Health and Social Care Bill

Memorandum submitted by the Men’s Health Forum (HS 83)

1. Who we are

The Men’s Health Forum (MHF) is a charity that provides an independent and authoritative voice for male health in England and Wales and tackles the issues and inequalities affecting the health and well-being of men and boys.

The MHF vision is a future in which all boys and men in England and Wales have an equal opportunity to attain the highest possible level of health and well-being.

We have been a Strategic Partner of the Department of Health (DH) since February 2009.

2. Introduction and summary

We welcome the publication of the Health and Social Care Bill. We believe that the reform of the NHS offers an excellent opportunity to address the poor health outcomes of men in this country. The vision set out for the NHS, particularly the commitment to tackling health inequalities, is encouraging.

However, in summary, we do not feel the bill goes far enough to deliver on this vision so our conclusion sets out amendments to ensure that systems are in place within the NHS Commissioning Board to tackle health inequalities and that there is engagement with organisations that can advise on, and help monitor, progress.

In the following sections, we set out our perspective on the Bill and highlight areas that we believe require further attention.

2.1 Current state of men’s health in England and Wales

Before addressing the detail of the Bill, we would like to contextualise our response by reflecting on the current state of men’s health in this country. We believe that too many men suffer unnecessarily poor health and die too young from preventable causes.

• A baby boy born in 2006-8 can expect to live 77.4 year and a baby girl 81.6 years, a difference of 4.2 years.

• Premature death mainly affects men. 42% of men die prematurely (before the age of 75) from all causes compared to 26% of women. 21% of men aged 16-64 die from all causes compared to 12% of women.

• Unskilled manual men have an average life expectancy of 73 and, in some parts of England, male life expectancy is as low as 65. The mortality rate of men in routine and manual occupations is 2.3 times that of men in managerial and professional occupations.

• The social gradient has a greater impact on men’s health than women’s – the life expectancy gap between men and women widens as deprivation increases.

• Coronary heart disease kills more men than women and on average men develop it 10-15 years earlier. South Asian men living in the UK have an even higher premature death rate from heart disease and stroke than men generally.

• Men are 60% more likely to develop and 70% more likely to die from a cancer that ‘should’ affect men and women equally (i.e. excluding breast cancer and the sex-specific cancers).

• Men use the range of primary care services far less then women and, crucially, take longer to present and receive a diagnosis.

• Men are slightly more likely than women to use Accident and Emergency Services. However, in the age-group that makes by far the most use of A&E, 20-29 year olds, men are in a significant majority.

• NHS smoking cessation programmes are less well used by men than women as are weight management services and health trainers.

• Black and ethnic minority men are less likely to seek help for mental health problems.

3 Men’s current level of engagement in health

We know that men, particularly men from marginalised and seldom-heard groups, have generally not been actively engaged in their health and have not accessed services or participated in health improvement programmes, to the same extent as their female counterparts. This phenomenon has a significant impact for men’s health outcomes.

3.1. Men accessing services

In Great Britain, men visit their GP 20% less frequently than women. The difference in usage is most marked for the 16-44 age group – women of this age are more than twice as likely to use services as men [1] .

Women have higher consultation rates for a wide range of illnesses so the gender differences cannot be explained simply by their need for contraceptive and pregnancy care [2] .

Men, especially young men, are much less likely than women to have regular dental check-ups [3] or to use community pharmacies as a source of advice and information about health [4] . Just 10% of NHS community contraception service users are male [5] .

NHS smoking cessation programmes are less well used by men than women [6] and the same is true of NHS and commercial weight management services [7] , health trainers [8] and of disease-specific helplines run by third sector organisations [9] . Male uptake was markedly lower than female uptake in the pilot programmes for the NHS Bowel Cancer Screening Programme [10] .

3.2 Consequences of lack of engagement for men’s health

An analysis of men’s use of GP services shows the potential impact on men’s health and the healthcare system. This research was based on a total of 35.8 million contacts with GPs and 1.2 million hospitalisations in Denmark in 2005 [11] . (Like the UK, Denmark has free access to primary and hospital healthcare.) The data is compatible with a scenario in which men are reacting later to severe symptoms than women with the result that they are more likely to be hospitalised or die.

