Our Vision for the Women’s Health Strategy for England – Department of Health and Social Care, and its pledge to “re-set the dial on women’s health”, is a timely intervention. As the vision points out, women in the UK on average live longer than men but spend a greater proportion of their lives in ill health and disability than men.
It might be worth noting that women are disproportionately represented when it comes to caring responsibilities. It could be argued that if a woman’s own health outcomes and experience is not enough to make her ill, the responsibility for others and the burden that adds, will not make her experience any better.
It is clear that the health of women has been at the margins of our healthcare system. The resulting poorer outcomes have cast a long shadow over women’s lives with just over 19 years of life lost to poor health, often in later life meaning more years than men but less quality. Within the dynamics of inequality, we see a clear driver of gender bias. The consultation that informed the recent DHSC vision, demonstrated entrenched problems within the NHS, with around 80 per cent of women feeling that they are not listened to by healthcare professionals. In addition, a feeling that services designed only to support women are of lower priority.
The reason for this might lay in the historical approach to women’s health, which has tended to focus on reproductive health. The World Health Organisation (WHO) considers that an undue emphasis on reproductive health has been a major barrier to ensuring access to good quality health care for all women. Its own definition of health - a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity – promotes an ideal where women are represented as a specific cohort within population health dynamics.
The current fresh thinking posits a life-course approach, which eschews the disease and event specifics of previous methodology and places women’s health within a framework built on a better understanding of health care needs during key life-stages. This could also provide a foundation for addressing the issue that 80 per cent of health outcomes are determined by non-clinical factors. The role played by social and economic factors in women’s long term health outcomes is fundamental to creating an equitable healthcare experience and results. Equally, variation in perceptions of what constitutes a healthcare need can be perpetuated by gender bias, often denying women the opportunity of gender-responsive services.
Viewing women’s health solely through the lens of reproductive health will not aid a reduction in health disparities, nor will it address gender-bias in how services are planned, commissioned and delivered. Neither will it increase the health capital of 51 per cent of our population.
If we are to close the gap between women’s and men’s healthcare outcomes through a less disease-based strategy, healthcare systems and healthcare practitioners need support in understanding the full range of both inter and intra-gender disparities.
In December 2019, the Royal College of Obstetricians and Gynaecologists (RCOG) published its report Better for Women - Improving the health and wellbeing of girls and women. It called for “a strategic approach is required across the life course to prevent predictable morbidity and mortality and to address the determinants of health specific to women’s health.” Two years on, we see the first of its 23 recommendations, the creation of national women’s health strategies, implicit in the DHSC vision.
"Women’s health extends far beyond reproduction"
Professor Lesley Regan
From the outset, the focus is on education and information, a tone set in the foreword by the then RCOG president, Professor Lesley Regan who outlined her perspective that “…women’s health extends far beyond reproduction...” and that providing advice and care for girls and women throughout their lives “helps them to remain healthy and not just to intervene when they experience problems”7
This is a clear motif for operationalising the vision for a women’s health strategy. Access to reliable information that serves women, healthcare professionals and healthcare systems alike is vital. Drawing on the insight of women indications of future health and healthcare needs. An examination of women’s experience and outcomes during their reproductive life-stage, will be valuable in predicting the likelihood of and/or preventing poorer health in later-life.
Approximately 13 million women in the UK are peri or post-menopausal, that is almost 40 per cent of the female population. Symptoms can last up to 15 years and around 60 per cent of women experience symptoms that result in behavioural changes. Around a quarter of women will experience severe and debilitating symptoms with almost half of menopausal women saying they feel depressed and a third saying they suffer with anxiety. This is not only felt during this life-stage but creates a legacy of poorer outcomes in the next. Often, women face incorrect diagnosis and many will be prescribed antidepressants. Over one third of women seek help from their GP but one quarter of those doing so say menopause symptoms are missed. One third of women are not made aware of their options in terms of HRT and there is variation and inconsistency in prescribing HRT where there is an existing family health concern, all of which leads to significant confusion about HRT among those who could benefit from that kind of intervention. Two thirds of women attest to a general lack of support and understanding.
The impacts of misdiagnosis and unmet need extend beyond the clinical realm and illustrate the additional social and economic challenges peri and post-menopausal women face. Three quarters of working-women say they feel unsupported. 90% cent of women say they feel unable to talk to their line managers at work about their experience of menopause and its effects in the workplace. One in five women regularly take time off work due to symptoms of menopause, one in fifty are on long term sick leave and 10 per cent of women consider giving up their careers as a result of symptoms. The implications for women’s health, social and economic outcomes are grave. As co-owners of the vision for a women’s health strategy, there is a clarion message in this for the NHS – women make up 77 per cent of the workforce with an average age of 43.
Early, peri and post-menopausal conditions span the life course of women’s middle and later years. Access to the right information and treatment options and a population health focus will be critical in driving forward the goals of reducing variation and disparities, improving outcomes and promoting and supporting healthy ageing. The recent reforms to accessing HRT with longer prescribing cycles and the reduction of prescription costs for self-payers will have an impact. However, access is only part of the solution and will need augmenting with
- Appropriate and comprehensive information on optimal treatment opportunities
- Support programmes for those seeking and getting treatment
- Timely interventions by the most appropriate healthcare professional in the optimal clinical setting
- An approach that combines clinical therapy with emotional and wellbeing support
- Education for healthcare professionals and healthcare systems informed by the experiences of women.
The final Women’s Health Strategy will be published in the spring of this year. Socialising it across healthcare systems and making it work will require many partners, chief among them women who have an expectation of better care and an experience to shape what that looks like. As a significant event in the life-course of women, improving healthcare during menopause will have an impact in reducing health disparities. However, to achieve healthcare not as it is but how it should be, solutions need to be developed by drawing on the capacity and capability of the widest group of stakeholders.
Collaboration and cooperation between the pharmaceutical industry and the NHS has matured over recent years, leading to a greater level of partnership working. Education, information, support and guidance on optimal treatment options during menopause and clinical patient support programmes are areas where a partnership approach could contribute significantly to improving health outcomes for women and support healthcare professionals in delivering optimal care.
In addition, a more effective healthcare management approach during the transitional life-stage during which menopause manifests, could prevent/delay the onset of chronic diseases such as osteoporosis, cardiovascular disease, frailty and dementia. This opportunity offers a financial saving opportunity for healthcare systems when considering the annual national cost to the NHS of
- Osteoporosis/fragility fractures, £4.4 billion
- Cardiovascular disease, £7.4 billion
- Frailty, £2.3 billion in hip fractures alone
- Dementia, £4.3 billion
While evaluating the scale of the financial opportunity is important, the impacts on women’s health, as a result of a strategic opportunity lost, are significantly more so and demand a focus on health services that empower women to live healthier at every stage of life. This means organisations across the public/private spectrum working in concert to identify approaches and interventions that assist with, but go beyond, the medicine. Co-created strategies that create outcome-based dividends at body-part, whole-person, life-stage and health and care system levels.