Women's health plan

9 Priorities, aims and actions

This section details work undertaken by sub-groups and the actions each group has developed.

These actions have been separated by priority area then into their anticipated timescales for delivery; short, medium and long-term. We will begin the implementation of some of the longer term actions within the next one to three years, but acknowledge they will take longer to fully deliver.

More detail, including who has responsibility for implementation of each action, will be provided in an Implementation Plan.

Short Term– delivery within one year

Medium Term– delivery within one to three years

Long Term– delivery within three years or more

Corinne Love, Vice Chair Women's Health Group, Consultant Obstetrician and Gynaecologist, Senior Medical Officer - Scottish Government

As an obstetrician and gynaecologist I have a specialist clinical interest in women's reproductive health so have been delighted to be Vice Chair of the Women's Health Group. I am acutely aware that this is just one part of a woman's journey through life and if we are to improve the health of women in Scotland we need to look beyond reproductive health.

In our discussions, both in our sub-groups and with the women we spoke to, we have identified some themes that cut across all areas and key actions that will go some way to ensuring that women have better access to information about their health and how to make positive life choices. This section includes actions to ensure that services are joined up, accessible and inclusive, and that we are innovative in our approach to addressing the needs of all, but particularly the most disadvantaged or marginalised, women in Scotland.

The actions that cut across all of our priority areas are set out below, and will underpin many of the other actions in this Plan. Many of these actions were recommended by more than one sub-group.

9.1 Actions which cut across all priority areas

Actions

Short Term

• Establish a central platform for information on women's health on NHS Inform.
• Seek women's lived experience, through the continuation of a lived experience group, to inform health policy and improve healthcare services and to ensure women are meaningfully involved in decision making and priority setting going forward.
• Share examples of good practice to encourage primary care to consider different and more flexible options for provision of women's health services to best meet the needs of their communities.
• Promote the use of video or telephone consultation where appropriate to support access to services for women, particularly those who may otherwise be required to travel long distances or who may have difficulty travelling to appointments.

Medium Term

• Establish a national Women's Health Champion and a Women's Health Lead in every NHS board to drive change and share best practice and innovation.
• Promote use of Relationships, Sexual Health and Parenthood (RSHP) resources to teachers and parents as part of the school curriculum and to support workers to ensure young people who are non-attenders or not in mainstream education have access to resources.
• Improve collection and use of data, including qualitative evidence of women's lived experiences, ensuring disaggregation by protected characteristics. Robust intersectional analysis of this data should be used to inform service design and improve healthcare services and women's care and experiences.

Long Term

• Adopt a life course approach in all services to improve women's health holistically.
• Provide and promote a 'Women's Health' Community Pharmacy service.
• Establish a Women's Health Research Fund with the aim of closing gaps in scientific and medical knowledge in women's health for both sex specific and non sex-specific conditions.
• Develop a programme to ensure that cultural competence, gender competence, trauma informed practice and human rights is embedded as a core component within all clinical education, training and Continuing Professional Development (CPD).

9.2 Contraception, abortion, sexual health and pre-pregnancy

Alison Scott, Consultant Obstetrician and Gynaecologist, specialising in sexual health, NHS Lothian

I was very privileged to chair the sub-group of the Women's Health Plan which was tasked with reviewing contraception, abortion and pre-pregnancy care. Having worked as a consultant gynaecologist in sexual health, I am passionate about equitable access to healthcare. Some years ago, I established a service for women who are socially excluded, have complex medical and social histories and are at high risk of unintended pregnancies and sexual ill health. I quickly learned how difficult it was for some people to access healthcare whilst also struggling to manage issues such as poverty, substance misuse, having children removed and/or trying to cope with domestic abuse, sexual assault or other traumas. Whilst as clinicians, our priorities relate to health and wellbeing, for the women I met their priorities often related to securing their housing, avoiding violence or ensuring they had money to feed their children. Working together with the third sector changed how we engaged with women. It allowed women to be supported in multiple ways and once their social issues were resolved, they could then focus on positive choices regarding their health.