3.2.1 This is also consistent with UK and Europe-wide data on malignant melanoma which shows that while women are more likely to develop this type of cancer, men are more likely to die from it [12] . This is almost certainly because men present to health services when the cancer is more advanced and harder to treat. Also, nearly four men in 10 are not diagnosed with prostate cancer until it has spread [13] .

3.2.2 Diabetes UK data suggests that middle-aged men are not only twice as likely to have diabetes as women they are also twice as likely not to know that they the disease. This is particularly important given the predicated large rise in diabetes over the next 30-50 years due to the increase in obesity rates, especially in men.

3.2.3 One secondary consequence of men’s poorer use of health services is that many attempt inappropriate self-diagnosis and self-treatment. Every year in the UK, an estimated 330,000 men purchase prescription-only medicines without a prescription from illicit sources, particularly internet sites [14] .

3.2.4 Thus, men’s poor access to services and engagement in health has serious consequences for their individual health. The burden of costly treatments on the NHS when men are treated in the later stages of illness is also significant, necessitating more costly and intensive treatments.

3.3 Men’s reluctance to seek help is an underlying cause of their poor use of primary health services.

3.3.1 This is a result of the way men are brought up to behave. Men are not supposed to admit to personal problems, weakness or vulnerability. Many want to appear strong, independent and in control, including in front of a health professional [15] . As a consequence, men often wait until they are in considerable pain or are convinced they have a serious problem [16] .

3.3.2 Male socialisation is not easy to change but, in our view, improved health education for boys in school would help. MHF believes that boys should not leave school without knowing the role of GPs and how to register and make an appointment. We also believe that as the health system as a whole begins to take men’s health more seriously and as health initiatives and campaigns aimed at men become more common, taking more of an interest in health issues will feel normal for men.

3.3.3 But men’s unwillingness to seek help is reinforced by a number of practical barriers, including the demands of long working hours and problems with accessing primary care services near the workplace [17] .

3.3.4 Anecdotal evidence suggests that some men are deterred by a perception that GP and pharmacy services are aimed mainly at women and children and feel like ‘feminised’ spaces. ‘It’s like visiting a ladies’ hairdresser’ was the comment of one man responding to a MHF survey on men’s use of GP services. Another man, commenting on the ambience of pharmacy services, highlighted the ‘racks and racks of make-up’ [18] .

3.3.5 Lack of familiarity with the health system may also be a factor. Women are much more likely to use health services routinely – for contraception, cervical cancer screening (after the age of 25), pregnancy, childbirth and for their children’s health. When they are ill, they are more likely to know how to access services, and which services to use, and to feel more comfortable with a healthcare professional.

3.3.6 Men in specific groups may be deterred because they fear or experience discrimination. There is evidence of widespread homophobia among health professionals that impacts on the ability of gay and bisexual men to access healthcare [19] . African and Caribbean men can be deterred from approaching mental health services because of a belief that they will be discriminated against [20] .

3.3.7 Gypsy and traveller men – the group with the lowest life expectancy in the UK (estimated at 48) –face particular difficulties accessing mainstream primary care services [21] .

Although men have poor health outcomes, these barriers to men’s effective use of health and related services have not yet been systematically addressed. Services are not routinely being delivered in ways that take proper account of men’s attitudes and behaviours. This is despite the Gender Equality Duty, in force since April 2007, which requires services to be tailored to the specific needs of men and women and to work towards achieving more equitable outcomes. The implementation of the NHS reforms offers an important opportunity to rectify this. In the next section we will outline a number of steps that can be taken, to this end.

3.4 What can we do to address men’s lack of engagement in health and to place them at the centre of the NHS?

The MHF firmly believe that the Bill should include provision for ‘gender sensitive’ service delivery.

• 3.4.1 Underlying the Bill is the assumption that the quality of interaction with the health professionals that serve the public and patients is important. In the past the NHS has failed to engage men in ‘traditional’ primary care services. Research tells us that men are far more likely to engage in health services, if they are adapted to become more gender sensitive.

• 3.4.2 The changes required are often subtle and straightforward, for example by making GP waiting rooms welcoming to men as well as women through the use of appropriate posters, leaflets, men’s as well as women’s magazines.

