I Challenged NHS BOB ICB's Female Sterilisation Policy. Its CEO Dr Nick Broughton Told Me the Governance Was Robust - It Was NOT

I Investigated the NHS Female Sterilisation Policy Myself. The CEO's Response Answered None of it, and The Ombudsman Found Tons of Maladministration

A note about language: this is my account of what I experienced and how I interpret the evidence. When I describe later assurances as misleading, or say that I came to regard some of them as lies, that is my conclusion from the mismatch between what I was told and what the documentary record later revealed. 

Please feel empowered to make your own conclusions by accessing and going through the Evidence!

How did a request for sterilisation turn into me investigating NHS policy?

I did not start out wanting to investigate an Integrated Care Board.

I wanted permanent contraception. I wanted access to an approved health-care procedure accessible on the NHS.

But the more I tried to understand why female sterilisation was effectively unavailable to me through the ordinary NHS route in Oxfordshire, the more I realised that the problem was much bigger than one decision about one woman.

I found the commissioning policy.

I found the Thames Valley Priorities Committee papers behind it.

I found the meeting minutes and read them.

I followed the references.

I looked at what the committee itself had recorded about cost-effectiveness, regret, LARC, male sterilisation, ethics and consultation.

And then something started happening that has repeated itself throughout this entire battle: the deeper I looked into the evidence, the less the official position seemed to make sense.

By July 2023, I was angry enough to put all of it into a formal complaint.

It ran to 12 pages.

And it was not a vague accusation of sexism. It was a detailed challenge to the logic, evidence and governance behind the policy.

What exactly did I challenge in that 12-page complaint?

I challenged the ICB on almost every layer of the decision.

I asked whether it could genuinely defend funding permanent contraception for men while making female sterilisation unavailable except through an exceptional-funding process.

I asked whether that could really be described as an equal and comprehensive healthcare service.

I challenged whether pushing women towards alternative contraception was genuinely healthier once side effects, risks and individual circumstances were taken seriously.

I asked whether making access to permanent contraception harder for women was compatible with bodily autonomy and informed consent.

I asked whether the policy was actually consistent with the NHS Constitution, GMC guidance, NICE guidance and the broader principles governing medical decision-making.

And finally, I asked the most basic question of all:

Those were not rhetorical questions to me.

I wanted evidence.

If sterilisation cost around £1,000, where was the evidence that decades of contraception were cheaper?

One of the first things I challenged was the policy's statement that female sterilisation was not normally funded because of the availability of "more cost-effective methods of contraception."

I had already found material in the NHS's own committee records that appeared to complicate — and in some cases directly undermine — that claim.

The records referred to female sterilisation costing around £1,000.

They also recorded cost-effectiveness modelling indicating that female and male sterilisation could become more cost-effective than Long-Acting Reversible Contraception over longer periods of contraceptive use.

So I asked a very simple question: more cost-effective over what period, and for whom?

I then did my own rough comparison.

Using the retail contraceptive-pill prices available to me at the time, I calculated an average price of approximately £22.04 per month. Over 20 years, that came to approximately £5,289.60.

That was more than five times the approximately £1,000 sterilisation figure I had found in the NHS documentation — before accounting for future price increases or inflation.

I was not pretending that my calculation was an NHS health-economics model. It wasn't. I was making a point that should have been obvious to the people actually responsible for commissioning:

Instead, I was looking at a policy that simply asserted that more cost-effective alternatives existed. Where was the evidence?

And what about the costs that are much harder to put into a spreadsheet?

This was another issue I raised that I felt was being treated as though it barely existed.

Contraception is not just a line in a commissioning budget.

It is something a woman experiences in her body.

I challenged the ICB to consider what happens when an alternative contraceptive method causes bleeding, pain, mood changes, loss of libido, thrush, weight changes, anxiety, or other side effects.

I challenged whether the NHS had accounted for additional healthcare use created by managing those problems.

• What about repeat GP appointments?
• What about changing methods repeatedly because one does not work for the individual?
• What about psychological distress?
• What about an unintended pregnancy?
• What about termination?
• What about the emotional cost of spending month after month anxious that your period is late when you know with absolute certainty that you do not want to become pregnant?

