Features

Women's healthcare: the invisible emergency

18 March 2022

There finally seems to be a focus on longstanding inequalities in women’s health. But what needs to be done to truly improve the quality of life for women and in turn, everyone? Journalist Anna Scott investigates.

In August last year, Scotland became the first country in the UK to publish a Women’s Health Plan, saying it wanted to be a ‘world leader’ in women’s health. It set out 66 actions to ‘ensure all women enjoy the best possible healthcare throughout their lives’ (Scottish Government, 2021a). The question then became, when will the rest of the UK catch up? And, of course, does the Scotland plan go far enough?

In December, England followed suit with proposals for a Women’s Health Strategy that aims to enable a ‘healthcare system that prioritises care on the basis of clinical need, not gender’ (Department of Health and Social Care, 2021a) and to address ‘decades of gender health inequality’. The government’s vision document set out the findings of its public consultation that received nearly 100,000 responses. The particulars of England’s Women’s Health Strategy are due to be set out in spring this year.

The Department of Health in Northern Ireland says it has no plans to deliver a gender-specific health strategy because it would largely duplicate actions it already takes to target women or men when there is a difference in health behaviours or outcomes.

Meanwhile, the Welsh Government hopes to publish details about future plans for supporting women’s health by spring 2022. It set up its Women’s Health Implementation Group (WHIG) in 2018. (See page 26 for more details on all plans.)

But is any of this enough? Charity Wellbeing of Women called the England plan ‘long overdue’ but a ‘unique opportunity’. However, Hilary Maxwell, a gynaecological specialist nurse at The Eve Appeal, a cancer charity, notes that any initiatives need to be ‘living documents, not ones that are two-dimensional paying lip service to the notion of women’s health’.

Both the documents for Scotland and England emphasise what has been clear for some time now: that gender inequality in healthcare has long been neglected and health and social care services need to meet the needs of all women, everywhere (Scottish Government, 2021a). ‘Women’s health is not just a women’s issue,’ said Scotland’s women’s health minister, Maree Todd, when the strategy was published. ‘When women and girls are supported to lead healthy lives and fulfil their potential, the whole of society benefits.’

Vital for everyone

Dr Bella Smith, a GP and co-founder of The Well HQ – a training organisation and movement attempting to erase institutional biases when working with women in sport – says women tend to make the majority of health decisions in families. ‘We are in control of our family’s health,’ she says. ‘We are looking after everyone else and if we don’t thrive, they don’t thrive. We need to focus on women’s health because it affects us, but it also affects our entire family.’

Diana Holland, assistant general secretary, equalities, Unite, agrees that the prime caring responsibilities for children, young people and older people, not always, but often, fall to women. ‘Women are more likely to encourage people to think about their health and to follow up on conditions, and they have the direct experience,’ she says. ‘There are overarching issues about investment in the NHS, and public preventative health. It’s important for everybody but I think it’s particularly important for women because of the way women traditionally have so many responsibilities and demands.’ But many women feel they do not get the support they need from healthcare professionals. More than four in five (84%) of survey respondents in England say there have been instances when they (or the women they had in mind) felt they were not listened to by healthcare professionals (Department of Health and Social Care, 2021b). 

Many women said they felt symptoms were dismissed upon first contact with GPs and other professionals, they had to persistently advocate for themselves to secure a diagnosis over multiple visits, months and years, and they found that post-diagnosis discussions about treatment options were often limited or preferences ignored (Department of Health and Social Care, 2021b).

Bella highlights the gender data gap in healthcare, citing a study that suggests women are 50% more likely than men to be given an incorrect diagnosis after a heart attack (University of Leeds, 2016). ‘We are trained as doctors to recognise the symptoms men experience – chest pain – and actually women [can] have more flu-like or indigestion symptoms,’ she says. (Though key symptoms may not differ – see page 48).

‘We think we’re the same, but we’re not. There’s this whole gap of knowledge that needs to be looked into.’