• 3.4.3 One of the simplest ways to ensure that General Practice is more accessible to men is by extending opening hours. Many GPs have extended their hours in recent years but this is still far from universal, often not on a daily basis and still rarely at weekends. We advocate longer opening hours, which would particularly help men who work full-time, work more than 40 hours a week, or who have lengthy commutes to work. , as well as the White Paper’s suggestion to allow men to register with any GP surgery. However, we suggest that this will only be truly useful if patients are allowed to register at more than one GP practice, e.g. near their place of residence and near their place of work. While it may be convenient to be able to attend a GP practice nearby work for routine appointments, if one is ill at home and needs to see a GP urgently, this obviously will not work, particularly for those who commute long distances to work. There is also an issue for transient workers. In the course of our consultation process, the situation of construction workers was raised. These workers tend to move from workplace to workplace to the extent that having access to only one GP surgery is impractical. The increased availability of NHS walk-in services is likely to serve this population best, as would improved occupational health services.

• 3.4.4 We believe that male take-up of GP services could be improved by the more rapid adoption of online self-booked appointments. Many men find the current appointments process – phoning at 8-9am, a time when many are travelling to work, ‘interrogation’ by a receptionist – off-putting and are more likely to use a straightforward, always-accessible and anonymous service. To mitigate the risk that this development would favour men with access to the Internet, we recommend that the potential for making universal automated bookings by telephone is also explored.

• 3.4.5 The workplace as a source of health information, advice and treatment should be better utilised generally. There is good evidence that workplaces with large male populations can help to deliver improved health outcomes through targeted health programmes. BT, for example, worked with the MHF to deliver a successful health improvement campaign (‘Work Fit’) to over 16,000 staff, the overwhelming majority of whom were men.

• 3.4.6 As already outlined, although men often report being uncomfortable seeking help for health issues in traditional settings such as General Practice, they often welcome the opportunity to undertake health checks in non-traditional, but male-friendly environments such as football stadiums and pubs. Many successful men’s health initiatives have sought to take services and health improvement campaigns to men – at work, sports stadia, military bases, pubs and prisons – and have used male-targeted health information, such as MHF booklets designed to look like Haynes’ car maintenance manuals. There are now a number of excellent examples of how these initiatives can be undertaken in a cost-effective manner.

3.5: Examples of cost effective methods of adapting health services to become more gender sensitive

• Knowsley PCT/MBC’s Pitstop programme used social marketing principles to deliver health checks to over 3,000 local men. 85 per cent of men who were followed up reported lifestyle changes [1] .

• NHS Halton and St Helens’ Go campaign encourages men over 40 in deprived areas to take better care of their health and to make more use of health services. 57% of men attending health checks have gone on to access further services, including diet and exercise interventions, smoking cessation and health trainer services [2] .

• Through Premier League Health, 16 top football clubs have developed physical activity and wider health programmes targeting a total of some 4,000 men in deprived communities near their stadia.

3.5.1 This work demonstrates that men are willing to take greater responsibility for their own health if the services provided are sensitive to their needs. These examples provide a good evidence base for further innovative activity in the area of men’s health. Men’s personal responsibility for health must be balanced with the availability of appropriate and accessible gender-sensitive services.

4 Commissioning and Democratic Legitimacy

4.1 Health and Well-being Boards

The idea of establishing health and well-being boards to promote integration across NHS health services, public health and social care is ambitious. An issue of particular concern is the representation of voluntary sector interests on Health and Well-being Boards. There is currently no statutory duty for this. We believe that it is vital that the voluntary sector is represented (probably through the local CVS) at this level.

4.1.1 Careful consideration must be given to the responsibilities of the health and well-being boards and accountability mechanisms at a local and national level. We believe that greater clarity is still required in the Bill in this area.

4.1.2 In the proposed format, it appears that Health and Well-being Boards will contain representatives from GP consortia (who will be working to deliver outcomes, to meet the indicators set out in the NHS Outcomes Framework), the Local Authority (who will be working to deliver national social care outcomes) and Public Health (who will be working to deliver outcomes, to meet the indicators to be set out in the national Public Health Outcomes Framework). However, in theory, the local Joint Strategic Needs Assessment should serve the function of identifying the local needs that all statutory bodies should be addressing.