I wrote from my own experience of that anxiety too.

I explained that my periods were irregular and that, despite using condoms and spermicide, I could still find myself looking at an app telling me I was several days late and wondering whether I was pregnant.

I knew I did not want children.

I knew I did not want to go through an abortion.

I knew hormonal contraception had not suited me.

So I asked why the NHS appeared to consider the theoretical future regret of sterilisation more seriously than the actual physical and emotional burdens women may experience through the alternatives it preferred them to use.

If the NHS was so worried about regret, why was regret treated so differently for women?

The policy's other major justification was anticipated regret.

This angered me perhaps more than anything else.

Because regret is not a medical contraindication.

It is a possible future feeling - not a guaranteed outcome. Moreover, there was NO EVIDENCE provided to support these claims. 

And in my complaint I challenged the entire logic of treating that possibility as a reason to restrict the decision of a competent adult.

In fact, I found research suggesting that regret was far from universal. So, in my complaint letter I also cited work reporting relatively low regret among women sterilised over the age of 30. I cited research discussing women who regretted being denied sterilisation. I cited newer work examining psychological outcomes among voluntarily childfree women who obtained or were denied the procedure.

But my wider challenge went beyond statistics.

I asked: why does the NHS assume responsibility for protecting women from regretting sterilisation, but not from regretting parenthood?

• People regret marriages.
• People regret careers.
• People regret surgeries.
• Some people regret becoming parents.

Yet we do not build public policy around the idea that competent adults should be prevented from making important life decisions because they may later feel differently.

Why was this one different?

Why could a young woman be trusted to become a parent, but an adult woman could not be trusted to choose permanent contraception?

This was where I challenged what I saw as the pronatalist assumption buried underneath the policy.

We culturally treat choosing to have children as normal.

Choosing permanently not to have them is treated as something requiring interrogation.

In my complaint I deliberately used a provocative comparison: society can accept a 16-year-old becoming a mother — an irreversible decision carrying responsibility for another human being — while an adult woman in her thirties can find herself treated as though she may not understand the consequences of deciding never to give birth.

To me, that exposes a profound asymmetry.

Parenthood is permanent too.

And arguably far more consequential, because it involves not just your own body and future but another person's life.

Yet the presumption runs one way:

I found that deeply paternalistic.

And, as a woman who had been thinking about sterilisation for more than a decade, I found it personally insulting.

Why was men's permanent contraception treated as a decision, while women's was treated as an exception?

I also raised the inequality between female sterilisation and vasectomy directly.

I knew the procedures were not medically identical.

That was never my argument.

The question was whether those clinical differences justified the difference in autonomy.

Men could be offered vasectomy as permanent contraception.

Women in Oxfordshire faced a policy saying sterilisation was not normally funded and an Individual Funding Request route requiring them to establish exceptional clinical circumstances.

That meant a woman did not simply have to understand the risks and permanence of the procedure.

She effectively had to establish why she was different from other women who also wanted it.

That is not the same kind of decision-making pathway.

One is built on informed consent - the other on gatekeeping access and making decisions for patients without their involvement.

And I asked the ICB bluntly whether it could seriously argue that such a system was not gender discriminatory.

What did the NHS's own guidance say about pushing women towards LARC?

This was one of the contradictions I had already found in their own records.

The committee papers referred to guidance from the Faculty of Sexual and Reproductive Healthcare, the Royal College of Obstetricians and Gynaecologists and the World Health Organisation.

That material acknowledged that some Long-Acting Reversible Contraceptive methods can be as effective as sterilisation.

But it also recorded that women should not be pressured into choosing LARC over female sterilisation.

Then, in the very same policy-development history, the NHS moved toward a policy under which sterilisation would not normally be funded because alternative contraception existed.

That left me asking what I still think is an extremely obvious question:

I could see that contradiction as a member of the public sitting at home reading the papers.

So why could I not find evidence of the people responsible for decisions affecting huge numbers of women properly confronting it?

Where was the justification for departing from clinical guidance?

This became a recurring frustration.

