Health, Social Care and Sport Committee (Virtual)

Meeting date: Tuesday, January 11, 2022

Official Report 644KB pdf

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Transvaginal Mesh Removal Reimbursement Scheme

Our third item is an evidence session with the Scottish Government on the draft transvaginal mesh removal reimbursement scheme, which the Cabinet Secretary for Health and Social Care sent to the committee in December 2021, and which, of course, comes off the back of our scrutiny of the Transvaginal Mesh Removal (Cost Reimbursement) (Scotland) Bill.

I welcome back to the committee Greig Chalmers, head of the chief medical officer’s policy division; Terry O’Kelly, senior medical adviser; David Bishop, mesh team leader; and Ailsa Garland, solicitor. I thank you all for your offer to come back to take us through the scheme and some of the issues that we raised in our stage 1 report.

I will start by asking you to take us through the crowdfunding issue, which came up when we took evidence on the bill. Some of the women affected crowdfunded for their surgery, and we had questions about how people who had gone down the crowdfunding route might be dealt with.

I am not sure who I should go to first. Perhaps Terry O’Kelly could explain how crowdfunding will be dealt with. However, if you want to defer to anyone else, please do so.

Thank you very much, convener, and welcome from Aberdeen. If it is not unreasonable to say so, as that is a policy rather than a clinical issue, I think that it probably best that Greig Chalmers responds. I do not want to steal his thunder.

Over to you, Greig.

Good morning and happy new year. I am very pleased to come back to speak to the committee about the bill and the reimbursement scheme.

I will turn directly to crowdfunding, which was one of the issues that the committee raised in its stage 1 report. We gave consideration to the different circumstances in which individuals will have received money from other people to help meet the costs of mesh removal surgery. The Government’s conclusion was to distinguish between private arrangements and arrangements that were, in essence, public. I recall that the committee discussed that with the cabinet secretary.

In relation to arrangements that were private—for example, between family members—it seemed to the Government most sensible not to get involved and to allow those family arrangements to be dealt with privately and for any moneys granted to be distributed privately between family members. Families come in all shapes and sizes and have different arrangements. That was our view on that aspect.

In relation to public and quasi-public arrangements, as is addressed in the reimbursement scheme, where moneys have been raised publicly through a recorded, quasi-public route such as a crowdfunding website, we thought it reasonable to expect applicants to declare that they have received moneys through such routes.

That is in part because crowdfunding websites will generally have recorded what has happened. Even if individuals did not retain the receipts or documentation at the time, that information is recoverable—it can be got from the organiser of the website. In those circumstances, we think that it is reasonable for those moneys to be declared.

It is also partly because, where private people made voluntary donations to the costs of somebody whom they know—albeit perhaps distantly or through social media—the Government considered that it is reasonable that those individuals did not expect to get the money back and that it was a purely charitable donation. That is the balance that we came to on that aspect. That is recorded in paragraphs 17(1) and 17(2) of the scheme.

Of course, people might have raised funds from various sources.

Before I allow my colleagues to come in, I have a question. How will we make sure that the process is not overly burdensome for individuals, some of whom are recovering from surgery? How will you facilitate the process so that they do not find it a burdensome task?

That is a very fair point. One thing from which we take encouragement is the fact that NHS National Services Scotland, which will operate the scheme, has a fair amount of experience in that area. I will give an example. When individuals have been making applications to the existing Scottish Government mesh fund, there have been occasions when applications were, for one reason or another, incomplete—possibly for the reason that the convener gave. In those circumstances, NSS has worked with people to get additional information to make sure that the application is complete.

We and NSS certainly plan to proceed in the same way with the scheme. The applications will be made in good faith and sincerely. If it so happens that there are issues with the information that is provided, whether in relation to the aspect that has been mentioned or whether in relation to something else such as travel receipts, we will make best endeavours to support people to find, or to help us to find, the information that they need

Okay; thank you very much. I will pass over to Gillian Mackay, who has questions on the scheme’s flexibility.