There are other groups of women too who may struggle to access healthcare, for example those living in geographically remote areas, those from minority ethnic groups, and disabled women, who all face barriers to receiving care and enjoying healthy, safe lives within their communities.

Members of the Sexual Health sub-group included specialist clinicians, GPs, nurses, third sector representation and Scottish Government policy leads, bringing with them years of experience of working with and supporting women directly. I am very grateful for their commitment to improving care for women through the Women's Health Plan.

The specific actions developed by the sub-group are set out below. In developing these one of our main considerations was that care must be accessible, holistic and person-centred. Care should be dictated by the woman's needs, priorities and preferences and not restricted to what a service provides. Women are about more than reproduction and simply addressing sexual health issues misses opportunities to provide other information or interventions that can hugely improve quality of life, health and wellbeing.

Moving to provision of more holistic care, for some, will be a big cultural shift. It involves deploying staff in different settings and taking services to women rather than expecting women to travel to services which only address reproductive needs. How these services are delivered will vary according to geographical area and also population need. Creative models of care are needed, and we must build on the examples of these that already exist in many areas of Scotland. Women need to be supported to address the needs they feel are the most important for them. Doing this leads to an increased likelihood of positive choices, stability and better health outcomes in the longer term.

We want to achieve the following:

Improve access to abortion services.

1. All women will be able to access timely abortion care without judgment.

2. All women will have choice about how and where they access abortion care.

Short Term

• Make telephone or video consultation universally available as an option for abortion services.
• For post abortion contraception, provide all women with 6 or 12 months progestogen only pill with their abortion medications. Fast track to long acting reversible contraception if desired.
• Review data collected on abortions to ensure it is relevant, whilst protecting anonymity.

Medium Term

• NHS, Local Authorities, Justice agencies and Scottish Government to work together to find ways of preventing women feeling harassed when accessing abortion care due to protests or vigils.
• Increase options for women around where they can take abortion medication (mifepristone).
• Provide mid-trimester abortion care locally or regionally for all indications.

Long Term

• Build on the recommendations above by reviewing the provision of abortion services in Scotland to ensure services for all those deciding to terminate their pregnancy are fully accessible and person-centred.

Improve access to contraception services, including rapid and easily accessible postnatal contraception.

1. All women will be able to access a full range of contraception easily, quickly and confidentially.

2. All women will be able to access sexual health services easily, quickly and confidentially.

3. All women, who choose to become pregnant, will have easy access to the information and advice they need to best prepare themselves for pregnancy.

Short Term

• Promote use of video or telephone, in addition to face-to-face, consultation for women, including those in prisons, to provide greater privacy, dignity, choice and flexibility.
• Provide accessible information and advice on pre-pregnancy care.

Medium Term

• Develop a Framework for Pre-pregnancy Care, to raise awareness and understanding of the importance of optimising health before pregnancy, including healthy diet, keeping active, stopping smoking and the risk of drinking alcohol during pregnancy or when planning for pregnancy.
• Provide training for non-NHS staff to support conversations with women about health and healthcare services.
• Provide creative, holistic and outreach models of care for sexual health and contraception services.
• Increase availability of LARC (Long Acting Reversible Contraceptive) as one of a range of options for contraception available to women.
• Ensure that discussions on contraception take place during pregnancy. Women should be given adequate and appropriate information on their options, as well as rapid access to their preferred method where applicable.

Long Term

• Provide more routine sexual healthcare through primary care, community pharmacies and online where appropriate, to enable specialist sexual health services to prioritise those most at risk of sexual ill health or unintended pregnancy.

9.3 Menopause, menstrual health including endometriosis

Heather Currie, Consultant Gynaecologist and Associate Medical Director – NHS Dumfries and Galloway

As a gynaecologist with special interest in menopause, I have been delighted to have the opportunity to help develop the Women's Health Plan for Scotland, by chairing the sub-group addressing menopause, and menstrual health, including endometriosis.

Most women and girls experience menstrual cycles and yet many are unaware of, and unprepared for, the impact that each cycle can have. The impact can be both from the physical aspect of bleeding and how that is dealt with, but also the multitude of symptoms that can arise from the natural hormonal fluctuations.

