The Quality Statement for women and girls’ health

Women and girls make up just over 50% of the population in Wales. Despite this, medicine and healthcare services have not necessarily met their needs, resulting in significant disparities in care between men and women, which have only been exacerbated by the pandemic. Whilst 'A Healthier Wales' makes clear its aim of ensuring person-centred care across the country, some approaches to healthcare need to be modified to ensure that women are able to access the care they need in a timely way, that the health service is responsive to their choices, and that research and development reflects women and girls’ lived experiences.

Diagnostic criteria and treatment for conditions that affect both sexes are often based on the male experience, largely because clinical guidelines are not sex or gender-specific but based on a medically modelled approach that often relies on evidence generated in ‘typical’ male experience^[footnote1]. This means that women’s gendered reporting of lived experience and symptoms can be undervalued, overlooked or dismissed^[footnote2]. There are also different patterns of need and presentation across ethnicity, disability, pregnancy and maternity. The health service in Wales must demonstrate competence across all protected characteristics ^[footnote3]to respond to the health needs of women and girls, specifically to reduce inequalities in health outcomes.

Examples of gender inequities are seen in data produced by the Office of National Statistics (ONS), which shows that women can expect to live fewer years ‘disability free’ than men so health inequalities can disproportionally affect women. Evidence on treatment of pain, both post-operative and in emergency settings, suggests that women wait longer than men for pain relief ^[footnote4], and many women report having their symptoms dismissed as either ‘normal’ or erroneously attributed to psychological causes ^[footnote5].  This can adversely impact on wellbeing through significant diagnostic delay, worsening prognoses, and failure to offer effective treatment ^[footnote6].

It is of paramount importance for health board services to reflect women’s needs across a wide range of conditions, not just gynaecological conditions- although menstrual disorders, endometriosis and menopause require significant attention. Women’s symptoms and clinical presentations of cardiac disorders, asthma, incontinence, and mental health conditions are often different to men, and their care must respond by recognising these patterns, and offer women diagnosis and treatment according to their specific needs, through a model of service delivery that is gender and culturally competent. A list of conditions where there is gender inequality and a need for gender competent services that women might require that are different from services historically provided, is at Annex A.

The health and care sector is predominantly composed of women, and any approach which minimises avoidable ill-health in this workforce presents a significant opportunity to improve NHS Wales efficiency, as well as care for individuals.  Health boards need to ensure their staff are appropriately supported whenever they need to access services, including through experiences of menstrual related pain and menopause.

Services for women and girls must also respond to the differing needs of individuals with protected characteristics under the Equality Act 2010, including the Anti-Racism plan for Wales, and services for people across all gender identities. People who are transitioning or non-binary may also encounter gender-related health issues. Health boards must acknowledge this and ensure they are offered appropriate care and support.

The introduction of quality statements was signalled in A Healthier Wales and has been described in the National Clinical Framework as the next level of national planning for specific clinical services, as part of an enhanced focus on quality in healthcare delivery. Quality statements set expectations for the future planning and accountability arrangements for the NHS in Wales.

Health boards and trusts are responsible for planning and delivery of women’s health services in line with professional standards and the quality attributes set out below. Health boards and trusts will be directed, supported and enabled to deliver improved services for women and girls by both the NHS Executive function and the Welsh Government’s Women’s Health Implementation Group or its successor.

The Women’s Health Plan being developed by the NHS Wales Collaborative must look to deliver the ambitions of this Quality Statement.

Equitable

1. There will be a national approach to service improvement led by the NHS Executive, who will consider whether a network board for women’s health should be established.

2. Health boards will collaborate across health services to support equity of access for women and girls to care pathways, consistency in standards of care, address unwarranted variation and provide mutual aid when necessary.

3. Services for women and girls will be measured and held accountable using metrics, clinical data and peer review that reflect the quality of patient care and its outcomes. Health boards will utilise the analytical capabilities of the National Data Resource to support evidence-based services for women and girls

4. Health boards will ensure the women’s health workforce is supported and developed, to address staff retention, comply with relevant standards including anti racist and anti-oppressive skills, and provide sustainable capacity to meet demand. This will entail a focus on developing service provision by nurses and allied health professionals to respond to models of care that meet the needs of women and girls.

5. Health boards will ensure appropriate levels of diagnostic, therapeutic and surgical capacity to enable women who require interventions for health needs specific to women and girls including menstrual and fertility care, endometriosis and menopause, to receive care as close as possible to home without significant waits.

