There has been much discussion about gender equality, but not as much with regard to the inequalities that still exist in women’s health. There remain enormous disparities that directly and indirectly affect women’s health. How can NHS Scotland help to prevent poor health and life chances in young families, improve the health and life expectancy of patients with established conditions and prevent the further widening of health inequalities in adults?
Not long ago I had a conversation with Dr. Anne Mullin, a semi-retired GP working out of hours. She worked as a partner at a Govan practice for 26 years, which is in the top 100 most deprived GP practices in Scotland. She was also involved with the Deep End Project which has been addressing the issues that can help reduce health inequalities, such as recognising the causes and consequences of the inverse care law (people who most need health care are least likely to receive it).
Women and children: not profitable pre-NHS and post-NHS
Women and children’s health, particularly in maternity – pre and post-natal – has always been an issue for the health service prior to the establishment of NHS and after its inauguration. Pre-NHS, women’s health was completely ignored because women and children were not really that profitable for providers. Pre-NHS GPs were paid to treat workers, mostly male because they would have insurance to pay for their health care. So female GPs, seeking to address this particular social inequity have always been pioneers in their field.
Female GPs since pre-NHS times have tended to serve very deprived communities. At the start of the 20th century, female GPs wouldn’t have been given a lot of lists with males, since these would be in the lists of their professional male counterparts. Although outnumbered by their male counterparts, female GPs brought a lot of expertise and accelerated the progress of maternal and child health simply because they were seeing the majority of women and children. They were the ones who would deal with issues that many of the male GPs at that time would not, such as contraceptive health, gynaecological problems, and emotional issues.
Since the founding of the NHS, the proportion of male and female trainees in general practice has evened out, so there is much more parity in GP partnerships. However, there are still barriers to women progressing in general practice and earning as much as their male counterparts. Though the earning issue is still there, female GPs continue to make a substantial contribution toward greater strides in women’s health, including in very deprived areas.
Maternal health care, universal pathways, nutrition, child health issues, infant health, have all seen progressively improved results over the years. Immunisation rates for children are as high in deprived areas as they are in affluent areas, sometimes higher. And that is because there are very effective teams in community health, not just GPs but also public health promoting the benefits of vaccination. Some areas, in contrast, remain stagnant.
Going backwards: health inequalities as bad as they were 20 years ago
There are still some disparities between areas of affluence and deprivation that manifest in certain categories of illnesses and cardiac conditions, such as coronary heart disease, where women are less likely to receive treatment. There are high levels of breast cancer in women; again, the outcome being worse in women from deprived areas. Life expectancy in women in deprived areas is 25 years behind those from affluent areas.
According to a recent report from the Glasgow Centre for Population Health, the difference in health inequalities in Glasgow is today as bad as it was 20 years ago in comparison with Scotland in general. So the progress made over a couple of decades has stagnated and that has a lot to do with cuts to public services and austerity measures imposed by the UK government – as Scotland’s budget is dependent on the Barnett Formula.
Aside from insufficient funding, given the amount of research conducted into public health inequalities, it is hard to understand why there are such big gaps between end-of-life care, life expectancy and earlier mortality rates between affluent and deprived communities. Unless there is the political will to address health inequalities and do something quite radical, then today’s generation, and future generations, are going to fair far worse. The existential challenges the NHS is currently facing threaten to plunge many more citizens into early death, disability, and poor mental health, adding to the whole issue of complex multimorbidity. We can expect far younger people to present with poorer mental health outcomes.
There are certain illnesses of despair, addictions, alcohol, and suicide – these as a direct consequence of Scottish governmental policies. This has to be understood far more than just the mortality data that gets pumped out by newspapers. Of course, that is relevant, but the public have to be allowed to understand, what the outcomes are of failing to adequately address the social determinants of health, which is the government’s responsibility.
Key policies currently implemented in Scotland to improve women’s health.
There are a raft of policies pertinent to different communities across Scotland, not necessarily rolled out nationally, for example the NHS Lothian Post-Partum Contraception Project, although, maternal health care is extremely important and is rolled out across Scotland to national standards. The Scottish government committed to the Women’s Health Plan in 2021 which addresses inequalities within health and promotes fairness for women.
