Health and Social Care Committee
Oral evidence: Men’s Health, HC 139
Tuesday 23 January 2024
Ordered by the House of Commons to be published on 23 January 2024.
Members present: Steve Brine (Chair); Paul Blomfield; Paul Bristow; Chris Green; Mrs Paulette Hamilton; Dr Caroline Johnson; Rachael Maskell; James Morris.
Questions 52 - 91
Witnesses
I: Chiara de Biase, Director of Support and Influencing, Prostate Cancer UK; Amy O’Connor, Global Lead, Policy and Advocate, Movember; Martin Tod, Chief Executive, the Men’s Health Forum; and Mark Brooks, Men’s Health Consultant and Trustee, the Men and Boy’s Coalition.
Written evidence from witnesses:
– [Add names of witnesses and hyperlink to submissions]
Witnesses: Chiara de Biase, Amy O’Connor, Martin Tod and Mark Brooks.
Q52 Chair: Good morning. This is the Health and Social Care Select Committee, live from the Palace of Westminster in London. Today we are doing the second public evidence session of our men’s health inquiry. The broader inquiry focuses on men’s health and wellbeing and suicide issues among men. We touched on mental health in our first session. We are also looking at health inequalities and boys’ and men’s health across their life course, and talking about men’s sexual health, a topic very often not talked about in this place.
As I said, this is the second evidence session of our inquiry. Today we will focus on the reasons for lower and falling life expectancy among men. We are going to talk about many health conditions and issues that are particular to men, including prostate cancer, testicular cancer and, as I said, male sexual health.
We have a stellar cast. We have only one panel today. Chiara de Biase is director of support and influencing at Prostate Cancer UK. Welcome. Amy O’Connor is global lead for policy and advocacy at Movember. It is nice to see you. Martin Tod is chief executive of the Men’s Health Forum. Thank you for coming in. Mark Brooks is men’s health consultant and trustee at the Men and Boys Coalition. Thank you very much, all of you, for coming in and giving up your time as part of this inquiry. We are going to finish today by 11.30 because we have Health questions in the Chamber. I will kick off and then bring in my colleague Paul Blomfield.
As I alluded to in the introduction, average life expectancy in the UK is 79 years for men and 82.9 for women. The ONS says that women outlive men by 3.9 years. Nomis tells us that, when it comes to the definition of premature death, men have a higher rate of death at every age from 0 to 75. Given that men are more likely to carry excess weight, and given that, according to CLOSER, which does longitudinal research at UCL, smoking is the biggest risk factor behind the difference in mortality between men and women, it seems very likely that poor health outcomes in men are the result of lifestyle factors such as drinking, smoking, diet and exercise. There is overlap between this inquiry and our prevention inquiry, which is about to look at some of the addictions.
Let’s start with you, Martin. To what extent are the lifestyle factors that I mentioned directly related to those poorer figures for men than for women?
Martin Tod: Without question, the fact that men are more likely to be overweight and obese, the fact that men smoke more and the fact that men drink more links very directly to much worse health outcomes—cardiovascular disease, most common cancers, liver disease and so on—but it is not just those factors that lead to the difference. We saw it really clearly in covid, when the mortality rate among men was 68% higher than among women. A range of factors led to that.
There was the pure biology factor. Men are more likely to die from flu. They are more likely to die from covid, like for like. There are environmental factors. For example, men are more likely to do jobs that were at higher risk from covid, such as being a cab driver, a professional driver or a security guard. There were certain jobs that had very high excess covid death rates.
There is a system problem, in the sense that in the early days of the pandemic not a lot of gendered data was published. Men have a weaker relationship with the health system. Men, particularly working-age men, use primary care less than women. To take heart disease, for example, hypertension has a lower diagnosis rate among men than among women. Work is a particular factor in that. Men go to the GP less than women until the day they retire. If you look at the rate at which men and women say that they go to the GP after retirement, there is almost no difference between men and women. The difference is all in working age.
There are psychological factors as well. We see that in all the attitudinal surveys that were done on vaccination, as well as mask wearing and various other things related to covid. Let’s take vaccination. People were more concerned about fear of vaccination among women, but, somewhat to everybody’s surprise, when the actual statistics came out the gap was among younger men. A lot of that was to do with attitudes to masculinity, a sense of imperviousness and strength: “I’m not going to show weakness. I don’t need to get vaccinated.”
It is absolutely the case that the risk factors of weight management, smoking, alcohol and drugs are all factors in the higher mortality among men, but there are a lot of other factors that need to be looked at.
Q53 Chair: Amy O’Connor, let’s bring you in from Movember. I will put the same question to you. Obviously, there are many other factors, but to what extent are the big killers—smoking, drinking, diet and exercise, or lack thereof—directly related to the poorer health outcomes that I referenced?
Amy O'Connor: I follow Martin in saying that they are important and cannot be overlooked in any way. At Movember, we talk about maladaptive coping mechanisms. We work really hard not to place the blame for men’s health at the feet of individual men only. We have seen some great progress in our young men’s perception of healthcare and what is socially acceptable, which is more progressive. There is something that we call the perception gap. Our younger men believe that it is society that doesn’t think that it is acceptable for our men to seek help, be vulnerable, look after themselves and not be stoic. We are seeing progress in that.
As I said, we are working really hard not to place the blame solely at the feet of our men and not to blame poor behaviours only. Instead, we are trying to look at the norms that underpin those behaviours, which Martin alluded to. At the moment, we are investing heavily in a couple of pieces of research, which I can talk to you about, on understanding those norms and the impact that they are having on men’s health.
There are two other factors. We have the piece about how men are behaving, but there is also their lower health literacy. We know that men are twice as likely as their female counterparts to have lower health literacy. A lot of the programmes that we have done that have had great impact with healthy outcomes are about going to where men are and improving their health literacy.
The third element is how men are engaging with healthcare systems. There is a stat from the University of Manchester that I always find shocking. Only 9% of middle-aged men who took their life in 2017 were not engaged with the healthcare system, or with a system. Over 90% of men were engaged with the system, which was not responding to their needs. Therefore, we were seeing the direst of outcomes. We really focus on the behaviours, the engagement with the systems and the norms at play. That tri-factor of things is where we are focusing on having collective impact, and getting behind those three elements.
The other thing to think of is the impact that poor men’s health has on others. We know that men are not a homogeneous group. When we have our women’s health strategy over here and our men’s health strategy over there, we forget that they are going home and often sleeping in the same bed, or going into work and being colleagues with one another. They are not two separate groups. Where we see poor men’s health, we see women having to pick up the burden of that. We see fathers passing it on to their children from conception all the way to adulthood. We talk about its being a full societal issue, with complicated multifactor steps, as opposed just to men not turning up for healthcare services. We know that things have progressed beyond that.
Q54 Chair: Are you saying that men pass poor health literacy and habits on to sons? Did I understand you correctly on that?
Amy O'Connor: Yes. There are a few different studies that look into how dads—role models, parents, fathers—engage with their healthcare and how it impacts their children if fathers as role models are portraying what we call traditional masculine norms. Again, it comes into those norms. We know that norms have moved on so far in the last 10 or 20 years—the last five minutes, I sometimes think—but there is a lot of work that needs to be done to understand the impact of norms on men’s health. If fathers are showing those traditional masculine norms, they are undoubtedly passing them on to their sons.
