The NHS CEO, Dr Nick Broughton, Said the Female Sterilisation Policy Was Robust. The Ombudsman Found Something Very Different

What exactly did the Chief Executive Dr Nick Broughton tell me?

BOB ICB's final response did not concede that something fundamental might have gone wrong with the female sterilisation policy.

Instead, it defended the process.

Chief Executive Dr Nick Broughton told me that the Thames Valley Priorities Committee had fully reviewed the policy and that the process included:

His letter also stated that policy recommendations were approved and adopted through a "robust governance process".

Those are strong assurances.

They invite the reader to believe that the NHS had properly gathered the relevant evidence, weighed it rationally, considered equality and ethics, followed proper governance, and arrived at a defensible policy.

The Ombudsman's investigation tells a very different story.

Did the NHS properly balance the evidence on female sterilisation regret?

The CEO's response: the policy had been through a full assessment of evidence, guidance and ethical considerations.

The Ombudsman's provisional finding: the evidence on regret had not been appropriately balanced.

The underlying papers themselves acknowledged that regret was subjective and difficult to quantify. Research showed wide variations in reported regret, dependent on circumstances and risk factors.

The evidence considered in relation to male sterilisation also said regret following sterilisation was experienced by a minority of people.

Yet female sterilisation policy was built around the idea of significant or substantial regret.

The Ombudsman found no adequate explanation for turning such a subjective measure into an objective commissioning barrier.

More importantly, it found that the committee had not given sufficient weight to informed consent and the Mental Capacity Act principle that an adult with capacity should not be treated as incapable of making a decision simply because somebody else thinks it is unwise.

The Ombudsman considered that comparable circumstances affecting men and women had not been handled fairly or consistently.

Were other contraceptives really shown to be more cost-effective?

This was one of the things that infuriated me from the beginning because the NHS's own papers appeared to contradict its policy.

The female sterilisation policy stated that other, more cost-effective contraceptive methods were available.

Yet evidence before the committee indicated that female sterilisation could become more cost-effective than LARC after six years in one study, and that male and female sterilisation were more cost-effective than LARC over 15 years in other modelling.

The Ombudsman's provisional view was remarkably clear: the committee had not demonstrated that alternative contraception was more cost-effective than female sterilisation.

It described the policy wording as appearing illogical given the evidence actually available.

It also identified something I had raised in my original complaint: the calculations had not properly dealt with wider costs, including the cost of side effects, alternative contraception, terminations and unintended pregnancies.

Even more strikingly, some of those broader costs had been considered when discussing whether male sterilisation should continue to be funded.

They had not been treated in the same way when deciding whether women should retain access to sterilisation.

Did the NHS properly consider the risks and side effects of forcing women towards other contraception?

The CEO's response told me clinicians could discuss the risks and benefits of the contraceptive options available.

But my challenge had never been whether clinicians were capable of explaining contraception.

My question was whether the policy itself had properly balanced those risks before making sterilisation unavailable except through an exceptional-funding route.

The Ombudsman found significant gaps.

The evidence considered by the NHS included recognised side effects and risks associated with other forms of contraception. Later records also showed women coming through the Individual Funding Request route because they had exhausted other contraceptive options through side effects such as low mood and weight gain or because of health risks.

By November 2021, the NHS itself was being asked to consider whether certain groups of women — including those unable to tolerate other contraception — should have access to sterilisation.

Yet the Ombudsman could find no proper record showing that this work had been completed and rationally fed back into the policy.

The action was simply marked complete.

The policy stayed essentially the same.

Was female sterilisation actually subjected to the consultation the NHS's own advisers said was needed?

This may be one of the clearest mismatches of all.

Before the policy was implemented, specialist advisers in ethics and health law had reportedly warned that withdrawing an NHS service represented a significant change and should be consulted upon.

They also recommended that male and female sterilisation should be considered together in the interests of fairness and consistency.

I specifically asked BOB ICB whether that consultation had happened.

The Chief Executive's response told me the process had included legal and ethical considerations.

It did not answer the consultation question.

The Ombudsman did.

The Ombudsman described that as a significant omission.

This matters because "we considered ethics" is not remotely the same thing as following ethical advice.

Did the policy treat women and men fairly?

The ICB had repeatedly pointed to differences between vasectomy and female sterilisation. Those differences are real. Vasectomy is generally simpler, cheaper and less invasive.

But that was not the whole equality question.

The Ombudsman found that the NHS had approached comparable issues in fundamentally different ways.

Both men and women can regret sterilisation.

Men were offered counselling about that risk.

Women faced restricted access partly because of that risk.

When considering the consequences of withdrawing vasectomy, the NHS looked at wider effects such as increased use of other contraception, emergency contraception, terminations and birth rates.

The Ombudsman found that equivalent considerations were not properly weighed when female sterilisation was restricted.

And men could access sterilisation by meeting eligibility criteria, while women faced the additional hurdle of having to demonstrate that their circumstances were exceptional compared with other women seeking the same procedure.

The Ombudsman concluded that this itself appeared to create health inequality in access.

Did the policy follow clinical guidance saying women should not be pressured into LARC?

The clinical guidance available to the NHS recognised LARC as highly effective.

But it also explicitly warned that women should not feel pressured into choosing LARC over female sterilisation.

That distinction is crucial.

Providing information about an alternative is informed consent.

Structuring access so that a woman effectively has to accept, attempt or justify rejecting the alternative is something very different.

The Ombudsman's provisional view was that the policy's reliance on the availability of other contraceptives was, in effect, pressuring women towards LARC.

It found that the NHS had not properly explained why it had departed from the clinical guidance it had itself considered.

