Promoting gender equality in health - CiteSeerX

Promoting gender equality in health Lesley Doyal, Sarah Payne and Ailsa Cameron School for Policy Studies University of Bristol

 Equal Opportunities Commission 2003 First published Autumn 2003 ISBN 1 84206 095 3 EOC RESEARCH DISCUSSION SERIES & WORKING PAPER SERIES The EOC Research Discussion Series and the Working Paper Series provide a channel for the dissemination of research carried out by externally commissioned researchers. The views expressed in this report are those of the authors and do not necessarily represent the views of the Commission or other participating organisations. The Commission is publishing the report as a contribution to discussion and debate. Please contact the Research and Resources Unit for further information about other EOC research reports, or visit our webpage: Research and Resources Unit Equal Opportunities Commission Arndale House Arndale Centre Manchester M4 3EQ E-mail: Telephone: Webpage:

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CONTENTS

Page

BOXES AND FIGURES

i

EXECUTIVE SUMMARY

iii

1.

INTRODUCTION AND METHODOLOGY 1.1 Introduction 1.2 Methodology 1.3 Structure of the report

1 1 1 2

2.

SEX, GENDER AND HEALTH 2.1 The impact of sex differences on health and illness 2.2 The impact of gender on patterns of health and illness 2.3 Gender differences in health care 2.4 Conclusion

3 3 4 5 6

3.

GENDER DIFFERENCES IN HEATH STATUS AND HEALTH CARE 3.1 Introduction 3.2 Life expectancy and mortality 3.3 Gender differences in use of health care services 3.4 Gender differences in health behaviour 3.5 Conclusion

7 7 7 13 17 20

4.

SEX AND GENDER IN NHS MODERNISATION POLICIES 4.1 Introduction 4.2 Putting modernisation into practice 4.3 Promoting greater equality in health and health care 4.4 Are NHS modernisation and equalities policies gender blind? 4.5 Policies for the new NHS: case studies of gender blindness 4.6 Conclusion

22 22 22 23 24 25 35

5.

GENDER MAINSTREAMING IN THE NHS 36 5.1 The case for gender mainstreaming in the NHS 36 5.2 Improving the knowledge base of health status and health care needs 38 5.3 Putting sex and gender into medical research 39 5.4 Good practice in the delivery of gender sensitive health care 40 5.5 Putting gender into quality assurance 42 5.6 Decision making and public accountability: achieving a gender balance 43 5.7 Conclusion 44

6.

CONCLUSION

45

REFERENCES

48

iii

INTRODUCTION AND METHODOLOGY

BOXES AND FIGURES

Page

BOXES 2.1 Biological differences between the sexes: some examples 2.2 Gender differences in health and illness: some examples

4 5

4.1 Gender critique of NSF Coronary Heart Disease standards

28

FIGURES 3.1 Male and female life expectancy: England, 1999 3.2 Ratio of male: female death rates: England and Wales, 2001 3.3 Death rates for selected causes: England, 2001 3.4 Death rates for most common circulatory diseases: England, 2001 3.5 Death rates by type of cancer: England, 2001 3.6 Levels of health of the population: England, 2001 3.7 Admissions to NHS hospitals under mental illness specialities: England, 2001-02 3.8 Out-patient referral rates for selected clinical specialty: England and Wales, 2000 3.9 NHS GP consultations per annum by ethnic group: England, 1999 3.10 Percentage of persons smoking cigarettes by age: England, 2001 3.11 Percentage of persons consuming more than recommended weekly intake of alcohol: England, 2001

1

8 9 9 10 11 12 14 15 16 17 19


EXECUTIVE SUMMARY

Introduction Gender issues are getting increasing attention on national and international health policy agendas. Two arguments have been used to justify this new focus. Equity principles require that women and men be given equal opportunities to realise their potential for health, while efficiency concerns demand that attention is paid to both sex and gender as determinants of health.

The impact of sex and gender on health and health care Biological or sex differences between women and men affect their need for health care. Women’s reproductive capacities give them ‘special needs’ relating to fertility control, pregnancy and childbirth. But there is also a growing volume of evidence to show that biological differences go far beyond the reproductive system with genetic, hormonal and metabolic variations affecting male and female patterns of heart disease, infections and a range of auto-immune problems. Health is also shaped by social gender. Differences in the living and working conditions of women and men and in their access to a wide range of resources put them at differential risk of developing some health problems, while protecting them from others. Gender also influences the experiences of women and men as users of health care.

Differences in the health of women and men UK statistics show that there are significant differences between women and men in both health status and use of services. However, all these differences are mediated in complex ways by differences in income and social class, age and ethnicity. When compared with men in the same social class, women in the UK have a longer life expectancy than men. This is a reflection of both biological and social differences. Men are more likely than women to die prematurely from heart disease, for example, as well as having higher mortality from lung cancer and from injuries, poisoning and suicide. Differences in male and female patterns of morbidity or sickness are more difficult to measure, but national survey results suggest that women are slightly more likely than men to report that they have recently experienced ill-health. 2


Women are slightly more likely than men to be admitted to hospital and they also make more use of GP services than men, but the gender gap is small. Women and men also differ in their patterns of health related behaviour; men have traditionally smoked more cigarettes and consumed more alcohol than women, for instance.

Sex and gender in NHS modernisation strategies The dominant theme of much recent health policy has been modernisation. The stated aim of these changes has been to achieve increased efficiency and effectiveness, improved quality of care, devolution of control to frontline professionals, more flexibility in delivery and greater involvement of consumers in managing the service. An equalities agenda has run alongside that of modernisation. However, a detailed review of policies reveals that in practical terms, sex and gender concerns have received very little attention. While there is some recognition of ‘special needs’ for women, such as family planning or breast screening, there appears to be little or no recognition of the need for gender sensitivity in mainstream services. This gender blindness is evident in the key documents published by the Department of Health: The NHS Plan, A plan for investment, A plan for reform (Department of Health, 2000d) and Saving lives: Our Healthier Nation (Department of Health, 1999c). Neither include gender equity as a goal to be pursued and differences between women and men are not built into performance targets or monitoring strategies. Similar lack of attention is evident in the work of the new agencies set up to advance the modernisation agenda including the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI). The new National Service Frameworks (NSFs) show little awareness of gender issues despite much recent evidence concerning the different needs of women and men in the context of heart disease, mental health and sexual health in particular.

The case for gender mainstreaming in the NHS Both sex and gender have obvious impacts on health and health care, yet most NHS modernisation policies have been gender blind. In order to address this deficiency, the NHS would have to adopt a strategy of gender mainstreaming. The concept of gender mainstreaming has been increasingly adopted in both private and public sector organisations. The argument for this approach was initially an equity one, but the last few years have also seen the emergence of a ‘business case’ for tackling gender discrimination in the workplace. Some aspects of gender mainstreaming have been incorporated into NHS employment policies as staffing problems have exerted 3


increasing pressure on old ways of working. However, there has been little evidence of mainstreaming in service delivery. The equalities case for gender sensitivity in the way services are delivered in the NHS has been well developed. Groups of women have campaigned for many years against what they have often experienced as discriminatory and sexist practices. In recent years, they have been joined by a number of men who believe they are not receiving the most sensitive and appropriate services. The ‘business case’ for gender mainstreaming in service delivery remains largely unexplored. However, it is increasingly evident that failure to pay attention to differences between women and men will lead to inappropriate and less than optimal care. This in turn will mean that scarce resources are wasted.

Putting gender mainstreaming into practice in the NHS A strategy is needed to ensure that more attention is paid to gender issues in planning and policy implementation. This should draw on examples of good practice from within the NHS itself and from health care systems in other countries. This will help to improve the effectiveness and efficiency of both the equalities and the modernisation agendas of the NHS. If the planning of services is to be optimised, methods of data collection will need to reflect the differences between women and men more fully. It is necessary to ensure that there is greater disaggregation by gender of routine health and health care data in official statistical sources. More sensitive indicators will also be needed to help in the understanding of differences in the health status of women and men and in their experiences of health care. In addition, there should be greater sensitivity to sex and gender issues in medical research. If the clinical requirements of all potential users are to be met as effectively as possible, research subjects need to be more representative of the population. Sex and gender sensitivity will need to be included in criteria for funding, researchers will require appropriate training and equity issues will have to be included on the agenda of ethics committees. If the NHS is to deliver health care which is sensitive to the needs of the whole population, all health care workers must be properly prepared. They will need to learn about gender issues in their initial training, but also as part of later professional development. Within the health service, there is now considerable expertise in the development of race awareness and this could be used to develop similar initiatives on gender. Wider organisational learning will also be required with the dissemination

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of examples of good practice in the gender field to those working at all levels of the service. A major theme of the NHS modernisation agenda has been the introduction of mechanisms for quality assurance and, here too, gender concerns should be integrated. The work of both NICE and CHI would be improved if these issues were to be more fully incorporated into the surveys and technical review processes which they undertake. Finally, it will be important to ensure that both women and men are active participants in the running of the NHS. The Commission for Patient and Public Involvement in Health has overall responsibility for ensuring that users are more involved in managing the service. Mechanisms are required to ensure that equal numbers of women and men participate in this process, while appropriate groups should be encouraged to represent their special interests.

The NHS and wider debates on gender equity Debates about gender equity in the NHS should be put into the broader context of equality policies in the public sector. There is evidence that these are generally fragmented and uncoordinated, with progress being dependent mostly on individual enthusiasm rather than organisational commitment. One way to improve this situation would be for the government to introduce a public sector duty to promote gender equality, preferably as part of a wider duty relating to other potentially disadvantaged groups. The creation of a statutory framework of this kind would provide a firmer foundation for the incorporation of gender issues into the modernisation agenda of the NHS and other public sector organisations.

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1.


1.1 Introduction In recent years, gender issues have been given greater attention on both national and international policy agendas. This has been evident across a number of different settings, but has been especially visible in the health field. Two arguments have been used to justify this new focus. First, principles of distributive justice require that women and men be given equal opportunities to realise their potential for health through access to appropriate care. Second, the more pragmatic goal of optimising the efficiency and effectiveness of services will not be achieved unless the differences between women and men are taken seriously. Both these arguments are increasingly accepted in the international health arena. The World Health Organisation (WHO) has frequently stressed the importance of gender equity issues, while the World Bank has led the way in building the economic case for gender sensitive health care (WHO, 1998; World Bank, 1993). In response to these developments, policy makers and practitioners in many parts of the world are now beginning to reshape the services they deliver. However, little has so far been done to address these issues in the UK. Though the modernisation process has called for radical rethinking on a number of fronts, gender issues have rarely been included in the paradigm for change. This research was commissioned by the EOC in February 2003 to fill this gap by increasing awareness of: •

the key gender issues within health;

•

how a gendered approach could benefit both individual women and individual men;

•

how gender analysis and mainstreaming could relate and contribute to core government objectives in public service delivery;

•

the key changes needed if gender is to be effectively mainstreamed within health policy and health service provision;

•

the potential benefits of a public duty in gender as it would affect health policy and health service provision.