Q55 Chair: Wow. No pressure on us dads. Mark Brooks, I will bring you in here, if that is okay. What are your opening reflections on what we are talking about?
Mark Brooks: Thank you, Chair. I would like to declare that I am employed by two Members of Parliament, but I am here on behalf of the charities that I represent. I want to be clear about that.
The issue around lifestyle is really an outcome issue. What we really need is to understand what is causing those lifestyles, as well as how we prevent them and how we deal with them when they appear. We need a whole-system change in men’s health. There is a lack of political delivery and accountability. We need to tackle the social determinants, especially poverty, place and employment practice. It is about accessibility of the health system for men, as well as acceptability. How suited is it to men’s lifestyle—how men are and their work patterns? There are issues around the training of health professionals to be far more professionally curious and for men’s health to be embedded in the education not only of GPs but of all health and social care workers when they start their training.
If we have whole-system change, it will help both to deal with prevention, to prevent men from going down poor lifestyle routes, and to improve the support for men who go down those routes. Obviously, that builds on the work that my colleagues have mentioned in their comments on the other factors—socioeconomic, biological and behavioural. The key thing is that we need a whole-system change to support that. In some of the evidence, a number of organisations said that a men’s health strategy, alongside the men’s health ambassador that has already been announced, would certainly help to drive that whole-system change, which would support the lifestyle issues that men face.
Q56 Chair: Wow. There’s a lot to do, right? It sounds like we are doing our work at the right time to help to inform that.
Mark Brooks: Absolutely.
Q57 Chair: Chiara, from your point of view, how important are high-profile people who are prepared to speak up about the challenges that they have in a health space? I am not suggesting for one minute that the King has prostate cancer. I am just suggesting that he spoke out about the treatment that he is having at the moment for an enlarged prostate. Some have criticised him for that. I certainly would not. I think it is incredibly powerful that he has done it. How important is it to have important, high-profile male role models who are able to speak out?
Chiara de Biase: It is everything to us. It is certainly true for a single disease like prostate cancer, but anything that raises awareness of men’s health generally and gets the public conversation about men’s health started is so important to us. I am really struck by what my fellow speakers have said. We have already talked about deprivation, health literacy, masculinity, race and the need for system change. Sadly, as I sit and reflect on the Venn diagram of what we have already covered, prostate cancer sits right at the middle of all of those things, as a perfect example of men being unfairly left behind by a system that reinforces health inequalities.
It is already the most commonly diagnosed cancer in men—one in eight men will get prostate cancer—yet we have a system where there are so many barriers between a man and a prostate cancer diagnosis. As Prostate Cancer UK, we are sort of going it alone, so whenever somebody shares their platform, as His Majesty, Bill Turnbull and Stephen Fry have done, we can see in real time the impact that it has.
It also allows us to step outside the cancer space just for a moment to talk about issues like male incontinence. When we are having a conversation around a taboo subject like male incontinence, it allows us to go into a different subject—specifically for prostate cancer, for example, around digital rectal examination. We know that more than 60% of men have admitted that they would not bring up prostate cancer for fear of having a rectal examination. Because of the way the guidance is at the moment, apart from the campaigning that we do as an organisation, we cannot tell men enough that the first step is a simple blood test. Very few GPs will undertake a rectal examination. We hate the idea that something that has such taboo wrapped around it prevents men from getting an early diagnosis.
Q58 Chair: It is a PSA test at first.
Chiara de Biase: A PSA blood test.
Q59 Chair: It was reported at the weekend that His Majesty speaking out has led to a big spike in men seeking advice. Would you back that up?
Chiara de Biase: Yes. Our health website pages have had a 500% increase in visits. You are absolutely right. This is not an issue of cancer, but it is absolutely an issue of men’s health, and prostate health, which is very important. There is also our risk checker. Because of the complexities around prostate cancer, we have developed a Prostate Cancer UK risk checker, which is a simple, 30-second tool to enable men to check their risk of getting prostate cancer. As I am sure you know, that is men over 50, and black men and men with a family history over the age of 45.
It is double the risk for black men. That is why we strongly advocate a change in guidance, so that black men and men with a family history of prostate cancer are proactively offered a PSA blood test. The way it stands now, men not only need to know about their risk of getting prostate cancer, but they need to understand that, in its most curable state, it is almost entirely asymptomatic, which is countercultural to the way that NHS England raises awareness around cancer and early diagnosis.
Then they need to advocate for themselves to get a PSA blood test. We all know that the PSA blood test is not a perfect test. It is not a test for prostate cancer, but for the 52,000 men diagnosed every year, it is certainly the first test for getting a prostate cancer diagnosis. We hear all too often from men who have made an informed choice only to be refused a blood test by the GP for looking too young, or to be told not to worry about prostate cancer as something else will kill you first. These are things men tell us about every single week. There are so many profound inequalities and barriers to men getting an early diagnosis—a curable diagnosis.
Chair: Right. That’s a hell of a start. You have set out your positions beautifully. I will bring in Paul Blomfield. Colleagues will decide where to direct their questions. They may not direct them to all of you. As you give answers, think all the time that what we are trying to do here is produce recommendations to Government. We are not looking to write reports that are great weighty tomes that sit on a desk for years. We are looking at short recommendations that Government can do to move the dial on men’s health.
Q60 Paul Blomfield: I would like to explore what Martin describes quite neatly as men’s weaker relationship with the health system. Clearly, you have all covered that in different ways. Martin made the point that it was only when men retired that they started using a doctor to the same level as women. I guess that the issue within that is whether that is to do with work or with age. Is it about system design not being accessible to men, or is the problem with men? That pitches in with the stuff Amy was talking about in relation to health literacy and is the sort of issue that I would like to explore. Martin, there was an implication in what you said that men are too busy at work and cannot be bothered. Women are busy at work, too. What is the factor going on there?
Martin Tod: There is a very simple factor, which is that men are more likely to be in full-time work than women. If you look at women’s use of GPs, women who are in full-time work are also less likely to use them than women who are not in full-time work.
There are other factors. A relationship is two way, and there are issues with how the health system works with men. There are some very basic factors that would lead you to expect men to use GPs less. Men are less involved in reproductive health, inevitably. Women who are having children use the GP much more. That shows up in the figures. Women also get invited in more. A point was made about targeted PSA screening. Women are invited in, rightly so, for cervical cancer screening. They are invited in for breast cancer screening. That is a good thing, but it means that women use primary care more than men.
The point about work is that it is not just something that is internalised to men. For example, when somebody is working as a subcontractor on a building site, if they don’t work they don’t get paid or, on a particular contract, they might not be the person who is kept on. There are actual consequences for taking time off work. We did some research on that to look at the different pressures. It varies quite a lot by industry. There are some industries where men find it harder to leave the workplace and where people are less tolerant of people taking time out for health support. We need to be careful, because people in white-collar jobs generally find it easier to access healthcare and take time off work in order to access the GP.
There is a second issue, which is when people do access the GP. We know that too many men and women are overweight and that it has all kinds of health consequences, but it is also known that referral to weight loss clinics is lower for men than it is for women, even at the same BMI. A lot of that is due to the attitudes of people working in the health service. Women’s weight is much more policed than men’s, generally. Health professionals judge men’s and women’s weight differently. They are less likely to observe that men are overweight and then less likely to engage with men to ask them to use weight reduction programmes. Even though weight reduction programmes are perceived to be quite gendered in their nature, men do well on them. Things like the football fans in training programme developed by the University of Aberdeen work very well for men.