Endometriosis can cause significant morbidity and additional distress exists due to delay in diagnosis and appropriate management.

Menopause affects all women and yet many feel unaware of and unprepared for the range, severity and impact of symptoms, and of treatment options. In addition, there is little awareness of the impact of menopause on later health, especially when menopause occurs early, and opportunities are missed to inform and advise. The general lack of awareness is sometimes compounded by inconsistent messages provided by healthcare professionals.

Working with representatives from primary care, gynaecology, sexual health, community pharmacy, third sector, and Scottish Government policy leads we have developed a number of actions which we hope will address many of the issues highlighted in research and by women with lived experience. Some of these will be straightforward to implement, all are achievable, and some will be life-changing. The combined expertise and commitment of this group to providing the best care possible for women has been invaluable.

While our aims are set out below, key points are worth additional mention in line with key themes identified by this sub-group; information and consistency. With the focus on provision of information, education from an early age is paramount, with additional opportunities identified to reinforce key messages at later stages, in line with the life course approach. Cognisance has been taken of the need for information to be consistent, reliable and accessible, in line with the overarching ambition of the Plan. Of all aspects of Women's Health, the area which often leads to inconsistent advice being given is around menopause. The need for education of healthcare professionals has been recognised and addressed, with the aim of women receiving consistent advice throughout Scotland.

Improve access to information for girls and women on menstrual health and management options.

Improve access for women to appropriate support, speedy diagnosis and best treatment for endometriosis.

1. All young people will be aware of normal menstrual health.

2. Average diagnosis time for endometriosis will be reduced.

3. All women will be able to access the right support and effective treatment for endometriosis.

4. When required, all women will have access to a specialist endometriosis centre.

Short Term

• Promote the use of positive language around menstrual health.
• Where appropriate offer women who are eligible for combined hormonal contraception, the option of a continuous or extended regimen and raise awareness of the option of no bleeding, even if contraception is not required.

Medium Term

• Use existing programmes, such as the HPV vaccination programme, to provide general information to young people about periods, menstrual health and management options.
• Provide access in each primary care team to a Healthcare Professional (HCP) or HCPs who have a specialist knowledge in menstrual health including awareness of the symptoms of PMS, PMDD, heavy menstrual bleeding, endometriosis and their treatment options.
• Implement and raise awareness of current national guidelines on endometriosis and develop and implement further pathways for care where these don't currently exist – for example endometriosis outside the pelvis.
• Commission endometriosis research to find the cause of the condition, leading to the development of better treatment and management options, and a cure.

Long Term

• Strengthen collaborative working between regional specialist endometriosis centres, territorial and special NHS boards and primary care providers, to drive improvement in patient pathways and achieve equitable access to care and treatment.

Ensure women who need it have access to specialist menopause services for advice and support on the diagnosis and management of menopause.

1. When required, all women will have timely access to menopause support and services.

2. Healthcare professionals (HCPs) will be aware of the impact medical or surgical treatments to induce menopause have on subsequent health.

3. All women will have access to a healthcare professional with an interest in menopause through primary care.

Short Term

• Develop, maintain and promote a support network for Menopause Specialists throughout Scotland. Each healthcare professional (HCP) with special interest in menopause should have access to at least one Menopause Specialist for advice, support, onward referral and leadership of multidisciplinary education.
• Provide a holistic approach to care by promoting greater joint working between healthcare professionals on menopause diagnosis and treatment across primary and secondary care and specialist clinics, including through joint education sessions starting with pre and post qualification training on gynaecology.
• Establish a dedicated menopause policy post within Scottish Government.

Medium Term

• Provide access in each primary care team to a HCP who has a special interest in menopause.
• Provide a specialist menopause service in every NHS Board, and where sub specialisation is impractical (eg. islands) develop a buddy system.
• Develop a menopause and menstrual health workplace policy, as an example of best practice, starting with NHSScotland, and promote across the public, private and third sector.
• Ensure women are properly supported around the time of menopause to assess their future risk of osteoporosis and fractures and given appropriate lifestyle advice.
• Launch a public health campaign to remove stigma and raise awareness of the symptoms of menopause.

