91ÌÒÉ«

Women’s healthcare in the UK is in crisis. 

Although women slightly outlive men, women in the UK spend a greater proportion of their lives in ill health or disability compared to men – around a quarter for women and a fifth for men¹. And these figures are getting worse – healthy life expectancy at birth has fallen for women since 2014, but has remained stable for men. A woman born between 2017 and 2019 could expect to live an additional year in suboptimal health than a woman born in the UK between 2014 and 2016. There was no significant change for males across the same period. In other words, these numbers show that women are suffering in a health service not designed for them.   

How did we get here? 

“Some years ago, I pushed the Secretaries of State Jeremy Hunt and then Matt Hancock to have a Women’s Health Task Force”, says Professor Dame Lesley Regan, Professor of Obstetrics and Gynaecology, 91ÌÒÉ« and newly appointed Women’s Health Ambassador for England, Scotland and Wales, “I argued that women had been disproportionately disadvantaged by many of the funding cuts since the 2012 Health and Social Care Act, which accelerated after 2014 when Public Health England lost 40% of their budget.  

“The net result is that we now have a 45% unplanned pregnancy rate, cervical screening is at an all-time low, while abortion rates are at an all-time high, mostly explained by the fact that women face numerous barriers when trying to access routine health maintenance services,” Professor Regan exclaims. 

She blames these figures on a lack of accountability in how healthcare is funded. “Women’s health services like cancer screening, contraception, abortion and maternity services have been in three silos of commissioning – Clinical Commissioning Groups, local authorities and NHS England
 None of those three funding pots picks up the pieces when they don’t get it right; the people that don’t give you contraception aren’t the ones to pick up the maternity bills or the abortion bills.

As well as the public consultation on personal experiences, the Call also invited written submissions from individuals and organisations with professional expertise in women’s health. A consortium of experts at 91ÌÒÉ« compiled a submission, from gynaecological Clinical Professors and Readers in HIV medicine to policy engagement professionals, global health experts and medical statisticians. I spoke to ten of them from across the university to paint a fuller picture of the context of women’s health in the UK, to hear about the work being done at 91ÌÒɫ to improve women’s lives in this area, and to find out what work is still left to do. 

Dr Ed Mullins, Clinical Lecturer at 91ÌÒÉ« and The George Institute for Global Health, coordinated 91ÌÒɫ’s response. 

“The idea of doing this had two edges. First, to get the research being done at 91ÌÒÉ« onto a minister’s desk with a series of small, ready to go policy initiatives based on each research area. The second was to get 91ÌÒÉ« to have a look at its own women’s health research. There’s a lot of it going on but there’s a lack of strategy, a lack of cohesiveness. That’s what we’re hoping to springboard off by doing this
”  

One of the central themes which arose in my conversations with 91ÌÒɫ’s academics was the negative impact of excluding women from research. Professor Neena Modi, Professor of Neonatal Medicine at 91ÌÒÉ« and Consultant in Neonatal Medicine at Chelsea and Westminster NHS Foundation Trust and the immediate past-president of the UK Medical Women’s Federation, gave me a recent example.   

 â€œIt was a triumph of science to produce so many COVID-19 vaccines so quickly. Scientists really saved the world,” she says, “but no one who was pregnant, might become pregnant or were breastfeeding were included in the original vaccine trials.  

“This meant that those who were pregnant or breastfeeding were prohibited from taking the [COVID-19] vaccine when it first became available in December 2020, and the advice didn’t change until April 2021,” she says. “So, a woman who was breastfeeding had to make this completely unacceptable choice pitting her own wellbeing against the wellbeing of her baby. To place anyone in that kind of situation is quite frankly unethical. And yet it is exactly what happened.”  

I – like, I suspect, many members of the public – assumed that this exclusion was for the health and safety of women and their babies. In fact, those who are pregnant or breastfeeding wouldn’t usually take part in the higher-risk first-in-human or early drug studies for these very reasons. But Professor Modi tells me their exclusion from the COVID-19 vaccine trials was due to something else entirely.  

When it comes to policy, Professor Regan makes the economic argument for overhauling the way that women access health services to do what she calls ‘maintenance stuff’.  

“At the moment you can’t go to a single clinic appointment and get your smear, STI check, breast check and get your contraception sorted. You should be able to go for a half an hour appointment, take your underwear off once and get three of those things done. Instead, we make the women go round the services which are incredibly expensive in a structure that disincentivises women – why would you want to go to four different appointments when you could do it all in an hour?   

“Policymakers need to think of the cost-benefit analysis of getting it right, by having Well Women centres that can do all of these things. It’s one of my real contentions with the way we deliver health services to women – most of the time they’re not sick, they’re just trying to do normal things like access contraception or have a baby. Being pregnant is not an illness.”  

Fragmented services were also a central theme in my conversation with Professor Marta Boffito, Clinical Reader at 91ÌÒɫ in HIV medicine. “We’re not understanding the needs of women living with HIV. The majority of women living with HIV in the UK are from particularly marginalised populations, and they experience incredibly high levels of stigma. This means their access to care is limited, they’re fearful, and they struggle to engage with HIV and other types of healthcare. This is because the care is fragmented, leaving them having to face telling their HIV story every time they need help, so they just don’t seek help anymore. It’s very complicated, but it’s actually also quite simple to understand.”  

Professor Boffito welcomes the government’s consultation because in her view it could be a good way of involving patients when redesigning or restructuring services. “You often hear ‘give women a voice’, well we’re actually a step before that. We don’t even know how to listen to their voices, that’s how behind we are. We have set up services for white MSM [men who have sex with men] and we’re very good at delivering that care. The number of new HIV infections in MSM is falling very rapidly. But in heterosexual cis-gendered women it’s stable, because we don’t have the right tools and the knowledge to target them.    

“In my experience, women from the HIV community want clinics dedicated to women. They need peer support from women and integrated mental health services with HIV services. We need funding for campaigns to break down societal, medical and internalised stigma. The advice [the women] give you is key to understanding how services should be structured and where the funding should go.”  

 Fragmented care for transgender women

Fragmented care seems to be a recurring theme in women’s health and is certainly true for transgender and gender-diverse people accessing the full spectrum of healthcare. And a 2022 report from the London Assembly Health Committee suggests we have a long way to go
 

In the UK, there are just 16 NHS Gender Identity Clinics currently set up to provide gender-affirmative healthcare. Up until last month, there had been 17, but the recent closure of the only dedicated clinic for children and young people means that already long waiting times between referral and first appointment will only increase further.  

A portion of the remaining clinics also provide sexual health, HIV and mental health services. But what of transgender women’s health needs outside of this narrow view of trans experiences? The grim truth is we don’t really know. NHS IT systems do not allow a person’s trans history to be captured in a consistent way. As a result, unless a transgender woman decides to disclose their trans status at every interaction with the health service, it is difficult for them to receive the right medical advice for their needs, and invitations to attend relevant life-saving screening programmes are easily overlooked.  

To truly address gender-based disparities in health and healthcare, we mustn’t forget the unique inequalities faced by transgender women and gender-diverse communities and we must push for better and consistent reporting of sex and gender information in NHS systems. Without this, they will remain invisible, and we will have failed in our quest for gender equality. 

The Women’s Health Strategy is a collation of women’s views and expert testimonies to decide what needs to be done to improve women’s health.