It is a complex range of factors. There is the attitudinal thing among men: “I’m strong. I’m fit. I’ll work my way through this.” There is the workplace. Some workplaces and jobs are unforgiving for taking time out of work. There is the fact that health systems are not always good at going to where men are and reaching out and engaging. Let’s take another example from primary care: health checks. Men have lower awareness of health checks and are less likely to attend health checks, yet that is the technique that is designed to catch the early signs of heart disease, which men are more likely to die from.
Q61 Paul Blomfield: You make a lot of really useful points there. A number of the points are about system design. You also make the point that men are less likely to have awareness of the checks that are available and to take them up. What is that about?
Martin Tod: Partly, it is the thing I talked about earlier. In their early years, men just don’t need to use the health system as much because they are not managing contraception, fertility or other such things. They just engage less with the health system than women, generally. That is a factor.
There is a general issue, and it is one thing that continuously surprises me. Given how much we spend on the health service, frankly, we don’t do enough to tell people how to use it effectively in their early years. It is well known, and there is endless evidence, that young men in particular understand the health system less well than women. I think that is something that carries on throughout life, just because men are using it less than women.
Q62 Paul Blomfield: Can I bring Amy in? You will all say that tackling all of those aspects of the problem is important, but is the primary problem with the system or is it with men? Do we address resources at making services more accessible, or do we try to get men to think differently about their health?
Amy O'Connor: That is the task in hand. Men need the health literacy. They need to know when to turn up. We know that when we do targeted health literacy for an audience we see them engage more with healthcare systems.
Martin made a point about the gap that we often see between boys being taken to the doctor’s by their parents, then turning up in A&E when they have hurt themselves in an accident, and then coming in far too late in their later years. There are opportunities to engage men in those younger years. When we have done targeted campaigns with our young men on testicular cancer, we have seen that they are 72% more likely to check their testicles and go to a doctor, versus 27% of men who may not have seen the campaign. We see testicular cancer and sexual health as a real opportunity to engage men with the health system in those younger years, so that they feel comfortable about going when issues crop up.
You are right. There is a balance. When men turn up at the healthcare system, it needs to respond to their needs. It needs to have gender-responsive healthcare. This is something the women’s health strategy talks about as well. There is a need to train clinicians, both in pre-qualification and in continuing professional development, on gender lenses and understanding how to help men when they turn up in clinic. I know that you are looking for really specific policy asks and those are two of ours: gender-responsive healthcare training for our clinicians and more support for the health literacy campaigns with targeted audiences.
Paul, in your area we work with Brothers Through Boxing. That is a really great way to meet our young men. We are talking about mental health, but also about all of health and health literacy. If we meet isolated guys in your area through boxing campaigns, they are going to turn up in the system. Then the system needs to meet their needs. I feel like you want a number—put £10 here and 20 quid here—but I don’t think we have that yet. When we talk about a men’s health strategy and coming together to make the big decisions, that balance needs to be decided, but it is not one or the other. It is definitely both.
Q63 Paul Blomfield: I am sure that colleagues want to follow up on the training issue, but I see that Mark is itching to get in.
Mark Brooks: It was to add to what my colleagues said about making sure that we bring the health service and the health system closer to men and don’t expect men just to accept what they are given. For example, research that the Men and Boys Coalition carried out said that 61% of men felt that there were barriers to accessing a GP. Long waiting times were the main reason, but the second area was that opening hours are not convenient due to work. Broadly speaking, the health system, especially primary care, is built around a nine-to-five work life.
I would say that the men who are most at risk are generally blue-collar men. Most health policies are written by people in white-collar roles. They are not thinking about men on industrial estates and construction sites. They are not thinking about HGV drivers or men on zero-hours contracts or shift work. The health service and the health system have to think about how they are going to access those men.
That is why I come back to system change. We would expect integrated care boards and the health and wellbeing boards to have a targeted men’s health strategy for their local area, to force ICBs and all the health services to think about how they are going to reach men in blue-collar roles. Our organisation proposes that there should be man vans on industrial estates and construction sites, for example. There have been pilots for those at the Royal Marsden and in Manchester. It is about bringing the health system closer to men. If you bring it closer to men, you make them more aware. If you make employers understand the importance of allowing their male colleagues to take time off for primary care or for testing, men will go.
We have seen real social change in the last five years. There has been huge growth in by-and-for organisations, set up by men for men, in the voluntary sector. There has been a huge increase in Andy’s Man clubs and talk clubs. We had UK Men’s Sheds here at the previous session, for example. In some respects, they are a response to the failure of the health system. Men are starting to use those organisations because they feel that the health system is not working for them. That is why we have seen a big growth in social prescription organisations of that sort. We need to bring in the health system. I come back to the fact that we need accountability and data at national and local level to force change.
Paul Blomfield: There is an interesting issue within that which I don’t have time to explore: it is as much about class as it is about gender. Perhaps other colleagues will pick up on that. I will stop there. I have to give my apologies. I have to leave for another meeting. I am really sorry, because this is a fascinating session. I apologise to you in advance.
Chair: No problem. As ever, that gives me an opportunity to remind people watching that they can see all this on Parliament TV or read it in Hansard. That includes Mr Blomfield, as he moves off to his other meeting. Let’s switch gender and go to Rachael Maskell.
Q64 Rachael Maskell: I want to continue the theme of access to services. From all the work that we are doing in other areas, it seems that early intervention—screening and health checks—is key to secure early diagnosis and better outcomes for patients. In dentistry, people are, or used to be, used to a six-month check-up. However, we do not talk about health checks until people reach at least the threshold of 40. Is there any evidence, particularly in the light of what you have presented around young men engaging more with their health, that a continuum of interventions around health checks and getting into that cycle could sustain people across all socioeconomic demographics? I am particularly interested in the issue around deprivation. Does anyone want to pick that up?
Chiara de Biase: I can certainly come in on the deprivation point, very specifically around prostate cancer. We know that men who live in areas of low socioeconomic status are 29% more likely to be diagnosed with incurable prostate cancer. As we have already touched on in terms of health inequalities, we know that the further away from London somebody lives, the more likely they are to be diagnosed too late for a cure. When you bear in mind that this is an entirely curable cancer when it is caught in its earlier stage, the health inequalities around Core20PLUS5, not just around race but around deprivation, are a huge challenge for prostate cancer as well.
We can see that there are specific geographical hotspots around England and the UK. We try to focus our awareness-raising on those specific areas. We have already talked about system change. Is it about the system? Is it about men? Having the trajectory of health from boyhood into manhood is really important, but again for prostate cancer it is all about family history. There is a blurring of lines, particularly in the black community, where men are being diagnosed in their 40s. There are misconceptions that this is a disease, a cancer, of older men. That simply is not the case. There are black men who are part of our Black Men’s Health Advisory Group diagnosed in their 40s and losing decades of working life. They do not have that connection. They often only find out that their father died from prostate cancer once they have been diagnosed. Understanding the family trajectory and engagement with the system is crucial.
To go back to the deprivation point, it should not be left to chance. Men should not have to join an 8 am queue. A very simple step would be to offer proactive PSA blood tests to black men over 45 and to men with a family history. They will, understandably, wait to be invited. We hear that all the time. Men assume that for something so important—the biggest diagnosed cancer in men—they will get invited for a test. That simply is not the case, unfortunately.
