in which they are assessed.
She also points out that the counselling that is offered has to comply with Marie Stopes's broad approach but that they have tried to maintain counsellor's independence as much as possible by not issuing detailed instructions on the type of counselling that is offered.
I've also just spoken with Phillip Hodson of the BACP who has explained the organisation's very nuanced position on the debate.
We are in favour of more and better pre and post abortion counselling, ipso facto we think all counselling ought to be independent. But we have never said that organisations should stop giving advice to their clients. BPAS, is a member of BACP and employs counsellors that are members of BACP. We did express support for her [Dorries'] work early on in so far as what she was campaigning for was more and better independent counselling. As the debate has gone on we are looking at a more complex field. We see no reason why Bpas and Marie Stopes should stop giving advice to their clients.
But he also makes a distinction between the "advice" that the abortion providers should offer and "counselling" which he defines as non-directive. He confirms that both Bpas and the anti-abortion charity Life are member organisations. Life runs crisis pregnancy centres that do not refer women for abortions and claims that all its counsellors operate according to BACP principles.
There is an interesting question about BACP accreditation. Counsellors can either be a member of BACP or an accredited member which means they have to renew their membership annually and are subject to spot checks. Anyone can be a member but getting accreditation, meaning you can advertise it, is tougher.
Women are already offered counselling, in the main under the BACP banner. The private clinics say they offer advice and counselling as part of the initial consultation though this is not always by BACP accredited counsellors. Women are offered the option of standalone counselling as well, which at Marie Stopes is offered by a BACP accredited counsellor. Bpas has organisational membership and overall is accredited. But BACP is not necessarily a guarantee that a provider is "independent" and impartial, as the membership of Life proves.
@Poppyest writes about her less positive experience with Marie Stopes – though a happy outcome for her.
I absolutely think there should be counselling for women seeking abortions. The current system is not right. I was 21 when I went to the doctor and said I wanted an abortion; I was 12 weeks. I was made to feel really bad by the nurse at the Marie Stopes clinic and I did ask for counselling but received none. During the scan I actually saw the baby and that is something that no woman would want to see if they are to have an abortion. In the end I changed my mind after talking to my sister and her helping me to realise that everything would be ok (I was at university and not with the father). Now my daughter is off to school today, I am with the father again and finished my degree and am now doing a job that I love. If I hadn't had my sister to talk to then maybe would have made the wrong decision that I would regret. So this is why women need the counselling as maybe they have no family to talk to like I did.
@dinky74 posted that the service suited her, but that that might have been different had she been less sure of her decision:
I had an abortion at age 33, in a stable relationship etc, but had just started a new job, so was unentitled to any maternity support. There was no way I could afford to bring a baby into the world. My decision to terminate was an easy one to make, and I do not regret that decision. My experience at Marie Stopes was of a very quick and efficient service, which was what I wanted as i had made a very firm decision. However, I feel that if I was was undecided, I'm uncertain as to how supportive the service would have been. The very nice staff member asked if I was sure I wanted to go through with the procedure, and had her pen poised in the 'yes' box before I even answered. It was all very swift, methodical and routine. Like I said, my mind was well and truely made up, so getting it all over and done with was what I wanted, but it was all a little cold and clinical, and I felt a little like I do at customs in airports: ushered through as quick as possible, and slightly guilty. My shoe slipped off as I was being taken to the procedure room, and i felt bad for causing delays and holding things up.
An ex-Bpas adviser @jessthecrip makes an interesting point about whether the NHS should be considered as "independent" if the charities are not.
And @BallaBoy makes the argument I've also heard from a few pro-choice MPs I've spoken to that there are plenty of other elective procedures that don't require any counselling.
Why is there no corresponding pressure to ensure that organisations such as BUPA are not "forcing" people into unwarranted procedures in order to make profit? The answer is fairly straightforward - that a combination of decent clinical governance and and an assumption of some intelligence on the part of the patient is deemed adequate to produce a regular system of informed consent.
I'd just like to point out that Dorries herself argues that this is not an amendment about the right and wrongs of abortion itself but about the quality of care women receive. @bluedixie do you have an opinion on that? We're also very keen to hear any evidence to back it up.
Next, I'm going to look at what the amendments Dorries has proposed will actually do.
Page 6, line 8 [Clause 10], at end insert—
'(2A) After subsection (1) insert a new subsection as follows—
"(1A) In this section, information, advice and counselling is independent where it is provided by either—
(i) a private body that does not itself provide for the termination of pregnancies; or
(ii) a statutory body.".'.
This is the most controversial element. It would mean that only organisations that are defined as independent could provide information, advice or counselling to women seeking a termination and defines independent as either a statutory body, ie the NHS, or a private body that doesn't itself provide terminations. This would mean that Bpas and Marie Stopes would be barred from counselling women. I've just spoken to Marie Stopes and their understanding, based on legal advise sought ahead of the debate tomorrow, is that this would bar them from providing any kind of counselling services to women at any stage in the process. They could inform women of the medical procedures or options, but if at any stage that women started to discuss doubts, or her feelings about the procedures, they would have to halt the process and refer her for counselling. But it would allow any other private specialist organisation to offer counselling so long as they don't also provide abortions. This would not bar religious groups with anti-abortion agendas from offering counselling services. Life or CareConfidential, the two main providers of "crisis pregnancy centres", which are both linked to religious organisations and do not refer women for terminations, could offer abortion advice and counselling.