1.2 Methodology The project began with a scoping review of a number of intersecting literatures both from the UK and from other parts of the world. This included a broad range of material on sex and gender as determinants of health and health care, with a

6


particular focus on debates concerning gender equity and good practice in the delivery of gender sensitive services. In the specific context of the UK, a review was then undertaken of statistical information on differences in male and female patterns of health and illness and use of services. This was followed by an analysis of the extent to which gender issues have been integrated into recent strategies for modernisation in the NHS. This was achieved through a brief review of the gender sensitivity of the key policy initiatives making up the government’s modernisation agenda. The work of two key new agencies (the National Institute for Clinical Excellence and the Commission for Health Improvement) was discussed. Three of the recently published National Service Frameworks (coronary heart disease, mental health and sexual health and HIV) were also selected for consideration as being important clinical areas that raised key issues of sex and gender difference. 1.3 Structure of the report Chapter 2 clarifies the role of both biological sex and social gender in shaping patterns of health and health care. Chapter 3 examines differences in the health status and service use of women and men in GB. Chapter 4 explores the extent to which these have been taken into account in the NHS modernisation agenda. Chapter 5 makes the case for a more positive commitment to gender mainstreaming in the NHS and sets out a programme for achieving this. Chapter 6 concludes by placing the NHS in the context of broader debates about gender equality issues in the public sector. Statistical sources in the report focus mainly on England and (to a lesser extent) Wales with relatively little data from Scotland being presented. Similarly, most of the policy initiatives and ideas for mainstreaming discussed in Chapters 4 and 5 apply specifically to England and Wales. However, gender issues within health and health care are broadly similar in the three countries and similar principles could be adapted to the Scottish context where health policy is devolved.

7

SEX, GENDER AND HEALTH

2.


Although many health care systems are trying to move towards greater gender sensitivity, there is still considerable confusion about how this should best be done (Doyal, 2001). If appropriate policies are to be put in place, two important questions need to be answered: what are the differences in male and female experiences of health and health care and how should these be reflected in the delivery of services? There are marked differences in male and female patterns of morbidity and mortality. In most (but not all) parts of the world, women live longer than men and this gap in life expectancy is greatest in the richest countries (UNDP, 2003). On the other hand, women in many countries (especially the poorest) experience greater sickness and disability over a lifetime. There are also significant differences in the types of health problems faced by women and men. They often suffer and die from different diseases and experience illness in different ways. The reasons behind these variations are complex and they come from both the biological and the social realms. The health of males and females is clearly shaped by their biological sex. However, socially constructed gender roles also have a major impact on well-being. These factors intersect in complex ways with age, race, class and ethnicity to determine the health care needs of individual women and men. 2.1 The impact of sex differences on health and illness It is widely recognised that women’s reproductive capacities give them ‘special needs’ for health care. Unless they are able to control their fertility and go safely through pregnancy and childbirth, their health may be seriously damaged. This reality has long been recognised through the provision of specialist services including family planning and obstetric care. Women and men are also at risk of suffering from sexspecific problems which affect particular organs: cancers of the prostate and cervix, for example. But there is also a growing volume of evidence to show that these biological differences between women and men go beyond the reproductive system (Wizemann and Pardue, 2001). Marked differences exist in the incidence, symptoms and prognosis of a wide range of diseases and conditions that affect both sexes. This is very evident in the case of coronary heart disease, for example, which affects more men than women at younger ages. It is also reflected in the epidemiology of some infectious diseases, including tuberculosis to which men appear to be inherently more susceptible. Recent studies indicate that these variations are due in large part to previously unrecognised genetic, hormonal and metabolic differences between men and women (Wizemann and Pardue, 2001). 8


Box 2.1 Biological differences between the sexes: some examples

•

Men typically develop heart disease ten years earlier than women.

•

Women’s immune systems make them more resistant than men to some kinds of infection including tuberculosis.

•

Women are around 2.7 times more likely than men to develop an autoimmune disease such as diabetes.

•

Male-to-female infection with HIV is more than twice as efficient as female-to-male infection.

Source: Wizemann and Pardue (2001).

2.2 The impact of gender on patterns of health and illness Biology is not the only factor shaping differences in male and female patterns of morbidity and mortality. There is also an extensive literature documenting the relationship between gender and health (Hunt and Annandale, 1998; Denton and Walters, 1999). Despite the obvious similarities in the lives of women and men from the same social group, there may also be marked differences which can have significant effects on their well-being. Gender differences in living and working conditions and in access to a wide range of resources put males and females at differential risk of developing some health problems, while protecting them from others. Many studies have shown that the domestic responsibilities usually associated with female gender can have a negative impact on both physical and mental health (Doyal, 1995). The higher levels of depression and anxiety reported by women have been explained in part by reference to their work in caring for others with what may be insufficient amounts of time, money and other resources. This is especially true for those women raising their families in poverty. Gender violence has also been highlighted as a major public health hazard for women around the world (Heise et al, 1994). As the links between women’s lives and their health are given greater attention, the potential health risks of masculinity are also beginning to emerge (Luck et al, 1999; Courtenay and Keeling, 2000). At first glance, being male might seem to be a privilege which gives greater access to health promoting resources. However, it may also require the taking of risks. The traditional role of breadwinner means that men 9


are still more likely than women to die prematurely from occupational disease and injuries. Again, this is especially true of men attempting to survive in conditions of poverty. As a result of their socialisation into masculinity, men in most societies have also been more likely than women to engage in dangerous activities including smoking, excessive drinking, dangerous driving and unsafe sex. Box 2.2 Gender differences in heath and illness: some examples •

Men are more likely than women to commit suicide.

•

Both community based studies and statistics on service use show that women are 2-3 times more likely than men to be affected by depression or anxiety.

•

Men are more likely than women to die of injuries, but women are more likely to die of injuries sustained at home.

•

The gap between male and female smoking rates is beginning to narrow as young women are taking up the habit more frequently than young

Source: Wizemann and Pardue (2001).

2.3 Gender differences in health care As well as being a major determinant of health itself, gender also influences the experiences of women and men as users of health care. Women are more likely than men to report practical problems in access to services. They are more likely to have caring responsibilities, for example, or to have transport problems (Broom, 1995; Doyal, 1998; Hamilton et al, forthcoming). Men, on the other hand, may find it more difficult to admit weakness, or to accept that they may be ill and hence may delay longer before seeking medical advice (Cameron and Bernardes, 1998; Sabo and Gordon, 1995; Watson, 2000). Once in receipt of care, there also appear to be gender differences in how women and men are treated (Beery, 1995; Foster and Malik, 1998; Wenger, 1997). Studies from a number of different countries have shown that health workers may make different diagnoses of men and women on the basis of similar evidence. They may also offer different treatment in what would appear to be the same clinical situations (Shaw et al, 2000). For example, women under 65 have more unrecognised myocardial infarctions than men (McKinley, 1996). Women are less often referred to acute catheterisation, coronary angioplastry, thrombolysis or coronary bypass surgery, despite evidence that such procedures are as effective for women as men (Wenger, 1997; Mark, 2000). 10


2.4 Conclusion Both sex and gender are therefore important determinants of health. Like ethnicity, age and class, they are important in shaping morbidity and mortality as well as influencing access to services and quality of care. The next chapter will examine the ways in which these differences are reflected in the health status of women and men in the UK and in their experiences of the NHS.

11

GENDER DIFFERENCES IN HEALTH STATUS AND HEALTH CARE

3.


3.1 Introduction The growing body of information on sex and gender differences in health and health care in Britain in official statistical sources published by the Department of Health and others is reviewed in this chapter. However, this evidence remains partial and difficult to interpret in some areas. Hence it is also important to identify gaps in the available data as well as limitations on our capacity to understand the existing information without further research. Differences in mortality and morbidity between women and men do not vary greatly across Britain and for that reason the data used will refer mainly to populations in England. However, gender differences in health and illness do vary in relation to class and ethnicity. While space does not allow for a detailed account of these intersections, examples will be given where they are deemed most relevant. 3.2 Life expectancy and mortality Life expectancy The most obvious difference between women and men is in the area of life expectancy. Women in all countries in the UK have a longer life expectancy than men. In England in 1999, life expectancy at birth for a female child was 80.2 years, compared with 75.8 for a male (see Figure 3.1). This gap results from biological factors including the greater susceptibility of men to specific conditions, combined with a range of gender related factors including differences in male and female patterns of health-related behaviour. Life expectancy also varies by social class. In England and Wales, life expectancy for female children at birth in the highest occupational group in 1992-96 was 83. This compared with 77 for females in the lowest occupational group. For male children there was a ten-year gap, with males in the highest group having a life expectancy of 78, compared with a life expectancy of 68 for males in the lowest class (Office for National Statistics (ONS), 2002).

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Figure 3.1

Male and female life expectancy: England, 1999

90 80 70 60 50 40 30 20 10 0 At birth

5

20

30 Male

50

60

70

80

Female

Note:

Selected ages.

Source:

Department of Health (2003a), Health and Personal Social Services Statistics, Tables A1-A2.

Mortality The male death rate in England and Wales in 2001 was 989.6 per 100,000 population compared with a rate of 1033.9 for women. Overall death rates for women and men are very similar, and rates for both have been falling slowly over time. However, death rates for women have exceeded those of men since the 1990s, due to the greater proportion of women among the very old. Although similar overall, death rates vary substantially by age group, and there are marked differences in the risk of death at different ages for men and women (see Figure 3.2). Figure 3.2 expresses male deaths as a percentage of female deaths – that is, 100 implies equal mortality for men and women, whilst values above 100 reflect greater male mortality. Male mortality rates are higher than female rates virtually throughout the life course, though the extent of this male excess varies. There is a slightly increased risk of death amongst males compared with females in the first years of life, but it is in youth and early adulthood that excess deaths in men are most notable.

13


Figure 3.2

Ratio of male: female death rates: England and Wales, 2001

300 250 200 150 100 50

ov er an d 85

U

Al

la ge s

nd er 1*

0

Note:

Male deaths as a percentage of female deaths.

Source:

Office for National Statistics (2003), Population Trends, Table 6.1.

Figure 3.3

Death rates for selected causes: England, 2001

450 400 350 300 250 200 150 100 50 0 All circulatory disease

All malignant neoplasms

Bronchitis & allied conds

Male

Pneumonia

All accidents and adverse effects

Female

Note:

Rates per 100,000 population.