All of those compounding factors, about engagement with a system that does not work for them, the lack of line of sight in family history and the health habits that they get from their fathers, just are not in place with prostate cancer.
Q65 Rachael Maskell: Thank you. Martin, could I turn to you and bring in the role of occupational health? Could occupational health have a more proactive role in encouraging employees and workers to engage with health services?
Martin Tod: Yes, I absolutely think it should. When we think about how we engage men with the health system, we need to think about the fact that they are not being invited in for cervical cancer screening; they are not being invited in for breast cancer screening. There isn’t that pulse of regular engagement with the health system.
There are countries that are pretty religious about health checking. Japan is the classic one, where you do a health check every year and the employer absolutely understands that you are not coming to work that day. There is evidence. I don’t know what it says particularly about men’s health versus women’s health, but there are cases that can be looked at to understand that.
There is a mixture of things that we need to look at. In the objective of better understanding men’s health and engaging them with health generally, the workplace absolutely plays a vital role. It is something that the NHS can get closer to as well. In the past, I have floated the role of the NHS accrediting workplace health checks. If there is a proper system in place for information exchange and all the privacy things that need to be sorted out, that becomes a way for the conventional NHS health system to understand better what is going on with their patients.
I am not entirely sure that it needs to start before the age of 40. Already, at the age of 40, there is not really the uptake that there should be. There is quite a strong age skew in how people engage with health checks. When it happens, there needs to be more thought about the fact that men engage less with the health system. There are useful conversations to be had that go beyond a generic gender-blind health check, looking at, for example, as has been discussed, prostate cancer among higher-risk groups of men and asking questions about erectile dysfunction, which is an early indicator of heart problems later on. I am sure that we will come to that topic later.
There are two elements to this. First, there is definitely a case for examining what it would take to get the same kind of pulse of engagement with the health system for men that you automatically have for women. Secondly, what needs to happen with that engagement beyond a gender-blind NHS health check that we have at the moment to make sure that the wider issues of men’s health are engaged? Thirdly, what can we do to take health checks to where men are—take them out of the GP surgery—while also using occupational health as a partner in an overall programme of identifying men at higher risk and intervening earlier with the problems that may emerge?
Q66 Rachael Maskell: Can I come back to you on the issue of 40? We have heard 45 and 40. We are not in a bidding war, but clearly if we are looking at issues around alcohol, smoking, obesity, exercise and diet, a lot of those trends will set in before somebody reaches the age of 40. If we are looking at a proactive health system, would that be the right threshold?
Martin Tod: I don’t have a definitive answer to that. It is certainly something that is worth looking at. I don’t think we should underestimate that it is worth taking a gendered view of what it takes to engage in a public health way in terms of weight, smoking and alcohol.
An example of how the system does not look through the gender lens enough is that one of the reasons that men put on weight is that they eat away from home more than women do. Even in smoking, although the gap between men and women has reduced, it varies enormously culturally and by ethnicity. Also, men smoke differently from women. They are much more likely to smoke roll-ups, and that has not been looked at in order to say, “Hang on, what’s going on here? Why are men doing this? What’s the intervention that is needed?” Similarly, alcohol is obviously very strongly associated, and men and women drink differently. That is not looked at either.
Yes, I think there is an opportunity to engage earlier. The evidence is that an early conversation on the subject of weight, smoking or alcohol from a health professional is more effective among men as a way of trying to drive behaviour change. Whether that means that the NHS health check per se is rolled out, I do not know, but thinking about how we close the engagement gap and challenging primary care to say, “If you haven’t seen somebody recently, you need to,” and making that a norm, so that there is an ongoing relationship between men and primary care, is definitely something that needs to be looked at.
I suppose, ultimately, it comes back to the point about a men’s health strategy and a wider picture that colleagues, and Mark in particular, have talked about. One of the reasons why it is needed is that, ultimately, it is a problem that is hiding in plain sight. Everybody knows that men die earlier. Everybody knows that men drink more. Everybody knows that men smoke more. Everybody knows that men are more likely to die of cancer and heart disease—yet nothing is done. That is why it is so important to have a men’s health strategy. We need to overcome the fatalism and say, “Actually, no, we are going to require you to do it. We are going to require every bit of the system to look at how you are performing with men and look at how you are performing with women. We are going to ask you to improve, tell us your plans and tell us how you are going to do a better job.”
We almost need to put something into the system, whether it is a strategy, a Minister or a clinical lead in the NHS—probably all of those—to say, “It is time to change.” You cannot carry on being fatalist about it. You cannot carry on looking at the statistics—the earlier deaths, the higher heart disease rates, the higher cancer rates and two thirds of diabetic amputations being men—and saying, “Well, that’s the way the world is.” It is time to do something about it.
Q67 Rachael Maskell: I want to ask Mark and Amy the same question. In South America, we know that health services are often taken out to communities. We also know that the University of Sheffield has been doing some really interesting work around placing health services at things like gyms, where men are more likely to engage. What is the role of place when delivering health services?
Amy O'Connor: We do a huge amount of work in the community. Movember’s motto has always been, “Go to where men are.” You were talking about the workplace. That has been a focus for us. We have a huge number of men who are growing moustaches with their work colleagues every year and talking about mental health and physical health every Movember.
Sports settings have also been an area where we have seen great success. It is something that we are really focused on. Our Ahead of the Game programme is one of the most evidence-based programmes out there. That is going into a sports setting. We have a lot in our northern cities. We have a great partnership with Rugby League Cares, where we have coaches going in and providing mental and physical health training for our young men. We are not just staying with the young men. We are bringing in their coaches. We are bringing in their dads, who perhaps normally stand on the sidelines. We are talking to them as well about healthcare.
We are really focused on bringing the whole community in via the sports setting. We know that sport is a great opportunity to engage men. We have another programme in Scotland called Changing Room, where we bring fans from local football clubs into the changing rooms. They get VIP access to places they would not normally see within the pitch. They come together as peers and talk about their health and they start building up health literacy so that they know, when they get to a point where they need to engage in a healthcare system, that it is there and ready for them.
I hope you don’t mind, but I want to come back on one of your questions about health checks. Our middle-aged men are the lowest performing age group in engaging with health checks. To fill that gap younger—our focus is always on prevention—is health literacy at a younger age and driving people to the existing health checks. On the point about tailoring them, we have seen some real success with the abdominal aortic aneurysm screening programme that was built specifically with Men in Mind. Uptake of that was 79%, which is remarkable when we look at other screening programmes. If we can do as Martin says and have a gendered lens when we are building these screening programmes and the health literacy to drive them, then yes, definitely. We cannot advocate enough at Movember going to where men are.
Q68 Rachael Maskell: Mark, could you briefly talk about boys as well and the importance of driving in that culture at a very early age?
Mark Brooks: Certainly. It is around building health literacy in schools. To be honest, when boys go to the GP they obviously go with their parents and they may not use the health system for many years afterwards. One of the issues around vaccinations, for example, was that young men weren’t registered with GPs, so it was difficult for them to be contacted on where to go for vaccination.
Martin talked about pulse irregularity. It is making sure that boys know how the health system works. There is no reason, for example, why GP surgeries should not invite young men in to understand how to make an appointment, what you need to do and how it all works. Young men do not know, and therefore that needs to be built in at school. To build on where men go, at my football club, Charlton, we had an organisation come in for PSA testing just before a big match. There were queues around the block. It was a huge success. That is really important.
