HC 1048-III Health CommitteeWritten evidence from Women’s Health and Equality Consortium (PH 57)

1. The Women’s Health and Equality Consortium (WHEC) was set up in 2008 as a Strategic Partner to the Department of Health with a view to addressing women’s health inequalities across England. WHEC is a partnership of women’s organisations, all of whom share the common goals of improved health and equality for girls and women. WHEC informs policy making by giving women’s organisations voice and visibility, and incorporating their views into our work.

2. This submission focuses on the key issues women and girls face to good health and wellbeing. In doing so, it draws on evidence from:

focus groups we held with over 120 women and girls and with over 80 representatives of the women’s sector, about their health and wellbeing; and

published documents and research reports.

3. Summary

Women and girls face particular threats to their health, including poverty and low pay, Violence Against Women and Girls (VAWG), discrimination, depression, a lack of confidence in their GP’s and not knowing what services and support is available.

Our research with girls and women showed that these specific barriers they face to accessing health and social care services have a negative impact on their physical, mental and emotional health. Yet the reforms lack a focus on addressing barriers to health and social care.

The NHS reforms and new structures must take account of the health inequalities women and girls face if they are to benefit from the new Public Health System. Gender must be included in any definition of “health inequalities”.

The creation of Public Health England within the Department of Health

4. Public Health England should have national oversight, particularly since local authorities face large budget cuts and there is potential for essential services to be lost (for example, Devon council proposed to cut all domestic violence services). It is not clear what sanctions will be used for not ring-fencing the public health budget – nor what “public health” is limited to.

5. Public Health England should work across government to ensure other decisions being made, do not compromise public health efforts (for example, changes to housing benefits, the cuts to welfare, the loss of jobs, pay freezes and reduced pensions within the NHS, all disproportionately impact women’s incomes and therefore health). It will be important that it is able to work effectively within the current context of national and local cuts; both in terms of its own resources within the DH, and in its ability to work more broadly to address some of the major challenges to public health that lie elsewhere. For example, it is not clear where responsibility lies in calculating the health impact of wider government reforms. There is a direct correlation between income transfers through social welfare and improved health outcomes. Benefits paid to women also substantially improve the health of women and their children.

The public health role of the Secretary of State

6. The Secretary of State should maintain some responsibility over public health to ensure proper accountability and national oversight. There needs to be central leadership to prioritise equality and that the opportunity to utilise the skills and intelligence of the Voluntary and Community Sector is incorporated.

7. Parliament should have a role in scrutinising the work of commissioners and the decisions they make.

The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

8. Directors of Public Health need to engage with VCS organisations to ensure diverse views and voices are heard. It is important that they have a central role in remaining independent and are responsible for ensuring the best evidence is used – including that of the VCS.

9. Health and Wellbeing Boards should have representation from diverse groups of VCS organisations to fully utilise their knowledge and expertise; and they need to have more powers to hold GP Commissioning Consortia to account. The VCS is not only a service provider, but also has vast and extensive knowledge about the needs of local populations, of what services exist, what works, and where there are gaps.

10. Additionally, the women’s sector has a history of directly responding to women’s health needs at national and local level, although the services they provide have not been readily linked or identified within JSNA and other local strategies. The sector has an in-depth knowledge of how to deliver services that take a “whole person” or holistic approach, which is able to fully address the multiple causes and consequences of issues women face and the impact on their health.

11. Local authorities will have responsibility for public health, which could allow for a more joined-up approach. However, the cuts to local authorities and social care budgets are likely to result in local authorities restricting services. This will further increase unmet need and gaps that women and girls already face, which will be compounded further by the of impact of cuts to women’s organisations.

Arrangements for public health involvement in the commissioning of NHS services

12. There was much concern raised in WHEC’s consultation events around the shift to using an “any willing provider” tendering process which could mean smaller and less resourced VCS can not compete to bid for contracts. This is of particular concern to small organisations providing specific support to particular people in society eg Black, Asian, Minority Ethnic or Refugee (BAMER) women seeking support for mental health problems. Central and local government play an important role in supporting and promoting the role of the VCS through intelligent commissioning and working in partnership with the sector in identifying need and developing service specifications that promote the role, value and impact of specialist provisions.

13. It is unlikely that preventative care will be invested in within NHS budgets unless there is more central leadership and a duty to do so, since there is more glory in stopping a problem than preventing it, and the impact of prevention is only visible in the long-tem. There will need to be more clarity as to how health and wellbeing boards will be able to influence GP Commissioning Consortia, and how consortia will respond to local health and wellbeing strategies. There is also a lack of accountability of consortia in their constitutions around tackling health inequalities.

14. Our focus groups highlighted mistrust, particularly by younger and marginalised women and girls of their GPs. Additionally the organisations WHEC engaged with have expressed caution about the knowledge GPs and some local authorities with regards to women’s health needs, particularly around violence against women and girls (VAWG) and the different forms it takes, for example, the harmful practices women and girls are subject to including FGM. It will be important that GPs receive training about these key public health issues.

15. There are key public health issues that impact women and girls that need much more acknowledgment within the NHS to ensure the appropriate service response. For example:

Violence Against Women and Girls (VAWG)—More than one in four women (4.8 million) aged between 16 and 59 have been affected by domestic abuse, 23% of women have being sexually assaulted as an adult and up to 6,500 girls are at risk of female genital mutilation (FGM) in the UK every year. Long-term consequences of sexual violence and child sexual abuse include post-traumatic stress disorder, anxiety and panic attacks, depression, social phobia, substance abuse, obesity, eating disorders, self harm and suicide, domestic violence and in some cases, offending behaviour.

