The Side of Hormonal Contraception NHS Cost-Effectiveness Calculations Can Choose to Ignore
TL;DR
For years, NHS commissioning policy in Oxfordshire justified restricting female sterilisation partly by saying that more cost-effective contraceptive methods were available.
But “cost-effective” depends entirely on what you count.
Do you count only the price of the contraceptive and the cost of preventing pregnancy?
Or do you also count:
- repeat prescriptions,
- appointments for insertions and/or injections,
- appointments for removals of IUDs,
- appointments for replacements or renewals,
- appointments for investigating and managing side effects,
- procedural pain and emotional distress,
- treatment of bleeding and pain,
- costs related to method switching,
- women's direct costs related to management of side effects,
- psychological and social costs related to sexual difficulties resulting from side effects,
- mental-health effects,
- women's time off work to attend all these appointments,
- contraceptive failure,
- unintended pregnancy and abortion costs,
- the burden of carrying contraception for another ten, twenty or thirty years?
In my case, this is not merely speculation. The Parliamentary and Health Service Ombudsman found that the evidence used to justify the female sterilisation policy had not been properly balanced. The papers themselves acknowledged that important indirect costs and the cost of managing hormonal-contraception side effects were not included.
That raises a much bigger question:
Was the NHS actually identifying the healthiest and most appropriate option for women — or was it using a narrow definition of cost to decide what women should be allowed to choose?
This article looks at what the research says, what the old economic modelling did and did not measure, and what genuinely evidence-based contraceptive policy should look like instead.
What does “cost-effective” actually mean in contraception?
Cost-effectiveness sounds objective.
It sounds like somebody has taken every possible consequence, put it into a model, compared the alternatives and scientifically identified the best use of NHS money.
That is not necessarily what has happened.
An economic model is only as comprehensive as the outcomes and costs it has been designed to count.
If a model counts:
- the price of the contraceptive;
- the clinician's time;
- insertion and removal;
- contraceptive failure;
- and the cost of unintended pregnancy;
but does not count repeated treatment for side effects, sexual-health impacts, psychological distress, switching methods, repeated appointments, procedural trauma or the burden placed on the patient, then those things effectively have a value of zero inside the model.
That does not mean they cost nothing.
It means they were not counted.
What did the contraceptive economic modelling actually count?
This is where the history becomes particularly interesting.
The influential NICE economic work on Long-Acting Reversible Contraception was developed in the mid-2000s.
Its economic model compared IUDs, hormonal IUSs, implants and injections with the combined pill and permanent contraception.
It counted NHS costs including contraceptive provision, clinical time, equipment for insertion and removal, counselling, follow-up and costs associated with unintended pregnancy.
Those are legitimate costs.
But that was not a whole-life model of everything contraception might do to a person.
The principal outcome was prevention of unintended pregnancy.
It was not designed primarily to quantify libido, relationship quality, treatment burden, trauma, mental load or every medical consequence of side effects.
And remarkably, that modelling did not actually demonstrate that female sterilisation was economically inferior over the long term.
The NICE-derived UK economic analysis found that female sterilisation became more cost-effective than LARC over longer periods of contraceptive use — roughly beyond five to six years in the modelling.
That is rather important when the patient asking for sterilisation is saying:
I do not want children. I do not want reversible contraception. I want permanent contraception for the rest of my reproductive life.
What did the Ombudsman find about the NHS cost argument in my case?
This is one of the strongest findings in the entire investigation.
The policy said female sterilisation was not normally funded partly because there were supposedly “more cost effective methods of contraception available.”
But the Parliamentary and Health Service Ombudsman found that the evidence considered by the commissioning committee did not demonstrate that conclusion.
The Ombudsman found that female sterilisation could actually be more cost-effective over longer periods of contraceptive use.
More importantly, the committee's own September 2017 material acknowledged that the available economic data largely considered direct costs and contraceptive-failure costs.
It did not adequately capture:
- indirect costs;
- wider societal costs;
- long-term consequences of unintended pregnancy;
- or the cost of managing hormonal-contraception side effects.
The Committee nevertheless used cost-effectiveness as part of the justification for restricting female sterilisation.
The Ombudsman ultimately concluded that the evidence had not been appropriately balanced.
This is why I find the word cost-effective so frustrating in this story.
They were making a cost argument without demonstrating that they had counted the real costs.
What costs did I raise in my original complaint?
When I complained in 2023, I deliberately challenged this narrow accounting.
I asked whether the NHS had considered not merely the acquisition price of contraception, but what decades of contraception could actually involve.