The last point is on occupational health. We have seen a big increase in International Men’s Day used for occupational health reasons. The Men and Boys’ Coalition looks after that platform in the UK and we had 800 events last year. The vast majority were employers doing occupational health events for their male colleagues. Again, that is using leverage in what is already there.
You mentioned the women’s health strategy. The important thing is that, if we want the women’s health strategy to work as well as it can, we need a men’s health strategy. If men are doing well with their health, that will support women as well. That is why we need both.
Q69 Chris Green: Rachael Maskell has taken us well into the area I was looking to cover, which is great. Amy O’Connor, it is easier to get the best outcomes if you work with people’s nature. Do you think the health system at the moment, when looking at men, works as effectively as it could or should, in terms of the way men are and the way men approach their health?
Amy O'Connor: It is a stretched healthcare system, and everyone is working really hard. We have the absolute privilege at Movember to be able to hear from our men in focus groups, in the office, in all the work we do, and from working really closely with clinicians. What we hear from our clinicians is that they are struggling as well to engage with men when they come into a hospital setting or a GP setting. The psychologists we work with see the masculine norms of stoicism and independence playing out in their sessions. It is a real challenge for them to know how to engage men in that short period of time.
Yes, we are hearing from men as well that the healthcare system is not meeting their needs in specific areas like prostate cancer and in mental health where we know that with men there is a really high drop-out rate. Where we have seen success is where we have provided training for clinicians, so that when our men turn up the clinicians feel qualified and confident in how they are engaging men in their health.
Q70 Chris Green: There is a huge challenge. Male nature tends, to some extent, towards stoicism and standoffishness in accessing healthcare. The health system itself, as was highlighted before, has nine-to-five access to GPs. A lot of workplaces do not allow it. Do you think local authorities, and particularly integrated care systems or integrated care boards, actually appreciate that and are, anywhere in the country, doing nearly enough to break down those barriers?
Amy O'Connor: We are seeing pockets of success. Where we have implemented, for example, our Men in Mind programme with mental health professionals, we see greater outcomes, with our clinicians feeling that they can engage men with their mental health. We have a sexual wellbeing programme specifically for clinicians working in prostate cancer, so that they can have the really difficult conversations about sexual health after prostate cancer care. We see pockets of success. The challenge is how we take that on to a larger scale and implement training for gender-responsive care—understanding the specific needs of men and women on a larger scale—to a wider body of clinicians. We are on that journey of understanding ourselves and would love to work with other organisations in a collective impact fashion to make that happen.
Q71 Chris Green: Mark Brooks, do you think there is enough recognition within the health system of the importance of maintaining people’s health rather than fixing people once things go wrong? If people participate in sport and are more engaged in the community, they actually maintain their health in a far better way than if something goes wrong and they are then told to get involved and engage.
Mark Brooks: I don’t think there is enough in terms of prevention or public health campaigns focused on men. I don’t think just making sure that they are regularly in touch with the health system happens enough. We see that from the figures that colleagues have mentioned. At the end of the day, we have to mainstream men’s health, just as we are mainstreaming women’s health now through the strategy, to create the conditions where men feel comfortable using the health system and that it is there for them. Having regularity will certainly improve it.
The other area is information on websites. A lot of men, if they start to think there is a particular issue or they want to find out about a particular issue, go online first. Lots of organisations have online chats, for example. Prostate Cancer UK has online nurses. There is lots of information for men, especially on domestic abuse and other fields which have physical and mental health issues. Men seek out information online first, so it is about making sure that local and national websites are conducive to speaking to men online.
Q72 Chris Green: Is the male preference to go online discomfort in talking to people and showing weakness, so the anonymity that online provides is actually quite useful?
Mark Brooks: Absolutely. Again, it comes down to some of our social norms, not only for men themselves but society expecting men to just get on with it and man up. That is a societal issue. Therefore, that impacts on how men initially want to seek help. The anonymity of websites is really important at that first stage.
Q73 Chris Green: Martin Tod, I had a concern earlier this year with Moss Bank Junior Football Club. The council was offering a lease on the land of 10 years. For them to access grants from the FA and other organisations they needed a lease for 25 years, ideally 30 years. Bolton Council actually changed it from 10 years to 25 years, which is quite good. Whether it is local authorities or the integrated care systems, do you think they are doing nearly enough at the moment to help maintain people’s health as they pass out of their early years as a young child or a teenager into their early 20s and on? Do you think there is enough focus and support?
Martin Tod: You have opened up a huge question there. I should probably declare that, separately from what I do at the Men’s Health Forum, I am leader of a district council, one that Steve knows well.
Obviously, there is an enormous amount that all levels of government can be doing to create a healthier environment. We can make it easier for people to walk so that men and women stay active into old age. We can make sure that open space is available. We can improve sporting facilities. We can design the planning system to enable people to live healthier lifestyles and to control the accessibility to fast food. It is all of those. There is a lot that needs to be done.
Similarly, there are actions that Government can take with alcohol, such as minimum unit pricing and better on-pack information. There is an enormous amount that we can do around men and women in order to make it easier for people to live healthier lives. I know how important that is to this Committee. The prevention agenda will help with men’s health as well. It is important that we do not just entirely focus on what the health system can do differently.
There is an intermediate space where we definitely need to do more work. We talked about International Men’s Day. I could mention Men’s Health Week. I am sure Movember will mention Movember at some point; implicitly, they always do. There is work to reduce the barrier between the health system and men, on top of everything else that is going on. It is incredibly important, but I would absolutely not want to underestimate the importance of creating an environment where it is easy for people to be healthier. That will definitely have a big impact for men.
Sport is a really interesting example. We often frame men and health quite negatively. It is actually a good example of where men can take a lead in the family’s health, and do, in encouraging good behaviours and supporting boys and girls to be physically active. It is quite important when we talk about men’s health that we also talk about the good things and encourage things that men do that are good for health. Sport is one of them. It is brilliant that a lot of work is going on to encourage women’s participation in sport, but it is incredibly important that we keep pushing and making it easier, better and innovating to enable men to take part in sport as well.
Q74 Chris Green: In society broadly, there is a lot of being a spectator of sport and going to watch your local team. It was positive to hear Moss Bank juniors saying that the number of clubs has gone up from 56 to 58. Post covid there is a lot more enthusiasm, with people realising perhaps what they missed out on during that period of time. Parents are getting more involved as coaches. There is a lot of positivity.
As was highlighted before on the pressures of funding and money, should there be a better reallocation of resources in these tight budgets towards support for people’s health so that the very young, and those who are getting older, have more ability to maintain their own health as opposed to something going wrong and it being dealt with later?
Martin Tod: That brings us back to something where we shouldn’t underestimate the power of the voluntary sector. There is an enormous amount of innovation going on in sports clubs, such as the development of walking football and other ways to involve people in more sports, with new sports coming to the fore.
One of the things I mentioned briefly in passing was football fans and training. That was a programme that started in Scotland. It was about getting football fans, who they knew had a relationship with the club but very often did not have good health, into the club using the sport professionals at the club to encourage men to find ways to improve their health. What was interesting about it was that they used football as a base for the programme, but what they did not do was require everybody to play football. They deliberately had a whole wide range of sports and other activities and information that men could access in order to improve their health. There is a lot of innovation going on, particularly in Scotland, where men’s health is particularly bad, in how men can be better engaged, particularly in weight management programmes.
