NHS commissioned services should operate fairly, transparently and with clear clinical rationale, the Parliamentary and Health Service Ombudsman (PHSO) has said following an investigation which found that an NHS body denied women, but not men, NHS funding for sterilisation.
This aspect of commissioned services falling short of what we expect them to be was brought to light when Leah Spasova complained to the Ombudsman after her request for sterilisation was rejected by Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (ICB).
At the time, the ICB did not routinely fund female sterilisation and cited the risk of regret as a reason for refusing women the procedure. Its policy for male sterilisation routinely funded vasectomy for eligible men and did not use regret as a reason for rejection.
The Ombudsman concluded that the ICB’s approach was unfair, inconsistent, and based on subjective reasoning.
The Ombudsman found that women were not given the same opportunity as men to make an informed decision about sterilisation. The ICB failed to explain why it chose not to follow clinical guidance. The guidance is not mandatory but says sterilisation should be available for women and that counselling – not blanket exclusion – should address the risk of regret.
The investigation also identified inconsistent use of cost-effectiveness arguments. Male sterilisation was recommended for funding without updated cost data, while female sterilisation was rejected due to a lack of recent evidence, despite older studies showing it can be more cost effective over time.
The Ombudsman found the ICB did not balance this evidence appropriately when devising their sterilisation policy.
In 2024, an advisory committee was given responsibility for making policy recommendations for six ICBs across the South East region, including Buckinghamshire, Oxfordshire and Berkshire West. Four of those six ICBs already funded female sterilisation.
Following Leah’s complaint, the advisory committee reviewed the female sterilisation policy recommendation and recognised the equality issues created by funding male but not female sterilisation. It recommended that female sterilisation should be funded. Regret or the availability of more cost-effective alternative contraception is no longer used as grounds for refusal.
Paula Sussex CBE, Parliamentary and Health Service Ombudsman, said,
The issue highlighted in Leah’s case about the commissioning and managing of services by ICBs is not an isolated one. We are concerned that there may be similar wider problems affecting multiple areas of healthcare, and we have concerns that the system is not consistently meeting people’s needs and is letting patients down.
"Our data has highlighted that there are often unclear explanations of treatment or diagnosis within in the NHS, confusing pathways, a lack of updates while patients wait for care, and poorly communicated changes to provision.
"This case shows the power of the patient voice. Leah complained about her experience and the ICB is now reviewing its sterilisation policy. This could benefit and empower many more women to make informed decisions about their health.”
The Ombudsman also found failings in how the ICB handled Leah’s complaint. This included unclear response times and inadequate engagement with her concerns and instead focused on reiterating its sterilisation policy to her.
The Ombudsman recommended the ICB writes to Leah to acknowledge its failings, apologise and explain how its review will take place and what it has done, or will do, to improve its commissioning and complaint handling processes. The ICB has agreed to comply.
Leah, a psychologist, from Oxfordshire said,
I have been enquiring about sterilisation for 10 years and was just passed back and forth between services. Then the ICB turned down my request for funding. One of the most important lessons from my case is the systemic problems and the lengthy process that patients must go through to challenge NHS decisions.
“Before approaching the Ombudsman, I conducted my own research and found that the policy in place at the time appeared inconsistent with key principles of NHS care, did not respect the NHS Constitution, and did not align with NICE guidance around contraceptive choice. It did not follow the widely recognised principle that clinicians provide advice, but patients ultimately make decisions about their own bodies.
“These concerns about autonomy and fairness prompted me to seek further accountability. Rejecting my application for sterilisation on the basis of regret means they were taking on liability for my feelings. The ICB says sterilisation is funded under exceptional circumstances, but nowhere do they list what those criteria are so it is impossible to know if you will be accepted or not. Someone else is making decisions about your body based on criteria you can’t even see.
“Policies like this are damaging for women’s healthcare and women’s access to health services - it’s absolutely discriminatory. There is continuing widespread inequality in how permanent contraception is accessed with concerns about fairness and respect for women’s bodily autonomy remain unresolved. The key lesson from my case is how commissioning policies can create unequal barriers and why people should fight for their rights through transparency and accountability.”
Read the investigation report.