Women's health plan: second annual progress report - January 2024

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Professor Anna Glasier: Scotland’s Women’s Health Champion

"I have thoroughly enjoyed the last year working as the Women’s Health Champion and am truly honoured to be given the opportunity."

It is now almost a year since I took up the post of Women’s Health Champion.

During 2023 I have met with scores of people working in government, in the NHS and in the Third Sector, as well as women themselves, who have kindly shared their experiences and health journeys with me. Their enthusiasm for the Women’s Health Plan has been palpable, and these meetings have helped me to understand how things are currently being done and what the potential barriers are to delivering high-quality services. I have heard many examples of good practice, and, importantly, have connected people who work in similar areas but who don’t know one another.

The Women’s Health Plan includes 66 short, medium and long-term actions. Although being involved with all the actions, when first appointed I chose three areas for my particular focus - menstrual health, menopause, and cardiovascular health.

Within menstrual health I am taking a particular interest in polycystic ovarian syndrome (PCOS) which is less well known than endometriosis, but which affects women from puberty to the post-menopausal years and is associated with an increased risk of cardiovascular disease and diabetes.

I chose the menopause since all women undergo menopause and yet there is widespread misunderstanding about its nature and the options for treatment if women have troublesome symptoms.

Cardiovascular disease (CVD) is among the most common causes of death among women in the UK. Of the four UK nations, Scotland has the highest incidence of both CVD and its associated risk factors. Importantly too, the social determinants of health have a big role to play in disparities in the prevalence of CVD.

Having spent much of my NHS career and my academic research working on contraception and abortion I have also continued to take a particular interest in the work of the sexual health and abortion policy teams.

Working with the Health and Social Care Alliance Scotland (ALLIANCE) provides opportunities to engage with women directly through the Lived Experience Stakeholder Group and raising awareness through speaking at webinars including PCOS and a panel discussion for World Menopause Day on 18th October on all things related to menopause. I recently had an enjoyable visit to the ALLIANCE in Glasgow for an interview with Irene Oldfather to talk about my role as the Women’s Health Champion.

I publish a quarterly blog to keep people informed of what I have been doing as Women’s Health Champion and the wider work that is being achieved.

Working with Health Boards

All Boards are now represented on the Women’s Health Leads Network. I chair a quarterly meeting with the Network where we update members on progress with the Plan. It is a forum for sharing examples of good practice, discussing things that are not going well and agreeing how best to take forward certain elements of the Plan. We have visited NHS Greater Glasgow and Clyde, NHS Lothian and NHS Grampian and held interesting and fruitful discussions on the role of the Boards in improving Women’s Health. In 2024 I hope to visit more Boards.

Menopause

Widespread publicity in the media about the menopause has resulted in a marked increase in women attending their general practice for menopause advice and a subsequent increase in referrals to specialist menopause services. In line with one of the actions of the Women’s Health Plan, all health boards in Scotland now have access to a menopause specialist (the Island Boards through a buddy system). A thriving Scottish Menopause Specialist Network meets quarterly to discuss challenges and facilitators to menopause care.

I feel that much routine menopause management can, and should, be done in General Practice and I strongly believe that there should be a GP in every practice with an interest in women’s health including the menopause. To this end we have been working with NHS Education for Scotland (NES) to develop a free and flexible training programme for healthcare professionals working in general practice in both menstrual health and menopause.

Menstrual Health

Stimulated by the success of the Menopause Specialist Network we have recently set up a Menstrual Health Clinical Network with the aim of improving the management of women with menstrual problems such as heavy menstrual bleeding, endometriosis, polycystic ovarian syndrome etc. It is already a useful forum for discussing difficult cases and providing clinical updates including a recent spotlight on pre-menstrual syndrome (PMS).

Health Inequalities

The purpose of the Women’s Health Plan is to reduce health inequalities and improve health outcomes for women in Scotland. I am working with the Scottish Deep End Project on a pilot study involving taking a specialist Women’s Health Service to a small number of Deep End Practices. The service would offer all aspects of women’s reproductive health care but also use the opportunity to deliver care in a holistic way assessing, for example, risk factors for cardiovascular disease and with a view to improving future health. The aim would be to ensure that practitioners already caring for women benefit from working alongside a women’s health specialist so that they can improve their confidence and the quality of their service.

Cardiovascular disease

I have been working to ensure that the actions within the Women’s Health Plan on cardiovascular disease are progressed. I have set up a small group to help provide tools to ensure that women with cardiovascular disease are given accurate and high-quality advice about prenatal health, contraception and management of the menopause.