I raised:
- ongoing contraceptive costs;
- bleeding and menstrual problems;
- thrush and other symptoms;
- bloating and weight concerns;
- loss of libido;
- physical side effects;
- psychological and emotional effects;
- blood-clot and cancer risks associated with some hormonal methods;
- appointments to manage side effects;
- and even the possibility of additional mental-health treatment where contraception badly affects somebody's wellbeing.
I also made a deliberately simple financial comparison using retail contraceptive-pill prices over twenty years.
That was not intended as an NHS procurement calculation. It was a challenge:
if you are going to tell me that a one-off permanent procedure is too expensive, show me the actual lifetime calculation that proves it.
I never saw that calculation.
Why is the price of the contraceptive itself only the beginning?
Imagine two interventions.
Intervention A costs more today but is completed once.
Intervention B appears cheaper today but must be repeated, monitored, replaced or prescribed for decades.
You cannot sensibly compare them using only today's invoice.
For contraception, a proper long-term model may need to include:
- prescription costs;
- dispensing costs;
- GP and sexual-health appointments;
- contraceptive counselling;
- IUD and IUS insertion;
- implant insertion;
- device removal;
- replacement procedures;
- injections every few months;
- management of abnormal bleeding;
- investigation of pelvic pain;
- treatment of adverse effects;
- method switching;
- failed insertions or removals;
- contraceptive failure;
- emergency contraception;
- pregnancy and termination;
- and the healthcare consequences of any serious adverse event.
Then there are costs that are much harder to turn into pounds but still matter enormously to health.
What does irregular bleeding actually cost?
Bleeding changes are among the most common reasons people struggle with some contraceptive methods.
Hormonal IUSs can eventually make periods substantially lighter or stop them altogether, which can be a major health benefit for somebody with heavy menstrual bleeding.
But during the first months they can also cause irregular or prolonged bleeding.
Implants are also well known for unpredictable bleeding patterns.
Copper IUDs can make periods heavier and more painful.
For some people this is tolerable.
For others it is the reason they ask for the device to be removed.
From the healthcare-system perspective, troublesome bleeding can mean another appointment, assessment, medication, investigation, eventual removal and then another contraceptive consultation.
From the patient's perspective it can mean pain, disrupted sex, anxiety about bleeding, ruined clothing, sleep disruption and planning life around unpredictable symptoms.
Where is all of that in a simplistic “device cost versus sterilisation cost” calculation?
What does IUD insertion pain cost?
IUD and IUS insertion is sometimes described as a relatively straightforward procedure.
For many people it is.
For some it is not.
Current FSRH guidance recognises that pain during intrauterine-contraception insertion ranges from none to severe and says analgesia options should be discussed and offered.
Research repeatedly finds substantial variation.
For example, one prospective study reported an average insertion-pain score of around 6.6 out of 10 among women who had never been pregnant, compared with lower scores among women who had previously delivered vaginally.
A 2026 Australian national survey found that approximately one in five respondents reported severe pain during IUD insertion.
Another UK study found that clinicians tended to underestimate how much pain their patients were actually experiencing.
This does not mean IUDs are bad contraception.
They are safe, highly effective and excellent for many people.
It means insertion is a real healthcare experience, not an invisible line in a spreadsheet.
What about women with sexual trauma?
This deserves particular attention.
An IUD or IUS insertion involves a speculum being inserted into the vagina, access to the cervix and placement of a device through the cervix into the uterus.
For somebody with a history of sexual assault, invasive pelvic procedures may be particularly difficult or triggering.
Trauma-informed healthcare emphasises safety, control, consent, the ability to stop, clear explanation and avoiding re-traumatisation.
FSRH guidance now emphasises that patients should be encouraged to say when they are in pain or distress, should know that the procedure can be paused or stopped, and should have analgesia options discussed.
The research base specifically quantifying re-traumatisation during contraceptive insertion is still limited.
That is not a reason to pretend the issue does not exist.
It is a reason to research it properly.
Good health economics should not treat a procedure as costless simply because the patient's pain, fear or trauma does not generate an invoice.
What about mood and mental health?
This is an area where the science is more complicated than either side of the debate sometimes suggests.
Some large observational studies have found associations between hormonal contraception and depression or antidepressant use, particularly in some younger populations.
But randomised-trial evidence is much less clear.
A 2021 systematic review and network meta-analysis of randomised trials did not find evidence that hormonal contraception generally caused worsening depressive symptoms in adult women, although the authors described the certainty of evidence as very low and noted that first-time and younger users were underrepresented.