Long Term

• Build a basic understanding of menopause among all healthcare professionals. This should include awareness of the symptoms of perimenopause and menopause and awareness of intermediate and long-term consequences, and know where to signpost women for advice and support.
• Acknowledge the importance of menopause, menstrual health and endometriosis within mental health policy, ensuring policies recognise the impact these conditions can have on women's mental as well as physical health, including awareness of the symptoms of PMS and PMDD.

9.4 Heart health

Maggie Simpson, Senior Nurse Specialist and Chair of the Scottish Obstetric Cardiology Network

Heart disease remains the leading cause of death for women in Scotland and is responsible for significant morbidity and reduced quality of life. When we talk about cardiovascular disease (CVD), we often do so in relation to specific conditions such as heart attacks and usually in the context of CVD in men. Therefore, there is a need to expand the narrative of CVD in Scotland, raising awareness of the range of CVD as well as CVD risk in women. This is required, not only in the public domain, but also among policy makers and healthcare professionals.

Women face several challenges in maintaining optimal heart health. There is a growing body of evidence which demonstrates that women presenting with symptoms of heart disease are under-investigated, less likely to access guideline recommended treatments and often have worse outcomes following interventions. Women are also less likely to have appropriate management of CVD risk factors such as diabetes and high blood pressure. This is further compounded by unique risk factors for CVD in women, including adverse pregnancy outcomes (hypertensive disorders of pregnancy, pre-term delivery, gestational diabetes or small gestational age), use of contraceptives that increase risk in CVD as well as endometriosis and menopause. In addition, there is often a failure to recognise CVD in younger women who present to healthcare services.

Women in Scotland who are born with CVD, either inherited or congenital, or who acquire heart disease, require lifelong care. The frequency and extent of that care will vary across the woman's lifespan and there are specific points in their care pathway that require particular focus. This includes the period of transition from paediatric to adult cardiac services, where there is a risk of patients being lost to follow-up. Women require appropriate education on the importance of safe contraception, the impact of pregnancy on their heart condition as well as reducing lifetime risk of CVD. It is therefore essential that women at risk of, or who have a CVD diagnosis, have access to healthcare professionals (HCPs) who are aware of sex-specific differences in the risk factors, presentation and management of CVD in women. These HCPs should be opportunistic in promoting good heart health.

Disparities in CVD outcomes for women are also associated with social determinants of health including access to healthcare services that meet the needs of women. Women are under-represented in health research related to CVD which has implications for recommendations on optimal care for women at risk of or who have a diagnosis of CVD. There remains under-representation of female cardiologists and of female clinicians in roles that design and develop guidelines and research in CVD.

Addressing disparities in CVD care for women in Scotland requires a life course approach that acknowledges their specific needs. Cross-specialty and multi-professional collaboration with the woman at the centre is essential.

The configuration of the 'Heart Health' sub-group of the Women's Health Plan reflects the multi-disciplinary approach required to improve outcomes and quality of life for women at risk of or living with heart disease in Scotland. Actions to address the disparities in cardiovascular health for women developed by the sub-group are set out below. These focus on raising awareness of CVD in women, providing a consistent message for the public and healthcare professionals, developing educational opportunities and promoting multi-disciplinary collaboration supported by pathways of care. This also includes the sharing of best practice.

It has been a pleasure to develop these actions with colleagues who are passionate about improving CVD outcomes. I would like to give special thanks to the women with lived experience of CVD whose voice has inspired us and provided additional motivation to take this work forward.

Reduce inequalities in health outcomes related to cardiac disease

1. Opportunities for optimisation of cardiovascular health and risk reduction will be taken across a woman's life course.

2. Healthcare professionals will be aware of sex-related differences in presentation and management of heart disease in women and act to reduce inequality of care and improve outcomes.

3. All women will have access to information on the risk factors for and symptoms of heart disease enabling them to quickly and confidently describe their own symptoms when speaking to healthcare professionals.

