Written evidence submitted by Men’s Health Forum (IMH0070)

Executive Summary

Men’s health needs urgent action, with a recent fall in life-expectancy, wider health inequalities than for women’s health, and significantly higher mortality, including from heart disease, cancer, diabetes, liver disease, suicide, accidents, overdoses and COVID‑19.

Despite men’s health challenges, the health system does not always adequately respond, with lower diagnosis rates and lower engagement with services, especially amongst working age men.

The Government’s recent women’s health strategy shows the importance of gender-informed healthcare. In the same way, a strategy for men’s health must deliver:

●        Better measurement and analysis including routine gender disaggregation of data - requiring Ministers, OHID and health system leadership to measure, recognise and act on the gender gaps;

●        Targeted improvements in outreach and access;

●        Dramatic improvements in health prevention - tackling the historic failure to engage men in weight management and continuing to drive reductions in alcohol and substance misuse;

●        Improved screening for heart disease and all cancers (not just sex-specific), linking community, workplace and primary care testing;

●        Support for voluntary sector organisations targeting those men and boys in greatest need;

●        Research, especially in improving early diagnosis of men’s health and in interventions where a gender-informed response will improve outcomes;

●        Embedding men’s health into all health professional training, and actively seeking to reduce shortfalls in male recruitment in health and care roles;

●        Reapplying relevant, successful elements of the Women’s Health Strategy, including the creation of a dedicated Men’s Health Strategy, appointment of a Men’s Health Ambassador, creation of a clinical men’s health lead in NHS England and support for the expansion of men’s health hubs and (men’s health) champions and other models of ‘one-stop clinics’.

About the Men’s Health Forum (Great Britain)

Founded by the Royal College of Nursing in 1995, the Men’s Health Forum has been the leading charity in men’s health since 2001. As well as delivering services and publications, it plays a major role in policy and research in both physical and mental health.

The Forum believes the best way to deliver high quality, cost-effective health care is to bring public health together with primary and secondary care in a gender-informed strategic approach: a Men’s Health Strategy to run alongside the much-needed Women’s Health Strategy.

Cardiovascular disease (CVD) illustrates the need for such an approach. UK women are twice as likely as men to die in the 30 days following a heart attack, yet 76% of premature deaths from heart disease are male. The ‘one size fits all’ approach fails both men and women.

Male life expectancy

The gap between male and female life expectancy in the UK is about 4 years (79 for males and 82.9 for females.)[1] In addition, the recent fall in life-expectancy[2] was higher among males than females because of the greater impact of COVID on men disproportionately interacting with other health inequalities - the male–female life expectancy gap is even higher in more deprived areas.[3]

In 2020, around one in five male deaths were before the age of 65[4] and two in five before 75: a needless loss of life which harms families and the economy - 676,000 years of life are lost in working age males (16-64) to premature death.[5]

The shocking headline figures hide starker inequalities. There is a 22-year gap in male life expectancy (MLE) between the English ward with the lowest MLE and that with the highest. MLE in Bloomfield, Blackpool is 68.2 years; in Warfield, Bracknell Forest, it is 90.3 years.[6] Comparing the lives of men in the most and least deprived 10% of areas of England, there is a 9.4-year MLE gap and a 19.0-year gap in healthy life expectancy. [7]

The age-standardised mortality rates (ASMRs) below show that men have poorer ASMRs than women for all conditions except asthma and, by a fraction, dementia. (This table does not include cancer which is shown separately later.)

There are four factors driving poor MLE.

Genetic Differences

Differences in chromosomes and hormones between men and women affect immunity, susceptibility to disease and thus life span. We often (wrongly) joke about this (‘man-flu’) but it had clear impact during COVID-19 when 63% of premature deaths from the disease were male. We can’t do much about genetic differences other than ensure that services are targeted towards those at greater risk, but we can impact the other three factors in low MLE.

‘Masculinity’’

All men and women are exposed to a social narrative around ‘masculinity’ which, while slowly changing, is recognisable to most people of all ages. Some men absorb these ideas into their identity more than others.

Research suggests that the more men hold to more traditional beliefs of ‘masculinity’, the poorer their health outcomes tend to be.[9] These beliefs, called, in some research, the Man Box, include self-sufficiency (not asking for help), the necessity of violence, hypersexuality and rigid gender roles including around authority in a relationship.

Compared to men whose beliefs place them outside the Man Box, men in and around it are more likely to feel depressed, have suicidal thoughts, take risks, drink heavily and be involved in violence. They’re less likely to seek help (including from health professionals).

Because these men are at high risk of poor health outcomes, it is key to reach them. Yes, men are changing. Yes, it is in their interests and those of wider society that they do. (There is a role here for education and other government departments in facilitating and encouraging this.) But, health policy is likely to be more effective if it reaches out to its users as they are rather than how it might like them to be. This is clearly true in the case of men. (Most may not be in the ‘Man Box’ but many will have a foot in and all will be able to relate to it.)

It is not just men who hold these traditional beliefs. Their partner might, family and friends might, employers might. This can create an environment in which to talk about a health problem (especially a mental health problem) is – or feels – risky.

Lifestyle and environment

Partly for these reasons, men are more likely than women to smoke and smoke more per day; eat too much salt, too much red and processed meat; eat too little fruit and too few vegetables; be overweight; drink alcohol and drink at dangerous levels; misuse drugs; and pay less attention to public health guidelines (as was seen on mask wearing, social distancing and vaccination rates on COVID-19).