Author and journalist (former editor of Elle and Cosmopolitan) Lorraine Candy, who co-hosts the podcast Postcards from midlife, says women need to be listened to properly. ‘If the NHS were to join up the dots of women’s health, from puberty to menopause, we could prevent many issues occurring and save the NHS time and money. A consistent record for women’s health in their lifetime would save the health service so much time,’ she says.


What exactly is UK policy on women's health, planned or otherwise?

England

The vision document explains the aims of the strategy, which seeks to improve both the way the health and care system listens to women and their health outcomes, and puts women’s voices at the centre of this discussion (Department of Health and Social Care, 2021b). It highlights a number of priority areas including fertility, pregnancy, pregnancy loss and postnatal support, the menopause and mental health (Department of Health and Social Care, 2021b).

On publication of the vision document, minister for women’s health Maria Caulfield said: ‘Many of the issues raised require long-term system-wide changes, but we must start somewhere’, calling the document ‘the first step’ (Department of Health and Social Care, 2021a). 

In the documents for England and Scotland, the government announced plans for a new leadership role or roles that should highlight women’s health concerns. In the case of Scotland, a national ‘women’s health champion’ and a ‘women’s health lead’ in every NHS board, and in England’s case, a women’s health ambassador to ‘drive women’s health to the top of the agenda’ (Scottish Government, 2021a; Department of Health and Social Care, 2021a). 

Northern Ireland 

A spokesperson for the Department of Health explains their stance on a non-gender-specific plan: ‘Where gender inequalities or specific health needs exist in Northern Ireland, they are already addressed within specific strategies or through service delivery.’

The country’s six Health and Social Care trusts provide health services for a number of gender-specific conditions, including breastfeeding support, sexual health services, promotion of uptake of cancer screening and support services, and work with lesbian and bisexual women.

Wales

The Women’s Health Implementation Group (WHIG) was announced in 2018 by then minister for health and social services, Vaughan Gething, tasked with ‘overseeing specific areas of women’s health requiring urgent attention and improvement’ over a five-year period, with £5m government funding. 

‘Women’s health is a priority for us and this is why we set up and fund the WHIG,’ a government spokesperson says. ‘The group has helped to achieve a number of key initiatives, including establishing a network of pelvic health and wellbeing coordinators in each health board. 

‘More recently it has supported the recruitment of a network of specialist endometriosis nurses in each health board to develop national pathways to help to reduce diagnostic times across Wales.’

Scotland

Among the Scottish plans for women’s health actions are to establish a women’s health research fund to close gaps in scientific and medical knowledge, develop a menopause and menstrual health workplace policy and promote it across the public, private and third sectors, and set up a Women’s Health Community Pharmacy Service (Scottish Government, 2021b).

Actions within Scotland’s Women’s Health Plan have been split into short, medium and long term, to begin being delivered within the year. Among those already established are a central platform for information on women’s health on NHS inform.

And in October 2021, the Scottish Government launched the NHS inform menopause information platform. ‘We are bursting menopause myths, highlighting menopause symptoms, options for care, treatment and support, mental health and much more,’ says a government spokesperson. ‘Our ambition is to ensure that all women and girls enjoy the best possible health throughout their lives.’


Education is key

‘We need to hear what is important to women and how poor health is impacting on their lives at all levels,’ says Hilary, who also runs Ask Eve, a specialist gynaecological health information service for women and their families and friends who may have questions about cancers. 

She says there is a common perception that women are ‘moaning’. ‘Women’s health is complex with many layers to it,’ says Hilary. ‘This can make disease difficult to diagnose – you are asking people to describe symptoms which can often sound vague and non-specific, but most often are not. This leads to frustrations for both patients and clinicians.’

It doesn’t help that awareness of sex-specific conditions is an issue among both healthcare professionals and women. All these factors contribute to healthcare treatment for women lacking in many areas.