Throughout the reproductive life course women have contact with specialist healthcare providers with conditions which are associated with an increased risk of CVD in later life. Premature menopause, PCOS, pregnancy-induced hypertension (PIH) and recurrent miscarriage are all associated with increased CVD risk and yet this lifetime risk is often not communicated to women when they are seen by obstetricians and gynaecologists, who may be focused on managing the immediate concerns and symptoms.

I am now discussing reinstating routine self-monitoring of blood pressure (BP) among women with PIH throughout Scotland. During the Covid-19 pandemic, throughout Scotland women attending maternity services and diagnosed with PIH were given a blood pressure monitor and urine testing strips to self-monitor their condition. After delivery they were asked to return the BP monitor. When service delivery moved into post-pandemic recovery, most health boards stopped the self-monitoring initiative. I am keen to trial encouraging women to keep the BP monitors and participate in regular telemonitoring through the Connect-me BP programme, as while some women with PIH may have their BP checked at the routine post-natal visit they may not be fully made aware of their increased risk of hypertension.

Contraception

Long-acting reversible contraception (LARC): Abortion rates have risen significantly in Scotland in the last year. While many factors influence abortion rates, including access to abortion services; the cost-of-living crisis; changing attitudes towards the acceptability of abortion and to different methods of contraception, it seems likely that access to contraception is playing a role. Contraception is one of the cheapest public health interventions available.

The most commonly used methods of contraception in the UK are oral contraceptives and male condoms which have annual failure rates during typical use of 9% and 18% respectively. The most effective contraceptive methods are the so-called longer-acting reversible methods of contraception (LARC - intrauterine devices and contraceptive implants) with annual failure rates of <1% and much higher continuation rates than pills or condoms. Yet general practices and sexual and reproductive health (SRH) services in Scotland are not meeting the demand for LARC.

With assistance from a short-life working group we have explored the reasons for this and discussed alternative models of LARC provision.

Improving provision of post-partum contraception (PPC): Working with the National PPC Network we are hoping to ensure that all women in Scotland attending antenatal clinics have a routine discussion by 34 weeks gestation on PPC and that their method of choice is recorded in their maternity record.

At a very recent meeting of the Network, we learned that considerable progress is being made with this initiative.

Contraceptive choices for younger women: We are aware of changes in attitude across the UK and Europe whereby younger women (<30 years) are moving away from hormonal contraception. We hope to look into this further with stakeholders from across the UK, and young women themselves, to understand what support we could put in place to provide young women with the information that they need to make decisions about their reproductive health, through access to accurate and comprehensive information resources, in the places where they are.

Reflections on my overall experience

I have thoroughly enjoyed the last year working as the Women’s Health Champion and am truly honoured to be given the opportunity.

Almost without exception everyone I have met has been enthusiastic and unfailingly helpful. I am particularly grateful to Professor Marion Bain and to the civil servants in the Women’s Health Team who have helped me to understand how things work in Government and kept me on the right track.

I think the Plan has made considerable progress in raising the profile of Women’s Health both among the public and among healthcare providers and enthusiasm for the plan is still strong. I hope that in the time that remains to me as Women’s Health Champion I will be able to make tangible changes to improve healthcare for women in Scotland.

Professor Anna Glasier, OBE

Women’s Health Platform

The development of content on the NHS Inform Women’s Health Platform is an ongoing part of the delivery of the Plan.

New content providing information around planning for pregnancy has been added to the platform and a new film has been added to support women around their pelvic floor health.

Spotlight: Taking care of your pelvic health

Whilst not one of the identified priorities in this iteration of the Women’s Health Plan, women’s experience of urinary incontinence and the importance of enabling good pelvic health were identified as areas where women and girls need more information.

A new pelvic health section has been developed on the NHS Inform Women’s Health Platform – with information on pelvic floor muscles, pelvic organ prolapse, transvaginal mesh implants, urinary incontinence in women and urinary tract infection. The content places an emphasis on prevention to optimise future health alongside advice on care and support for those experiencing symptoms.

In August 2023, a new animation on the pelvic floor was added, to illustrate where the pelvic floor muscles are in the body, their function, and why it is important to exercise them like any other muscle in the body.

In January 2024, an additional supportive film was added which provides women and girls with information from healthcare professionals about how a woman’s life course can impact her pelvic floor and future health, why it is important to maintain pelvic floor muscles and how to do pelvic floor exercises.

Did you know?

You can create a QR code for the pages of the women’s health platform that you can share on posters, correspondence etc? Just click ‘create QR code’ in the toolbar.

It’s a quick and easy way to share good quality, reliable health information.

Lived Experience: Health and Social Care Alliance Scotland (the ALLIANCE)

"It was a great meeting and I always learn so much!"