Third Dorries amendment
* Page 9, line 37 [Clause 14], at end insert—
'( ) After paragraph 8 insert—
"Provision of independent information, advice and counselling services for women requesting a termination of pregnancy
8A (1) A local authority must make available to women requesting termination of pregnancy from any clinical commissioning group the option of receiving independent information, advice and counselling.
(2) In this paragraph, information, advice and counselling are independent where they are provided by either—
(a) a private body that does not itself refer, provide or have any financial interest in providing for the termination of pregnancies; or
(b) a statutory body.'.
This mandates local authorities, which are set to take over responsibility for commissioning abortion services, to provide optional independent counselling where "independent" is similarly defined.
Fourth Dorries amendment
* Page 226, line 31 [Clause 240], at end insert—
'(1) Regulations must require NICE to make recommendations with regard to the care of women seeking an induced termination of pregnancy, including the option of receiving independent information, advice and counselling about the procedure, its potential health implications and alternatives, including adoption.
(2) The regulations must require health or social care bodies or any private body that provides for the termination of pregnancies to comply with the recommendations made by NICE under subsection (1).'.
This requires the National Institute for Clinical Excellence to set out guidelines to abortion services instructing them to offer independent counselling and dictating that the guidelines should include informaiton about potential health implications and alternatives, such as adoption.
I've relabelled the amendments below and added in an explanation for each. I think along with our previous work today, we can now reach something of a judgement on the debate.
• The changes would mean that all women would be offered independent advice (not forced to have it) but as we've established (12.17pm) women are already offered dedicated abortion counselling if they need it and it is currently provided by trained or accredited counsellors.
• The abortion charities that provide terminations are charities, and not motivated by profit as reported at 9.40pm.
• The changes would bar Marie Stopes and Bpas from offering any kind of counselling to women but it would also allow religious groups to advise women on abortions, funded by the NHS. Dorries has claimed she doesn't religious groups to offer advice either.
Dorries wrote on her blog:
Bear in mind this amendment is to offer women the option of independent counselling, delivered not by the abortion provider, not by a religious organisation, but by one of the 36,000 BACP professional counsellors across the country who are prohibited at present from working with pregnant women.
But there is nothing on the amendment to stop religious organisations being involved and as we have established BACP is already closely involved with the abortion providers – and as Marie Stopes point out they are also inspected by the CQC, unlike private providers.
The changes, if the Commons approve them, would strip the existing services of their ability to provide a timely service and open it up to groups that may oppose abortion. There is a risk that abortion services could end up less independent under the reforms.
At 12.45 today MPs will debate a set of amendments to the health and social care bill that would overhaul abortion services, stripping the charities that currently carry out around half of abortions in England of their role in counselling women. Critics, led by the Conservative MP Nadine Dorries, claim that private clinics are financially conflicted because they both advise women and carry out abortions, which they are paid for.
Yesterday we investigated the facts of the debate. We had an in depth and incredibly useful debate in the comments on this blog – influencing some of the conclusions we reached - and have decided to keep the thread open ahead of the Commons debate to allow that debate to continue. Last night we sent Dorries a link to this blog asking for a response to our conclusions, but we not have not yet received a reply. There has been one other significant development overnight: The Guardian's chief political correspondent Nick Watt reports that a pro-choice amendment tabled by Julian Huppert has also been selected for debate. Follow our politics liveblog with Andrew Sparrow for all the twists and turns of the debate. A summary of yesterday's inquiries and conclusion are below.
We asked: Is abortion counselling independent? Are abortion services motivated by profit? What is the current process for women seeking an abortion via the private groups that offer abortion processes? What exactly do the Dorries amendments propose and who would carry out independent counselling if the amendment passes?
We saw the evidence that the private organisations providing abortions are charities and that any profit they receive is reinvested in the services. We saw no evidence that they are motivated by profit. There is no systematic evidence of a problem – Frank Field, one of the signatories to the amendments admitted that. Below the line a number of women shared their experiences of abortions – good and bad. Readers pointed out that registration of counsellors with the British Association of Counsellors and Psychotherapists is no guarantee of quality, raising questions about the regulation of counselling generally. A claim from Dorries that all counsellors would be registered with BACP is contested in an analysis of the wording of the amendments which would bar the specialist charities from providing advice and counselling, but allow any other organisation that doesn't deliver abortions to step in.
There is no evidence that current counselling services are motivated by profit. The changes, if the Commons approve them, would strip the existing services of their ability to provide a timely service and open it up to groups that may oppose abortion. There is a risk that abortion services could end up less independent under the reforms.