It is important at a time when budgets are squeezed that the value of open space and of sporting activity and sporting provision is properly recognised in government. That is a wider discussion, but it is something about which I personally feel very passionate.
Chair: We have four colleagues and 34 minutes. Let’s see how good my colleagues are at doing the math, as they say.
Q75 Dr Johnson: It is very interesting to hear all you have to say. I want to ask Chiara about the PSA test and PSA screening. On the one hand, we know that PSA tests can be helpful, but we also know that one in seven men who have prostate cancer may have a normal PSA test, so it is falsely reassuring. Prostate UK released figures that show that, if we instituted a PSA screening test, after 16 years we would save the lives of 70 men, which is fantastic, but there would be 315 men who would be living with the associated morbidity from having had a diagnosis of cancer, and treatment, potentially, for cancer that would not have caused them any harm if they had not known about it.
My understanding is that there is now a TRANSFORM trial going ahead to look at the best form of screening, and whether it involves scans and such things. You made a very specific request for screening for black men over the age of 45. I wondered what the scientific basis of that specific request was.
Chiara de Biase: Unfortunately, as I am sure you are aware, black men have been systematically kept out of clinical trials. They do not feel seen. They are not part of that set-up. They do not have a huge amount of trust in academic institutes nor the health system.
Q76 Dr Johnson: When you say that they have been kept out of it, do you mean that they have been specifically excluded, as in “If you are a black man, you can’t take part”?
Chiara de Biase: Historically, there has been unconscious bias in the way that we approach research. Whether it is intentional or unintentional, black men have not felt welcome to be part of trials.
If we look back at historical evidence, you are quite right. The reason why we are investing millions of pounds in TRANSFORM is to get the gold-plated evidence that the National Screening Committee needs for a screening programme for all men. We cannot wait 19 years. What we can see really clearly, and we strongly support, is a targeted screening programme for black men over 45, men with a family history of not just prostate cancer but other relevant cancers, and importantly that includes men with genetic variations such as BRCA, so men from the Jewish community as well.
We can see, from contemporaneous real-world evidence, that that makes a huge difference. The evidence is there, and the pathway needs to change. Our own published paper demonstrated, referring to the old pathway and the new pathway, that about 10 years ago multi-parametric MRI came into the diagnostic pathway. We have seen a 67% reduction in harm in what we now refer to as the new diagnostic pathway. You are absolutely right that PSA is not a perfect test, but now the new diagnostic pathway can transfer someone from a PSA blood test straight to an mpMRI. What we now have is a high-definition image of that man’s prostate.
One of two things can happen. Brilliantly, we can tell men much quicker that they don’t have prostate cancer and get them out of the queue and the wait. Men who have abnormalities on the mpMRI can now have a highly targeted biopsy so that they can very quickly get into treatment with curative intent. We got very hung up on the old pathway. You are absolutely right that there was a lot of harm built into it, but we now know that the 60% drop in harm meant unnecessary biopsies, a reduction in sepsis and, really importantly, a reduction in men being diagnosed with clinically insignificant prostate cancer. We do not want to drive up men diagnosed with clinically insignificant prostate cancer. We want to bring in targeted screening of the highest risk men to drive down those diagnosed too late for a cure: 12,000 deaths a year that should not happen. We can see that from the real-world evidence, which obviously is not taken into consideration for the National Screening Committee.
We undertook our own academic process for a PSA consensus—a full academic consensus—for black men having a PSA test. That full consensus, which was academics and clinicians and men with lived experience of prostate cancer as well as nursing staff, now strongly recommends that black men speak to their GP about having a regular PSA blood test, such is the strength of feeling among the clinical community. Unfortunately, we are beholden to guidelines and memories of an old, harmful pathway that simply have not kept in step with the current real-world evidence.
Q77 Dr Johnson: Thank you. That is really helpful evidence. It is good to hear that. The other thing I want to ask about in a bit more detail is the training that has been recommended by Mark and Amy.
I should declare that I am a doctor. As part of medical training we get told about various different physical and biological training differences between men and women, hormones, sexual development and specific pathologies that can only occur in men, like testicular cancer. There are issues affecting men’s health and why men may be reluctant to involve themselves in healthcare, particularly in specific fields. When you talked about a gender-responsive health lens, I presume you mean in this context the differences between the two sexes. It is a very generic term, so what is it that you want people to be specifically taught that they are not taught at the moment?
Amy O'Connor: Exactly what we are talking about with gender-responsive healthcare are the specifics of managing and working with men. My understanding from our clinical team is that, when you are looking at the women’s health strategy and the big areas of focus in women’s health, there are very specific therapy areas—menopause, endometriosis and the lack of knowledge and skills around them or the need for more.
When we are looking at men’s health and talking about gender-responsive healthcare training, it is about how to engage men in the healthcare system and how to keep them there. It is about the understanding of norms and how men are showing up; how they might be engaging with their clinician; the language that they are using; and the space that they are in.
Our Men in Mind training was a six-week course of training for our professionals. They felt so much more confident to be able to engage with men afterwards and talk to them about their mental health. At the moment we are looking at how we can take what we have learnt from that training and build other training programmes for a wider group of clinicians. It is helping with pre-qualification training, making sure how to engage with men in that pre-qualification training, as well as continuing with the training. We are on that journey ourselves, looking specifically at what that training looks like. We know it is about how to engage men and keep them in the healthcare system by understanding the norms that underpin their behaviours.
Q78 Dr Johnson: Thank you. Mark, do you want to mention something?
Mark Brooks: Building on that—I have touched on professional curiosity—the national centre with regard to suicide produced figures about middle-aged men who had taken their life showing that two thirds had been in contact with some form of service. Our healthcare professionals, including GPs and others, are asking additional questions about what really is causing anxiety or depression, or what is underlying you drinking too much. Is it relationship breakdown? Is it economic problems? Obviously, there is a level of suicide ideation, and it is not being picked up by the system.
Another area to look at in terms of assistance is that we are starting to see a real shift in the workforce in the health system. For example, 69% of GPs in training now are women. Only 11% of nurses are men. If we want to encourage more men to access the health system, it is really important not only to have a diverse workforce generally but that they see men working in the system. That is a real issue that needs to be addressed; there aren’t enough men actually working in the health system.
Q79 Dr Johnson: The other thing I want to ask is specifically about boys. We know that men are more likely to die earlier, but that starts very early. If you are a pre-term baby boy, you are more likely to die than if you are a pre-term baby girl. That cannot just be societal because they have literally just been born. We also know that, when you start school, boys are very slightly more likely to be obese by the time they leave primary school. They are already 6% more likely to be obese than girls.
What can we do early to set boys on a pathway to good men’s health in the future? In particular for sport, it is quite easy if you have a boy who is really good at football and always scores the goals to encourage him to get involved with sport, but that is a few in each class. The majority are not that way. How do you engage the less sporty or less interested boy in keeping fit?
Chair: One of you. The Charlton fan can answer this one.
Mark Brooks: I’m not sure that Charlton are playing much football at the moment.