A 2024 systematic review found a more complex picture, including small increases in depression risk in some populations and differences by contraceptive type.
So the scientifically responsible conclusion is not:
Hormonal contraception makes women depressed.
Nor is it:
Mood effects do not exist.
The responsible conclusion is:
average effects are mixed, individual responses vary, some women report clinically important mood changes, and policy should be capable of responding to that variation.
And if someone repeatedly attends a GP because a contraceptive method is affecting her mood, switches medication, requires mental-health support or simply spends months feeling unlike herself, those consequences matter even if the average trial effect is small.
What about libido and sexual function?
Sexual health is another area that has historically received surprisingly little attention in contraceptive research.
The European Society of Sexual Medicine reviewed the evidence and concluded that hormonal contraception's effects on female sexuality remain controversial.
Most women do not experience major deterioration.
But a minority report changes in desire, lubrication, orgasm, arousal or relationship satisfaction.
That minority matters.
Research on IUDs and implants also suggests that how women perceive a method's effect on their sex life can strongly influence whether they continue using it.
In one prospective study, women who felt their IUD or implant had negatively affected their sexual experience were substantially more likely to discontinue it during the first year, although the number of discontinuations was small and the confidence interval was wide.
A small 2026 retrospective LARC study also found differences in sexual-function outcomes between copper IUD, hormonal IUS and implant users, with poorer scores in some domains among hormonal-IUS users. Because the study included only 90 women and the groups differed in some baseline characteristics, it should not be treated as definitive.
But taken together, the evidence tells us something important:
sexual wellbeing is a legitimate contraceptive outcome.
Why could libido loss create costs far beyond the bedroom?
Sexual desire exists inside relationships.
If somebody experiences a major change in libido, lubrication, pain, attraction or sexual satisfaction, the consequences may extend into intimacy, self-esteem and relationship satisfaction.
That does not mean contraception “causes divorce”.
The evidence absolutely does not justify that claim.
But it is equally unreasonable to pretend that sexual side effects have no social consequences simply because a cost-effectiveness model does not have a column labelled “relationship strain”.
Research on contraceptive sexual acceptability has found links between perceived negative sexual effects, dissatisfaction and discontinuation.
That can itself generate another chain of healthcare use:
sexual side effect → dissatisfaction → consultation → removal or switching → another prescription or procedure.
Even before we attempt to value relationship distress, there can therefore be direct NHS costs.
Can the pill change who women find attractive?
This is one of the most fascinating — and most easily overstated — areas of contraceptive research.
Earlier studies suggested that oral contraceptive use might alter some mate preferences.
One line of research examined the major histocompatibility complex, or MHC — genes involved in immune function.
Some early experiments suggested women might show odour preferences for genetically dissimilar men and that starting the contraceptive pill could shift those preferences toward greater similarity.
Other research suggested women who met partners while using oral contraception differed in sexual satisfaction, attraction or later relationship experience.
That created a striking hypothesis: could changing hormonal state after meeting a partner affect attraction?
But this is where good science requires restraint.
The popular claim that the pill makes women choose genetically incompatible partners and then stop being attracted to them when they discontinue still needs further research.
A comprehensive 2020 meta-analysis found no significant overall relationship between MHC dissimilarity and actual human mate choice, relationship satisfaction or odour preference.
A 2025 meta-analysis of the so-called contraceptive “congruency hypothesis” concluded that changing oral-contraceptive use was unlikely to have a substantial effect on partnered women's sexual satisfaction on average.
And a large 2026 study across 51 countries found no robust support for the idea that changing hormonal-contraceptive status after relationship formation substantially altered relationship quality.
There are still interesting unresolved questions here.
But I would not want NHS policy to be based on weak evolutionary speculation any more than I want it based on unsupported assumptions about female sterilisation regret.
The lesson is not that the pill destroys relationships. The lesson is that sexual and relational wellbeing are legitimate outcomes to research properly rather than dismiss or sensationalise.
Does hormonal contraception make the body think it is pregnant?
There is some truth underneath this common expression, but it needs to be explained carefully.
Hormonal contraception does not leave the body in its usual naturally cycling, non-pregnant state.
In a normal ovulatory cycle, hormones produced by the hypothalamus, pituitary gland and ovaries rise and fall in a coordinated pattern. Follicles develop, oestrogen rises, an LH surge triggers ovulation, and progesterone rises during the luteal phase.
