This is a study about circumcision services in Kensington & Chelsea & Westminster (KCW). It captures the experiences and views of the community and the relevant health professionals in order to recommend how existing arrangements may be improved.

This study also forms an equality impact assessment designed to assess how the current approach to the provision of circumcision services for non-clinical reasons is affecting the communities who practice male circumcision.

In this study, 63 interviews were conducted with parents who are residents in

KCW and whose sons were recently circumcised for non-clinical reasons. In addition, 10 GPs, 2 NHS surgeons, 3 private practitioners (all of whom were local GPs), 1 service manager and 1 rabbi were interviewed.

The most significant findings of the study were:

1. Complications after circumcision are far more prevalent in older children than in newborns. Our study, which explicitly looked for cases of complications found that all instances of complications occurred in children aged 3 months or older (15/44) while none occurred in children aged 1 week-2 months old (0/22).

2. Complications are far more likely to occur when the practitioner is medically unqualified. In our study, all cases of circumcision performed by a non-medical practitioner were followed by complications (4/4).

3. Boys ages 1-11 years old are frequently circumcised in the community under local anaesthetic. However, all NHS practitioners interviewed agreed that boys aged 1 year old or older should always be circumcised under general anaesthetic because of the difficulties medically and ethically in restraining a child this age in order to perform the procedure. Most NHS practitioners interviewed thought the same applied to boys aged over 4 months old.

4. Circumcisions as they are currently performed in the community or in

hospitals examined under this survey do not fully conform to the BMA guidance The relevant issues of guidance are: a) appropriate analgesia and b) informed consent by both parents, including informing the parents about the risks associated with the procedure and the fact that any associated benefits of the procedure are still a matter of debate within the medical community.

5. The overwhelming majority of parents would prefer to have their sons circumcised in an NHS service rather than a private one (53/62).

Furthermore, more parents preferred an NHS service because they thought it would be caring and of high quality rather than because it would be free. Generally, for most parents, the cost of the procedure was not a factor of very high importance when choosing a provider.

Recommendations

Monitoring and Regulating

Given that the circumcision of boys for non-clinical reasons is legal and widely practiced in many communities, the state has a duty to ensure that they are performed competently and safely regardless of the fact that they are not widely regarded to be medically beneficial.

• The Care Quality Commission should regulate circumcisions for non-clinical reasons
• The local NHS has a responsibility as part of its Public Health role to monitor and regulate the local arrangements for circumcisions for non-clinical reasons, possibly in cooperation with the voluntary and community sectors.

NHS commissioning of circumcision services

One of the most effective ways to reduce complications and the suffering of children would be to introduce circumcision services commissioned by the NHS. Two services need to be commissioned:

• A service for children to be circumcised under general anaesthetic. The full costs of such a service for children would be considerable for the NHS (£500-£700) but it would be possible to charge some costs to the parents (up to £300). Such a service is necessary because children who are circumcised in the community undergo considerable suffering when the procedure is performed under local anaesthetic and are particularly vulnerable to complications.
• An outpatient service for newborn babies aged up to 10 weeks or an inpatient service for newborns on the first or second day after they are born. The circumcisions would take place under local anaesthetic. Full or nearly full costs (£100-150) can be charged to the parents. Ideally, for those on benefits a cheaper service could be offered, funded by external organisations. Such a practice would reduce complications significantly, including ‘repeat’ circumcisions that are performed by surgeons within the NHS and therefore could reduce costs to the NHS as well as suffering in the community.

Both services should follow BMA’s guidance for best practice with regard to    analgesia, consent from both parents, and the explanation of medical risks and benefits.

Information

Information about circumcision services needs to be publicised in a number of languages and locations particularly maternity hospitals and local community groups. Any such leaflet should contain information about:

• How the procedure is performed
• Risks and benefits
• The much lower risk of complications if the circumcision is performed while the baby is very young and if the practitioner performing the procedure is medically qualified.
• A list of medical practitioners who practise circumcision safely.
• After-care
• What to do in an emergency