The long-awaited first Women’s Health Strategy for England was published last week (20th July 2022) following the vision for women’s health paper on the 23rd December 2021. And as a women's health startup focused on tackling this gender health gap for women we were very excited to see what they came up with over the past eight months. Here are some of my initial thoughts as a GP on the current strategy including if we at Kensa Health, think it will make a big difference to women's lives.
Where did this all start?
The vision for women’s health paper set out the problem through the collated views of nearly 100,000 women in England who responded to the initial government call for evidence back in 2021. It finally put into words the gender health gap women have been suffering from for years. The main takeaways were:
84% of these women have had incidents of being dismissed and feeling not listened to by health professionals
Stigma and taboos in women’s health make women believe that they have to live with debilitating symptoms and they are “normal” parts of “being a woman”
More than 50% struggle with discomfort at discussing health issues with their workplace
Two-thirds of survey respondents expressed a lack of services available supporting women with health conditions or disabilities
An urgent and critical need for specialists services to address the significant health impacts caused by violence against women and girls
A huge need for improved information and support for mental health conditions affecting women
A lack of compulsory training in women’s health for GPs
A lack of accessible information, including from the NHS website and a lack of information on different media platforms
A lack of access to women-specific health services such as menopause and contraception clinics
A lack of access to timely diagnosis, especially in gynaecological health which has waiting lists of up to two years in some places, and with conditions like endometriosis which can take seven years or more to get a diagnosis
A lack of support and understanding for many health conditions, and specifically in neurodiversity conditions including autism that present differently in women
A critical lack of research and data across the board in women’s health
The gender health gap has far-reaching outcomes in society from loss of work days, loss of caring roles, and loss to the economy. We also know that outcomes for women such as ill health, quality of life, and life expectancy have been at best stagnant but generally are worsening for women. So it is great news that the government is finally taking these issues seriously and that they produced a women’s health strategy to address this and improve outcomes over the next 10 years.
Is it enough?
This is long-awaited and a welcome step forwards for women’s health but is it just paying lip service to the problem? Is it focused enough on real actions to tackle all the problems we just listed above? Let's take a look.
This new strategy includes
Expanding the information on women’s health topics on the NHS website
Investment into improved data on women’s health
Increased education on women’s health for medical students and doctors
A certificate for baby loss before 24 weeks
New mobile breast screening units
Better access to contraception
Better access to IVF and fertility services for same-sex couples
Improved support during and after pregnancy including mental health support
A fitness program for building muscle strength for older women to help tackle conditions like osteoporosis which can impact the quality of life in older women and is linked with higher death rates
Investment in family hubs and services such as breastfeeding support
Special women’s health clinics (in a small number of initial centres as a trial)
The strategy also touches on a few of the other areas of women’s health access that we think are key obstacles to moving forward including:
Record high waiting times for hospital appointments
Lack of accessible / relatable information
Lack of community and isolation with health experiences
Lack of education in prevention, awareness of symptoms and how to access help
But it has said these areas will be covered by other improvements within the NHS, such as part of the COVID recovery plan. It has not set out any new actions from the women’s health strategy to tackle these issues specifically for women. This is already a bit of a concern as a number of the women’s based waiting lists require very specific skills and support and it isn’t clear if this will be covered by the combined improvements approach.
So how does this relate back to the issues uncovered in their initial survey?
As we mentioned earlier, one of the main concerning aspects of the government study was that 84% of women had instances of not being listened to by health professionals, and as a result, are disempowered. But more serious than this is that in too many cases the lack of being listened to can lead women to missed or delayed diagnosis with potentially unnecessary suffering or tragic outcomes such as debilitating disease, loss of employment, or worse: baby loss; maternal or general female premature death.
As we feel this is one of the most crucial gaps in women’s health, we thought it would be good to see if the new strategy would tackle this issue and we are not yet convinced that the planned strategy addresses this issue.
Could the proposed changes in the education of doctors during their medical training help women get the support they need?
Women’s health is already included in the curriculum during medical school and then for postgraduate GP exams. It is significant however that GP training has been previously highlighted by the Royal College of GPs as not being long enough and recommended for this to be extended to allow for more experience in different specialties. This action however was not taken up due to a lack of funding and the need for fast-track training due to the workforce crisis. Obstetrics and gynaecology are not compulsory placements for general practice training and these new proposals will not change this. So this will not automatically improve the knowledge in this very specific area.
It is also only helpful for new doctors and medical students. What about the thousands of GP’s already practising in the field who might have outdated knowledge or training on women’s health.
We feel this approach could be improved by making training and education in women’s health a recommended or essential part of continuing professional development (alongside other mandatory aspects such as moving and handling, fire safety, diversity training, basic life support, child and adult safeguarding). Another way to help build in long-term change for general practice would be for critical areas of women’s health to be made part of the Quality and Outcomes Framework (QOF) measures used to incentivise monitoring and improved outcomes in important areas. GP practices are already incentivised by NHS Digital to report on quality and outcomes every year, so additional women’s health-based data wouldn’t require the introduction of new practices, just additional measures for GP’s to look at. This would not only help to better understand the provision of women's health services across the UK, it would also provide more data that could help improve the women's health data gap.
Does the problem run deeper than an issue with the training of doctors?
Absolutely. There is a well-evidenced built-in bias towards women’s health, and this is even more severe for women from ethnic minorities and racially diverse backgrounds. Changing a historically white male lead health system will take years to turn around.