Anxiety and depression—Recorded rates of anxiety and depression are one and a half to two times higher in women than in men and a staggering 63% of girls and women have experienced some form of low-level mental health problem. Many of the reasons for this are a direct consequence of gender inequality including experience of violence, economic inequality, debt, pregnancy, gender stereotypes and insufficient support.

Arrangements for commissioning public health services

16. As we have set out in paragraph 12, the “any qualified provider” tendering process risks putting smaller organisations at a disadvantage, who cannot compete with large better resourced organisations (at a lower price and limited capacity to go through lengthy processes). WHEC believe this process will therefore place well established specialist services at risk of closure and in doing so, services that are highly competent in delivering support for women and girls, are marginalised from commissioning processes. For example, there is a great deal of documented evidence and research showing that women trust and use women-only services. More needs to be done to ensure GPs, for example, are aware of what is available in their areas and the types of interventions that have a positive impact on the health and wellbeing of women and girls.

17. There needs to be more detail as to how the VCS, which already provides effective services that are value for money to groups facing some of the greatest health inequalities, will be supported in the new public health structures. The capacity limitations of VCS organisations and their ways of working must be understood by commissioners and local authorities.

The structure and purpose of the Public Health Outcomes Framework

18. The proposed outcomes framework does not provide detail as to how gender inequality will be measured and monitored, or how the data for the indicators will be broken down by equality characteristic to ensure inequalities can be tackled. The final outcomes framework needs to disaggregate data by equality groups, but also local authorities will need to be encouraged to address the issues that do not make it onto the final framework.

19. There is a serious lack of acknowledgment of the issues women and girls face in the proposed framework, and it is not clear how this will be addressed. Depression, poverty and VAWG should be included as indicators. The main health issues they face across their life course include:

Young women’s health issues include higher rates of self-harm (nearly four time more than boys), body image issues (one in five are unhappy with how they look), eating disorders (one in every 20 women will experience some form of eating distress during her lifetime, with the majority of sufferers aged between 14 and 25), low-level mental health problems and sexual health and healthy relationship issues.

There is a lack of investment in ensuring high quality maternal health and social care for all pregnant women and mothers, despite a pre-election pledge to increase the number of midwives by the Prime Minister. The months surrounding the birth of a baby carry the greatest risk for women of developing mental illness – with 15% experiencing postnatal depression. Perinatal mental ill health is a potentially preventable cause of maternal mortality. Teenage mothers are three times more likely to suffer from postnatal depression and other mental health problems than older mothers. Furthermore, more than one in ten women reported significant depressive symptoms during pregnancy. The majority do not receive adequate support, and this is even more so for vulnerable women, including mothers living in poverty, BME women, asylum seeker and refugee women and teenage mothers.

Women in later life are often living with the cumulative impact of poverty, having had lower earnings throughout their lives and are more dependent on state pensions than older men. They experience higher rates of long-term illness, but also mental health problems – women aged 50 to 54 have the highest prevalence rates for any neurotic disorder (25%). Older women are particularly vulnerable to the factors leading to poor mental health including poverty, social isolation, chronic illness, living in care and the loss of loved ones. They are also more likely than men to suffer from physical ill health and longer-term disability, leading to restrictions in mobility and inability to care for themselves.

Arrangements for funding public health services (including the Health Premium)

20. Funding should be used to address need rather than as a notional reward for progress. Targeting resources to improve health inequalities (by investing where there are high levels of deprivation, households with low incomes and complex needs), would be a better way of supporting good public health outcomes for the nation. The proposal for a health premium could see areas with less complex health issues receive further funding, whilst those with layers of complex public health issues would be penalised. Financial reward being aligned with progress made around the outcomes framework may mean public health issues beyond what is included in the final framework, would risk being ignored.

The future of the public health workforce (including the regulation of public health professionals)

21. Regulation of public health professionals is important for the safeguarding of service-users and to maintain the credibility of the workforce to the public. However, regulation should not result in the exclusion of the VCS as part of the public health workforce because of limited capacity.

22. Training on equality and gender to tackle barriers groups face in receiving care as well as receiving a response that provides appropriate services, is essential.

23. There must be clear processes of accountability within the new public health system and the professionals working within it.

How the Government is responding to the Marmot Review on health inequalities

24. WHEC feels the Government’s response has been inadequate. There has not been a rise in the promised number of mid-wives – which is an essential aspect of improving maternity care and the wellbeing of mothers and babies. Additionally, the Government failed to include the Review’s essential recommendation to ensure a decent standard of living for all, which is likely to get worse under proposed cuts to public services and job losses. Women also make up larger proportion of those relying on benefits, which are not paid at an adequate level to maintain a healthy standard of living.

25. We are extremely disappointed that pilots on breastfeeding, set out in the strategy, have been cut. As the Marmot Review pointed out, breastfeeding is of central importance for the physical and mental health of women and their children. This decision is of deep concern to the women’s sector, and reflects a clear lack of commitment to issues affecting women.

26. There needs to be more integration of disadvantaged groups set out under the Equality Act 2010 (including gender, race and ethnicity, age, disability, religion and/or belief, sexual orientation, gender reassignment, pregnancy and maternity, marriage and civil partnerships) as part of the Government’s discussion and action to address “health inequalities”.

27. The barriers to accessing health and social care, leading to unequal and unacceptable differences in health outcomes, must be included in any discussion of public health and population wellbeing. Health inequalities will narrow where there are appropriate services that respond to need (including women-only services) and where this is fully integrated into the health system.

June 2011

Prepared 28th November 2011