“To be an unwell woman today is to fight against ingrained injustices against women’s bodies, minds and lives.” 1 – Elinor Cleghorn.
Since the inception of medicine, women have rarely received medical justice. From the mysterious wandering wombs of ancient Greece, through the Victorian preoccupation with hysteria, to the recent, ‘modern’-day overturning of Roe v. Wade (a scenario which previously only seemed conceivable in a dystopian scene from The Handmaid’s Tale) women have perpetually suffered at the hands of the medical establishment.
It is for this reason that women’s health proves to be a highly emotive and often polarising subject. When the UK Government issued a call for evidence to a public strategy on women’s health in 2021, it received over a hundred thousand responses, in contrast to the paltry few thousand or so that prior similar initiatives generally attract.2 The UK’s first women’s health strategy was published in July 2022 in attempt to ‘reset the dial’3 on medical care for women, to ‘improve the way in which the health and care system listens to women’s voices’, and to ‘boost health outcomes for women and girls’.3 But can this ten-year strategy right the wrongs of the past where women and medicine are concerned? It is a colossal undertaking, and many people have their doubts.
This is not least because the catalyst for the strategy seems to be the UK’s multitude of medical scandals. The ministerial forewords to the call for evidence, and the strategy itself, reference no fewer than three reports of malpractices of recent years.3,4 Taken together, the Ockenden review, the First Do No Harm report, and the Paterson Inquiry paint a bleak picture for women’s health in the UK. Respectively, the reports investigate serious failings in maternity care,5 avoidable harm suffered by patients related to medical device safety (including vaginal mesh implants),6 and the case of breast surgeon consultant, Ian Paterson, who was found guilty in 2017 of performing unnecessary and damaging surgery on women.7 Cases such as these are as devastating as they are (fortunately) rare, but feminists have pointed out that the barriers to women’s healthcare don’t have to be as malicious as these cases to be as equally detrimental to the lives of women.8 Innumerable holes in the Government’s strategy have therefore prompted criticism from some quarters.
One media outlet posited that the strategy may become an umbrella for publicising disparate initiatives related to female health, rather than providing any meaningful or cohesive change,9 and it is easy to see why.
The strategy boasts earmarking £10m for more breast cancer checks via 25 new mobile screening units.3 But some suspect this investment was already happening anyway as part of the planned catch-up programme following the COVID-19 pandemic, rather than being linked specifically to the new women’s health strategy.9 Furthermore, while breast cancer is the most common type of cancer in the UK,10 women are twice as likely to die of cardiovascular disease (CVD) than breast cancer,11 but the strategy neglects to mention any new targets or funding committed to tackling CVD in women.
Mental health was selected by 39% of respondents to the call for evidence survey for inclusion in the women’s health strategy, and was one of the major areas where women felt they had not been listened to by their healthcare professionals.3 The strategy does include some positive action in this area, including the introduction of trauma-informed practice in the healthcare sector and a focus on mental health disparities for minority women.3
The Government also promises to dedicate £2.3bn toward expanding and transforming mental health services by 2023 to 2024,3 but it would be erroneous to credit this investment as part of the women’s health initiative, because this funding was set up in 2021.12 Moreover, campaign groups, such as Agenda, have pointed out that the women’s health strategy promises no new money to tackle the growing mental health crisis among women and girls, who suffer anxiety and depression at three times the rate of men.13 They also claim the strategy does not go far enough to address the mental health needs of women and girls which have historically been overlooked, including experiences of abuse, violence, poverty and discrimination.13 This has led many people to question whether the Government’s new measures are only skin deep.
As one might expect of a strategy born of scandals relating to maternity deaths, butcher surgeons, and faulty vaginal mesh implants, the Women’s Health Strategy has been forced to address some of the more deep-seated, cultural issues surrounding women’s health. Yet these attempts prove somewhat superficial.
For example, much of the strategy focuses on dedicated women’s health training for doctors, including undergraduate curricula for all healthcare professionals that includes teaching and assessment to ‘ensure the next generation of healthcare professionals are better educated in women’s health’.3 The focus of this training is predominantly for GPs,3 however, the strategy makes no mention of mandatory training for those already working in the profession; of which 43% with a full time permanent contract are men over 50-years-old.14 With England’s shortage of GPs and practice nurses expected to escalate over the next decade to as many as 20,000 vacant posts,15,16 one wonders who there will be left to train.
The Government promises their strategy will identify gaps to women participating in clinical research and prioritise tackling the data gap that has omitted women from decades of advancement.8 The Government will work directly with the National Institute for Health and Care Research (NIHR) to ensure the inclusion of both sexes in the design of animal research and promises to guarantee that analyses involve a wide range of groups and backgrounds currently underrepresented.3 They also have longer-term goals to prioritise the disaggregation of data in clinical research, which feminist campaign groups have been advocating for years.8
In other places, however, the wording of the strategy sounds alarm bells. It states that it will aim to ‘ensure women and men are given equal opportunity to participate in research’,3 but opportunity is not the same as guaranteeing that women will be equally and fairly represented in this research. This is particularly concerning when we consider that women’s caregiving responsibilities are often blamed for the difficulty in recruiting them to clinical trials.8
In addition, the recently published strategy also shines the spotlight on reproductive health.