I was not saying commissioners were forbidden from ever reaching a different conclusion from a guideline.

Healthcare commissioning involves limited resources and difficult choices.

But if a public body departs from recognised guidance, particularly where autonomy, equality and access to healthcare are involved, there should be a reason.

There should be analysis.

There should be records.

You should be able to see the bridge between the evidence and the policy.

What I was finding instead felt like a gap.

The papers would acknowledge one set of considerations.

The final policy would state something much simpler.

And the reasoning connecting one to the other was often extraordinarily difficult to locate.

This was why I invoked the NHS Constitution, NICE, GMC guidance around informed decision-making, and the principle of bodily autonomy.

I wanted BOB ICB to explain how its policy could be reconciled with those standards.

If their own ethical advisers said consultation was needed, where was the consultation?

Another thing I had found in the records was advice relating to Public Consultation.

The material indicated that ethics and health-law advisers had raised the point that withdrawing or significantly changing access to an NHS service was significant and should be consulted upon.

I went searching.

I went through annual reports.

I went through meeting records.

I tried to find evidence that the required consultation had actually taken place.

I could not find it.

So I asked them.

That is what makes what came next so important.

Why did it anger me that I seemed to be considering more than the people making the policy?

This is perhaps the most emotional part of the entire episode for me.

I am not an NHS commissioner.

I am not employed by a Clinical Effectiveness Team.

I was not sitting on the Thames Valley Priorities Committee.

I was a member of the public who wanted access to healthcare.

And yet sitting at home with publicly available documents, I was asking questions about:

• long-term cost versus short-term procedure cost;
• direct versus indirect healthcare costs;
• side effects of alternative contraception;
• psychological and relationship consequences;
• regret after sterilisation versus regret after denial;
• informed consent and mental capacity;
• male versus female access;
• bodily autonomy;
• clinical guidance;
• public consultation;
• postcode inequality;
• and the cultural assumption that motherhood is the default future for women.

These people were making policy capable of affecting the lives and bodies of hundreds of milions of women across a region.

Why was I having to ask whether those things had been considered?

And more importantly:

where was the evidence that they had?

So what did the Chief Executive finally tell me?

After months of delays, partial replies and chasing, I finally received BOB ICB's formal response by Chief Executive Dr Nick Broughton on 22 November 2023.

The first page acknowledged the breadth of my complaint.

It recognised that I had raised funding, commissioning, male versus female sterilisation, gender discrimination, contraception, medical side effects, cancer risks, ethical guidance and whether women were being treated with equality and respect.

And then it said:

"To answer the questions, we have described how decisions about clinical commissioning policies are made..."

That sentence captures the problem almost perfectly.

I had asked substantive questions about the quality and logic of the decision.

The answer largely described the existence of a decision-making process.

Yet - explaining a process is not the same as providing evidence that you have followed that process.

What was I told about the supposedly "robust" governance?

The CEO told me that policy recommendations were approved through a "robust governance process".

He told me that the female sterilisation policy had been fully reviewed in 2017.

He said that review included a:

He said that when the policy was reviewed again in 2021 there had been no meaningful updates requiring it to change.

And he told me that the ICB regarded sterilisation as the "least preferred option" for female contraception because other contraceptive alternatives existed.

Then the response returned once again to the Individual Funding Request process.

If a woman could demonstrate clinical exceptionality, her clinician could apply.

That was presented as the answer.

But where were the answers to the questions I had actually asked?

This was the point at which my confidence in the organisation collapsed.

Because telling me a review was "full" did not answer how the evidence on cost-effectiveness had been balanced.

Calling the governance "robust" did not tell me where the public consultation was.

Saying that legal and ethical considerations had been assessed did not tell me how bodily autonomy had been weighed.

Saying that clinicians could discuss contraception did not answer why the policy itself preferred LARC over sterilisation.

Saying there were alternative methods did not answer whether the risks, side effects and longer-term costs of those alternatives had actually been compared fairly.

And explaining an IFR process did not answer why women were required to prove exceptionality when men seeking vasectomy were not being treated through the same conceptual framework.

The response acknowledged my questions and then seemed to move around them.