Combined hormonal contraception deliberately interferes with that system.
The synthetic oestrogen and progestin provide negative feedback to the hypothalamic-pituitary-ovarian axis. FSH and LH are suppressed, ovarian follicular development is reduced and the LH surge that ordinarily triggers ovulation is usually prevented. Endogenous ovarian production of oestradiol and progesterone is therefore also altered.
In other words, the body is no longer operating in its ordinary cyclical reproductive state.
This is why hormonal-contraceptive treatment has historically sometimes been described as creating a “pseudo-pregnancy” state. There are similarities: ovulation is suppressed and sustained hormonal signalling replaces the normal cycle.
But the comparison should not be taken literally.
A real pregnancy involves implantation, production of hCG, maintenance of the corpus luteum and eventually a placenta producing very large quantities of hormones, alongside major cardiovascular, immune, metabolic and endocrine changes. Hormonal contraception does not reproduce that physiological state.
A more accurate description is that it creates a distinct pharmacologically induced endocrine state: neither a normal ovulatory menstrual cycle nor an actual pregnancy.
That distinction matters because the consequences of spending years in that altered hormonal state — including possible effects on mood, sexual function, bleeding, metabolism and other aspects of wellbeing — deserve to be researched rather than dismissed simply because the medication is effective at preventing pregnancy.
What about blood clots?
Some contraceptive methods carry small but real vascular risks. And the NHS states that combined hormonal contraception can increase the risk of blood clots.
For the combined pill, the NHS estimates the risk at up to around 1 in 1,000 users.
That is a low absolute risk.
But “low risk” and “zero cost” are not the same thing.
A serious clot can involve emergency care, hospitalisation, imaging, anticoagulation, follow-up and, in rare cases, permanent harm or death.
A proper whole-system economic model should at least determine whether such adverse events materially affect the comparison rather than automatically omit them.
What about cancer risk?
This also needs balance.
Hormonal contraception does not simply “cause cancer”.
Different methods alter different risks in different directions.
The NHS and Cancer Research UK report that combined oral contraception is associated with a small increase in breast-cancer risk and possibly cervical-cancer risk while being associated with lower risks of ovarian and endometrial cancer, with some evidence of reduced bowel-cancer risk too.
The excess breast and cervical risks reduce after stopping.
So this is not a simple argument against hormonal contraception.
It is an argument against pretending that every contraceptive option is medically interchangeable.
Different women have different family histories, cardiovascular risks, bleeding problems, cancer risks, reproductive plans and preferences.
“What is healthiest?” cannot be answered by one commissioning committee for every woman.
What about bone health?
Depot medroxyprogesterone contraceptive injections are another example of why method-specific consequences matter.
The NHS states that prolonged use can reduce bone mineral density, although bone density usually recovers after stopping.
The method can also involve weight gain, menstrual changes and repeat injections every eight to thirteen weeks.
For somebody who likes the method, those trade-offs may be entirely worthwhile.
For somebody who wants permanent contraception and has no desire to retain fertility, repeatedly receiving injections for years may make far less sense.
What does the mental load of contraception cost?
Some contraceptive methods have another characteristic that economic models struggle to capture:
the patient has to keep doing something.
The pill must be remembered every day.
Patches must be replaced.
Rings must be managed.
Injections must be repeated.
Devices eventually need replacement or removal.
This is not merely convenience.
Studies using electronic monitoring repeatedly find that people miss more pills than they report remembering.
Research also shows that stress and hectic daily life contribute to missed pills.
That means the cognitive burden of contraception can affect its real-world effectiveness.
For somebody who knows with certainty that she never wants to become pregnant, permanent contraception removes that recurring cognitive task.
While that benefit may be difficult to capture in monetary terms - it is not worthless.
Does method switching matter economically?
Very much.
A method can look inexpensive if an economic model assumes somebody starts it and keeps using it.
Real life is messier.
People discontinue because of:
- bleeding;
- pain;
- sexual effects;
- mood concerns;
- acne;
- weight concerns;
- desire for pregnancy;
- or simply disliking the method.
Every switch can involve appointments, counselling, prescriptions, removal, another insertion and another period of adjustment - which goes from weeks to months at a time. Now imagine having to go through 3 different methods before you find one that works for you - that is easily a year before you land on something that works for your body and lifestyle.
The research confirms method-switching is a common, recurring part of contraceptive use driven mainly by side-effect-driven dissatisfaction, and that some women go through several methods over their reproductive years before finding one that works — but no study in this retrieved literature reports a standardized average "number of methods tried before success." That specific metric appears to be a genuine gap in the literature; what exists is rates and predictors of switching rather than a count of attempts per woman.