Martin Tod: I was going to touch on this earlier. One of the problems—it is a bit of a cliché—is that more research is needed. If we have a problem, are the research bodies saying, “We have this problem; we need to put some trials in place; we need to understand the interventions that work”? I would love to be able to sit here today and say right across the board, “Well, we know exactly what needs to be done. We know exactly why 68% of diabetic amputations are men and what needs to be done about it.” The truth is that in some cases we do not know, so the evidence and knowledge is not there to be able to give the training to medical practitioners and to say, “This is what the answer is.”
It is something we have not talked about much. There used to be a Centre for Men’s Health at Leeds Beckett University. There isn’t now a Centre for Men’s Health. There is a need to say that we do not know all the answers on this. I have a personal view as to what you should be trying to do to put more time against sport in primary school. That is a personal view. It is not an area I have studied or have particular expertise in.
There are areas where the health system underperforms because of bias. I mentioned earlier the referral rates to weight management services, where GPs, for whatever reason, refer men less than women. I suspect the answer to that is a mixture of training and awareness: “Did you know that you’re referring men less than women, despite the fact that men are more likely to be overweight and obese?”
At the core of all of this are some questions where we do not have answers. Part of that is the lack of gendered research. One of the interesting examples that came out of the women’s health strategy was the fact that, in the 30 days following a heart attack, women are twice as likely to die. There is a challenge to the secondary care system: “You need to do something on this. What is going on with heart disease? Do you know why it is? What’s the intervention?” That does not take us away from the fact that three quarters of the people who die prematurely from heart disease are men. A lot of that is because it is not picked up early enough in primary care.
We have been talking about early identification of problems. That is a systemic issue. The measures that need to be measured are known in order to predict risk. There are some questions that are not asked enough, such as the erectile dysfunction question, but that comes back to system design. Ultimately, medical leadership has a role in that as well, but it is an area where we need to be pushing, researching, innovating and feeding good practice back into the system.
Q80 Dr Johnson: The men’s ambassador recently announced by Government may help with that.
Martin Tod: A men’s health ambassador is a useful start. For the scale of change that is needed, I don’t think that is enough to get the NHS juggernaut and the wider health community to change direction. It needs more than that, as I touched on earlier.
Q81 Mrs Hamilton: Good morning, all. I am sorry that I was late to the meeting. This is really interesting, and I am going to start with Mark. In your initial conversation, you highlighted the fact that we need a men’s strategy. You also talked about ICSs. Do you not believe that ICSs are being asked to do far too much at the moment? On the idea about a men’s strategy, what do you really hope to get from it when there are about 30 other strategies out there that would probably take precedence?
Mark Brooks: In some respects, it goes back to what Martin said. Do we just accept the status quo or do we want to see change, not only at national level but at local level? The key thing is that, if we continue to go down the conditions-based approach to men’s health, we are not going to pick up issues that affect all the different conditions that men face, or those in terms of prevention. I talked about social determinants, poverty, financial wellbeing, isolation, race and class, for example. There are also issues about the accessibility of the health system locally to men. Unless ICBs and the public wellbeing boards are tasked to deal with those issues, nothing will change.
Q82 Mrs Hamilton: Mark, I don’t like stopping people in mid flow, but do you not think that secondary care also has a responsibility? As well as primary care, should we bring the whole system into this? If you are just highlighting ICSs, are you not then missing a trick? I am just asking the question.
Mark Brooks: Absolutely. It comes back to the whole-system approach. That is why a men’s health strategy would help overall, but you have to start somewhere, and you have to look at what structures are in place. Those structures would certainly help. Once you start treating men’s health as a thing, and something that we need to look at nationally and locally, you change the conversation and the narrative around men’s health. At the moment there is no narrative or conversation about men’s health apart from this Select Committee. That is what we need to change. Men’s health is not being seen as a subject or an area.
Q83 Mrs Hamilton: If you have finished what you are saying, I am going to ask Amy a follow-on question.
Mark Brooks: Yes, I’ve finished.
Q84 Mrs Hamilton: Amy, I genuinely believe the reason why men are falling through the cracks is that it is not joined up enough. Everybody believes they don’t have ownership of men’s health. Earlier, a couple of you talked about training. A number of my colleagues highlighted training. What do you believe needs to happen with training to help join up the system in a more comprehensive way? I hate lengthening my question, but it isn’t just about doctors and nurses. As you can see by some of the comments that were made today, doctors and nurses do not always get some of the biases that are out there or some of the negativities. What about the wider primary care community and the wider health service? How can training be given to those people to help with men’s health? I will throw you in, Mark, and then I will ask my last question.
Amy O'Connor: We talk about maximising our time with men when they show up in the healthcare system. If a man has done some manual labour or been in an accident and is turning up at an A&E with a cut hand, how can we use that as an opportunity to talk to them about their cardiovascular health? What training has the triage nurse—the person who is suturing the hand—had to say, “Hold on, I’ve got a man in front of me now, who might not have been engaged in the healthcare system since his mum brought him as a child. How can I use this as an opportunity to bring up some of the other key topics that are causing men to fall through the cracks?”
We are now definitely advocating that there needs to be, as Martin says, a lot more research. One of our asks and one of our big commitments for this year is doing a huge piece of research to see how men are engaging with the healthcare system. Why, when and how are they dropping out? What can we do to jump on them when they are dropping out? We are looking for partnership in that piece of research. That training, to your point, definitely needs to be to a broader audience.
Q85 Mrs Hamilton: Excellent. Martin, do you have anything to add?
Martin Tod: There is a range of things that training needs to reflect or that needs to be looked at in the system. It is important that we don’t think that we can just train an individual, because if there hasn’t been work to create the system around them to support them to help men with their health more effectively, that is unfair on the individual, frankly. It cannot stop at, “We’ve trained a bunch of individuals and therefore the world is going to change.”
There is a lot that it is helpful for people to understand. Sometimes the language that you need to use with men is different. The language that men use about mental health, for example, is a very obvious example of where men talk differently about mental health. They are quite guarded about showing weakness, but will use terms like “stress” and other such things to describe when they are actually talking about a mental health issue.
There is wider awareness. There is really important work going on in NHS England through the Core20PLUS5 programme to look at health inequalities. What matters is that it becomes gender informed. For example, if you are engaging with a black man who has come to you—we talked a lot earlier about prostate cancer—among older black men there will be a much higher incidence of high blood pressure. The gender gap in the black community is very different from other communities in smoking. It is one of the things that is quite interesting in the way that gender, ethnicity and culture can interact. Overall, the gender gap on smoking is quite small, but in some communities it is absolutely enormous. If you are not informed about that and able to have that conversation, you won’t be as effective as you should be when you are engaging with the man, or the woman sometimes, in front of you.
Q86 Mrs Hamilton: Thank you. My final question is to Chiara, and it is about black men. As you so eloquently said earlier, black men are twice as likely to develop prostate cancer. The notes talk about sexual health issues that can often be a warning sign for all men. How can services be adapted to engage more black men to come forward for assessment? I’ll be honest with you. A lot of black men will say to their wives or girlfriends, if they have a sexual problem—it is not only black men, but the question is related to black men—“Do not tell the doctor that I’m having this problem.” What they tend to do is hide what is going on at home because they feel it affects their masculinity. What do we need to do to engage more black men to want to come forward for assessment? That’s a good way to end it.
Chiara de Biase: Thank you for asking the question. From a system perspective, it is very simple. We must change the guidelines so that GPs can proactively offer a PSA blood test to black men and men with a family history. Just that step—allowing GPs to have a proactive rather than a reactive conversation—will reduce the inequalities.
