Former health and social care secretary, Wes Streeting, said the current system is ‘failing women’ but progress may be stalling on initiatives such as women’s health hubs. While the refreshed Women’s Health Strategy initially raises the profile of the health issues facing women, there is a danger that it’s slipping down the agenda as ICBs tackle workforce cuts and cost pressures. Kathy Oxtoby reports
Women across the country will be ‘better heard and served’ under new plans set out in the renewed Women’s Health Strategy for England, the Department of Health and Social Care (DHSC) says.
Women will be ‘directed to the right professional first time through a single referral point, along with marrying local services with online support to drastically cut waiting lists and ensure women no longer face years-long waits for diagnosis and treatment for conditions like endometriosis, which can take nearly a decade to diagnose’, says DHSC.
As part of the renewed strategy published this April by DHSC, a new standard of care will be produced to ensure women are offered appropriate and effective pain relief for invasive gynaecological procedures, from contraceptive fitting through to hysteroscopies, ‘addressing long-standing concerns around inadequate pain management’, says DHSC.
Former health and social care secretary, Wes Streeting, said the current system is ‘failing women’. ‘Women’s voices must be central to delivering effective, respectful and empathetic care. We need to hit medical misogyny where it hurts – the wallet. [The] renewed strategy will tackle the issues women face everyday and ensure no woman is left fighting to be heard.’
The Royal College of Psychiatrists ‘welcomes the commitments to promote collaborative working between mental health and women’s health sectors, strengthening perinatal mental health care’, says Dr Lade Smith CBE, president of the Royal College of Psychiatrists.
‘Additionally, we welcome the introduction of a modern service framework for women and girls, and the rollout of a national domestic abuse and sexual violence referral pathway across Integrated Care Boards.
‘These ambitions are a positive step in the right direction. However, delivering them will require sustained investment in women’s health and a credible workforce strategy that addresses recruitment, retention and staff wellbeing. Without this, progress risks falling short of delivering what women need,’ she says.
Other reforms set out in the renewed strategy include redesigning clinical pathways for heavy periods, urogynaecology and menopause to speed up diagnosis and treatment, and funding a specialist centre in each region to introduce group-based approaches to care.
The state of women’s healthcare
‘There are strides being made in bringing women’s health to the fore of policy and practice and addressing inequalities and poor outcomes in women’s health,’ says Dr Loreen Chikwira, a researcher at The King’s Fund.
She says, although there were some criticisms of the Women’s Health Strategy when it was initially published, it has been instrumental in raising the profile of women’s health nationally, and investments and scaling of women’s hubs across England – even though their establishment was slow.
It has also played an important role in championing the voices of women in design and delivery of care, and bringing more focus on different areas of women’s health that have been ignored previously, such as gynaecological waiting lists with around 600,000 women waiting for procedures compared to other surgical specialties.
There are other areas of women’s reproductive health that continue to be a topic of challenge, for example, research shows that women’s experiences of maternity care are less satisfactory than five years ago, says Dr Chikwira.
Beyond women’s reproductive health, there are continuing inequalities and disparities in other medical conditions such as life expectancy, mental health and cardiovascular disease (CVD). And there is more work needed to tackle health inequalities in trans women’s health, she says.
There are also ‘persistent system challenges that need addressing in order to deliver equitable, quality care for women’, she says. ‘Some of the challenges cut across all health and care, such as poor access to timely care, and some are specific to women’s experiences of health and care, for example medical misogyny which negatively impacts women’s access, experiences and health outcomes.’
Dr Philippa Greenfield, the Royal College of Psychiatrist’s joint presidential lead for women and mental health, says women’s lives are affected by specific biological and psychosocial factors, for example, reproductive and hormonal transitions, gender-based violence (GBV), alongside being disproportionately impacted by poverty and caregiving responsibilities, that pose risk factors for mental ill health throughout their lives. These factors can increase risk of developing common mental disorders, such as anxiety, depression, severe mental illnesses such as bipolar, schizophrenia, trauma-related disorders, and eating disorders.
‘Yet, women’s mental healthcare remains siloed and under-resourced, with consistently low investment and women’s symptoms and concerns too often dismissed, misunderstood or labelled incorrectly,’ she says.
Work currently being undertaken to improve women’s health in England includes maternity care inquiries and tackling inequalities, with a national maternity and neonatal investigation. There are plans for cervical cancer elimination by 2040 in England and increased funding and research in reproductive health with work being carried out by the National Institute for Health and Care (NIHR).
There are also more innovations in women’s health – Femtech – though there are concerns about their accessibility and benefit to all women. Hormone Replacement Therapy Prepayment Certificates (HRT PPC) were introduced in 2023. And there is a cross government strategy for freedom from violence and abuse against women.
Women’s health hubs
ICBs are supposed to have at least one women’s health hub in place, and should deliver a core set of eight services, including cervical screening and menopause care. However, ‘not all of them were delivering them – there are differing priorities, models and workforce skills and training’, says Dr Chikwira.
And while ICBs were given allocated funding for these hubs, it is no longer ring fenced and some have reprioritised the funding, she says.
The rollout of women’s health hubs is no longer specified in central operational guidance, and at the end of 2024, an FOI request established that only 7% of ICBs provide additional funding to support hubs in their area, says Dr Greenfield. ‘The target number of hubs has been reduced and there is concern women’s health will no longer be prioritised at a local level, and when funding has expired, it hasn’t been renewed. As provision remains inconsistent, so does the care provided,’ she says.