Source:


There are important differences in causes of death between women and men. Across the UK, the major killers for both groups are cancer and circulatory diseases. In 14


England, for example, 39 per cent of men and 38 per cent of women die from circulatory disease. However, whilst overall deaths from circulatory disease are similar for women and men, females are more likely than males to die from the cerebrovascular disease associated with older age, whilst male deaths are higher for ischaemic heart disease (see Figure 3.4). This is reflected in age-related differences in mortality, with higher female mortality for those conditions associated with increasing age. Figure 3.4

Death rates for most common circulatory diseases: England, 2001

250 200 150 100 50 0 Ischaemic heart disease

Cerebrovascular disease

Male

Female

Note:


Source:


Cancer mortality also varies between women and men (see Figure 3.5). There is excess male mortality from lung cancer in particular, which relates to higher levels of tobacco use amongst men (see pp. 17-18), and also from stomach and colon cancer. The number of deaths from less common causes also differs between men and women. Female death rates are much lower than those of males for injuries, poisoning and suicide. Deaths from suicide, for example, are more than three times greater in men than in women. In 2001, more men than women died as a result of accidental injury, while male deaths as a result of road accidents were nearly three times the number for women. The number of male deaths from chronic liver disease and cirrhosis was nearly twice the number of female deaths (Department of Health 2003a, Table A3-A4).

15


Figure 3.5

Death rates by type of cancer: England, 2001

80 70 60 50 40 30 20 10 0 Stomach

Colon etc

Pancreas

Lung

Male

Prostate

Breast

Uterus

Female

Note:


Source:


Male and female patterns of morbidity Whilst there are clearly identifiable differences between male and female patterns of mortality, differences in ill-health and morbidity are more complex and difficult to interpret. This is partly because ill-health itself is much harder to measure. In this section, the differences between male and female health status are explored through the answers given to self-report questions in a number of health surveys in the UK. Figure 3.6 suggests that there are few differences in health status between women and men. The Health Survey for England (Department of Health, 2001a) found that three quarters of the population, both male and female, reported their health to be either good or very good. Slightly more women reported acute ill-health (illness in the fortnight before the survey interview) and there has been a consistent gap of around 4 per cent in the responses of women and men to this question over the last eight years. The 1998 Welsh Health Survey (The National Assembly for Wales, 1999) asked questions concerning long-term limiting illness. The survey used the standard question found in other studies including the 2001 UK Census. Overall, 34 per cent of men and 35 per cent of women reported such illness. This finding – which has been replicated in a number of other studies (for example, the General Household Survey and the Census) casts doubt on the common belief that women in the UK are more likely than men to suffer poor health. However, the complexities inherent in the measurement of differences in the health status of women and men are only beginning to be understood. Figure 3.6

Levels of health of the population: England, 2001

16


80 70 60 50 40 30 20 10 0 Very good/good health

Very bad/bad health

Male

At least one longstanding illness

Acute sickness

Female

Note:

Percentage of population reporting condition.

Source:

Department of Health (2001a), Health Survey for England, Table A.5.

Recent studies show that women and men may assess their health according to different criteria, such as ability to get through the day compared with being physically fit, and this is reflected in the findings from self-report surveys (e.g. Curtis and Lawson, 2000; Macintyre et al, 1999). It is also clear that gender differences in reported morbidity vary according to the age, level of domestic commitments and paid work of those being questioned (Matthews et al, 1998; Walters et al, 2002; Arber and Khlat, 2002). Hence it is difficult to draw definitive conclusions about gender differences in health status from the simple questions used in surveys of this kind. In addition to self-report data, clinical measurements of health are also available from the annual Health Survey for England. These include information on conditions such as hypertension and obesity, which may be indicative of increased risk of heart disease, stroke and possibly some cancers (in the case of obesity). In 2001, the Health Survey for England found that 41 per cent of men and 35 per cent of women had high blood pressure. The majority of those with hypertension were not receiving treatment. Morbidity also varies in relation to class and deprivation. Key Health Statistics from General Practice 1998 (ONS, 2000a) gives details of the prevalence of key health conditions in England and Wales for both women and men. These data show, for example, that whilst the age standardised male prevalence of treated coronary heart disease in 1998 was 35.8 per 1,000 patients for England and Wales as a whole, the rate for women was 21.3. However, for both women and men, prevalence varied in relation to levels of deprivation, with the highest rates in deprived industrial areas for

17


both men (44.6 per 1,000 patients) and women (29.7) and the lowest in what the Office for National Statistics (2000a) describe as ‘prosperous areas’. Finally, morbidity data also show a relationship between ethnicity and health amongst both women and men. The 1999 Health Survey for England found levels of limiting long-standing illness were higher for both men and women in Black Caribbean, Pakistani, Bangladeshi and Irish groups and also for Indian women, whilst rates were lower amongst both Chinese men and women. Levels of both limiting illness and long-standing limiting illness were also higher amongst minority ethnic men and women in lower occupational groups (Department of Health, 2001a). 3.3 Gender differences in use of health care services Figures for both primary care and hospital services show different patterns of use for women and men. In patient treatment Women are more slightly more likely than men to be admitted to hospital as inpatients (ONS, 1998). These figures also reveal differences between women and men by ethnic group. Men from most ethnic minorities have slightly lower rates of inpatient treatment compared with women in the same group (Dench et al, 2002). However, data from the Health Survey for England (1999) show that when maternity services are excluded, Indian and Pakistani men have higher rates of in-patient hospital treatment than women in the same group. For Indian women and men the difference is especially high. In 1999, fewer than 1 per cent of Indian women entered hospital as in-patients, compared with 7 per cent of men. This is difficult to explain. Self-reported health amongst Indian women is lower than for other groups, and Indian women have relatively high levels of self-reported longstanding conditions such as those related to the nervous and musculoskeletal system (Dench et al, 2002). Indian women’s lower rates of hospital care may be explained by a complex set of factors. These include cultural differences, which result in lower consultation rates in primary care for disorders that can lead to hospital referral, and higher probability of non-attendance for hospital appointments due to anxieties over male doctors and concerns over the availability of interpreters (Hussain and Cochrane, 2003; Firdous and Bhopal, 1989; Mhadok et al, 1992). Chapple et al (1998) for example discuss Asian women’s lower rate of consultation for menstrual disorders. Asian women were more likely to be referred to hospital by their GP, but also were more likely not to attend hospital appointments due to anxieties over language and not being able to see a female doctor. Another study found that amongst women and men admitted to hospital following head injury, South Asian women had significantly shorter in-patient stays than white women, whilst the reverse was true for men. However, no explanation was offered for these differences (Moles et al, 1999). There are also differences between women and men in hospital treatment for mental health problems. In-patient data reveal higher admission rates amongst men in early life and again in old age, while female rates are higher in middle age (see Figure 3.7).

18


Figure 3.7

Admissions to NHS hospitals under mental illness specialities: England, 2001-02

14 12 10 8 6 4 2 0 Under 15

15-19

20-24

25-44

Male

45-64

65-74

75-84

85+

All ages

Female

Note:

Rate per 1,000 population.

Source:

Department of Health (2002b), Hospital Episode Statistics, Table B25.

This pattern of male over-representation in younger and older age groups is relatively recent. Until the early 1980s, more women than men were admitted to psychiatric hospital. Since that time there has been a marked change with younger men and those over 75 experiencing an increased risk of hospitalisation for psychiatric illness (Payne, 1996; 1998). Out-patient treatment Patterns of hospital attendance as outpatients also vary between women and men. Though they have similar numbers of visits, men are more likely than women to attend accident and emergency departments. Age-standardised data from the Key Health Statistics from General Practice (ONS, 2000a) reveal that women had higher rates overall of GP referrals for out-patient appointments. However, the sex ratio varied between clinical specialities, with higher rates of referral for in-patient treatment for women in general surgery, general medicine and psychiatry in particular (see Figure 3.8).

19


Figure 3.8

Out-patient referral rates for selected clinical specialty: England and Wales, 2000

35 30 25 20 15 10 5 0 General medicine

General surgery

Orthopaedic

Male

Gynaecology

Psychiatry

Female

Note:

Age standardised rates for 1,000 patient years at risk.

Source:

Office of National Statistics (2000), Table 5B1.

Again, these gender differences vary by ethnic groups. The 1999 Health Survey for England showed that more men than women had attended hospital in the past year in all ethnic groups other than Black Caribbean, where male and female attendance rates were equivalent. However, both Chinese women and Chinese men were less likely to have attended as out-patients compared with the general population (Dench et al, 2002). This reflects lower rates of GP consultation, and also higher proportions of the Chinese population reporting their health as either good or very good, compared with other groups (Dench et al, 2002). Chinese men and women are less likely to report being affected by a number of key health conditions, including those which may lead to hospital referral, such as cardiovascular and metabolic disease and diabetes (Department of Health, 2001a). GP consultations Data for Britain show that women make more use of GP services than men, but the differences are small. In 2000, women made an average of five visits per year compared with an average of four for men. Not surprisingly, the gap between women and men was greater in the reproductive years; women aged 16-44 made an average of five GP visits per year compared with only three for men of the same age. The number of consultations rose with age for both women and men (Dench et al, 2002). Figures from the General Household Survey for consultations in the two weeks prior to interview, suggest that around 18 per cent of women are likely to have seen their GP in this period, compared with 12 per cent of men (ONS, 1998). However, these differences need to be seen in the wider context of both social class and ethnic 20


variations in consultation rates. Women consult GPs more frequently than men, in all ethnic groups other than those from Bangladesh. The female: male ratio is highest amongst the Pakistani and Irish groups (see Figure 3.9). Figure 3.9

NHS GP consultations per annum by ethnic group: England, 1999

Black Caribbean

Indian

10 9 8 7 6 5 4 3 2 1 0 Pakistani

Bangladeshi

Male

Chinese

Irish

General population

Female

Note:

General population includes individuals from white and ethnic minority groups.

Source:

Dench et al (2002), Table 8.44.

3.4 Gender differences in health behaviour Women and men differ not only in their use of services, but also in their patterns of health-related behaviour such as exercise, food and alcohol consumption and smoking. These behavioural differences are mediated by social class and by ethnicity, and also vary over time. Smoking There are significant differences between women and men in patterns of tobacco use.

21


Figure 3.10 Percentage of persons smoking cigarettes by age: England, 2001 40 35 30 25 20 15 10 5 0 16-24

25-44

45-64

Male Source:

65+

Female

Department of Health (2003a), Health and Personal Social Services Statistics, Table A7.