What happened when new evidence emerged in 2021?

This is another part of the story that I find extraordinary.

By November 2021, the NHS was seeing enough requests for female sterilisation that its own paper reportedly observed that these women now appeared to represent a cohort, rather than exceptional individual cases.

That is important because the whole Individual Funding Request model depends upon exceptionality.

The system was effectively receiving evidence that the "exceptions" were not exceptional.

The committee agreed further work should be carried out on groups including women unable to tolerate other contraception, women who had undergone multiple caesareans and women for whom another pregnancy was contraindicated.

The action was later marked complete.

But the Ombudsman could find no proper documentary trail explaining how that work affected the policy.

The policy remained unchanged.

Indeed, an internal exchange later suggested uncertainty about whether the review was even still underway.

To me, this is the kind of thing that makes the word governance almost meaningless if nobody is required to show what actually happened.

So how "robust" was the governance process?

By the Ombudsman's provisional assessment, the ICB had:

• adopted a policy where evidence had not been appropriately balanced;
• failed to give proper regard to relevant legislation;
• failed to explain departures from clinical guidance;
• adopted a policy whose reasoning was not clearly recorded;
• failed to adequately investigate groups of women for whom alternative contraception was unsuitable;
• treated comparable male and female circumstances inconsistently;
• and inherited a major service change that had not undergone the public consultation it should have received.

And crucially, the Ombudsman said the ICB did not appear to have put those failures right.

I struggle to reconcile that with the phrase "robust governance process."

Was the complaint itself properly investigated?

No — and this matters almost as much as the policy itself.

My original complaint identified many of these problems before the Ombudsman ever became involved.

• I raised the evidence on regret.
• I raised cost-effectiveness.
• I raised consultation.
• I raised bodily autonomy.
• I raised side effects and health risks of other contraception.
• I raised the unequal treatment of vasectomy and female sterilisation.

The Ombudsman's provisional assessment found that the ICB repeatedly failed to engage with those issues.

Instead, the responses disproportionately focused on explaining the existing policy and the Individual Funding Request process.

In one of the most important sections of the report, the Ombudsman said the final CEO response only partially addressed the evidence question. It specifically noted that BOB ICB had not answered what research supported the claim about regret, why the difference between male and female policies did not amount to discrimination, or how bodily autonomy had been considered.

It also noted that my question about consultation had simply not been answered.

What did the Ombudsman ultimately say about my concerns?

For me, one paragraph cuts through years of institutional reassurance.

After independently examining the evidence, the Ombudsman said its provisional findings suggested that my views about the policy were likely to have been right.

It recognised that I had consistently and clearly laid out the evidential basis for my argument that the decision-making process was flawed.

That is difficult to square with an organisation whose own complaint process had spent months failing to answer those same questions.

Were the NHS CEO Dr Nick Broughton's statements lies?

This is where I separate the documentary finding from my personal conclusion.

I can say what I think - I have the right to my opinion - and you, dear reader, have access to the Evidence and can make your own opinion.

When the Chief Executive of an NHS organisation tells me a process was robust and the policy was developed following a full consideration of guidance, evidence, law and ethics — and an independent Ombudsman later finds evidence to the contrary, with unexplained departures from guidance, inconsistent treatment of men and women, inadequate records, missing consultation and poor complaint investigation — I regard those original assurances as lies. 

Whether that resulted from deliberate dishonesty, institutional defensiveness, negligence, poor briefing or a culture in which senior leaders make claims about governance without interrogating whether they are true is a different question.

And, frankly, none of those explanations is reassuring.

Was this a cover-up?

Again, I use that term as my interpretation rather than as a legally established finding.

A cover-up does not always require a secret room full of people agreeing to conceal something. But honestly, if you keep reading about how defensive and evasive the ICB's leadership and organisation overall continued to be through and beyond the Ombudsman's investigation - you'd likely see it the way I do - the fish rots from the head down - and it truly stinks under the leadership of Nick Broughton.

Institutional concealment can be much more banal.

A complaint raises uncomfortable evidence. The organisation repeats its policy. The complainant is redirected towards an individual process. Questions are not answered. Delays accumulate. Senior assurance is provided. The complaint is closed.

If the person accepts the response, the underlying problem disappears administratively even though nothing has actually been resolved.

That is what I believe was happening here.

I think the system expected me to stop.

I did not.

What did the Ombudsman recommend should happen next?

The Ombudsman's provisional recommendations show how seriously it regarded the problems.

It proposed that BOB ICB should formally acknowledge and apologise for the failures, share the findings with the body responsible for recommending commissioning policies, explain how the female sterilisation policy would now be reviewed, ensure the same failures were not repeated, consult properly, examine the human factors that allowed the failures to occur, and improve its complaint-handling processes.

It also proposed that the final findings should be shared with NHS England and the Care Quality Commission.

That is a very long way from "everything went through a robust process."

Why does this matter beyond my own case?

Because I only got this far because I did not believe them.

I had the time, anger, research skills and stubbornness to keep opening documents, comparing dates, finding minutes, challenging assertions and eventually asking an independent body to investigate.

Most patients should never have to do that.

And most will not.

That leaves a frightening question.

This case has taught me that authority is not evidence.

A senior signature is not evidence.

A policy saying it was reviewed is not evidence that it was reviewed properly.

And an organisation calling its governance robust does not make the governance robust.

Sometimes you have to keep asking the deeply annoying question:

Show me.

Where can I see the evidence?

You can read my original complaint, the BOB ICB Chief Executive's response, the Ombudsman material and the wider documentary history in my Evidence Folder.