1 Why we need a Women's Health Plan
The aim of this Plan is to improve health outcomes and health services for all women and girls in Scotland. It is underpinned by the acknowledgement that women face particular health inequalities and, in some cases, disadvantages because they are women.
Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.
World Health Organisation (WHO).
A range of biological factors impact on women's health. Women and girls experience various health needs and risks during their lives which are not the same as those of men. This may relate to starting and managing periods, choosing contraception, accessing abortion services, planning for pregnancy, managing menopause symptoms and the manifestation of chronic conditions such as heart disease.
In its 2019 publication 'Better for Women' the Royal College of Obstetricians and Gynaecologists (RCOG) highlighted some of the unmet needs of women in the UK and concluded that too many women are struggling to access basic healthcare and, when they do, health services too often miss opportunities to ask the right questions, optimise the resources available to prevent illness and ensure the best outcomes.
This is not just about differences in reproductive health: various studies have shown that women do not always receive equal healthcare to men and that outcomes for women are poorer than those for men. For example, when it comes to heart health, women are less likely than men to be prescribed drugs that reduce the chance of a second heart attack and women are less likely to receive diagnostic testing, such as coronary angiography imaging, within 72 hours of hospital admission.
According to a British Heart Foundation Report, in Scotland there are inequalities at every stage of a woman's medical journey.
There is also considerable evidence of women being undertreated or presenting disease in a different way to men. However, there is a significant data gap in medical research which further contributes to health inequalities in the UK. Women make up 51.5% of Scotland's population and yet women are less likely to be invited to, or participate in, medical trials and research. There is a historic, and ongoing, failure to include sex and gender differences in the design, delivery and analysis of clinical research studies. A 2016 Oxford University report highlights this issue, stating that for many years it was widely assumed that the occurrence and outcomes of disease were the same for men and women, and that our understanding of disease processes based on studies involving only men would be equally relevant for women. An increasing body of evidence suggests that this is not the case, and that we can improve our knowledge about disease occurrence and disease outcomes – for both men and women – by undertaking analyses of health data disaggregated by sex and informed by a gender perspective, as well as by including sufficient numbers of women in scientific studies.
This document will use the term 'women'/'woman' throughout. It is important to highlight that it is not only those who identify as women who require access to women's health and reproductive services. For example, some transgender men, non-binary people, and intersex people or people with variations in sex characteristics may also experience menstrual cycles, pregnancy, endometriosis and the menopause. The actions included within this Plan make clear that all healthcare services should be respectful and responsive to individual needs.
In the UK one in three women will experience a reproductive or gynaecological health problem at some point in their lives. Despite this in 2018 just 2.1% of publicly funded research spend was dedicated solely to reproductive health and childbirth, a reduction from 2.5% in 2014. Endometriosis affects around 10% of women and girls globally, it is therefore estimated that one in ten women in Scotland have endometriosis. Despite this high prevalence, the average time to diagnosis from onset of symptoms in Scotland is 8.5 years. Although endometriosis is as common in women as diabetes and asthma, it has failed to attract the same attention, support and funding as those diseases.
Simply put, we know less about how best to treat diseases in women.
Research suggests that patients' health outcomes can be related to the gender of who they are treated by. For example a study, published in 2021, suggested that that gender concordance (when a female doctor treats a female patient) increases a women's access to treatments and specifically that gender concordance reduced the risk of death following a heart attack.
Inequities are also faced by the health and social care workforce. Women make up the vast majority of the NHS workforce and whilst in the past ten years the proportion of female doctors and consultants has increased, patterns of occupational segregation remain, with women significantly under-represented in areas such as cardiology and surgery. Women's health is also impacted by various social factors, including where they are born, their age, their ethnicity, their sexual orientation and much more.
Some NHS boards are involved with the Equally Safe at Work accreditation programme. The programme supports employers to improve their employment practice to advance gender equality at work and prevent violence against women.
It is important to consider and understand the conditions in which women live, as this significantly impacts overall health and women's ability to access healthcare services. For example, the risk of poverty is much higher for women, disabled people, minority ethnic people, lone parents (the majority of whom are women) and children and young people. Between 2017 and 2020 the poverty rate in Scotland was highest for single women with children and 20% of single female pensioners were living in relative poverty. Being in employment is not necessarily protective against poverty and women are more likely to be in working poverty than men. Women are heavily over-represented in occupations which tend to be lower paid and undervalued compared to those which are male dominated. Living in poverty is known to be damaging for health and one of the main causes of poor health and health inequalities. Public Health Scotland note that gender-based violence (GBV) is a major public health, equality and human rights issue and is experienced unequally, with 17% of women and 7% of men having experienced the use of force from a partner or ex-partner at some point in their lives. The latest annual data for Scotland shows that 82% of domestic abuse incidents reported had a female victim and male perpetrator. 20% of women have experienced sexual abuse before the age of 18.
The Scottish Government is committed to tackling poverty, addressing the Gender Pay Gap and the eradication of male violence against women and girls. Significant work is being undertaken across the Scottish Government, the public and third sectors to address these major societal issues (see section 5). While the primary focus of this Plan is on the reduction in inequalities in health outcomes and the improvement of health services for women, it is vital that the wider determinants of health are considered (see section 4).
All of this adds to avoidable health inequalities for women.
It is also clear that the impacts of the Covid-19 pandemic have not been felt equally across the population and that the most negative impacts fall on those least able to withstand them. The majority of unpaid carers are women, women make up the majority of the health and social care workforce, the vast majority of lone parents are women and women are more likely to be victims of domestic abuse. Research conducted by Close the Gap suggests that Covid-19 has had a disproportionate impact on women, particularly in the area of employment. In Scotland, women have accounted for the majority of furloughed staff since July 2020. According to the Institute for Fiscal Studies mothers are more likely to have quit or lost their job, or to have been furloughed, since the start of the lockdown. The challenges of balancing childcare, paid work, caring responsibilities alongside managing the stresses and uncertainties of the pandemic should not be underestimated, particularly how this has, and continues, to impact women's health.
Another aspect of inequality that has been particularly prominent has been the disproportionate impact on minority ethnic people. The reasons for this are complex and include the interplay between socio-economic disadvantage, high prevalence of chronic diseases and the impact of long-standing racial inequalities. To address these issues an Expert Reference Group on Covid-19 and Ethnicity was established to provide advice and recommendations to the Scottish Government. The Women's Health Plan has not specifically investigated the impact of Covid-19 on women and women's health, but presents in some of its proposed actions opportunities to focus on groups of women who may have been disproportionately affected by the pandemic.
The Covid-19 pandemic has also created opportunities to implement new ways of providing patient care, particularly in respect of the provision of contraception and the delivery of abortion care. A number of the new and innovative ways of working have developed quickly in response to the pandemic and are captured in this Plan for longer-term implementation.
We have an opportunity to address these inequalities. That is why we have developed this Women's Health Plan to focus on the specific health needs of the women of Scotland.
This Women's Health Plan sets out how the Scottish Government intends to reduce inequalities in health outcomes affecting women over the next three years, and beyond.
We need to be careful to avoid bias in how patients are diagnosed and treated. Women and men should have an equal chance of receiving the correct diagnosis and treatment. This is work in progress.
Professor Colin Berry, Professor of Cardiology and Imaging (Institute of Cardiovascular & Medical Sciences)