As Figure 3.10 shows, similar percentages of both women and men smoke in the younger age groups, whilst there are more male smokers aged 25-44 and 45-64. Women then predominate over the age of 65. The 1998 Welsh Health Survey (The National Assembly for Wales, 1999, Appendix 3) reported that 29 per cent of men and 25 per cent of women were smokers, with the highest percentages in younger age groups. The 1998 Scottish Health Survey found that 34 per cent of men and 32 per cent of women currently smoked, with higher rates in younger age groups (Boreham, 2000). Rates of smoking also vary by social class and ethnicity. The 1998 General Household Survey revealed that both women and men in lower income groups are more likely to smoke, with 36 per cent of men and 31 per cent of women in manual occupations being current smokers, compared with 15 per cent of men and 14 per cent of women in professional occupations (Office for National Statistics, 2000b). Data on smoking by ethnic group for England reveal that Black Caribbean women and men are more likely than the general population to be ‘light’ smokers (under 20 a day), but are less likely to smoke more than 20 a day (Dench et al, 2002). There has been considerable concern over the extent to which younger women may be taking up smoking and the likely impact of this on their health. Changing patterns of tobacco use take some time to be reflected in mortality patterns, but there are already signs of increases in lung cancer and other tobacco related diseases amongst women in Britain. Findings from a 2001 survey of young people in England indicated that 11 per cent of girls aged 11-15 were regular smokers, compared with 8 per cent of boys, and 20 per cent of girls were either regular or occasional smokers, compared with 15 per cent of 22


boys (Department of Health, 2003a, Table A8). Similarly, 11 per cent of secondary school boys in Scotland smoked in 1998, compared with 13 per cent of girls (cited by Boreham, 2000). In Wales too, girls are more likely to smoke than boys. In 2000, 6 per cent of 13-14 year-old boys reported that they smoked on a weekly basis, compared with 17 per cent of girls in the same year group, whilst 30 per cent of girls aged 15-16 reported smoking on a weekly basis, compared with 20 per cent of boys (The National Assembly for Wales, 1999). Whilst girls have been more likely to smoke than boys, this very high proportion of girls smoking in Wales is both surprising – smoking rates amongst adult women in Wales are not higher than in other parts of the UK – and worrying. These figures suggest a major problem is likely in the future for all kinds of health outcomes for women. Alcohol use Figures for alcohol consumption also show different patterns for women and men. As Figure 3.11 shows, men in all age groups are more likely than women in England to consume more than the recommended number of units per week. Overall, 27 per cent of men and 15 per cent of women were found to consume more than the recommended total. The difference between women and men remained fairly constant across the age groups despite suggestions that women’s alcohol intake has increased in recent years. Department of Health data for England suggest that the proportion of women drinking above the recommended 14 units a week has not changed since 1998 (Department of Health, 2001a). In the 1998 Scottish Health Survey, 32 per cent of men and 14 per cent of women between the ages of 16 and 74 reported a weekly consumption over recommended limits. The highest proportion of those consuming in excess of the recommended amounts was found in the younger age groups. Forty-three per cent of men and 24 per cent of women aged 16-24 reported a weekly consumption over suggested limits (Erens, 2000). In the 1998 Welsh Health Survey, 19 per cent of men and 8 per cent of women were reported to consume harmful levels of alcohol (The National Assembly for Wales, 1999). These figures are considerably lower than those found for England and Scotland. However, the Welsh study used self-completion forms rather than interview schedules and this may have encouraged respondents to under-estimate alcohol consumption. Figure 3.11 Percentage of persons consuming more than recommended weekly intake of alcohol: England, 2001 50 45 40 35 30 25 20 15 10 5 0 18-24

25-44

45-64

23 Male

Female

65+

Total


Note:

Recommended maximum intake is 14 units for women and 21 for men.

Source:

Department of Health (2003a), Health and Personal Social Services Statistics, Table A7.

Substance misuse Gender differences in substance misuse are difficult to measure since so much is concealed, especially among women who are likely to be more stigmatised. Data which come from use of services are also likely to underestimate the numbers of women, as women are less likely to attend drug services. In England, these data suggest that around three times as many men as women sought help in the six month period ending March 2001 (Department of Health, 2003a, Table A10). In Scotland, in 2001-02, 67 per cent of service users were male and 33 per cent were female (Drug Misuse Information Scotland, 2003). In Wales in 1996 only 25 per cent of notified drug addicts were female (Welsh Office, 1998). However, there is some evidence to suggest that these gender differences are reducing. Amongst secondary school pupils in Scotland, 16 per cent of boys and 13 per cent of girls had used drugs in the previous month (Child and Adolescent Health Research Unit, 2002). Diet Diet and lifestyle surveys now collect regular data on patterns of food consumption and again gender differences are very evident. For example, the diet of women in Scotland appears to be significantly better than that of men. They are more likely to eat vegetables, fruit and wholemeal bread and are less likely to eat fried food or have sugar in hot drinks. However, they are more likely to eat chocolate, biscuits and crisps every day (Deepchand, Shaw and Field, 2000). Similarly, in Wales only about a quarter of women have what could be called an unhealthy diet compared with a third of men (Welsh Office, 1998). Obesity and exercise Men are more likely than women to be overweight or obese. The 1998 Health Survey for Wales found that around three fifths of adult men had a body mass index (BMI) greater than 25, compared with around a half of adult women (Welsh Office, 1998).1 In England, the 2001 Health Survey found 68 per cent of men and 56 per cent of women to be either overweight or obese (Department of Health, 2001a). However, women were less likely to participate in physical exercise on a regular basis. Recent data from Wales indicate that 90 per cent of young men (aged 16-24) participated in physical exercise in comparison with 75 per cent of women of the same age. Amongst older people, around half of both men and women reported taking part in physical activities (Welsh Office, 1998). 3.5 Conclusion This brief overview has demonstrated the influence of sex and gender on patterns of health and health care in the UK. It has also illustrated the complex ways in which these effects are mediated by differences in income and social class and by age and by ethnicity. These differences in the health and health care needs of women and men have important implications for policy interventions and the prospect that health targets will be met.

1

The BMI is a measure of obesity based on height and weight.

24


The government’s targets for health improvement are general, rather than specific to either men or women. However, the differences between men and women outlined here will affect the success of policies to reduce premature mortality which do not draw on an understanding of such differences. For example, the targets on coronary heart disease (CHD) have to reflect on the data on smoking rates amongst women and men and how these might need to be addressed specifically within a gendered framework in order to reduce premature mortality associated with tobacco use. The differences between women and men in exercise may be significant in CHD targets, yet are not considered in the relevant plans. The next chapter will explore the extent to which current policies in the NHS take the reality of these gender differences into account. This analysis will concentrate mainly on the modernisation and equalities agendas as they have been put in place since 1997.

25

SEX AND GENDER IN NHS MODERNISATION POLICIES

4.


4.1 Introduction The government’s commitment to modernisation is a powerful theme cutting across all areas of health policy. This agenda was outlined in The New NHS: modern and dependable (Department of Health, 1997) and the details were spelled out in The NHS Plan: a plan for investment, a plan for reform (Department of Health, 2000d). In Scotland, broadly similar agendas, though with slightly different emphases, were outlined in Partnership for Care: Scotland’s Health White Paper (Scottish Executive, 2003). The main goals to be achieved are improvements in quality of care, more devolution of control to front line professionals, more flexibility in patterns of service delivery and increased opportunities for the active involvement of consumers in managing the service (Office of Public Services Reform, 2002). These different strands are expected to lead to improvements in efficiency and effectiveness through the use of new technologies based on a firm foundation of appropriate evidence. 4.2 Putting modernisation into practice At the heart of the NHS Plan is a commitment to the right of patients to high quality health care, with the work of all trusts being monitored through a Performance Assessment Framework. A series of National Service Frameworks (NSFs) are also being put in place to set standards for the delivery of care in a range of specialties and clinical settings. The monitoring of progress towards the achievement of these standards of practice is the responsibility of the newly established National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI).2 The Plan also emphasises the importance of devolving responsibility to ensure greater transparency and accountability in the planning and delivery of services. This is to be founded on a new relationship between the centre and the locality. The introduction of Primary Care Groups and Primary Care Trusts, for example, is seen as a way of giving greater responsibility for the commissioning of services to local professionals. The introduction of Foundation Hospital status is also seen as a way of ensuring more local control over decisions about the delivery of health care. Greater flexibility in the use of the health care labour force is another key theme. The NHS Plan calls for a breaking down of historical demarcations between different professional groups in order to make health services more efficient. Contracts are 2

In June 2003 the Department of Health announced that a new body, the Commission for Healthcare Audit and Inspection (CHAI), would be established. Covering England and Wales it will, in the future, take over the work of the CHI as well as that of some other bodies. 26


therefore being renegotiated and many professionals are receiving extra training so that they can work across traditional boundaries. The move towards ‘evidence based practice’, underpinned by the use of care protocols and performance monitoring, is designed to support this drive towards the more efficient use of human resources. Allied to these developments is a commitment to ensuring that health services themselves are organised in more flexible ways. They are to be better co-ordinated, more easily accessible and provided within a ‘customer service culture’. New initiatives include on-the-spot booking systems to give patients greater choice over appointment times, one stop and out of hours services and hospital outpatient consultations in primary care and community settings. Central to this part of the Plan is a series of initiatives designed to give patients more knowledge and a greater say in their own treatment. These include the ‘Expert Patient’ programme to allow patients to take more control over the management of some types of chronic illness including heart disease, diabetes and mental illness. A number of interactive information systems have been introduced including NHS Direct and Care Direct. Patients will also be given more chance to choose their own GP, as well as more control over the services they receive, including the timing of elective hospital admissions. At the same time, policies have been introduced to give the wider public more say in how the NHS is run. Statutory patients forums are to be set up in all trusts (except those with foundation status) and Patient Advocacy and Liaison Services have been established to strengthen the ‘patient voice’ and support the complaints process. The government also plans to strengthen the role of patients and citizens on regulatory and monitoring bodies including NICE. The newly established Commission for Patient and Public Involvement in Health will take overall responsibility for ensuring that the voice of the public is heard at all levels of the NHS. 4.3 Promoting greater equality in health and health care Running alongside the modernisation agenda is a range of initiatives designed to reduce inequalities in health. Under the Labour Government, there has been a greater recognition of the contribution of poverty and deprivation to the burden of illness, disability and premature death among the neediest groups in the population. As part of this refocusing of the inequalities agenda, the 1999 White Paper, Saving Lives: Our Healthier Nation (Department of Health, 1999c) identified priority areas for action and set key targets to be achieved in each area by 2010. In Scotland, broadly similar aims were outlined in Health Improvement Challenge (Scottish Executive, 2003). These targets cover the major causes of avoidable mortality and morbidity, including cancer, coronary heart disease and strokes, fatal accidents and suicide. The means identified for meeting these targets include increased funding for the NHS, greater 27


integration of policies to tackle poverty and social exclusion and more emphasis on health promotion to raise standards of public health. Particular attention has been focussed on the reduction of smoking which is seen as a key cause of morbidity and premature mortality (see pp. 17-18). 4.4 Are NHS modernisation and equalities policies gender blind? The modernisation and equalities agendas have therefore provided a new framework within which radical change is expected in how services are delivered. There is a clear emphasis on the importance of taking diversity into account in order to deliver care which is appropriate to the needs of all patients. Surprisingly however, there is little discussion of how sex and gender concerns should be incorporated into this new paradigm. The review undertaken as part of this project suggests that most of the modernisation and inequalities initiatives in fact have been gender blind. That is to say, they have failed to acknowledge the impact of gender differences on health outcomes and on the delivery of health care. Of course, these policies do pay some attention to the different needs of women and men. But this applies only when specialist services are being considered for one group or the other. There is a recognition, for example, that improved breast screening will be required if the needs of women are to be better met. There is also a growing acknowledgement that separate and targeted services may be needed if men are to be persuaded to take greater care of their own health. However, there seems to be little recognition of the fact that sex and gender issues also need to be incorporated into other aspects of health planning. Chapter 2 showed that the health of women and men is strongly influenced both by their biological sex and their social gender. However, the NHS Plan does not include a strategy for addressing these issues. Broad reference is made to the need for greater equality in health care with gender, ethnicity, age, disability and sexual orientation all cited as potential sources of disadvantage. But as we shall see, there are few practical suggestions for how this should be pursued. Issues such as staffing, funding, infrastructure and service delivery are addressed in considerable detail, but few concrete recommendations are made for promoting equity in general, or gender sensitivity in particular. The NHS Plan is to be put into practice through the Modernisation Agency which has a brief to spread good practice throughout the service. But here too, gender concerns are largely invisible. Despite the reference to diversity in the Plan itself, the criteria used by the Agency for evaluating the modernisation process do not reflect this aspect of the agenda. Their 2003 Progress Report does comment on improvements in women’s experiences of screening for breast cancer for example, but no reference 28