6. Health boards will ensure provision of access to evidence-based support for reproductive choices, including abortion, IVF, clinical genetics and antenatal diagnosis, miscarriage/ pregnancy loss and bereavement support.

7. Health boards will support women and girls with regard to all protected characteristics throughout the whole life course. This will require a continuum of care including public health and prevention, screening, diagnostic and therapeutic interventions throughout their lifetime, to help women lead healthy and fulfilling lives for as long as possible.

Safe

8. Health boards will ensure an immediate system-level focus on transforming pathways in line with recognised care standards and evidence based clinical guidance to enable recovery and reset of services to at least pre-pandemic levels.

9. Health boards will ensure that services which are fragile or cannot meet recognised standards (e.g., NICE guidance or national audit standards) will reconfigure into more resilient regional, supra-regional or national services, using RPB or Primary Care cluster models as appropriate. This is of particular importance in the delivery of tertiary gynaecological services, where there is known to be fragility.

10. Health boards will support women who have experienced health adversity as a consequence of previous treatment. Examples of this are in relation to the use of vaginal mesh and tape, and the use of sodium valproate ^[footnote7]

Effective

11. Health boards will ensure that national, evidence-based pathways for women’s health services will be co-produced, comprehensive, and fully embedded in local service delivery.

12. Health boards will ensure that evidence-based surgical techniques and therapies are available without delay throughout the care pathway. This will include effective use of specialist Women’s physiotherapy and Sacral Nerve Stimulation in the treatment of bladder and bowel conditions

13. Health boards will consider the benefits of a Pelvic Health Hub approach to gynaecological care to maximise benefits of joined-up care at the earliest stage.

Efficient

14. Health boards will ensure they adopt a blended approach to clinical consultations with the use of digital capability and virtual appointments.

15. Health boards will work with partners to further develop research, innovation, and education to enable delivery of a high quality, evidenced based, gender and culturally competent clinical care by a well-trained workforce.

16. There will be a national approach to informatics systems to provide rapid diagnostics and relevant, high quality, standardised data available by gender to drive service improvement.

17. Health boards will adopt a wider use of novel IT solutions such as Endometriosis Cymru to support early diagnosis and treatment.

Person-centred

18. Health boards will adopt a collaborative and equitable approach to person-centred care which is culturally embedded, anti-racist and anti-oppressive.

19. Health boards will adopt care pathways supported by a common approach to referral, escalation of care, follow-up and rehabilitation.

20. Health boards will ensure that women and girls receive appropriate gender-based care, taking account of the differences that exist in presentation of symptoms and diagnosis.

21. Health boards will ensure their care plans are co-produced and consistent with NICE guidance on shared decision-making to ensure women and girls achieve the health outcomes that matter to them.

Timely

22. Health boards will ensure timely access to all appropriate services for women, not just gynaecology services, in line with patient need including early recognition and intervention for patients whose condition is at risk of deterioration.

23. Health boards will provide care pathways that minimise delays in treatment, maximise join-up of services, emphasise good communication between professionals and service users, and make every contact count.

Asthma

Autism

Autoimmune conditions

Anaesthesia

Behavioural disorders

Bone health and osteoporosis

Cancer screening and diagnosis

Carer wellbeing

Carpal tunnel syndrome

Chronic fatigue syndrome/ME

Continence- bowel and bladder control problems, and infections

Dementia and fragility

Dental care

Endometriosis

Fertility management, abortion and contraception

Fibromyalgia

Heart disease and Stroke

Hypermobility

Irritable bowel syndrome

Maternity services

Menstrual health and menopause

Mental wellbeing, anxiety and depression

Migraine

Obesity

Prolapse and gynaecological disorders

Research and development inclusion

Screening and prevention

Thyroid diseases

Violence against women and girls, domestic abuse and sexual violence

The NHS Executive will develop service specifications for women’s health services to inform accountability discussions. These will be added as they become available.

[1] Caroline Criado Perez ‘Invisible women – exposing data bias in a world designed for men’ Chatto and Windus 2019

[2] Cleghorn, Elinor ‘Unwell Women: Misdiagnosis and Myth in a Man-Made World’, Dutton, June 2021

[3] Equality Act 2010

[4] Robertson, J. (2014) Waiting Time at the Emergency Department from a Gender Equality Perspective 

[5] Floyd, B. (1997) Problems of accurate medica diagnosis of depression in female patients 

[6] Kiesel, L. (2017) Women and Pain

[7] First do no harm Independent Medicines and Medical Devices Study published by Baroness Cumberlege 2021