4. All women with heart disease will receive appropriate support in managing their risk factors, recovery and living with a long-term cardiac condition through appropriate follow up and access to cardiac rehabilitation and psychological support.

5. All women with heart disease will be provided with individualised advice and co-ordinated care to access safe contraception, abortion, assisted conception, pregnancy and gynaecological care.

Short Term

• In all heart health consultations, opportunities should be taken to provide individualised advice and care to women, and in all pregnancy and pre-pregnancy discussions and interactions opportunities should be taken to optimise women's heart health to optimise women's holistic health as part of the life course approach.
• Where research shows there are sex-related differences in prevention, diagnosis, investigation or treatment of CVD these should be detailed in guidelines and pathways.
• Improve information and public awareness of heart disease symptoms and risks for women.

Medium Term

• Ensure women with CVD have access to mental health support, regardless of whether they are accessing a cardiac rehabilitation programme.
• Establish appropriate representation of women in clinical research and where appropriate pregnant and postpartum women should be included in clinical trials.
• Establish a peer support forum for women with lived experience of CVD.

Long Term

• Improve awareness and education among healthcare professionals of sex-related differences in presentation and management of heart disease in women of all ages.
• As part of Cardiac Rehab, provide an individualised biopsychosocial assessment and a shared decision care plan with interventions specific to women's needs and choices.
• Encourage increased representation of women clinicians by promoting diverse role models and encourage mentoring for trainees.
• Every cardiology department will have access to a clinician with expertise in women's heart health.
• Establish appropriate representation of women clinicians on guideline committees and within research design and development teams.

9.5 Gender and health

Emma Ritch, National Advisory Council on Women and Girls and Executive Director of Engender

Sadly Emma Ritch died on 9 July 2021 prior to publication of the Women's Health Plan. As a member of the Women's Health Group and chair of the Gender and Health sub-group she was central to its development. Her personal reflection on the Plan and the work of her sub-group is presented here, as she drafted it:

I was delighted to represent the National Advisory Council on Women and Girls on the Women's Health Group and to be invited to chair a sub-group tasked with thinking about how to overcome gendered barriers to women's health. Women have specific health needs because of physiology but also because of social norms, stereotypes, and persistent gendered inequalities.

The National Advisory Council on Women and Girls has focused, in its first three years, on making recommendations for system change. The Gender and Health sub-group has brought together clinical experts with gender equality experts, data experts, and academics to consider what needs to change in the system to make health policy, planning, and services more responsive to women's gendered needs. I am grateful for the energy and enthusiasm of the sub-group members and their ambition to see decision-making done differently.

At the moment, too many women are less healthy than they could be. Structural inequality like the gender pay gap, women's experience of poverty, men's violence against women, and a lack of women around health decision-making tables undermines women's health. Too many curricula, health services and interventions are designed around the needs of the white, non-disabled male 'default human'. All of this means that women's ill-health takes longer to diagnose, and longer to treat effectively. Women's disease is less likely to be prevented. Black and racialised women and disabled women are even more likely to experience worse health outcomes, at great cost to them, their families, and wider communities.

Changing norms requires leadership, investment, commitment, and sustained focus. The actions we have developed are a first step towards creating systems that enable all women to live healthy lives. We know that they will not make all the change that women need to see, especially for disabled women, racialised women, lesbian and bisexual women, trans women, and older women.

We have focused on creating the conditions for change:

• Gender-competent sex-disaggregated data that will enable improvement to healthcare policy, planning and service design and provision.
• Health improvement of, and healthcare for, women and girls should be holistic, inclusive, respectful and fulfil women's right to the highest attainable standard of health.
• Health budget decisions should be reflective of the needs and rights of women and girls.
• Undervaluation of caring professions must be addressed in the health and social care sectors.
• Gender and cultural competence should be built into health policy and healthcare services, including training and coaching in equality, diversity, and human rights for clinicians and policymakers.

Reduce inequalities in outcomes for women's general health.