is made to sex or gender-related issues in other areas of health care (Department of Health, 2003b). Little of the monitoring data in the Progress Report is disaggregated by sex. In the chapter on improvements in clinical quality for instance, information is given on changes in patient waiting times, but only as a global total. Though the targets for reduced waiting times are the same for both sexes, the results would be of much greater value if they were disaggregated for women and men and for different clinical specialities. This is important because targets may be reached at different speeds for different specialities and may also reflect specific difficulties facing women and men in accessing care. For example, Hamilton and Gourlay (2002) have identified the difficulties which women on low incomes experience in making ante-natal appointments. But without a framework in which gender is identified as a relevant factor, the possibility of gender differences cannot be properly explored. Similar evidence of gender blindness is evident in the inequalities agenda. The targets set in Saving Lives for reducing mortality and morbidity are presented for the population as a whole, with no separation of women and men. This ignores the reality of marked sex differences in the incidence and prevalence of particular diseases and disregards the ways in which gender differences affect patterns of risk. There are differences between women and men in the underlying causes of the death and disability being targeted. Moreover, the health services promote women's and men's health and treat their illness in different ways. Unless these differences are incorporated into the targets themselves and into the strategies proposed for meeting them, progress is likely to be significantly hindered. Male and female patterns of suicidal behaviour, for example, are very different and this needs to be clearly acknowledged in prevention policies. 4.5 Policies for the new NHS: case studies of gender blindness The failure to take gender adequately into account in the key documents which established the modernisation and inequalities agendas is clearly reflected in the more detailed policies designed to move these agendas forward. This is evident both in the working of new NHS agencies and in the National Service Frameworks devised to reshape the delivery of care in specialist areas. Gender in the work of the new agencies: NICE and CHI The discussion paper NICE: Faster Access to Modern Treatment, how NICE appraisal will work (Department of Health, 1999b) outlines the methods to be followed in carrying out reviews of new interventions. The process is to include a technology briefing covering a description of the proposed intervention itself, the potential patient group, the current diagnostic or treatment alternatives, an estimated 29


unit cost of the treatment and current research evidence relating to both clinical and cost effectiveness. Interventions are selected for appraisal by NICE where there are questions relating to their appropriateness for particular conditions and also where there is concern about the best use of resources. Complex judgements are often required where clinical outcomes are not easy to measure, where there are serious ethical concerns about the use of a particular drug, where there is doubt about whether or not a particular treatment is appropriate for the generality of patients and where there is controversy over best practice in the use of existing interventions. Under these circumstances, it is clearly important that the diversity of the potential patient group is taken properly into account. However, there is little or no requirement in the guidelines that a differentiating characteristic as basic as gender should be formally included in the assessment. The framework for reviewing the quality of the original clinical trials does not include any reference to potential sex or gender bias. The guidelines indicate that ‘significant differences in clinical outcomes between patient/population sub-groups should be discussed’ (Department of Health, 1999b, section 19). However, there appears to be no requirement that questions are asked about the relative proportions of women and men in the original trial sample, or about the possibility of sex and gender differences in clinical outcome or in patient satisfaction measures. Most clinical research ignores the fact that patient satisfaction might vary in relation to gender. Yet there is a considerable body of evidence to suggest that men and women may value a range of outcomes differently (e.g. Drossman et al, 1991; Weisman et al, 2000). In the case of irritable bowel syndrome for instance, both women and men clearly seek improved symptom management, but specific symptoms appear to have differential significance in the two groups (Drossman et al, 1991). This needs to be reflected in the techniques used for measuring patient satisfaction. When an intervention is to be appraised by NICE, the views of patient and user groups are sought in addition to the material provided by the manufacturer. However, there is no specific requirement that gender (or any other) difference be included in the protocol for these studies. Similarly, though the guidance recommends the use of ‘quality of life’ measures to assess the potential value of an intervention, there is no explicit guidance to ensure that attention is paid to any gender differences in expectations, roles and responsibilities.

30


The work of the Commission for Health Improvement also seems to be proceeding with relatively little attention to gender concerns. The CHI has statutory functions relating to clinical governance reviews in England and Wales. These are to be carried out for all NHS service providers and must include patient and user views as well as those of the staff and the inspection team. CHI also has responsibility for evaluating the implementation of the different NSFs and for ensuring that the NHS meets the recommendations of NICE. The work of CHI is therefore central to a number of other policy initiatives, and to the evaluation of the overall modernisation agenda. To date, reviews have been carried out of the implementation of the NSF on cancer, investigations have been done of individual service failures and a number of clinical governance reviews have been undertaken (for details, see the CHIs’ website, www.chi.gov.uk) Thus far these publications offer little indication that gender concerns are seen as relevant to this work. Though the numbers of male and female respondents are recorded, little or no information is offered on gender differences in use of services, in levels of satisfaction or in quality of care. Nor are the methods recommended for consulting service users likely to ensure that such information is collected in the future. The guidance offered by CHI for self-assessment of mental health services, for example, details the number of users to be interviewed, but makes no recommendation about the proportion of women and men to be included in the sample. Nor does it discuss the possible benefits of matching the gender of interviewers and respondents. More sensitive issues are sometimes easier to reveal to a same sex interviewer and this could be important in understanding health care experiences. Gender in National Service Frameworks: coronary heart disease and mental health The National Service Framework on Coronary Heart Disease (CHD) (Department of Health, 2000a) introduced a ten year plan to reduce premature mortality from heart disease. Twelve standards were proposed to ensure improved service models and structured delivery of care. However, the large body of evidence already in existence on sex and gender differences in the risk of heart disease, in the use of services, in patterns of symptoms and diagnosis and in treatment was hardly acknowledged (Sharp, 1998; Wenger, 1997) in the NSF document. The opening pages of this plan do recognise that rates of CHD vary by social circumstance, gender and ethnicity. However, there is no discussion of how these variations should be reflected in preventive or curative care. The plan proposes that both children and adults should be helped to lead healthier lives. But as we have seen, there are very important gender differences in the patterns of health behaviour that will need to be changed. These differences will need to be recognised and the

31


structural factors which lie behind them will need to be properly addressed if the effectiveness of strategies to combat CHD is to be maximised. Similarly, the paper promises help for people wanting to give up smoking. However, tobacco cessation programmes will be much more successful if they are designed around male and female patterns of smoking and take into account the meaning of cigarettes in the lives of women and men (Perkins, 2001; see also pp. 17-18). Women of childbearing age are more likely to succeed if they give up during or shortly after a menstrual period for example, rather than just before. There is also some evidence that the use of particular anti-depressants are more helpful to women than to men, since they are more likely to smoke in response to emotional stress and depression (Gritz et al, 1995). The use of single sex cessation support groups also seems to be of particular value for women. Throughout the NSF document, discussion of standards refers to patients in gender neutral terms. Evidence concerning differences between women and men, and the implications these might have for public health campaigns and appropriate treatment and rehabilitation strategies are not discussed. As a result, there is no imperative for services to develop gender sensitive approaches to CHD. As we saw earlier (p. 10), there are critical differences between men and women in their experience of heart disease. The box below illustrates the need to include sex and gender issues in each of the standards in the NSF and highlights the potential consequences of gender blindness. Box 4.1

Gender critique of NSF Coronary Heart Disease standards

Name of standard (from NSF paper)

Standards 1 & 2: Reducing heart disease in the population

(Standards 1 & 2):

Description of standard (from NSF paper) 1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.

Gender implications (critique of standard) There is a need to build in awareness of differences re prevalence and incidence and risk factors. Gender sensitive smoking cessation strategies are also required.

2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.

32

Examples

Although heart disease is stereotypically seen as a male disease, being male is a risk factor for early heart disease only. There is increasing evidence that whilst smoking is a risk factor for both women and men, the risk for women who smoke, in comparison with nonsmoking women, is greater than the risk for men who smoke, in comparison with non-smoking men. In addition, hormonal


Standards 3 & 4: Preventing CHD in high risk patients

Standards 5, 6 & 7: Heart attack and other acute coronary syndromes

(Standards 5, 6 & 7):

3. General practitioners and primary care teams should identify all people with established cardiovascular disease (CVD) and offer them comprehensive advice and appropriate treatment to reduce their risks. 4. General practitioners and primary health care teams should identify all people at significant risk of cardiovascular disease but who have not developed symptoms and offer them appropriate advice and treatment to reduce their risks. 5. People with symptoms of a possible heart attack should receive help from an individual equipped with and appropriately trained in the use of a defibrillator within 8 minutes of calling for help, to maximise the benefits of resuscitation should it be necessary. 6. People thought to be suffering from a heart attack should be assessed professionally and, if indicated, receive

Identifying people with established CVD may miss more women than men: General Practitioners and primary health care teams need to be sex and gender aware in identifying those at risk who are symptom free. Women may need to be specially targeted, since their symptoms are more likely to be unrecognised.

Greater awareness of how CHD manifests in women differently from men is required. It is necessary to ensure emergency services are called promptly. Good practice re use of emergency treatments for women/men should be disseminated. Trust protocols should explicitly discuss areas of difference in assessment and response.

33

change and hormone therapies adversely affect women’s risks of CHD (Judelson, 1994; Prescott et al, 1998) Women are more likely to suffer ‘silent’ myocardial infarction (McKinley, 1996) which means that symptoms remain undetected for longer. In addition, research has found that women with chest pain, or with abnormal results after exercise thallium testing, are less often referred for full evaluation and diagnostic procedures such as coronary arteriography (Wenger, 1994).

For example, women first present more often with atypical forms of angina, whilst men present more often with myocardial infarction. Silent myocardial infarctions – without symptoms – are also more common amongst women. These differences affect diagnosis. However, for younger women in particular, there is also a greater prevalence of noncoronary related chest pain. Some of


it is due to hormonal factors, that means that there is a higher risk of false positives with some coronary diagnostic procedures –such as the exercise test. This in turn can lead practitioners to use such tests less often and to see chest pain women as being due to non coronary factors. As women have a less favourable outcome in coronary events, this indicates that all symptoms of chest pain in women need further investigation. Good gender sensitive evaluation of interventions designed to reduce risk factors, such as exercise and smoking, are also needed.

aspirin. Thrombolysis should be given within 60 minutes of calling for professional help. 7. NHS Trusts should put in place agreed protocols/systems of care so that people admitted to hospital with proven heart attack are appropriately assessed and offered treatments of proven clinical and cost effectiveness to reduce their risk of disability and death.