Can the witnesses provide more detail on the exceptional circumstances provision at paragraph 16? Can you provide an example of circumstances that may require that provision to be used?

The purpose of paragraph 16 is to give the administrator—NSS—the scope for flexibility that it needs in relation to all the different circumstances that will have transpired with regard to people travelling some way to get their surgery, whether in the United Kingdom or internationally.

On specific flexibilities, as the committee would expect, we specify in the scheme that reasonable travel costs are, generally speaking, economy-class travel or standard-class hotel rooms that one would ordinarily use. However, one cannot know all the circumstances that will be involved in each situation.

For example, if it so happens that, for one reason or another, there was no standard-class room available in the hotel in the United States during a particular period, or that it was necessary for somebody who was in particular pain or discomfort to upgrade their air transport so that they did not travel by what we would all understand as economy class, NSS would, if the circumstances were reasonable and the explanation made sense, have the flexibility to pay that bit more.

The provision is to give NSS the commonsense flexibility to take account of things that have happened outwith the applicant’s control.

Given that many of the women who travelled did not expect to be reimbursed, do you believe that there is sufficient flexibility to address the many different situations that may arise, to ensure that anyone who claims under the scheme will be covered?

We certainly hope so. For example, we are conscious that it is very likely that individuals will not have kept receipts—why would they?—for meals, taxis and other items that, although they are small individually, will add up in aggregate over a few days, or up to a week, when people are travelling. We hope that, for smaller items for which people will not have kept receipts, the provision for exceptional circumstances will be wide enough.

It is reasonable to expect that, even if people did not keep plane tickets—indeed, people do not get plane tickets these days—or receipts, they will, for large expenditures, be able to draw on bank statements. Given that we know where the surgery has taken place, if it so happens that people have not kept receipts for the surgery costs—I expect that they probably will have—we would be able to get that information from the surgery provider. In general, we would hope that there is sufficient scope to cover exceptional circumstances.

One point to make is that, because the scheme is administrative, we would have scope, if something transpired that we did not anticipate, to remake the scheme or add to it, as we did in the case of the Scottish Government mesh fund.

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After the mesh fund had been operating for a while, it transpired that some women had had mesh implanted in a private hospital. We had not been aware of that at the outset. However, because the scheme was administrative, we were able to amend it very quickly and bring those women within the scope of the existing fund. We would have that option with this scheme, too.

That is great—thank you.

We move to questions from Sue Webber on medical issues arising from mesh surgery.

I am a bit confused—it might just be because it is the first day back, or the first committee meeting—about the other costs. Can someone explain the rationale behind allowing only treatment for complications arising directly from the mesh removal surgery to be reimbursed, whereas medical issues arising as a result of mesh removal surgery will not be reimbursed? What is the difference? Why are we reimbursing one and not the other?

I am happy to start on that, and then I will hand over to Terry O’Kelly, if he does not mind, to address the more clinical aspects.

We are trying to make a distinction in relation to issues immediately arising from the surgery. I should say in that regard that we are not aware of any issues immediately arising. In essence, if something has happened during the surgery—if, to put it in layman’s terms, something has gone not quite right—and that needs immediate attention afterwards, we want to draw a distinction between that and the healthcare that we would offer patients on their return to Scotland—that is, the continuing care that all individuals can access from the NHS. We would expect individuals to access that care through the NHS, as everyone else does.

I will let Terry O’Kelly come in to better explain the distinction.

The scheme specifically addresses reimbursement for mesh removal, and therefore it is entirely appropriate to think that, if there is a complication or an issue relating to that procedure—for example, a surgical site infection or some other issue resulting in the patient returning to theatre or having to have an additional length of stay—that will be reimbursed.

For a number of women, there will be on-going problems. We have seen from correspondence and requests from the women themselves that they are linked to local services and the national multidisciplinary team so that their future care will be taken forward in a coherent and seamless fashion. That will involve pain management, if that is appropriate; care for psychological and psychosexual issues; and perhaps further urological surgery.