The ALLIANCE’s Lived Experience Stakeholder Group has continued to meet on a quarterly basis. The Group has met with both Scottish Government and NHS staff responsible for actions in the Plan, to discuss progress and input their feedback. This included meeting with the NHS Near Me team to discuss their work on endometriosis, and the Scottish Government heart health policy team. In September 2023, the Group met with Professor Anna Glasier, Women’s Health Champion, to highlight their experiences and priorities.

The ALLIANCE has also supported members of the Stakeholder Group to contribute to other areas of work on women’s health including speaking at ALLIANCE women’s health events, participating in focus groups, and sharing their experiences via blogs and videos. There were also several training and learning workshops across 2023 for lived experience group members to attend at their interest.

Did you know?

You can find out more about the ALLIANCE work on Women’s Health online.

Spotlight: Conversation Café toolkit

In July 2023, the ALLIANCE launched a Conversation Café toolkit for women’s health. The toolkit brings together guidance and resources to support groups, organisations and communities to host independent discussions on women’s health.

A conversation café is an informal space where a small group of people can come together in a facilitated but open conversation on a particular topic. There is emphasis placed on creating an environment where relationships are formed, where everyone feels comfortable to speak, but where listening is also a valuable act.

The model of Conversation Cafés is a way to bring women and people with lived experience together in a safe and supportive environment to debunk myths and dispel shame and allow them to feel listened to and valued when it comes to their health.

The toolkit can be used flexibly by each group to help them set up, host and evaluate their own independent Café. It includes example session plans, prompt discussion questions, facilitator support and links to an online resource hub. The toolkit promotes NHS Inform as a resource to be used within the Cafes so that participants have access to information on their health needs.

Since its launch the ALLIANCE has been working with partners to promote the toolkit’s use across Scotland. An information and support session was held in November 2023, and further facilitator support sessions will continue on a quarterly basis. Interest in the toolkit has been positive, and a number of case studies will be produced next year with groups who have used the toolkit locally.

Did you know?

You can host your own Conversation Café in your community or workplace? You can find out more online.

Sharing good practice in primary care

Policy in Practice

Opportunistic support for women in Dumfries and Galloway: c ervical screening visit

The cervical screening visit, which takes place between ages of 25 and 65, is an ideal opportunity to offer advice, support and signpost to trustworthy resources about aspects of women's health across the life course. A project carried out a number of years ago by Dr Christine Grant and Dr Heather Currie in Ayrshire and Dumfries and Galloway showed the benefits in this approach for providing advice about menopause. A pilot is now underway to expand on this work to other aspects of women's health.

Meetings are currently taking place with practice nurse teams across NHS Dumfries and Galloway to engage, offer support and seek needs. Meetings so far have been resoundingly positive with a willingness to implement and a sense that this is achievable.

Needs identified and resources to be developed so far:

Information leaflets or fold out booklet showing QR codes for more information on stages of contraception, menstrual health, pre pregnancy optimisation of health, menopause, heart health, hypertension to be developed.

Adjustment of cervical screening visit template to include triggers for certain questions for example:

• If not using contraception and trying for pregnancy, advise folic acid etc
• If premenopausal and not trying for pregnancy, advise on menstrual health and contraception if applicable
• If premenopausal and had pregnancies, any history of pre-eclampsia etc to alert re risk of hypertension
• If aged 45+ ask specifically about menopausal symptoms
• If postmenopausal, what age was last period—may alert to those with untreated early menopause and hence a focus on bone and cardiovascular health

If you would like more information about this project, please email womenshealthplan@gov.scot.

Women’s Health Leads

All NHS Boards are now represented on the Women’s Health Leads Network. The Network meets quarterly to discuss areas of learning and challenge across Scotland. The Network also highlights where Scotland wide approaches can be of benefit – which to date has included a national approach to access to LARC and the provision of education around women’s health, through ‘Women’s Health Masterclasses’, aimed at those working in women’s health.

Women’s Health Masterclasses were recommended by the Women’s Health Leads, who articulated the importance of understanding why women experience inequality in their health, how this impacts their lives and what can be done to address it.

In October 2023, the first ‘Women’s Health Masterclass’ was held by NHS Education for Scotland and was attended by 290 colleagues. The first of an ongoing series, ‘Understanding Women’s Health’ featured presentations from Dr Amy Small, Dr Heather Currie, Dr Sarah Luty and Lucia Condron.

More information is available online with more Masterclasses to be held in 2024.

Relationships, Sexual Health and Parenthood (RSHP) Education

The provision of RSHP education is one of the key, evidence-based interventions to support the wellbeing of children and young people. Through the provision of age and stage appropriate education from 3-18 we can support children and young people to understand the importance of happy, safe, healthy and consensual friendships and relationships. This includes learning about issues that can affect women in particular to help promote an early intervention approach.