Standard 8: Stable angina

Standards 9 & 10: Revascularisation

(Standards 9 & 10):

8. People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events.

Investigators should be trained in gender sensitive/aware CHD assessment and treatment.

9. People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency.

PCTs and NHS trusts should develop agreed protocols on how increasing severity is to be interpreted and how this varies for women/men. Agreed assessment practices which are appropriate for women and men, and also agreed sex and gender

10. NHS Trusts should put in place hospital-wide t f

34

For example, women are more likely to first present with forms of angina that make initial diagnosis more difficult, but also make it more difficult to assess increasing severity. The associated risk, when presenting with


Standard 11: Heart Failure

Standard 12: Cardiac Rehabilitation

(Standard 12):

systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events. 11. Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (e.g. electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to both relieve their symptoms and reduce their risk of death should be offered. 12. NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return

sensitive treatment protocols are required. Training needs of health workers in this field should also be identified.

angina, is lower for women than men, so increasing severity does not carry the same risk. The implications of angina for CHD risk vary both by age and sex and these need to be taken into account (Mark, 2000).

Protocols re appropriate investigation for women/men should be developed and training needs assessed. More research is also needed into sex and gender differences in causes of heart failure.

For example, observed differences between women and men in symptoms such as chest pain and their association with coronary heart disease need further investigation.

All systems of care should include a section on gender specific needs in developing plans for rehabilitation or secondary prevention.

For example, coronary heart disease affects more older women and rehabilitation plans need to take the age structure of CHD patient populations into account. Older women need help in differentiating cardiac symptoms from other age-related changes. Women are also more likely to die after myocardial infarction than men and this too affects rehabilitation. Research also suggests women are more likely than men to experience co-

35


to a full and normal life.

Source:

morbidity which needs to be taken into account when planning after-care (Clark et al, 1994).

Columns 1 and 2: Department of Health (2000a), National Service Framework, Coronary Heart Disease.

As the box suggests, gender sensitive approaches to coronary heart disease in the NSF strategy would specifically focus on the symptoms, treatment needs and experience of women and men and this in turn might offer additional opportunities to enhance life expectancy and morbidity for both.

Unlike the NSF for coronary heart disease, the National Service Framework for Mental Health (1999) does highlight a number of gender issues including differences in the vulnerability of women and men to mental health problems. This understanding was taken further in a subsequent consultation document Women’s mental health: into the mainstream (Department of Health, 2002a).

In these pages, the specific needs of women are identified in the context of pregnancy, domestic violence, abuse and prostitution. The circumstances of particular groups of women are also explored including those who are offenders, those with learning disabilities and those from minority ethnic groups. The document also spelled out the necessity for care which respects women and values their strengths and recommended that services should be available in safe and single sex environments. An argument was also made that gender should be a key variable in all future research and in service evaluation.

This strategy was an important step forward in developing a gender sensitive approach to mental health care. However, it has two significant limitations as a model for gender mainstreaming. The first is that the particular mental health needs it identified were related mainly to women in their role as mothers, or to those women whose behaviour is seen by society as deviant or different. Services do need to be designed to meet these needs. But it is also important that they address the wider mental health needs of women especially those experiencing homelessness, poverty and social exclusion or work-related mental health problems.

36


The second limitation of the mental health NSF as an example of gender sensitivity is that it pays no attention to the needs of men. For example, the NSF recommends ‘initiatives to promote healthy schools’ but fails to recognise ways in which the development of healthy mental status may be different for males and females. A gender sensitive approach to healthy schools initiatives might aim to support young women’s confidence, self-esteem, eating and body image, but also to support young men’s emotional development and communication skills. Similarly, standard seven of the framework discusses suicide prevention, but this is not linked to differences in the suicide risks of women and men. Unless they include targeted interventions which reflect the reality of suicidal behaviour and different risk factors among women and among men, these recommendations are likely to be too vague to be successful. For example, there are gendered patterns in the use of different methods of suicide, with men being more likely to use motor vehicle exhaust gas and hanging whilst women more often use self-poisoning by solids or liquids (Amos et al, 2001; Schapira et al, 2001; Gunnell et al, 2003). Similarly, evidence suggests women and men may differ in their use of health care services prior to a suicidal act, with women more likely to be in contact with such services beforehand (Payne et al, 1997; Luoma et al, 2002). Other studies have found gender differences in risk factors such as unemployment, substance abuse and poverty, which also need to be considered (Hawton et al, 2001). The modernisation of the mental health agenda therefore offers important insights into the ways in which treatment could be tailored to meet the needs of particular groups of women, but gender concerns will need to be more fully integrated into mainstream service delivery if real change is to be achieved. Gender in the National Strategy for Sexual Health and HIV In 2001, the Department of Health launched the National Strategy for Sexual Health and HIV (Department of Health, 2001b). This strategy identified a number of targets including a reduction in the incidence of sexually transmitted infections (STIs) and in the levels of stigma associated with them. It also called for a reduction in the number of unintended pregnancies. The strategy identified women, gay men, people from minority ethnic groups, and young people as the groups most at risk. The document does refer to sex specific aspects of STIs including the particular hazards they pose to women’s reproductive health. Gender differences are also mentioned with reference being made to the increased vulnerability of young girls from poor backgrounds. Sexually transmitted infections have been increasing. Between 1996 and 2002, diagnoses for all sexually transmitted infections increased by 42 per cent (Health 37


Protection Agency, 2003). However, STIs increased more amongst men than women, with a particularly marked increase in male infections homosexually acquired. Rates for syphilis, the fastest growing STI, increased by 1100 per cent amongst men compared with a 291 per cent increase amongst women. In terms of frequency, however, syphilis is relatively rare. The most widespread STI is chlamydia which represented 7 per cent of all diagnosis in 1996 and 12 per cent of diagnosis by 2002 (Health Protection Agency, 2003). Whilst more women are diagnosed with chlamydia, there has been a slightly greater increase in the infection rate amongst men than amongst women since 1996, and the rate of homosexually acquired chlamydia amongst men has increased by over 400 per cent. Again, in the policy documents there is very little discussion of how these differences in infection rates between women and men should be translated into policy and practice. Part of the strategy refers to improvements in health information and to the need for young people to develop personal and social skills to help them in making informed choices. However, there appears to be little awareness of how important sensitivity to gender issues will be in achieving this. A report produced by the government's Social Exclusion Unit, Teenage Pregnancy (Social Exclusion Unit, 1999), suggested that lack of information about safe contraception and safe sex increased the risk of teenage girls becoming pregnant. It also cited peer pressure, fears of losing their partner, and the need for love as significant reasons for having unprotected sex. However, the boys questioned were most likely to talk about opportunity, attraction and peer pressure, whilst girls more often cited love and desired commitment. This suggests that health promotion strategies will need to be carefully tailored if the target for reducing unintended pregnancies is to be met. Similar problems are evident in the screening programme proposed in the strategy for the most common sexually transmitted diseases. Chlamydia trachomatis screening is recommended for both women and men attending genitourinary medicine clinics and for women seeking termination of pregnancy as well as opportunistic screening of young sexually active women. Partner tracing is also recommended for any person found to be suffering from the disease. Whilst these recommendations do include both women and men, there is a focus on screening women. As a result, there is a strong likelihood that sexually transmitted infections in men will remain undetected and untreated. In turn, this increases the likelihood of (re)infection of women, and thus limits the effectiveness of the strategy. The reasons given for focussing on women include the fact that they are more likely to attend for health care, that the consequences of infection are more serious for them than for men and that computer modelling has indicated that this is a costeffective approach. However, the danger is that this will reinforce the stigmatising 38


belief that women bear the major responsibility for sexual health and that chlamydia is predominantly a female disease. In reality, 43 per cent of cases identified in the UK in 2001 were found among males. Without opportunistic screening of men as well as women, the incidence of male prevalence is likely to remain high and this will significantly reduce the likelihood of an overall reduction in the disease. 4.6 Conclusion It should be clear from this analysis that neither sex nor gender issues have received the appropriate amount of attention in current NHS policies. There has been some discussion of sex differences, but this appears mainly in the context of women’s reproductive health. References to gender are extremely rare despite the large body of evidence demonstrating its impact on health and health care. Returning to the original goals of both the modernisation and the inequalities agendas, there will be major constraints on the degree to which they can be achieved if the biological and the social differences between women and men are not given greater attention. Service delivery will not be patient centred if the gendered nature of daily life is not recognised in the planning process. Improvements in quality of care will be limited if the physical and psychological needs of both women and men are not explicitly addressed in both research and clinical care. Moreover, public participation in the running of the health service will not be optimised unless women and men are appropriately represented at all levels. The next chapter examines some of the ways in which gender issues could be mainstreamed into the NHS.

39

GENDER MAINSTREAMING IN THE NHS

5.


Chapter 3 highlighted the differences in the health status of women and men in the UK and in their patterns of health care utilisation. But as we have seen, current policies are largely gender blind. In the first part of this chapter, the case will be made for ‘gender mainstreaming’ in the NHS in order to increase the efficiency and effectiveness of services and also to promote greater equity in the delivery of care. The second section goes one step further in setting out the broad parameters of a strategy for putting this into practice. Using some of the main themes of the Department of Health’s own modernisation agenda, we identify the arenas in which greater attention to gender would lead to better outcomes from existing polices and practices. Attention is drawn to lessons that can be learned from health care systems in other parts of the world and to examples of good practice from within the NHS itself. 5.1 The case for gender mainstreaming in the NHS The idea of ‘gender mainstreaming’ has been widely discussed in recent years. It was highlighted in the Platform for Action of the United Nations Fourth World Conference on Women in 1994 and has since been adopted by many international organisations, by national governments and by both public and private sector institutions. The fundamental principle of mainstreaming is that women and men should benefit equally from all aspects of an organisation’s activities. However, the focus thus far has been mainly on workforce issues (Escott and Whitfield, 2002). While the push for mainstreaming was initially an equity one, the last few years have seen the emergence of what has been called a ‘business case’ for fighting gender (and other) discrimination in the workplace (Fredman, 2002). This is based on two arguments: the merit principle and the perceived value of diversity. The merit principle argues that if workers are hired solely on the basis of what they have to offer, then the organisation will benefit by getting the best people for the job. At the same time it is assumed that a diverse workforce can give an employer the benefits of greater creativity as well as helping to meet the needs of a broader range of customers/clients. In most employment settings, it is women who face discrimination in recruitment, who earn the least and who have the lowest status jobs. Hence most gender mainstreaming policies have been designed to reshape appointment practices, terms and conditions of employment and wider organisational cultures to ensure that female workers are able to compete on equal terms with men for the range of resources on offer.