The reimbursement is about the primary procedure to remove the mesh and what surrounds it and any expenses related to that, rather than about additional issues that might have been taken care of beforehand or subsequently.

Okay—I think that I have got that now. The language is very subtle, is it not?

I absolutely agree. As Greig Chalmers described, the issue is the way in which the scheme is applied. We hope that the application will be as flexible as possible, and that each individual case will be assessed on its own merits, because cases will undoubtedly differ.

Is it acceptable that long-term care is not reimbursable under the scheme if such care was required because of the original mesh surgery? I am talking about the implantation surgery, not the removal.

The bill specifically addresses mesh removal rather than other aspects of care for these women.

Are you suggesting that, if a patient has significant issues resulting from their original surgery, the treatment would be carried out under the new Scottish mesh service?

Yes, that is absolutely right. Treatment will be accessible locally, but we hope that it will be accessible through the service. Now that we have a centre, which is aligned with the other centres in the United Kingdom, it will act as a hub and spoke. Patients will attend the centre and be consulted with as needs be, but we hope that they will be able to access as much care as possible locally.

With regard to long-term issues such as psychosexual and psychological issues, the centre will, over time, develop expertise on specific aspects of care. Nonetheless, those areas of care are, and have been, accessible through the NHS, throughout Scotland and the rest of the United Kingdom.

What we have added to that is—[Inaudible.]—centres for the act of mesh removal. I appreciate that there are issues around that, such as reconstructive surgery and so on.

Thank you—that is great.

We move on to questions from David Torrance.

Apologies, David—I have just realised that Emma Harper has asked for a supplementary on the points that Sue Webber raised.

It is just a quick question to ask Dr O’Kelly to clarify a matter. If a person needs anticoagulant therapy, which would require them to have an extended pre-operative assessment and may even affect their post-op recovery, leading to a delayed discharge to enable the anticoagulants to be managed, that would be covered as part of the mesh removal procedure. Is that correct?

That would be my understanding, yes. It would be very difficult not to support that.

My other question is on the flipside of that. If somebody acquires a complication because of mesh removal surgery, such as urethral transection or something in the ureter that requires additional surgery, such as a urostomy, is that covered as something that happened because of the removal surgery?

My understanding and belief is that that would not necessarily be covered, unless it was an immediate problem that required urgent or emergency care.

With regard to the longer-term aspects of urinary diversion or other major urological reconstructive surgery, I am not sure how much of that surgery goes on in the private sector, but I think that one would expect to be given that care. When I gave evidence to the committee previously, I think that I highlighted that such care is for the major centres, with all available resources. We would anticipate that such care would have been picked up by the NHS, and that, in future, it will be given under the auspices of the NHS.

If there was a urethra or urological injury at the time of mesh removal, and it had to be corrected at that time, that should be reimbursed for sure. That would not necessarily involve the care that you have suggested. It might do, but I think that that would be a very rare occurrence.

My question is for Greig Chalmers. Some of the women will have taken out loans or used credit cards, or even remortgaged houses in some cases. Will they be eligible for reimbursement of costs that they have incurred through interest payments on the loans?

In general, yes—that is the policy intention. We would look to the cumulative—actually, “cumulative” is a big word. We would look to an individual’s circumstances and the way in which they had raised the money, which might well involve interest payments.

As Terry O’Kelly said, our general approach is to maintain as much flexibility as we can in the administration of the scheme. Where individuals entered into credit agreements and other financial instruments, the cost to the person will be considered. That will be within the broad scope of reasonableness, which is a point that I should always add. As the cabinet secretary said in his evidence to the committee, we need to keep a balancing eye on the use of public funds. Nevertheless, I fully expect that the actions that people have taken in such circumstances will have been reasonable.

As I do not see any other member wanting to ask questions, I thank all the witnesses for their time this morning, and once again thank them for giving us sight of the draft scheme.