The strategy also promises to improve care for women who experience pregnancy and baby loss through the introduction of pregnancy loss certificates as recommended by the interim update of the independent Pregnancy Loss Review.3 The scheme will enable parents who experience the loss of a baby before 24 weeks to receive a certificate in recognition of their loss. While nothing can soften the devastation felt at the miscarriage of a wanted pregnancy, there are more pragmatic steps that can be taken to treat grieving parents with sensitivity and empathy that have been overlooked. Feminist campaigners have pointed out that ‘apparently a streamlined process is more important than sparing a bereaved woman further pain’.17 This refers to reports of miscarrying women who were turned away from hospital because they were bleeding ‘out of hours’ and ended up with sepsis. Women have also been sent letters admonishing them for missing appointments and ‘wasting NHS time’, following miscarriage, because there was no automated process to cancel future scans.17 The strategy makes no mention of rectifying such oversights.
This isn’t to say that it is all bad news for maternity support. The women’s health strategy will be a landmark moment for female same-sex couples who no longer have to self-fund six rounds of inauterine insemination (IUI) to prove their infertility status prior to qualifying for in vitro fertilisation (IVF); a process which can prove prohibitively costly for many couples.3 But there remains ‘considerable progress’ to be made in the variations in provision of NHS-funded fertility services for same-sex female couples.18 Guidelines aren’t set to be reviewed until 2024, and the strategy includes no commitment to the provision of NHS-funded donor sperm.19
Reproductive health is always an area rife with contention, perhaps never more so than in 2022, as women ponder the future of their reproductive rights.
The overturning of Roe v. Wade has cast a sombre spectre over several Western countries as we witness the removal of what many women view as control over their own bodies.20 The 1967 Abortion Act legalised abortion in the UK under the conditions that two doctors permitted the termination of a pregnancy, if, in the good faith of these doctors, continuing it would affect a woman’s mental or physical health.21 Yet under the Offences against the Person Act of 1861, which has never been repealed, abortion is still technically illegal.22
In the wake of overturning Roe v. Wade, women within the UK are seeking reassurance of their existing rights. In July, the European Parliament endorsed a resolution to enshrine abortion as a fundamental right for women, but following Britain’s exit from the European Union, women in this country currently do not benefit from this protection.23 The UK government say they have no plans to review or change current abortion laws, and information on abortion in the strategy is scant, with plans for abortion care to be set out later this year.3
One oft-heard criticism of women’s health is that it is too focused on maternity care, to the detriment of issues such as menopause and other gynaecological issues. The government certainly could not be accused of neglecting these areas in its new strategy, perhaps owing to the pressure put on them by campaign groups backed by celebrity endorsement in recent years, such as The Menopause Charity.
The reduction of the cost of hormone replacement therapy (HRT) prescriptions is a major milestone for women for whom HRT is suitable, as is accessibility to specialised, personalised support and treatment and the availability of vaginal oestrogen tablets over the counter for the first time.3 The UK Menopause Taskforce was set up in February this year in recognition of the need to take a holistic approach to the menopause, and will focus on improving support for women, raising levels of awareness in the population and among healthcare professionals, encouraging workplace support and considering where further research is needed to address gaps in the evidence base.3
There is still, however, more to be done. The strategy claims to be informed by the life course approach to women’s health, meaning it will focus on the potential for early intervention to reduce disease risk or severity in later life.24 It will therefore include recommendations for exercise to preserve bone health, for example, but it has faced criticism from groups such as the Royal Osteoporosis Society. They point out that the vision ‘misses the brief’’ in tackling the osteoporosis gap, which currently leaves 90,000 people who suffer from the condition without the treatment they need every year.25
This isn’t to ignore positive developments. Much attention has been paid both in the strategy itself and in media coverage to the rollout of surgical hubs and diagnostic centres across the country,3 which are aimed tackling the 69% increase in gynaecological waiting lists compared to pre-pandemic levels.26 These are in addition to expansion of ‘one-stop-shop’ hubs across the country, which will allow ‘women and girls have more of their health needs met at one time and in one place’.3 Furthermore, with gynaecological conditions being found to be the top topic that respondents indicated for inclusion in the strategy, the NHS is updating the service specification for severe endometriosis imminently, and the National Institute for Health and Care Excellence (NICE) will also consider the development of a guideline on polycystic ovary syndrome (PCOS).3 This is a positive step forward in the recognition of patients with these conditions, particularly as they are notoriously difficult to diagnose.
The role of women’s voices is a key theme of the Government strategy. 84% of respondents to the call for evidence survey reported concerns about not being listened to by their healthcare professionals.3 This was evident in women’s experiences across the board in healthcare – from discussion of symptoms, further appointments, discussion of treatment options and follow-up care.3
While it is encouraging that the Government recognise this problem in the new strategy, there is concern as to whether enough is being done for ethnic minorities and those with disabilities; in other words, the disadvantaged women whose voices are seldom heard and are the least likely to speak up in the first place.
The initial response rate to the call for evidence was so low among disadvantaged groups that it was necessary to extend the deadline for submissions by two weeks,27 proving that there are significant hurdles to advocating for and putting the spotlight on these groups. Furthermore, once these voices are recognised and heard it is vital that we do not lose momentum in empowering them. This would avoid accusations of tokenism which are symptomatic of key areas of the strategy.
The very fact that a strategy is finally being introduced is no doubt a positive step forward in the historically overlooked area of women’s health, and many will be watching with keen interest to see how the measures are implemented by the Government. However, the lack of attention to detail in responding to what women really want proves that there is a real need to go further. After all, there is very little point in calling for evidence if you are not going to address that evidence in full.