Contained within the plan is the ‘life course’ approach that aims to ensure people’s well-being at all ages by addressing changing needs, guaranteeing access to health services, and safeguarding the human right to health throughout their lifetime. The Scottish government would take into account different sections of women’s health at different ages: very young, 13 years, reproductive years and reproductive health, and post-menopausal focusing on different issues related to disparities between women’s health and men’s health in terms of outcomes and gender equality.
As stated by Marie Todd, then minister for public health, women’s health and sport: “I am proud to present the Scottish Government’s Women’s Health Plan. I believe that our vision for Women’s Health is an ambitious one – and rightly so. Women’s health is not just a women’s issue. When women and girls are supported to lead healthy lives and fulfil their potential, the whole of society benefits.”
“Women’s Health is not only about reproductive health. Our Women’s Health Plan aims to reduce avoidable health inequalities for women and girls across the course of their lives – from puberty to the later years – focusing on those areas that are stigmatised, disregarded or dismissed as ‘women’s problems’. By supporting health in women and girls we can expand their choices and opportunities to achieve their potential.”
Putting this statement into practice requires complex implementation. It is easy to write documents with big mission statements – the challenge is actually to put them into action.
Some of the issues around health and equalities are related to working conditions for women, as they tend to be in lower paid jobs, and therefore have less financial security. There’s almost a direct correlation between income and security in lone female parents and child mental health and wellbeing. The lower the income or financial security a single female parent has, the more unwell her child is likely to be in terms of its wellbeing.
There is an urgent need to look at the wider social determinants affecting health outcomes within the women’s health plan to deal with health inequalities for women, poor outcomes, mental health outcomes, end-of-life care, and life expectancy between deprived and affluent communities. The Scottish government may well have a mission statement, but how will the results obtained by this plan be compared to the government standards? By which metrics are standards measured?
Wider issues affecting health
Women who are mostly low paid workers within NHS Scotland don’t have pensions and they have never been offered a pension or other financial benefits. Women also tend to be poorer in their later years, when they survive beyond their 70s. Moreover, they tend to be living alone during those years.
To make the situation worse, women have been affected by the changes to the state pension age and the WASPI campaign has been fighting for justice for women born in the 1950s. The increase of the state pension age for women to 65 is an example of incoherence between actions and government’s supposed commitments, as this will result in financial hardship with consequences to women’s health.
Sometimes despite good intentions, improvements to services actually put more barriers up for patients. Dr Mullin has concerns with regard to the confidence that Scottish government places in ‘digital health’– markedly, that it will improve access to health services for patients. She does not think that is going to happen in its current form – patients who struggle with IT, and tech/digital literacy will not benefit from such ‘improvements’. There are issues involved that lack cohesion within the current provision of health care system.
Improving the situation?
A GP practice doesn’t have to have a massive list of patients to increase revenue. A competent practice can actually deliver really good outcomes and build links with the community to address health inequities even in the most difficult of circumstances – but professionals are just giving up – this is the difficulty NHS faces. There is currently a demoralised workforce across communities and acute health services. Staff just cannot deal with the demand at the moment because there are all sorts of issues within social care in communities.
If there were enough resources in place to conduct preventative holistic care, this is arguably what GPs should be concentrating on. Is there enough health expertise in the political realm? Do political advisors have enough health expertise and is there enough of a conduit between politicians and frontline health care staff?
Perhaps the NHS could be remodelled on its founding principles. Undoubtedly, there should be more frontline clinicians but effective policies must be formed around the social determinants of health for there to be any long-term sustainable improvements.
The core of Aneurin Bevan’s founding principles remain valid: comprehensive treatment within available resources, universal access based on need and services delivered free at the point of delivery. As Professor Graham Watt says when referring to NHS in Scotland and the founding principles:
“The NHS is, and more and more needs to become, a social institution based on mutuality and trust, as an alternative to market competition.”
“The inverse care law is not a God-given law. It is a man-made policy. Since the beginning of the NHS access to the frontline has been rationed, in the same way that bread, butter and eggs were in World War II – everyone gets the same.”
“The suggestion that we can no longer afford the NHS … lacks moral authority and is disrespectful to our parents and grandparents whose gift to us, the NHS is.”
The huge disparities that directly and indirectly affect women’s health have their roots in the past. Such inequalities are still an egregious feature both within and between countries. Women generally live longer but studies have found they are more likely to suffer disability and ill-health throughout their lives.
I would like to extend a profound thank you to Dr Mullin for agreeing to be interviewed by myself and Lynne Copland.