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Both the equity and the business cases for gender mainstreaming are now accepted as part of NHS employment policy. Indeed the latter has assumed particular significance as the service has experienced severe staffing problems in recent years. In pursuit of this new approach, equal opportunities appointments procedures have been put in place and targets for the creation of a more diverse workforce have been introduced in some areas. Policies have also been developed to promote more parttime and flexible working. The impact of these policies on gender equality has yet to be properly evaluated, but the business case for their introduction now goes largely unquestioned (Coyle, 2003). It has become increasingly clear however, that in the context of service organisations the principles of gender mainstreaming will need to be applied beyond the workforce. If the potential benefits of this approach are to be fully realised, polices will be needed to ensure that both female and male service users are treated in ways that are sensitive and appropriate to their needs. In the case of health care systems, this means that differences between women and men will need to be understood and acknowledged in all areas of work from the planning of services through recruitment and management of staff to education and training, delivery of care and audit and evaluation (Commonwealth Secretariat, 1996; Group of Specialists on Mainstreaming, 1998; UN Division for the Advancement of Women, 1998). The equalities case for such an approach is well developed in the NHS. Groups of women have been campaigning for decades against what they have experienced as discriminatory and sexist practices in the NHS (Doyal, 1998). In recent years, they have been joined by a number of men’s organisations who believe that they are not receiving the most sensitive and appropriate services (Banks, 2001). Both argue that men and women are treated in stereotypical ways which do not respect their individual humanity. In addition, many women have suggested that they are seen by health workers as being of less value than men and are treated accordingly. Neither women nor men are ‘minorities’ needing special treatment. All patients in the NHS are either male or female and if services are to be effective, efficient and evidence based, the recognition of this reality needs to be at the heart of the planning and delivery of care. Failure to pay attention to differences between women and men will clearly reinforce existing gender inequalities. But just as importantly, it will lead to the delivery of inappropriate and less than optimal care which in turn is likely to involve the waste of scarce resources. Under these circumstances, the implementation of both the equalities and the modernisation agendas will be unnecessarily constrained. The next section will spell out a programme for avoiding this through the mainstreaming of gender in the NHS.

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5.2 Improving the knowledge base of health status and health care needs Chapter 3 outlined the evidence relating to differences in male and female patterns of health and illness and use of health services. Gaps in that evidence were also identified. If the planning of services is to be based on accurate data, these gaps will need to be filled, using methods of data collection that are sensitive to both sex and gender differences. Gender sensitivity in official statistics in the UK has improved significantly over the past few years. Recent guidelines from the Government Statistical Service recommended the routine disaggregation of all data unless this is outweighed by considerations of cost or practicality. A Gender Statistics User Group (GSUG) has also been formed to help in the implementation of this policy and the group includes members from the ONS and EOC, as well as other interested parties. A recent review of gender in official statistics in the UK included a consultation with both users and providers (National Statistics, 2003). It revealed widespread dissatisfaction across a number of different areas with two thirds of respondents reporting problems in accessing data broken down by gender itself and also by gender in relation to age, ethnicity and region. The Women and Equality Unit report, Key Indicators of Women’s Position in Britain (Dench et al, 2002) made similar observations and highlighted the need for government surveys to collect data on both women and men and to report the findings in ways that clarify any differences. It is clear that the further development of health statistics should be following this trend with a commitment to the gender disaggregation of all routine information and to the collection of survey data from both women and men. In government surveys which include questions on contraceptive use (e.g. the General Household Survey), women, but not men, are asked about the methods they are using. If services are to be improved and sexual health promotion targets met, data will need to be collected from both women and men. Measures of health status and health service use therefore need to be sex and gender specific. But they also need to be presented in ways that reflect the very complex patterns of causality that lie behind any observed differences between women and men. As we have seen, women in most social groups do consult their GPs more than men. However, this cannot be taken to mean that they are ‘sicker’ in any straightforward sense. Much of this extra consultation relates to sex-specific diseases, to what are called ‘ill-defined conditions’ and to routine reproductive care. More work is needed to disentangle complexities of this kind and to assess their implications for the delivery of sex and gender sensitive care.

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Whilst it is important that official data sources always include evidence relating to both men and women, there is also a need for more information to be collected on health problems disproportionately affecting one group (Murgatroyd, 2000). Physical and sexual violence for example, affect women much more often than men but very little information is collected on the health (as opposed to their legal) implications of such violence. Similarly, data on occupational health have tended to focus only on male experiences of occupational mortality and morbidity. Almost no attention has been paid to the particularity of the health hazards faced by women in both paid and unpaid work. Unless data of this kind are routinely collected, it will be impossible to develop effective health promotion policies that reflect the gendered reality of daily life for women and men in the UK. In addition, data for both men and women need to be disaggregated by ethnicity, given the important differences in health status and experience of minority groups. 5.3 Putting sex and gender into medical research Alongside these changes in the collection of routine data on health and health care needs, there is also a need for greater sensitivity to sex and gender issues in medical research. There is a strong emphasis in the modernisation agenda on what has come to be called ‘evidence based medicine’. But there is also a growing awareness of the problems of gender bias in the production of medical knowledge. Many reviews have demonstrated that much of the evidence used in every day clinical practice has been generated by studies based on the experiences of young white men (Bandyopadhyay et al, 2001; Lee et al, 2001). This is true of both epidemiological studies and also of clinical trials. The extent of this bias has been demonstrated with particular clarity in the case of coronary heart disease, but it is also evident in a number of other settings. In the US, this bias has been seen as an equality issue and has received a great deal of attention. In the late 1980s, groups of women began to claim their right to be involved in clinical trials in the same numbers as men. They argued that as individuals they should have an equal opportunity to benefit from any therapeutic potential the drug being tested might offer. More importantly perhaps, they also claimed that medical knowledge should be produced in such a way that it would be of equal value to both women and men (Kass, 1998; Mastroianni et al, 1994). In addition to these equity arguments, the scientific case was also made that gender bias in the selection of research samples was likely to lead to considerable inefficiencies. Studies which did not include appropriate numbers of women and men were seen to be insufficiently rigorous since the generalisability of their findings would be indeterminate. Drugs that were tested on men, but then used on both women and men, ran the risk of being less effective or more hazardous in one sex 43


than in the other. This in turn could lead to the waste of scarce resources either in the initial treatment or in dealing with any damage caused by inappropriate care (Kass, 1998). In response to both the equity and the efficiency arguments, the US government moved on a number of fronts to ensure that medical research became more sex and gender sensitive. A law was passed in 1993, requiring all applications for federal funding to show that women and men (and ethnic minority groups) were represented in appropriate numbers in the proposed research design. In addition, a range of stakeholders including regulatory bodies, internal review boards (ethics committees) and individual scientists were now required to pay attention to gender issues in their evaluation of projects. Similar initiatives have been implemented in a number of other countries including Canada, Australia and South Africa. However, these arguments have received little attention in the UK. Guidelines for the implementation of clinical trials used in both the UK and the EU show almost no awareness of either the ethical or the scientific relevance of gender issues. These issues are similarly absent from the current guidelines for research ethics committees. The proposed research governance framework for health and social care in England does talk in very broad terms about the need to ensure that the body of research evidence ‘reflects the diversity of the population’ (Department of Health, 2003c). However, it offers no practical guidance on how this should be achieved. If the evidence base of clinical medicine in the UK is to be optimal in meeting the clinical needs of both women and men, policies should be developed along the lines of those adopted in other countries. This will require the inclusion of sex and gender sensitivity in the criteria for peer review of funding, appropriate training for researchers and the addition of gender (and other diversity issues) on the agendas of ethics committees. Experience in the USA has shown that the implementation of such policies poses considerable challenges (Mastroianni et al, 1994). But without changes in practice, medical care in the NHS will continue to be based on partial and biased knowledge. 5.4 Good practice in the delivery of gender sensitive health care If the NHS is to deliver health care which is sensitive to the needs of the whole population, it will also require a workforce which is both individually and collectively capable of recognising these needs and meeting them in appropriate ways. As we have seen, the modernisation agenda has already generated a wide range of training initiatives and these will need to be extended to include capacity building in the delivery of gender sensitive services. 44


Health care workers need to learn about gender issues both in their initial training and also as part of life long professional development. In a number of countries, these issues are now beginning to be incorporated into medical, nursing and other curricula. In the US and Canada for instance, a wide range of resources are now available to help students (and faculty) to develop their understanding of sex and gender issues in health care. But again, initiatives of this kind are scarce in the UK. A recent survey of British medical schools revealed very few examples of systematic innovation in the area of gender (Doyal, 2003). Some schools have introduced one or two lectures, usually as part of the social science curriculum. However, ‘women’s health’ remains a specialist area with few attempts at mainstreaming beyond the traditional boundaries of obstetrics and gynaecology. A similar pattern exists in the education of nurses (and other health related professionals). Some schools have developed specialist courses on women (though not on men), but few have approached the topic of gender and health in a systematic way. The gaps in professional education and training in the UK reflect the low priority given to these issues in the context of wider government policy. Though the initial push for change in the US (and in Canada and Australia) came from individual educators, it was reinforced by national guidelines from the professional bodies with support from national government. Similar policy initiatives will be needed in the UK if individual schools are to be persuaded to take these issues seriously. As well as mainstreaming gender issues in the undergraduate curriculum, there is also a need for training for those already working in the NHS. This will need to focus on issues relevant to participants’ own work settings, while also raising their general awareness of the importance of gender in health care. As we have seen in the case of both coronary heart disease and mental health, those involved in the delivery of services should be able to recognise the different symptoms and illness behaviour of male and female patients and to respond appropriately to their needs. Similarly, those working in accident and emergency services and in primary care should learn how to recognise and to deal sensitively with specific problems such as gender violence. Strategies for promoting greater awareness of ‘diversity’ issues among NHS staff have already been developed in the wider context of the equalities agenda. However, the main focus of these initiatives has been on race and ethnicity: service improvement toolkits, new sets of quality indicators and innovative training programmes have all been developed (for details of the Department of Health’s work on race equality, see www.doh.gov.uk/race_equality/). There is now a wide range of expertise both in the NHS and in the voluntary sector 45


on developing race awareness initiatives. This will need to be drawn upon in the development of similar programmes relating to awareness of sex and gender issues. As well as generating greater sensitivity to gender issues among individual health workers, there is also an urgent need for wider organisational learning. Again, considerable expertise already exists within the NHS in the facilitation of such learning. Recent policies, including the Equalities Awards and the Beacon Scheme, have encouraged the identification and dissemination of examples of good practice as they relate to both the modernisation and the equalities agendas. But these strategies have rarely been deployed in the pursuit of greater gender sensitivity. A recent review of good practice databases shows some evidence of innovations designed to meet the particular needs of women or men. A number of trusts are now offering dedicated one-stop clinics to support women in danger of miscarrying for instance, while specialist cessation clinics have been developed to support women in disadvantaged areas wishing to give up smoking (Doyal, 1998). In Sheffield, a health bus has been used to reach some of the city’s most vulnerable women. Well women clinics and NHS Walk-In Centres have also been designed to help meet some of women’s particular health needs (Women and Equality Unit, 2001). Similarly, a range of health promotion initiatives have been designed to meet what are seen to be the gender-specific needs of some men. Services are being offered through local football clubs for example, or in one case in a barber's shop and in another in a Harley Davidson showroom. Male drop-in centres have also been set up with many designed to target gay men (Davidson and Lloyd, 2001; Luck et al, 1999; see also the list of projects and initiatives specifically aimed at the health of men on the Men’s Health Forum’s database, www.menshealthforum.org.uk). These are important additions to the range of services designed to meet the specific needs of women and men. However, initiatives are also required to demonstrate the importance of delivering gender sensitive care for all patients in mainstream services. In the case of sexual health or HIV/AIDS services for example, there is a need for the dissemination of good practice in respecting both the commonalities and the differences between women and men. Guidelines are already available for ensuring that health care in these areas is responsive to ‘cultural diversity’, but more needs to be done to include gender issues. 5.5 Putting gender into quality assurance As we have seen, the NHS modernisation agenda has placed a great deal of emphasis on the introduction of mechanisms for quality assurance. All trusts have been required to put systems of clinical governance in place and performance assessment indicators have been developed to measure their achievement in 46


