Background

Before the creation of the National Health Service (NHS), the health of the British nation was in a perilous state and hospitals survived on the philanthropy of rich benefactors. Following its introduction on 5 July 1948, the NHS was the biggest and most expensive social reform of the era.1 It was founded on three core principles: that it should meet the needs of everyone, that it should be free at the point of delivery, and that its use should be based on clinical need, not ability to pay. These principles govern the NHS today.

The NHS should not discriminate against anyone who requires health care. Yet abortion care remains almost the only acute health need not comprehensively provided for within the NHS.2 In England and Wales in 2013, 98% (185 331) of all abortions were funded by the NHS,3 but only 34% of abortions took place in NHS settings. The majority were in the independent sector, funded by the NHS.4 This is in sharp contrast to Scotland, where in 2013 only 40 women out of 12 447 (0.3%) had their abortions in a non-NHS setting.5 The question is why?

Invisibility of abortion within the NHS

The independent abortion sector in England and Wales has grown out of the need to provide women with abortion services. The clinical commissioning groups may now be setting the abortion agenda, rightly placing the requirements of quality and access as a priority above that of who the provider is. But does removal of abortion care from the hospital setting contribute to the apparent invisibility of abortion care as part of mainstream obstetrics and gynaecology, and a lack of doctors trained in abortion care within the NHS?6

It might be suggested that in countries such as Great Britain where abortion is not legally available on demand, abortion stigma will be higher in the public system as opposed to the private system. It is argued that this is because the public system (i.e. the NHS) must make value judgements in order to decide how to allocate resources. Yet the 2012 NHS constitution decrees that all patients have the right to access services without discrimination.7 Given the large number of women who have abortions in England and Wales, their absence in NHS hospitals and other NHS settings may suggest to some that abortion is uncommon. The invisibility of abortion in NHS health care situations perpetuates the social norm that abortion is indeed uncommon (and therefore deviant), which in turn contributes to the potential stigma that NHS funding of private sector abortions may infer.

Independent provision of abortion services in the UK offers the NHS an important and valued service, yet it is a double-edged sword. Independent abortion providers rely on continuing referral of NHS patients, thereby denying the opportunity to those who work in the NHS to provide abortion care as part of their NHS role. I would argue that being seen to provide abortion services within the NHS as part of a routine existing work role would herald the reality of abortion as part of women's reproductive life and would give an opportunity to those who wish to provide the full gamut of women's reproductive health services within the NHS to do so.

Abortion stigma in the NHS?

In a country in which abortion is paid for and supplied by a government department, one might expect there to be substantially reduced stigma around performing abortion work. It is therefore significant that not only do patients experience stigmatisation, but those who choose to work in abortion care also do so, even though it is part of a national commitment to universal health care.8–10 Although there are many examples of exceptional care provided to women who request abortion from NHS providers, and the rationale for providing state-funded abortion care is laudable, nevertheless the gesture is diminished by its continued invisibility in the very system that upholds it.

The solution is complex. Do we insist that women are cared for in NHS settings, thus reducing their option to choose an independent sector abortion, or do we refer women to non-NHS units that specialise in abortion care? We could take the view that employees who work in independent sector units may be less likely to hold prejudices against women seeking abortion, as opposed to some NHS staff who work in departments that provide abortion as part of their service, but which are staffed by employees who have not chosen to work in this area and who may potentially hold prejudiced views.

Disparity in provision in England, Wales and Scotland

Reducing stigma is a conundrum that is not easily resolved. One question that we must ask ourselves is, how is Scotland able and willing to provide virtually all its abortions in NHS settings as opposed to only one-third in England and Wales? In an ideal world women would be free to choose where they have their abortion without the likelihood that they will be ‘set apart’ from the general health care environment. I believe it is the ‘setting apart’ that contributes to the stigma-related impact of NHS funding of independent sector abortion. Not until we have eroded the secrecy, shame and stigma that women carry with them when seeking abortion11 will they truly be free to choose the circumstances of their own care.