Bella says many women’s health conditions have been previously misunderstood: premenstrual dysphoric disorder, endometriosis, the menopause, vaginal atrophy and urinary incontinence. Only now are they beginning to be fully recognised, correctly diagnosed and appropriately treated. ‘[As many as] 69% of women will experience urinary incontinence, but only half will seek help. We [as health professionals] need to do better.’ Complications of the menopause such as osteoporosis, heart disease and dementia are also underserved, she says.

Lorraine says educating both the medical profession and women is key. ‘The myths and misconceptions around perimenopause and menopause and the prescribing of hormone replacement therapy [HRT] need to be addressed,’ she says. ‘[There is evidence that] HRT is a preventative medicine for osteoporosis and heart disease and should be prescribed as the first line of treatment based on patients presenting with symptoms of perimenopause.’

The Well HQ does a lot of work with sportswomen, and one of the issues that arises is the number of women who leak urine but haven’t had children. ‘For some reason leaking urine is only acceptable after you’ve had a baby, and that’s the only time anyone really talks about it,’ says Bella. But the problem could be caused by a range of factors, from weak pelvic floor muscles to medication (as well as obesity and neurological conditions). ‘These young women don’t talk to each other about it because it’s like it’s the biggest taboo of all. It’s almost as if women are only given permission to seek help for certain conditions at certain phases of their lives.’ 

‘Women’s health is surrounded in shame and stigma and embarrassment, women are literally suffering or dying of embarrassment.’ Bella is clear in her view on what should be happening: removing stigma and talking in clear language is crucial, and should start at school with teachers, boys and girls, and continue in the workplace.


UK life and health expectancy for women and men

Life expectancy at birth in the UK 2018-20 is females: 82.9 years; males: 79.0 years (ONS, 2021b).

Even though women’s life expectancy is greater than men’s, women spend over a quarter of their lives in ill health and disability, compared with about one-fifth of men’s lives (ONS, 2021c).

Women’s healthy life expectancy – the number of years people are expected to spend in different health states – has fallen from 63.7 years in 2014 to 2016, to 63.3 years in 2017 to 2019. Men’s healthy life expectancy has remained stable, at about 62.9 years (ONS, 2021c).

In 2017 to 2019, men could expect to spend 62.3 years of their lives free of disability, whereas women’s disability-free life expectancy was 61.0 years, a decrease of just over a year on the previous two-year period (ONS, 2021c).

These figures do not take into account the impact of Covid-19 on health.


The research gap

Another issue is that many areas of academic research (not just medical) assume men are the standard of measurement. ‘If I think about health and safety and the way a number of occupational standards were set at one point, the average standard was the male US marine,’ says Diana Holland. ‘Obviously that doesn’t fit a lot of men either, but it’s absolutely unsafe for women.’ In this context she believes that women’s healthcare, including research and treatment, should be considered in the context of their whole lives rather than individual conditions or issues. 

This is also crucial for a truly intersectional view of women’s healthcare. Black women are more than four times more likely than white women to die in pregnancy or childbirth (MBRRACE-UK, 2021). And there are differences in women’s life expectancy across socioeconomic groups, with those in the most deprived areas dying 7.6 years earlier than those in the least deprived areas of England (Office for National Statistics (ONS), 2021a).

‘It’s really important that [research and treatment] looks specifically at women then looks at the circumstances for black women, for disabled women, for lesbian, gay, bisexual and trans women, for example,’ Diana says. Both documents from the Scottish Government and the Department of Health and Social Care include references to healthcare needs of transgender men, non-binary people and intersex people, or people with variations in sex characteristics, who may also experience menstrual cycles, pregnancy, endometriosis and the menopause. 

Women’s health research itself has also been lacking, says Bella. She says that research into the impact of hormones on women’s health is critical, yet the little that is done is carried out at the wrong time of the menstrual cycle, when hormone levels are more similar to men’s. 

‘No one is taking into account the fact that for most of our lives we have a beautiful roller-coaster of hormones that affects the way we digest food, metabolise medicine, the way we think, the way we sleep, our body temperature. No one understands how that affects us, mentally, physically, emotionally,’ she says.