Indeed, discontinuation was one of the major variables determining cost-effectiveness in the original NICE LARC modelling.
This makes patient preference economically relevant as well as ethically relevant.
A contraceptive somebody hates and rapidly removes may be less cost-effective than a supposedly more expensive option she actually wants.
What does female sterilisation cost — and what does it avoid?
Female sterilisation is not risk-free.
It requires surgery, usually under general anaesthetic.
The NHS identifies possible complications including infection, blood clots, injury to nearby organs or blood vessels and an increased risk of ectopic pregnancy if the sterilisation fails.
Those risks belong in any honest comparison.
But sterilisation also has characteristics that matter enormously for somebody who does not want future fertility.
It is more than 99% effective.
It is permanent.
It does not alter hormone levels.
After recovery, it does not require another pill every day, an injection every few months or a device replacement every few years.
So the comparison should never be:
“surgery has risks; LARC therefore wins.”
The comparison should be:
What are the total benefits, risks, burdens and costs of each realistic option for this particular patient over the period for which she actually needs contraception?
So what is the healthiest contraceptive method?
There is no universal answer.
And I think that is precisely the point NHS policy has repeatedly missed.
An IUS may be one of the healthiest options for a woman with very heavy painful periods who also wants reversible contraception.
A copper IUD may be preferable for somebody who wants highly effective contraception without hormones.
The pill may suit somebody perfectly.
An implant may remove the burden of daily adherence.
A vasectomy may be the simplest permanent choice for a couple.
And for an adult woman who is certain she does not want future fertility, understands that sterilisation is permanent and accepts its surgical risks, female sterilisation may be the option that best fits her health, values and life.
Evidence-based medicine should help people make that decision. It should not make the decision for them.
What would genuinely evidence-based contraceptive commissioning look like?
If I were designing the policy-analysis framework I expected the NHS to have used, it would not begin with:
Which method costs us the least this year?
It would begin with:
What outcomes matter to patients, what does the best evidence show, and what is the full cost of providing safe and equitable care over time?
A serious model should examine:
- contraceptive effectiveness in both perfect and real-world use;
- time horizon — one year, five years, ten years, twenty years and remaining reproductive life;
- direct treatment costs including drugs, devices, surgery and professional time;
- repeat healthcare use including prescribing, insertions, removals, replacements and follow-up;
- adverse events and side-effect management;
- method switching and discontinuation;
- pain and procedural burden;
- mental-health outcomes where evidence supports inclusion;
- sexual function and sexual wellbeing;
- quality of life;
- contraceptive mental load and adherence;
- unintended pregnancy, emergency contraception and termination;
- patient time and travel;
- waiting times and service capacity;
- trauma-informed care needs;
- patient preference;
- sex-based equality;
- geographical inequality;
- and the consequences of denying or delaying the patient's preferred method.
Some of those outcomes can be assessed in monetary terms.
Some belong in quality-adjusted-life-year analysis.
Some are better represented through patient-reported outcome measures.
Some may remain qualitative.
But difficult to price should never silently be treated as if it has zero worth.
Why is this also a human-rights and equality issue?
Healthcare economics does not exist outside the NHS's other responsibilities. The NHS Constitution says care should reflect individual needs and preferences. Patients have rights to information about available treatment options, their benefits and their risks. They have rights to involvement in decisions about their healthcare.
The NHS must respect human rights, promote equality and have regard to reducing inequalities in both access and outcomes.
That matters particularly in contraception because the intervention happens to somebody's body for the explicit purpose of controlling their reproductive capacity.
Cost matters. But it cannot be the only value in the room.
Why does the male vasectomy comparison make this harder to defend?
There is another economic question that I still do not think has been adequately answered.
Why is permanent contraception being treated differently depending on whose body requires it?
The original Ombudsman investigation found that the Committee did not handle comparable questions about male and female sterilisation consistently.
Later, I found NHS-funded vasectomy being delivered through private providers and, in some areas, direct self-referral pathways.
You can read that investigation in The Gender Gap in Healthcare: The Vasectomy Pathway NHS Thames Valley Would Not Explain.
If commissioners are willing to pay for permanent contraception for men and improve the convenience of accessing it, while simultaneously treating permanent contraception for women as something to defer in favour of decades of alternatives, the equality analysis needs to be exceptionally strong.
I have not seen evidence that it ever was.
