Dr. Mary Favier:

On behalf of the Irish College of General Practitioners, ICGP, I thank the Chairman and members of the committee for their invitation to discuss the matter of clinical guidance in the context of impending legislation for the termination of pregnancy in Ireland. The ICGP acknowledges that changes that will be required by the outcome of the May 2018 referendum on the repeal of the 8th amendment. As a result of the referendum outcome, a patient centred clinical care pathway for termination of pregnancy as part of a comprehensive reproductive and sexual health service that is appropriately resourced will be required in Ireland. The proposed legislation on this matter needs to be accompanied by measures and policies which aim to reduce the incidence of crisis pregnancy and provide support for those who experience it, including comprehensive contraceptive services and sexual health education programmes.

The result of this referendum has created a new reality. What has principally changed is that terminations of pregnancy which were previously undertaken in another jurisdiction will now be carried out in Ireland. How this is done, the standards and quality of care, the legal implications and the supports given to women at a difficult time is of concern to all of us. As healthcare professionals, it is imperative that we engage to ensure a safe and workable outcome. Our college needs to be part of designing the service and we would like to do so with our colleagues in the Institute of Obstetricians and Gynaecologists.

More detailed information is needed to inform legislators and to enable the Department of Health, together with the postgraduate training bodies and the representative bodies, to comprehensively draw up the detail and resourcing of services for those with unwanted pregnancies. Whichever model of care is developed, the patient must be front and centre in the required clinical care pathway. To ensure the delivery of safe, high quality and timely services to our patients, a series of critically interconnected elements will clearly need to be in place.

These will include the following: legislation; clinical guidelines and clinical care pathways; the licensing of appropriate medications; secondary care referral pathways clearly delineated and resourced; community-based opt-in provision; clarification regarding medical indemnity, if there is any; Medical Council guidelines; and a 24-hour helpline that includes a clear referral pathway to a known community provider, referral to in-person counselling, if required, expert advice to pre and post-termination expectations of care and complications and triage out-of-hours advice to address patient concerns and side effects, post-procedure, with onward referral to medical follow-up, if that were to be required.

This opening statement summarises the work, which may change as new evidence arises, required to address the pertinent concerns such as ultrasound and blood typing, and it summarises key elements of a clinical care pathway. Termination of pregnancy will be legalised for the first time in Ireland. Few clinicians are trained to deliver this clinical care pathway, unless they received training outside this jurisdiction. Naturally, this leads to concerns about patient safety in community-based provision of this new service. To address these concerns, and to generate solutions in the design of a termination of pregnancy service, the college undertook an electronic member engagement process, which does not close until the end of this week.

We have received some good and innovative suggestions for how a service might be offered. Clinical guidelines need to capture the full clinical care pathway from initial appointment to follow-up care post-termination. Clinical guidelines would map to the expected legislation and would undergo the usual best-practice rigorous review process in the college. GPs would prefer an opt-in mechanism by which they choose to provide this clinical care pathway. Clinical guidelines would be expected to address the totality of care provision, including appropriate means of confirming and dating a pregnancy, medical termination of pregnancy for those at up to nine weeks’ gestation, consideration of the additional complexities of providing medical termination of pregnancy at up to 12 weeks’ gestation, and secondary referral to hospital care where required in complex cases or cases where there is uncertainty about dates, known risk factors, etc. Following discussion of all the options available to her, the final decision about whether to undergo a medical or surgical termination of pregnancy should be the woman’s own choice and the appropriate informed consent obtained.

The evidence base on the need for administration of anti-D and the need for ultrasound scanning is becoming clearer and the guidelines would clarify these issues. If ultrasound is required, rapid access to this facility, including the expert provision and interpretation of sonographs, will be a critical element of the pathway. A 24-hour helpline, staffed by appropriately trained clinical staff will be required. This helpline will serve a dual purpose, namely, to provide immediate access to clinical information and care to those with a crisis pregnancy who are considering termination, and to provide post-termination assistance to answer specific questions and make onward referral for care as indicated. Whether GPs wish to provide this service, college members have expressed concerns regarding capacity and resourcing challenges such as staffing, facilities and training; the potential lack of appropriate specialist support; the possibility of medical complications for their patients; the public reaction for those who choose to provide and those who do not choose to provide this clinical care pathway; and a fear of litigation. They wish to see an acknowledgement of conscientious objection and how to accommodate this in the care pathway, and an acknowledgement of conscientious commitment and how to support this in the care pathway. There needs to be an integrated and resourced contraceptive service, provided to reduce the incidence of crisis pregnancies. They want clinical care pathways to keep the patient central to the service and be free at the point of care. They have concerns about the remuneration for service providers and desire a commitment from the Department of Health to a timeline within which a woman can expect to receive a service.

This is a significant juncture in medical care in Ireland. We have an opportunity to ensure the provision of a safe, best-practice, appropriately resourced, patient-centred termination of pregnancy clinical care pathway. The ICGP looks forward to playing a significant role in the development of this pathway.