And no - NO EVIDENCE of following any of these was provided. And the later investigation found that such evidence does not exist.

Was the message basically: "We've checked ourselves, everything is fine"?

That is how it felt to me.

I had sent a 12-page complaint saying, in effect:

I have read your evidence. Parts of your own record appear to contradict your policy. I cannot find evidence that important steps were taken. Please explain this.

And the response I got back amounted, in my reading, to:

Perhaps the expectation was that this would close the matter.

A Chief Executive, Dr Nick Broughton, had sent the response, after all he is the highest authority - I should trust him, right? No. Wrong.

The organisation had formally answered.

The complaint could now be marked complete.

But a senior signature does not turn an unanswered question into an answered one.

Why didn't I simply believe them?

Because I had already seen too much of the underlying material.

This is one of the defining features of everything that happened afterwards.

I kept asking for evidence rather than accepting statements about evidence.

I kept asking for the record rather than accepting assurances about the process.

I kept asking "show me".

And every time I did that, new questions appeared.

That continued during the Ombudsman investigation.

It continued when I later started using Freedom of Information requests.

It continued when I tried to establish how later replacement policies had been developed.

Again and again, I found the same structural problem: an official statement would tell me that a process had been followed, something had been considered, something had been reviewed, something had been compliant.

And when I asked for the documentary chain proving it, things became considerably less straightforward.

Why did this response push me toward the Ombudsman instead of ending the complaint?

Because by that stage the complaint process itself had become part of the problem.

I no longer trusted BOB ICB to investigate BOB ICB.

I had raised specific evidential contradictions.

I had raised ethical concerns.

I had raised equality concerns.

I had raised questions about consultation.

I had raised the treatment of regret.

I had raised cost-effectiveness.

I had raised the physical and psychological consequences of alternative contraception.

I had raised autonomy and informed choice.

I had raised the radically different pathway for men.

And after all of that, the final answer still essentially told me the process had been proper.

I could either accept that assurance or ask somebody outside the organisation to examine what had actually happened.

I chose the second option.

What makes the CEO's, Dr Nick Broughton, final response so alarming in hindsight?

At the time, I already thought it had failed to answer my complaint.

What I did not yet have was an independent investigation going through the same documentary trail.

That came later.

And it is why this episode matters so much in the wider chronology of this battle.

The Ombudsman did not simply accept the ICB's statement that everything relevant had been considered.

It looked at the evidence.

It looked at the committee records.

It looked at the complaint handling.

It looked at the underlying decisions.

And many of the questions I had been asking in that original 12-page complaint came back again — this time as concerns identified by an external investigator.

And why does this pattern still matter now?

Because it did not end in 2023.

As the case continued, I repeatedly encountered the same tension between institutional assurance and documentary proof.

The Ombudsman later scrutinised the original decision-making.

Freedom of Information requests later became necessary to establish what evidence sat behind subsequent policy decisions.

Questions about equality analysis, consultation, policy approval and compliance did not magically disappear because a new policy was written.

The longer this has gone on, the more convinced I have become that this case is not simply about female sterilisation.

It is also about a deeper accountability problem:

What happened when the Ombudsman finally looked behind those assurances?

That deserves its own article, because the comparison is extraordinary.

In the next part, I compare the CEO's, Dr Nick Broughton, statements directly with what the Parliamentary and Health Service Ombudsman's investigation found when it examined the underlying evidence.

The questions become very simple:

Was the evidence really properly balanced?

Was the cost-effectiveness claim actually supported?

Was regret handled fairly?

Were men and women treated consistently?

Was clinical guidance properly followed or were departures from it explained?

Did the consultation happen?

And did BOB ICB actually investigate the complaint I had made?

Read Part Two: The NHS CEO Dr Nick Broughton Said the Female Sterilisation Policy Was Robust. The Ombudsman Found Something Very Different

Where can I read the original evidence?

I do not want anyone reading this site to have to rely solely on my interpretation.

My original 12-page complaint, BOB ICB's final response and the wider documentary record are available in the Evidence Folder.

Read them.

Compare what I asked with what I was told.

That comparison is where this story really begins.