1. Gender and cultural competence will be built into health policy and healthcare services.

2. Undervaluation of caring professions will be addressed.

3. Accountability, transparency and participation should be the basis for budget decisions and public expenditure will be reflective of the needs and rights of women and girls.

4. Clinical training and CPD will include education, training and long term coaching, in equality, diversity and human rights.

Short Term

• Establish a Health Equality team within Scottish Government, to pursue intersectional healthcare policy with a particular focus on sex, race, disability and sexual orientation.
• Encourage NHS boards to engage with the Equally Safe at Work employer accreditation programme.
• Ensure National Performance Indicators are disaggregated where appropriate.

Medium Term

• Build an intersectional evidence base around women's health inequalities ensuring women's healthy life expectancy and quality of life are used as measures in addition to total life expectancy.
• Build an evidence base on women's health inequalities, with specific focus on the impact of sexism, racism, ableism, and other forms of discrimination including homophobia and transphobia on women's health.
• Develop gender competency across Scottish Government and NHSScotland, starting with the knowledge, information and data workforce and key decision makers such as those in finance and procurement.
• Increase awareness and understanding of how to effectively use and apply the Public Sector Equality Duty within health and social care, and work to close the implementation gap, as a means to improving women's health.
• Encourage greater transparency in budget decision making, through intersectional gender budget analysis, within health-specific budget processes.
• Establish Gender Equality and Gender-based Violence policy lead positions to work within Health Directorates and with NHS Boards.

Long Term

• Ensure mental health policy and service provision is gender and culturally competent, and that the implementation of actions in the Mental Health Transition and Recovery Plan takes account of women's specific mental health inequalities. Ensure gender and cultural competence is reflected in any future mental health policy.
• Develop tools, including a toolkit and coaching, to support HR managers in the health and social care sector to develop and implement employment practices and policies which are intersectional and gender-competent.
• Address undervaluation within health and social care sector pay, taking into account recommendations from the independent Review of Adult Social Care.

9.6 Lived experience

Irene Oldfather, Director of Strategy and Engagement – Health and Social Care Alliance Scotland (ALLIANCE)

The Women's Health Plan has the potential to change and improve the lives of women, and narrow the gender equality gap. For myself as Chair of the Lived Experience Group, it was heartening to see such a huge response to our work – our online survey alone attracted over 400 responses.

Over the course of what we heard through both our survey and our development session, I suppose for me the asks of women are not unreasonable. Strong themes of breaking down barriers, providing choice and flexibility and educating everyone about women's health issues emerged. It was also vitally important for women that symptoms are taken seriously and there is a robust investigation carried out to determine the causes of illness.

Report from our online survey

Women want to see a system which provides them flexibility around their lives, both when accessing appointments and for treatment and support options. One of the strongest themes was difficulty getting an appointment that works around their work commitments and caring responsibilities. The same issue was identified by disabled women and those with long-term conditions who felt that their capabilities were questioned when they missed appointments due to their health. Women suggested the need for diversity in delivery of service to meet each woman's needs, and discreet and easy access.

Report from our online engagement sessions

When it came to accessing information, participants spoke of the importance of understanding their options, particularly in relation to contraception, though this applies to all areas of health. Women who have different communication needs want easy access to interpreters and information in various languages and formats. Women highlighted the importance of good communication by illustrating that they cannot take responsibility for their own health without enough information about it. It was also remarked that the way that healthcare professionals engage with women is very important and women have been made to feel hysterical when not being taken seriously in a medical context.

Women want to see stigma broken down around mental health, menstrual health and contraception. They feel this could be achieved through more information raising and conversations in communities and better understanding of potential cultural barriers from staff.

Education, peer support (particularly for women experiencing menopause symptoms) and periodic health and wellbeing assessment for all women were highlighted as important steps required to ensure that no woman falls through the gaps of support and services.

Overall, women want services and information that fit their lives instead of needing to disrupt their life to access a service. They want to be taken seriously no matter their concern, without feeling judged for their skin colour, culture or choices.

Action

Seek women's lived experience, through the continuation of a lived experience group, to inform health policy and improve healthcare services and to ensure women are meaningfully involved in decision making and priority setting going forward.