In areas where hubs have been implemented, progress has been made, she says. This includes a reduction in the number of gynaecology referrals that needed to be seen in secondary care, (only 25% of referrals needed hospital care within the first 12 months, representing a 60% reduction) and a decrease in the average wait for a gynaecology appointment from 27 weeks to 11 weeks, with waiting lists falling by 30% in a matter of months. Another success is 95% of patients receiving an initial response from their referral within 48 hours and 100% doing so within 5 days.
‘Yet, hubs often are not equipped to meet the specific needs of women with severe mental illness (SMI), and this must change,’ says Dr Greenfield.
The renewed Women’s Health Strategy confirms that where high-quality women’s health hubs exist, they will continue to lead service delivery. However, in other areas it is anticipated that a dedicated space will be established within broader neighbourhood health centres.
Concerns and challenges
The deprioritisation of women’s health is a concern. ‘Restructures and changes to ICB functions combined with the pressure to deliver on specific national priorities and in addition their local priorities, with tight financial controls risks women’s health and services being deprioritised,’ says Dr Chikwira. ‘In some ICBs, women’s health may continue to be incorporated into other health priorities. This has implications for data collection and analysis in relation to demonstrating impact – improvement in women’s health – and the ability of ICBs to better understand gendered needs of their populations.’
Also of concern is leadership and accountability. ‘Leadership and commissioning of women’s health services have been inconsistent across ICBs. Continued inconsistencies in leadership or a dedicated leadership in women’s health can result in lack of accountability for performance. Additionally, there are concerns about the impact of the cuts to ICB senior leadership, some of whom have championed women’s health,’ she says.
And commissioning for women’s health is ‘fragmented’, she says. Some services are commissioned by local authorities, for example, contraception services and others by ICBs. This can be further compounded by the reduction in ICB and local authority budgets leading to a deprioritisation of some areas of women’s health, she says.
‘We are already seeing that in the face of cuts, targeted interventions for women’s health are being seen as “luxury” rather than an essential service, which will undoubtedly have a negative impact on women’s safety and mental health outcomes,’ says Dr Greenfield.
Lack of sex disaggregated data and gender specific research means they often fall short of diagnostic thresholds, she says. ‘This frequently results in women experiencing delayed diagnosis, inappropriate care and ultimately poorer outcomes.’
Gender-based violence (GBV) is ‘one of the most significant drivers of women’s mental ill-health, yet, despite its scale, domestic abuse is still often treated as a “social issue” rather than the significant public health priority it is’, she says. ‘Mental health services are not consistently designed or commissioned in a way to support identify and respond, or to prevent, the long-term health and psychological impacts of violence and abuse. While national policies increasingly reference trauma-informed approaches, meaningful system level implementation, governance and accountability is still lacking.’
Structural barriers, including race, sexual orientation, gender identity and disability and neurodevelopmental conditions, continue to be overlooked when considering access of current “mainstream” health pathways which further prevents women from accessing care, she says. Additional barriers arise from migration status, socioeconomic inequality, caring responsibilities, class and limited language accessibility. ’Acknowledging these intersecting factors, as well as listening to women’s lived experiences, is essential for delivering equitable and responsive healthcare,’ says Dr Greenfield.
‘People first approach’ to commissioning of services
‘It is important that system leaders take a people first approach to the commissioning of services and ensure that ICBs and providers collaborate with women including transgender women in commissioning and delivery of services,’ says Dr Chikwira. ‘This is to ensure that services meet the needs of women and reduce inequities – inclusion and equity principles must be embedded in commissioning services and outcome measures.’
She says progress in women’s health within the current policy changes (10 year health plan and the three shifts), and system structural changes (ICBs, neighbourhood health and Integrated Health Organisations (IHOs)) can happen if there is ‘dedicated leadership at both national and system level with clear accountability pathways that align with other priority areas’. ‘These must be anchored in the governance structures to avoid women’s health being deprioritised or being side lined. There must also be agreed system data metrics and outcomes measures as part of the accountability process.’
There is also a need for joined up commissioning and care. Women’s health is ‘more than reproductive health and is shaped by wider determinants of health’, she says. ‘To address the fragmented commissioning and wider determinants of health, system leaders and commissioners must work with other partners – local authorities, VCSEF organisations and people with lived experience to create shared goals.
‘The shared goals need to inform the joint commissioning of services and consequently use of resources. There must also be better use and resourcing of existing infrastructure such as women’s hubs in delivering on the shared goals,’ she says.
Government must support local systems to act effectively, says Dr Greenfield. ‘Women’s mental health must be embedded across policy, strategy and service planning at a national, and local, level.
‘It is essential that women’s lived experiences and mental health needs help to inform policy and design services if ICBs are to meet the needs of women, and ensure integration of mental, physical and reproductive health pathways,’ she says.
There is ‘clear opportunity to really improve women’s mental health, but cross sector change is essential for this to happen’, says Dr Greenfield. ‘Progress will depend on sustained leadership and shared responsibility with governance and accountability for change. National policy, local systems, regulators, funders and professional bodies all have a role to play. So too does the meaningful involvement of women whose experiences have too often been overlooked, but whose insight is essential to improving care.’
Updated to reflect the resignation of health secretary Wes Streeting on 14 May.