It also doesn’t address the giant clock in the room. You could have an extremely well-trained women’s health expert GP, but they still only have 10-15 minutes to see a patient. For many women’s health issues this tiny window of time is not fit for this purpose. The reason for this is that women often present with multiple problems (due to caring responsibilities, being generally short of time to attend to their own health), the problems present in a different way to men which can make the assessment more time-consuming and on top of this if an intimate or gynaecological examination is required it is something that requires respect, patience, and privacy taking time. If a woman has mobility problems then just the journey from the waiting room / to the examination couch can take up a third of the consultation time. There is nothing in either the women’s health strategy or the larger NHS improvement strategies around increasing appointment times.
There was also no mention of priority access for urgent women's health needs where women might have to wait 4 weeks or more to get an appointment with the GP in some areas. There is also nothing on how they plan to tackle the current huge wait for over half a million women trying to get specialist gynaecological care.
A final, and personal issue for me is that there was nothing looking at cuts to GPs providing obstetric reviews to pregnant women. The funding for this was stopped with the GP contract change in 2004 and since then GPs no longer are required to review women in pregnancy unless they have a problem that is thought to be unrelated or they need a prescription for something. This means that if a midwife deems an issue not to fit the guidelines to refer to the obstetrician a patient might fall through the gaps. For example, if during pregnancy a woman’s blood pressure is high but does not meet the criteria to be checked in the hospital then it can go unmonitored for months at a time between midwife appointments and could lead to unnecessary harm through the missed diagnosis of preeclampsia. As someone who has personally suffered as a result of this change, I was hoping to see more being done to correct this.
So we're not convinced women will be listened to better or that GP's will be able to help women in their day-to-day practice. But, what about some of the other suggested solutions?
Will the family hubs and women’s health hubs help fix everything?
The creation of specific women’s health clinics is a great step in the right direction, but this isn’t actually a step forward when we consider what we have previously lost in these areas. If anything we are just trying to get back to where we were before there were cuts to women and family services prior to and during the pandemic. In most parts of the country, there have been steps backward in access to contraception and sexual health services, menopause clinics, health visitor services, parenting and breastfeeding support. This is due to a combination of cuts in funding, services being put out to tender (with services being offered to private sectors and being granted to the lowest bidders for the lowest cost at the expense of reduced access and or quality) as well as in-person services being reduced due to covid.
This strategic action also doesn’t have a plan for the recruitment and delivery of these clinics. In the news this week, there has been the announcement of a critical lack of staff within the NHS. If we don’t have enough people to run the NHS as it is at the moment, how will the government staff the new women’s health clinics and services? At the moment there is very limited budget information outlined in the strategy and when speaking on Women’s Hour last week, Maria Caufield MP wasn’t able to share any major spending commitments to roll this plan out. She highlighted that this is just a pilot for now, which does make sense. To get large investments, there will need to be evidence of improved outcomes. However, this doesn’t backfill all the services that were lost and there was also no information on how quickly additional clinics will be rolled out or how long the trial might take. So for millions of women, there will still be a long wait for women’s health clinics in their local area.
Does it really progress women’s health to offer a certificate for baby loss before 24 weeks?
Yes, this is progress in terms of demonstrating respect and value to the importance of these losses, however surely what is needed more is research, interventions and policies for prevention. And the first step to this is to actually record these losses as part of national health data as quite rightly pointed out by this article First Women's Health Strategy released | Tommy's from Tommy’s the baby loss charity.
We would like to see not just the quick fix of the certificate for baby loss, but rather the long-term investment into prevention and support for families who have lost children. While there are a number of wonderful charities that step in to help families at this time, there is a noticeable lack of investment within the NHS in this.
Alongside improved training in women’s health, improved training on supporting women who are going through or have gone through loss should be deliverable alongside the certificate. For starters, all medical professionals should have the training to increase awareness, understanding, and empathy as well as in communication skills specific to baby loss including miscarriage, termination for medical reasons, stillbirth, and neonatal loss. Care, sensitivity, and kindness in this area costs nothing once improved awareness is in place.
Finally, beyond recognising the loss and helping parents to grieve, it’s also about ensuring that the causes and possible long-term health impacts of those causes are considered for that person’s health journey across their lifetime. Complications that cause baby loss could have lasting health implications, not just on fertility but on a woman's general health including heart disease, cancers, and dementia. For example, there needs to be more done to highlight women who have had pregnancy issues including gestational diabetes, hypertension, preeclampsia, and placental abruption to know what screening and preventative measures should be in place even 5-10 years after the initial incidence occurred. This is a key part of the "predictable life course approach" encouraged by Women's Health Ambassador Dame Lesley Regan in her conversation about the women's health strategy on Women's Hour last week.
So will anything actually change?
While I wish the strategy had a lot more in it, a lot of the recommendations in the strategy appear well intended. I hope that they will make a difference. However, I am concerned that there seems to be a lack of a delivery plan, a budget that meets the size of the problem and a complete lack of any way to track the progress and impact of their proposed actions. Right now it is a collection of great intentions and timely sound bites. The areas looked at are important and comprehensive however some of the sections covered by the strategy are a bit wishy-washy. It could be optimised and transformed into something deliverable with this simple commonly used management template:
Or even better still to add:
Still, at least this is a start and we are very excited to see the very skilled Dame Lesley Regan at the helm, steering this forward. At Kensa Health we look forward to hopefully being a part of a larger wave of actions to tackle the women's health gap.
And as a GP I'm looking forward to a bunch of new doctors, nurses, and medical professionals who are all better informed in women's health and ready to help me ensure women get the best quality of care possible. Please send them my way!
References (accessed July 2022)