meeting the proposed targets. This will do much to facilitate the development of higher standards of care within the NHS. However, there is little evidence of creative thinking about the implications of diversity, in general, or gender differences, in particular, for undertaking quality assurance. If NICE is to ensure that the evidence base for an effective and equitable service is developed, gender issues will need to be incorporated into its formal assessment framework. Changes will also need to be made in the guidelines for the implementation of clinical trials. Following the approach adopted in other countries, studies should be designed in such a way that sex differences in effectiveness and toxicity will be more easily identifiable. Any significant findings should be included in the formal report and should also be indicated on the information sheets provided with drugs and other medical products. The work of CHI will also need to be more sensitive to sex and gender issues if it is to achieve its goal of improving clinical practice. Some of the early surveys carried out by CHI (Commission for Health Improvement, 2003) have hinted at interesting differences in the experiences of health care reported by women and men. But if these are to be followed through and their implications for practice more fully developed, gender issues will need to be integrated into the methods used for data collection. A significant literature now exists on the differences that exist between women and men in their perceptions of health and disease, in their illness behaviour, patterns of use of health services and judgements about quality of care (see Chapter 3). Studies need to be designed in such a way that they can measure the extent of such variations in different parts of the NHS and begin to explain their causes. Only then will it be possible to develop quality assurance policies which respect the needs and desires of all service users. 5.6 Decision making and public accountability: achieving a gender balance A major commitment in the NHS modernisation agenda has been greater public involvement in the setting of local health priorities and in the running of services. But again, little attention has been paid to gender issues. Traditionally, women have been the major providers of health care both inside the NHS and outside it. However, they have always had less control over decision making. Men have held the majority of high status positions both in the medical profession and in the wider management system. The shift towards greater public participation in the running of the NHS offers an opportunity to begin to redress these inequalities.

47


The Commission for Patient and Public Involvement in Health will have overall responsibility for facilitating public involvement and the Patients Forum will bring together organisations concerned with user issues in the NHS. As yet, the detailed working methods of these organisations have still to be decided. However, they are committed to ensuring the representation of all service users. Hence mechanisms will need to be developed to ensure the active involvement of women and men both as individuals and also as members of special interest groups. As well as introducing new mechanisms to encourage public accountability, significant steps have also been taken to broaden the range of people on NHS boards in order to make them more representative of local communities. In 2002, the Commissioner for Public Appointments reported an increase of 4 per cent in the proportion of women appointed to chair the new primary care trusts. However, this was accompanied by a slight down turn in the overall proportion (from 39 per cent to 38 per cent) of women appointed as members These figures suggest that more work is needed to ensure gender equality in the running of the service. Alongside a commitment to greater public participation, the modernisation agenda has also stressed the importance of increasing individual patient choice through access to knowledge. Here too, gender issues are potentially of great significance. A number of initiatives have been developed to offer service users more information about a range of heath issues and treatment options (for details of many of these initiatives, see www.patient.co.uk) However, little effort has been paid to gender inequalities in access to these new sources of knowledge. The growing use of information technology for example, is likely to benefit men more than women since they are more likely to have access to computers. 5.7 Conclusion A policy of gender mainstreaming could considerably improve the running of the NHS. The most immediate benefits would probably be the political ones that would derive from a demonstration of the government’s commitment to tackling gender inequalities in health. However, more long term benefits would also accrue through improvements in effectiveness and efficiency. There is therefore a powerful argument for including policies for gender mainstreaming as an integral part of plans for the future of the NHS.

48

CONCLUSION

6.

CONCLUSION

This project has highlighted the impact of both sex and gender on the health of women and men. It has reviewed the modernisation agenda of the NHS and has concluded that it currently shows little commitment to the promotion of greater gender equality in service delivery. In light of this analysis, a strategy has been identified for mainstreaming gender throughout the health service. This approach has been justified on the grounds of both equity and efficiency. From the perspective of equity, it is clear that greater recognition of gender issues would benefit individual women and men in their encounters with the NHS. If service providers understand the impact of gender on the daily lives of all their patients, the quality of the care they offer is more likely to be both sensitive and respectful. From the standpoint of efficiency, the integration of sex and gender issues into the planning and delivery of services would promote better use of scarce resources. As we have seen, these are key determinants of health. Unless they are taken seriously in medical research and practice, expenditure will be wasted on interventions that are less effective than they might be in addressing both individual and population health problems. In conclusion, these arguments for gender mainstreaming in the NHS need to be placed within the broader context of current debates on equality policies in public services in the UK. At present there is an inconsistent patchwork of equality duties across Britain and the only comprehensive legislation relates to race, though the Welsh Assembly and the Greater London Authority legislation do encompass a general equality duty. This means that across public sector organisations, approaches to this issue are fragmented and piecemeal and progress too often depends on the commitment of individuals. One approach to this problem has been the introduction of a gender equality objective into the DTI’s Public Service Agreement (PSA) (Women and Equality Unit, 2003). More radically, a public duty on gender equality has also been proposed. In a recent report commissioned by the Equal Opportunities Commission, Karen Escott and Dexter Whitfield examined the Government’s modernisation agenda as it has been implemented across a range of public sector bodies (Escott and Whitfield 2002). They argued (p. 22) that these initiatives have ‘not taken sufficient account of an equality dimension…’ and that ‘gender had not been effectively mainstreamed’. These results are very similar to the more detailed findings described here for the NHS.

49

CONCLUSION

In an attempt to explore the factors promoting and inhibiting the development of gender equality policies, Escott and Whitfield carried out case studies of six public sector organisations with a track record on equality initiatives (none were in the health sector). They found that even in these organisations, policies on mainstreaming were usually applied in a piecemeal way. Major gaps continued to exist between equalities statements and their practical implementation with most initiatives being fragmented and piecemeal. Progress usually depended on the enthusiasm of individuals rather than being properly embedded in the work of the organisation and gender mainstreaming had been confined mainly to employment with little attention being paid to service delivery. In their report, Escott and Whitfield identified a number of strategies essential for effective gender mainstreaming in public sector organisations. As a starting point, there will need to be a corporate framework where gender equality has commensurate weight with other drivers of public service modernisation. This will need to be accompanied by a clear commitment from senior managers to the pursuit of an equalities agenda. In addition, proper attention will have to be paid to the location of expertise and accountability for gender equality within the organisation with responsibility for the overall agenda resting at a senior level. This is turn, should be linked to the budgetary process so that resource allocation within the organisation is directly connected to equality standards and targets. Such strategies are as central to the development of an equalities agenda in the NHS as they are to other public sector organisations. In addition, and again in line with the evidence of Escott and Whitfield, it is important that gender mainstreaming in the NHS moves beyond personnel policies and is integrated into service delivery. This will need to include the incorporation of equality issues into the consultation processes that the NHS and other public sector organisations are increasingly required to undertake. It is also essential that a gender-disaggregated information base should form the foundation for appropriate quality assurance. For example, Escott and Whitfield reported that while some of their case study organisations had developed appropriate indicators for measuring progress towards greater equality in the workforce, few had done the same for service delivery. In the final section of their report, Escott and Whitfield examine the case for a public sector duty on gender. Based on comments from their respondents, they highlight the potential value of a statutory framework for ensuring that public sector organisations meet their equality obligations in a consistent way. Debate continues about the relative benefits of specific versus general duties on equality. However, there appeared to be general agreement amongst their respondents that some duty would be of great value in reshaping policy priorities. This finding is as applicable to the NHS as it is to other parts of the public sector.

50

CONCLUSION

It is clear that, within the NHS, a statutory duty to promote equality could contribute significantly to a wider recognition of the importance of gender issues. Race equalities legislation has demonstrated the potential value of such an approach as new initiatives for ethnic minority staff and service users have created important models of good practice which could be extended into the gender field. However, legislative changes alone will not be enough. If the pursuit of gender equality is to become a key component of the modernisation agenda in the NHS and other public sector organisations, the creation of a formal framework and the dissemination of effective methods of implementation will need to be accompanied by significant cultural and organisational change.

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CONCLUSION

REFERENCES Amos, T., Appleby, L. and Kiernan, K. (2001), 'Changes in rates of suicide by car exhaust asphyxiation in England and Wales', Psychological Medicine, 31, 5: 935-39. Arber, S. and Khlat, M. (2002) 'Introduction to social and economic patterning of women's health in a changing world', Social Science and Medicine, 54, 5: 643-47. Bandyopadhyay, S., Bayer, A. and O’Mahoney, M. (2001) 'Age and gender bias in clinical trials', QJM, 94, 3: 127-32. Banks, I. (2001) 'No man’s land: men, illness and the NHS', British Medical Journal, 323: 1058-60. Beery, T.A. (1995) 'Gender bias in the diagnosis and treatment of coronary artery disease', Heart & Lung: the Journal of Critical Care, 24, 6: 427-35. Boreham, R. (2000) ‘Smoking’ in A. Shaw, A. McMunn and J. Field (eds) (2000) The Scottish Health Survey 1998. Volume 1. Report for Scottish Executive Department of Health. Edinburgh: The Stationery Office. Broom, D. (1995) ‘Masculine medicine, feminine illness: gender and health’, in G. Lupton and J. Najman (eds), Sociology of Health and Illness: Australian readings (2nd edition). Melbourne: Macmillan. Cameron, E. and Bernardes, J. (1998) ‘Gender and disadvantage in health: mens health for a change’ in M. Bartley, D. Blane, and G. Davey Smith (eds) Sociology of health inequalities. Oxford: Blackwell. Chapple, A., Ling, M. and May, C. (1998) ‘General practitioners perceptions of the illness behaviour and health needs of South Asian women with menorrhagia’, Ethnicity and Health 3: 81-93. Child and Adolescent Health Research Unit (2002) Scottish Schools Adolescent Lifestyle and Substance Use Survey. Interim Report by CAHRU, University of Edinburgh. Available from: http://www.drugmisuse.isdscotland.org/publications/abstracts/salsus_interim02.htm

Promoting gender equality in health.doc

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CONCLUSION

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