4.1.3 There are a number of potential conflicts within this system:

4.1.3.1 National vs local priorities

Although the Bill provides for a move towards localism, there is a danger of confusion arising amongst GP consortia and others about the outcomes they should be working to achieve. On the one hand, it is proposed that GP practice income is linked to how well the commissioning of services to meet NHS Outcome Framework indicators is carried out. However, it is the JSNA that will determine the needs of the local community and identify those who are experiencing the worst inequalities. Unless there is integration between local needs and the national NHS Outcomes Framework, there is a danger that these needs may be overlooked. It is vital to bring clarity to this situation.

It is important that the meeting of local health inequalities is monitored. We believe that Health and Well-being boards should have the statutory powers to do this, in collaboration with the NHS Commissioning Board.

4.1.3.2 Who takes responsibility for meeting local needs?

With Local Authorities, GP consortia and the Public Health service all working to meet the needs outlined by JSNA, there must be a mechanism in place to ensure that the most vulnerable and those who it is difficult to access do not ‘fall through the cracks’. There may well be the temptation to pass responsibility to another statutory agency for time-consuming and expensive-to-access groups. There must be a means to ensure that this does not happen. Again, with all bodies working towards different sets of national outcomes, there is the potential for this situation to be problematic, if there isn’t sufficient local and national oversight. Thus it is important that Health and Well-being Boards have an overview and scrutiny function. There should also be an inbuilt mechanism for HWBs to feed back concerns to the NHS Commissioning Board, if they feel that GP consortia are not addressing the needs of local populations as identified by JSNA.

4.1.2 Local and National HealthWatch

Service user representation must not begin and end with local HealthWatch.

4.1.2.1 In order to reach out to marginalised and seldom-heard groups, local authorities and GP consortia will have to engage with these groups in a manner appropriate to them. Traditional consultation methods, such as surveys and focus groups, often overlook these groups. We believe the local HealthWatch groups should be required to engage with the groups identified within the Joint Strategic Needs Assessment as experiencing the greatest health inequalities. This should be done using the most suitable means available within the community, e.g. by working with community, voluntary and faith groups.

HealthWatch England has the potential to become a useful and relevant body. In order for this to happen, it must have real engagement with the NHS commissioning Board.

4.2 Commissioning

4.2.1 NHS Commissioning Board

· 4.2.1.2 We welcome the explicit duty of the NHS Commissioning Board, to promote equality in line with the Equality Act (2010) and tackle health inequalities in access to healthcare. We suggest that in order to fulfil this duty the NHS Commissioning Board should establish a Gender Equalities Board. This Board could take responsibility for developing guidelines to help GP consortia to promote gender equality and tackle inequalities, and to monitor progress on this duty. The Board should be required to publish an annual report on progress towards gender equality in health and the steps it will take to achieve further progress. This work will need to be undertaken in collaboration with the Equality and Human Rights Commission. It is important to note, however, that the EHRC’s ability to lead change within the NHS is limited. The Commissioning Board will therefore have a crucial role. We recommend that this Board co-opt members from relevant statutory and voluntary organisations with expertise in this area. We would be pleased to offer the assistance of the Men’s Health Forum in this endeavour.

· 4.2.1.3 We are unclear as to exactly how the NHS Commissioning Board will monitor the performance of GP consortia in meeting duties to tackle health inequalities and promote equality in line with the Equality Act (2010). The Bill specifies that the NHS Commissioning Board will take over current CQC responsibility of assessing NHS commissioners and will hold GP consortia to account for performance and quality, but it is unclear how this will actually work in practice. We believe that it is important that if the NHS Outcomes Framework is to provide that main means of monitoring performance, that it has indicators around health inequalities built in.

· 4.2.1.4 We believe that the NHS Commissioning Board’s role in providing leadership for quality improvement through commissioning is extremely important. We believe that the commissioning guidance the Commissioning Board will develop in this capacity, will be key to GP consortia commissioning appropriate services and standardising good practice across consortia. We suggest that particular guidance around the commissioning of male-friendly services should be developed.

· 4.2.1.5 We also welcome the duty that the NHS Commissioning Board will assume to tackle inequalities in outcomes from healthcare. Again, in order to fulfil this aim it is vital that the indicators developed within the domains of the National Outcomes Framework reflect this objective.