The Women’s Health Plan highlights the need for access to high quality resources for schools for both parents and teachers, as well as those young people in school and those who struggle to attend.

The revised statutory teaching guidance on RSHP was out for public consultation until November 2023. This guidance links to key RSHP resources, including RSHP.scot and helps schools to provide consistent, high-quality provision of RSHP education for all young people in Scotland.

Parental Engagement on Relationships, Sexual Health and Parenthood (RSHP) Education: ‘the Chat’

A coalition of NHS Boards (NHS Borders, NHS Grampian, NHS Greater Glasgow and Clyde, NHS Tayside and NHS Eileanan Siar) have commissioned an independent company, TASC (Scotland), to conduct a parental engagement exercise exploring RSHP learning, known as ‘the Chat’.

The Chat is a facilitated conversation with parents and carers about where, what, when, why and how children and young people learn about relationships, sexual health and parenthood.

There are four key areas of interest:

1. Finding out from parents and carers how they support their child’s RSHP learning at home.

2. What they know and think about the RSHP learning going on at school.

3. How they want home and school to work together (so that children and young people get the best learning experiences).

4. What would help parents and carers at home in their role as their child’s most important educator on all these matters.

More information about the programme of work can be found online.

Holistic health care for women

Spotlight: Women’s Health Hubs in the Deep End

The aim of the Women’s Health Plan is to improve health outcomes and health services for all women and girls in Scotland. It is underpinned by the acknowledgment that women face particular health inequalities and, in some cases, disadvantages because they are women.

Studies have shown that women do not always receive equal healthcare to men and that outcomes for women are poorer. The conditions in which women and girls live significantly impacts overall health and women’s ability to access healthcare services.

Services are not often developed with the needs of women in mind, and in particular those women who – for numerous reasons – may not have confidence in health practitioners where a relationship of trust has not been established.

All women and girls should have good access to specialist women’s health services, but evidence shows that women who live in more deprived areas need them even more and, in addition, need support to be able to access them.

Working with General Practitioners at the Deep End we plan, over one year, to test a new outreach, community-based approach whereby we bring specialist women’s health services directly to women who need them most, in the general practice setting. The aim being that by providing these services where women feel comfortable, and have already built trusted relationships with staff, there is increased uptake amongst women who are traditionally less likely to access specialist care and support.

Policy in Practice

NHS Highland: Support for Gypsy / Traveller Women’s Groups

An NHS Highland Health Improvement Specialist has been working in partnership with Highland Council Tenants Participation Officer and MECOPP’s Community Health Worker to establish Women’s Groups for Gypsy / Traveller communities, with one worker based in Inverness and one in Fort William.

These groups have followed a ‘conversation cafe’ approach at the pace of the women who have participated. Participation has varied from session to session as these women tend to live a very busy and spontaneous life, revolved around their children. Relationship and trust development has been crucial to the success of these groups, with the women taking the lead on the topics they have discussed. These groups have also included fun activities; building on cooking, baking and crafting skills that the women have been interested in.

Topics that have been discussed during the group sessions have included:

• Oral Health for children: Childsmile worker visited
• Nutrition
• Exercise: with a walking group established in one area
• Smoking cessation
• Accommodation and environmental impacts on health
• Access to primary care including GP’s and Dentists

Health topics that have been asked about by women on a one-to-one basis following the sessions (possibly as these issues are culturally sensitive to discuss in a group) have included:

• Access to contraception: information regarding local sexual health services provided
• Pregnancy: registering with midwives
• RSHP education in schools
• Cervical Smears
• Domestic abuse

Other outcomes have included building trust and confidence in agencies, building social capital and seeing confidence grow.

If you would like more information about this project, please email womenshealthplan@gov.scot.

Women’s Health in Community Pharmacy Services

Did you know?

NHS community pharmacies in Scotland can offer support and advice on women’s health and provide treatment that can be accessed without an appointment with general practice.

NHS Pharmacy First Scotland provides advice, treatment and referral, if necessary, for a number of women’s health issues, for example cystitis, period pain and thrush as well as providing antibiotics for specific common clinical conditions such as uncomplicated UTIs in women.

There’s more information on the service online.

Women can access free emergency hormonal contraception (EHC) from the pharmacist. A three-month supply of progesterone only contraception (POP) is also available free of charge from community pharmacies. Known as ‘bridging contraception’ this supply is available for any women who might need it until they can access a longer-term supply of the contraception they would like. This is usually walk-in without the need for an appointment or blood pressure check.