Is the healthcare postcode lottery finally changing?
There is one wider NHS reform that could create an opportunity to do this better.
England's commissioning structure is currently being reorganised.
Integrated Care Boards are being merged into fewer, larger organisations, partly to reduce administrative costs and duplication. NHS England's Strategic Commissioning Framework says the number is expected to reduce from 42 to around 26.
The government's 10 Year Health Plan also envisages ICBs becoming much more focused strategic commissioners, supported by a national commissioning framework, shared benchmarking and the ability to commission services at larger scale.
That could help reduce the kind of postcode lottery my case exposed.
But it is important to describe the reform accurately.
The NHS is not simply moving toward one national policy for every treatment.
The current model still gives ICBs substantial responsibility for local commissioning and explicitly talks about local autonomy.
So consolidation alone will not solve variation.
Could the NHS have national minimum standards without nationalising every service?
Yes.
And the NHS already does versions of this.
Specialised services can be locally or regionally delivered while still being governed by consistent national service specifications and evidence-based policies intended to provide equivalent access regardless of geography.
There is no obvious reason that the NHS could not establish stronger national minimum standards for other rights-sensitive services.
For permanent contraception, that could mean:
- a national evidence base;
- a national minimum access standard;
- consistent principles for informed consent;
- no mandatory trial of another contraceptive purely because of geography;
- national equality requirements;
- transparent criteria for any local departure;
- and referral to another NHS provider if the procedure is not available locally.
The hospital performing the surgery does not have to be in every town.
The patient's right to fair access does not therefore need to disappear at the county border.
What is interesting about the NHS's own new commissioning framework?
The irony is that NHS England's new Strategic Commissioning Framework describes almost exactly the kind of process I expected to see in this case.
It describes strategic commissioning as a continuous evidence-based process.
It says commissioners should understand population need, examine access, costs, capacity, waiting times, quality and outcomes, gather feedback from people using services and incorporate lived experience into decisions.
It also says commissioning should improve population health, reduce inequalities and improve equitable access to consistently high-quality care.
That sounds excellent.
But policies are not evidence-based because the framework says they should be.
The evidence has to actually be there.
The balancing has to actually happen.
The patients have to actually be heard.
What has troubled me throughout this entire case?
I keep coming back to the same problem.
Where is the evidence?
When I asked what evidence supported the claim about female sterilisation regret, I did not receive a convincing answer.
When I asked how bodily autonomy had been considered, the answer was inadequate.
When I challenged the cost-effectiveness rationale, the independent investigation later found that the evidence had not been appropriately balanced.
When I asked about equality with male sterilisation, the Ombudsman found that comparable circumstances had not been handled consistently.
When the policy was rewritten after the Ombudsman investigation, another restriction on women appeared — the requirement for a 'therapeutic trial' of LARC.
I then asked Chair Dr Priya Singh to explain the legal, clinical and evidential basis for that restriction - I never received the clear answer I asked for.
You can read that correspondence in Why NHS Chair Dr Priya Singh Couldn't Defend the February 2026 Female Sterilisation Policy.
Why does this feel bigger than one contraception policy?
Because this is what concerns me about healthcare policymaking generally.
A policy can look beautifully professional.
It can contain references to evidence-based care, equality, patient choice, safety, affordability and good governance.
But the important question is not what the policy says about itself.
The important question is:
Can the people who wrote it show the evidence, calculations and reasoning that justify what the policy actually makes patients do?
In my experience of this case, again and again, I have found impressive language describing how policy should be made and an astonishing lack of documentary evidence demonstrating that those standards were actually followed.
What would I want the NHS to do differently?
I do not want an NHS that automatically promotes sterilisation.
I do not want an NHS that automatically promotes LARC.
I do not want an NHS that promotes the pill.
I want an NHS that does the difficult thing:
genuinely compares the options.
Compare their effectiveness.
Compare their risks.
Compare their burdens.
Compare their actual lifetime costs.
Study sexual wellbeing.
Study mood properly.
Study pain.
Study discontinuation.
Study trauma.
Study why women switch.
Study how much repeat healthcare those switches generate.
Study equality.
Study patient preference.
Then give people accurate information and let competent adults decide what trade-offs make sense for their own bodies.
The cheapest contraceptive is not necessarily the one with the lowest purchase price.
The healthiest contraceptive is not necessarily the method that performs best in an average population.
And the most cost-effective healthcare policy is not necessarily the policy that spends the least money today.
A serious healthcare system asks what happens next.
Read the evidence behind this case
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