· 4.2.1.6 The undertaking of the NHS Commissioning Board to promote patient and carer involvement and choice is encouraging. In order for this involvement to be worthwhile, patients must have early input into key decisions. The idea of involving patients in developing commissioning guidelines is to be welcomed. However, it is important that sufficient resources are dedicated to these activities, to ensure that innovative consultations, to access seldom heard patients are carried out. This should be a responsibility for HealthWatch England that the NHS Commissioning Board monitors.

4.2.2 GP Consortia

There are a number of issues that we believe need to be clarified, if the new system is to work to improve the health of men.

· 4.2.2.1 In the past, we know that most Primary Care Trusts have not commissioned services that take proper account of men. We believe it is important to develop practical Guidance that will help GP consortia, the overwhelming majority of which will lack experience in this area.

· 4.2.2.2 We know that the public sector equality duty, which covers gender, will apply to the workings of the NHS Commissioning Board and GP consortia. While the proposals confirm that GP consortia will have a duty to promote equalities, and to work in partnership with local authorities, it is unclear how this will be operationalised. Thus, again we recommend that there are specific indicators within the National Outcomes Framework to incentivise this.

· 4.2.2.3 We also recommend that the reformed Quality Outcomes Framework should include specific indicators to promote gender equality in access to healthcare and in healthcare outcomes.

· 4.2.2.4 Similarly, the proposal to link GP practice income to the outcomes consortia achieve, collaboratively through commissioning and the effectiveness with which they manage financial resources, offers a mechanism for improving men’s health outcomes. We recommend that the commissioning of male-friendly services, and tackling health inequalities are factored into these stated outcomes.

· 4.2.2.5 It is imperative that GP consortia engage with people who do not traditionally access general practice, in order to ensure the commissioning of relevant and suitable services for these groups. The proposed GP consortia duty of patient and public involvement is a step in the right direction on this front. We recommend that this includes a duty to engage with marginalised and seldom heard groups, to take their views on service commissioning into account. This could be achieved by a number of means, e.g. through GP consortia patient panels, by requesting the assistance of local HealthWatch and by engaging with local voluntary, community and faith groups.

· 4.2.2.5 With the abolition of SHAs and PCTs there is a danger of good practice information around men’s health being lost. At the MHF we are in the course of developing a database of good practice in the area of tackling men’s health inequalities. We believe that this offers a means of capturing good practice from across statutory, voluntary and private organisation.

· 4.2.2.6 Extending opening hours, making it easier to book appointments and allowing patients to register with more than one GP should go some way to increasing accessibility. However, this must be coupled with community outreach work. It is vital that GP surgeries adjust service provision to take services to the places where patients are. Opportunistic health checks and health promotion at suitable events and venues such as sports stadia and workplaces should be considered.

· 4.2.2.7 It is currently unclear how the ‘health premium’ will work in practice. We believe that this should be used as a further mechanism to encourage GPs to tackle health inequalities in their communities, paid to GP practices that are particularly successful on this front. However, the level of the health premium is the factor most likely to incentivise GPs to work towards achieving it. Thus, we believe it must be at a high enough level to be attractive to GPs.

5 Conclusions

We believe that the following amendments to the Bill are necessary:

1) Establish a Gender Equalities Board within the NHS Commissioning Board, to ensure that gender health inequalities are tackled throughout the NHS and task it with developing best practice guidance for GP consortia, to assist them to commission and operate gender sensitive health services.

2) Incentivise the commissioning of services that tackle gender inequalities in health outcomes by linking these outcomes to GP practice income.

3) Ensure that local HealthWatch organisations are required to engage with those who experience the worst health inequalities either directly or through appropriate local voluntary, community and faith groups.

4) Ensure that HealthWatch England engages with organisations that represent and have access to seldom-heard and marginalised groups who experience the worst health inequalities.

5) Give Health and Well-being Boards sufficient powers to ensure that GP consortia and others, commission services to address the health inequalities highlighted by local Joint Strategic Needs Assessments.

6) Ensure that the NHS Commissioning Board has sufficient powers to ensure that GP consortia fulfil their duty to tackle health inequalities.

7) Ensure that there is a duty to include voluntary sector representation on Health and Well-being Boards.

March 2011

References