‘Women’s health is surrounded in shame and stigma and embarrassment – women are literally suffering or dying of embarrassment’

Bella says the bias and ‘systematically ignoring half the population’ in healthcare and medical research is not intentional but a lack of insight into the fact that women are different. But the good news is that there is a growing appetite from employers for support and guidance on women’s healthcare.

‘The number of hours lost through work because of the menopause or other women’s health issues is very high, and I think corporations are now realising this and understanding that they need to support women and have the ability to adapt,’ says Bella. 

That subjects such as the menopause and guidance on pelvic floor exercises are on the school curriculum in England and increasingly in the public arena also shows things are getting better. ‘Women’s voices are being heard,’ says Lorraine. ‘There are so many more books being published by experts and Channel 4’s documentary Sex, Myths and the Menopause with Davina McCall addressed [the menopause] very publicly.’

A brighter future?

Hilary says: ‘Over the next five to 10 years we need to see real change and action at the grassroots level. We have to invest more. We simply cannot keep marginalising women’s health at the back of the cupboard in the hope it either gets forgotten and goes out of date or the next generation forget what went before and they have to start all over again from scratch.’

Improved understanding, treatment and knowledge of women’s healthcare issues would impact community practitioners, both personally, as many are women, but also professionally, as they may be implementing new policies, Diana says. ‘Hopefully, some of the multiple and more complex [health] issues may be reduced. And there may be more solutions for them to refer to. It [an effective women’s health policy] should both improve health outcomes for women and make the job of a community practitioner more rewarding.’


Resources

BMA’s reply to the Women’s Health Strategy bit.ly/BMA_WHS_reply

RCOG’s Better for women report bit.ly/RCOG_BFW_report

Vision for Women’s Health Strategy for England bit.ly/GovUKEng_vision_WHS

Wellbeing of Women’s reply to the Vision for Women’s Health Strategy bit.ly/WOW_reply_vision

Women’s Health Plan for Scotland bit.ly/GovScot_WHP


References

Department of Health and Social Care. (2021a) Government sets clear ambition to close gender health gap. See: gov.uk/government/news/government-sets-clear-ambition-to-close-gender-health-gap--3 (accessed 2 February 2022).

Department of Health and Social Care. (2021b) Our vision for the Women’s Health Strategy for England. See:  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1042631/dhsc-our-vision-for-the-women_s-health-strategy-for-england.pdf  (accessed 2 February 2022).

Department of Health and Social Care. (2021c) Results of the ‘Women’s Health – Let's talk about it’ survey. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1043211/results-of-the-womens-health-lets-talk-about-it-survey.pdf (accessed 2 February 2022).

MBRRACE-UK. (2021) Saving lives, improving mothers’ care: lay strategy 2021. See: npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_Lay_Summary_v10.pdf  (accessed 2 February 2022).

ONS. (2021a) Health state life expectancies by national deprivation deciles, England: 2017 to 2019. See: ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/healthstatelifeexpectanciesbyindexofmultipledeprivationimd/2017to2019#slope-index-of-inequality-in-health-state-life-expectancy  (accessed 2 February 2022).

ONS. (2021b) National life tables – life expectancy in the UK: 2018 to 2020. See: ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/2018to2020  (accessed 2 February 2022).

ONS. (2021c) Health state life expectancies, UK: 2017 to 2019. See: ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/healthstatelifeexpectanciesuk/2017to2019  (accessed 2 February 2022).

Scottish Government. (2021a) Women’s health plan. See: gov.scot/news/womens-health-plan/  (accessed 2 February 2022).

Scottish Government. (2021b) Women’s health plan: a plan for 2021-2024. See: https://bit.ly/WHP21-24 (accessed 2 February 2022).

University of Leeds. (2016) Heart attacks in women more likely to be missed. See: leeds.ac.uk/news/article/3905/heart_attacks_in_women_more_likely_to_be_missed  (accessed 2 February 2022).

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