How we get more men through the door is a great point. We are just about to recruit an associate director of racial health equity at Prostate Cancer UK to spearhead all of the work that we are doing, driving towards becoming an anti-racist organisation, so that we can credibly work with the black communities. You are right that we already work with the Black Men’s Health Advisory Group. Almost 40 men attend our regular groups, so that they can bring insight to us.
What we have got wrong in the past is starting projects and not seeing them through, so we have not been able to develop trust. We are entirely committed to do better in that space now. We are looking at barriers to access, cultural references and the language that we use and ideas around masculinity and thoughts on faith. I chaired a break-out group with the Black Men’s Health Advisory Group just last week and asked them specifically about faith and its role.
I worked at King’s College Hospital 20 years ago in Lewisham, Southwark and Lambeth. I did lots of counter-awareness work. As a six-foot white woman, there is only so much you can do in putting across a message around cancer awareness. When you tackle the community from a faith perspective, and community cultural leaders, it makes all the difference. I can’t do that, but if we bring somebody into the organisation so that black men see themselves as part of Prostate Cancer UK, we can start to have a really authentic conversation about how we engage men and then how we can change the system to bring them in to have the PSA blood test.
Q87 Mrs Hamilton: Before I bring in Martin, I am very conscious that my notes just talk about black men. I am very keen to understand what the issues are with our south Asian community. The biggest issue is about language, especially with older men. Over to Martin, and then I am finished, Chair, and it will be back to you.
Martin Tod: Continuing on the subject of black men, we did a project with the Race Equality Foundation, working through barbers to engage with black men and have conversations, because that is a classic way that men have conversations with a trusted person. We gave barbers the information to be able to have good conversations with people. I suppose the point is that, when we are thinking about how to engage with men, we work with the men. Work with the men you are trying to engage with, to make sure that you are co-designing with them what the programmes need to be. The people with the answers on how to engage black men in their health are ultimately black men.
There are absolutely different issues in the south Asian community. There is still a gender gap on smoking and, for example, diabetes is an area where there is a disproportionate issue in that community. A gender and ethnicity-informed approach is absolutely essential. That is why our view is that when the NHS is thinking about Core20PLUS5, or their approach to inequalities, they always have that gender-informed approach as an overlay with whatever group they may be engaging with.
Q88 Paul Bristow: Mark Brooks, you and many of the others on the panel made a very convincing case for the need for a men’s health strategy. In your view, why isn’t there one?
Mark Brooks: That is hard to answer.
Q89 Paul Bristow: Give it a go.
Mark Brooks: First of all, I would ask the Committee to ask Ministers that question when they come before you. Broadly, there has been an empathy gap, and the fact that it has not always been as politically acceptable to look at areas of male disadvantage. Therefore, that creates an institutional barrier in government and in political parties in general. We see that across the piece on boys’ education, barriers around fatherhood and all sorts of other issues. There seems to be a political narrative issue about addressing male disadvantage in a number of areas.
Coming back to the point, the statistics are there in plain sight. We all know that to support women’s health better, we need to support men’s health as well. We all co-exist and live together. There continue to be issues. Even when men are at a disadvantage, the lens is somehow transferred to it being a women’s issue. I can give you a couple of quick examples. A couple of years ago, the ONS did a report on covid-19 and the impact in the first year. Their opening line was, “While more men died from COVID-19, women’s well-being was more negatively affected than men’s during the first year of the pandemic.” You cannot be more negatively affected than being dead, but that was the opening line.
We see it with the Health and Safety Executive. Every year they produce figures on workplace deaths; 95% of the people who die at work or have a related injury are men, but their press release does not mention that. Actually, the gender figures are buried on page 12. Somehow there is a political blockage in the narrative and the acceptability of talking about male disadvantage, where it exists. I think that comes round to, why is there not a men’s health strategy when there is a women’s health strategy? There are lots of organisations in the men’s health space. Academics and professionals in the health sector have been talking about a men’s health strategy for a long time. There seems to be a narrative issue.
Q90 Paul Bristow: Can I get Martin to concur? The reason I am rushing you is that we literally have one minute to go, and I want to make sure my colleague gets the chance to ask a question. Martin, would you concur with that?
Martin Tod: Yes. When the women’s health strategy was announced, I thought, “Slam dunk,” and that there would be a men’s health strategy along in a minute. I have been quite surprised that it has not happened. One of the reasons for the empathy gap that Mark talked about, or just the fatalism, as I would describe it, is that men are more unequal. There is a bigger gap between men. People look at the fact that there are more male billionaires, there are more male MPs and more male company chief executives and go, “Men are fine.” Actually, there are more men in contact with the criminal justice system. There are more men sleeping rough. There are more men dying from suicide. There are more male drug addicts. There is greater inequality. Sometimes the presence of the people at the top of the tree hides the fact that men overall are not doing as well as we want them to. Years of life lost and years of working life lost are quite disproportionately high among men. The challenge is there. We need to get past that barrier and say, “It’s fine. We have this problem; we need to do something about it.”
Paul Bristow: Very well said. I hope that the many people who shouted down Nick Fletcher for asking for a men’s health strategy will listen to your testimony. It is very powerful. Chair, I have to go.
Chair: Nick deserves mention because he has done a lot of good work in the all-party group on men and boys. Finally, we have James Morris.
Q91 James Morris: There has been a lot of discussion about men talking to men about the issues. We have Men’s Sheds and lots of evidence that, particularly with mental health, where peers talk to each other about mental health, it is much more powerful and leads to behavioural change. Do you think there is a role for education to encourage peer-to-peer discussion among boys at school, for example, about health issues? Are we doing enough?
Amy O'Connor: There is definitely more opportunity. This answers Dr Johnson’s earlier question as well about how we can reach our young males. You talked about sports. Some guys aren’t sporty. We have done a huge amount of work using YouTube influencers, who are the ultimate peer to so many guys who are online. We have worked with some of the top YouTubers in the country to show vulnerability and to talk about their healthcare needs on their YouTube channels. That is reaching millions of men and young boys instantly. We were able to track and monitor that increased behaviour change intent and actual behaviour change in young men who saw that content, to have more vulnerable conversations about their healthcare. There is definitely an opportunity through that group.
James Morris: Thank you.
Martin Tod: The shoulder-to-shoulder Men’s Shed approach is a great one. We have worked with the Men’s Shed Association for many years and have tried to support them so that they can have conversations about wider health issues as well. I know that other charities have been involved with that.
We have also put in place a men’s health champions programme to encourage, enable, train and support men to have conversations with colleagues in a non-threatening way. One of the things we know is that there is stigma against showing weakness. Creating a safe environment for people to have those conversations is incredibly important. We do not have a boys’ health champions programme, but maybe we should.
It almost comes back to the point about cultural shift that was talked about earlier. The basic idea is making it okay for men to be mutually supportive and making it clear that health is not a competition. It is not something where showing weakness to people you trust is a problem. It is helping men to have the literacy so that, if people open up to them, they are able to help their friends, colleagues or whoever it may be to use the health system, manage their health and do the right things for their health more effectively.
Chair: I hope you have talked to MrBeast, who is the world’s most popular YouTuber, as I frequently hear at home. That concludes our second session on men’s health. Thank you, Amy O’Connor, Chiara de Biase, Mark Brooks and Martin Tod. We are very grateful to you for your very compelling evidence today. Thank you.