The traditional public health approach of telling men not to do these things has clearly not worked: we need an approach that addresses men as they actually are.

Services

Health services engage men, especially working-age men, less effectively. Men are 32% less likely to visit the doctor[10] – particularly during working age. Despite being 75% of suicides, men are only 34% of those referred to Improving Access to Psychological Therapies[11]. Men are 76% of premature deaths from heart disease and the majority with Type 2 diabetes, but a minority of those undertaking NHS Health Checks[12], despite their potential effectiveness in detecting both conditions[13]. A higher proportion of men (69%) than women (59%) are overweight or obese[14] yet men make up just 23% of NHS weight-loss programmes[15]. Men are also less likely to participate in current screening offers. 

This lack of engagement means that male wellbeing is under-supported by regular check-ups and can result in more serious issues going untreated for longer, sometimes until it is too late.

Actions with the biggest impact

Discussions around men can be polarised. Some suggest that ‘men’s health problems’ result from poor services and the mindset of those who provide them. Others, by contrast, blame men. Neither are true. Ideally services and men would meet halfway. However, on the basis that it’s easier to change services than thousands of years of socialisation, services need to do all they can to meet men where they are today.

Public health messaging that does this might appeal to the more socially-useful aspects of traditional masculinity (eg doing X helps you look after your family or help others, other men are doing X, doing X is free so don’t miss out etc.)

It might address symptoms that men can’t help but notice (eg erection problems) or disease outcomes that men can’t help but be concerned about (eg smoking or diabetes may lead to losing your leg).

Services that meet men, especially men working full-time, where they are will be available out of hours or online in male-friendly environments. (More on services below.)

One of the reasons for women’s greater engagement with services is its routine nature. It makes sense to create this routine around health checks.

Already effective around CVD[16] (the main killer of men), NHS Health Checks could include more on cancer (the second biggest killer of men[17]) and on mental health (suicide is the third biggest killer of men).

Men could be contacted more proactively to book an appointment. Employers could be required to give time off. NHS Health Checks could be in workplaces - especially male-dominated ones – or in the community in locations such as those mentioned below in the section on Services.  Mobile hubs or man vans[18] could offer checks etc to communities where men don't access clinic-based services. NHS Health Checks could be offered opportunistically during medical consultations for other reasons.

Cancer

We know Prostate Cancer UK, Movember and CHAPS amongst others are planning detailed responses on male-specific cancers. We would welcome greater evidence-based screening including, for example, for prostate cancer,[19] but we must also ensure a gender-informed approach for non-male-specific cancers.

Men have a 37% higher risk of dying from cancer than women.[20] This rises to 67%, once breast cancer and cancers that only affect one sex or the other are removed from the figures. As the ASMR table below shows, men are significantly more likely than women of the same age to die from all cancers. This difference is more pronounced in some (eg. oesophageal, bladder, stomach, kidney, liver) than others.

The afore-mentioned factors (genetic differences, lifestyle and environment, services and masculinity) all play into men’s greater cancer risk. After-care services face the same access challenges for men as all health services.

Mental health and suicide

Australian research found that 64% of men in the Man Box had had suicidal thoughts in the previous two weeks[22].

Taking your own life is the end of an often lonely road but that doesn’t mean nothing can be done. A study of suicide in middle-age men found that two-thirds had been in touch with health services in the three months before they took their lives,[23] suggesting it may be possible, with the right services and approach, to intervene.

Many of the factors in male suicide - disadvantaged upbringings, relationship breakdown, structural insecurity, addiction issues, poor or no housing, poor or no work and poverty - require political action beyond the remit of the health service. (Male suicide is, as the Samaritans have described it[24], a ‘social issue’.) However, a radical overhaul of existing services to catch more men sooner could make an enormous difference.

The mental health of boys and men is underdiagnosed and undertreated. The symptoms and diagnoses currently used tend to reflect women’s signs of poor mental health rather than men’s. Too often men’s symptoms (anger, addiction, violence) are not considered as such but as problems in their own right: sanctions (eg. from the criminal justice system) are more likely than support.

The disproportionate number of men facing challenges such as homelessness, contact with the CJS, self-medicating with alcohol and drugs and higher rate of exclusion in schools further indicates that there is a level of male mental distress that is not adequately addressed using conventional methods of assessment. It is surely more effective – not least financially - to treat addicts or to house those who are homeless than to lock them up.

While male reluctance to seek help for poor mental health is in part a reflection of traditional ‘masculine’ mindsets, a major contributor is that stigma and self-stigma are real social forces and not ‘just’ psychological. They can be reflected in lower income, status and damage to careers.

Not all men face the same challenge.  There are gross inequalities in the experience of mental health associated with age, ethnicity, deprivation and (un)employment. Unskilled males are three times more likely to take their lives than men in managerial or professional roles.[25]

Good practice for supporting boys’ and men’s mental health will be materially different from that for supporting women – but this is seldom reflected in mental health services. These too need reform to meet men where they are.

Access to services

Men’s low engagement with services is discussed above. It might be more helpful here to look at the features of services that more successfully engage with men. Effective services[26]:

●        Go where men are - workplaces, sports and leisure clubs and venues, male-friendly retail outlets, barber’s shops, sports grounds, industrial estates, cattle markets, Men’s Sheds etc. They err on the side of seeking men out: many men won’t want to waste a health professional’s time so invite them with a nudge (‘at age 60 most men like to take a poo test to check all’s well’ ) and use direct contact to arrange appointments.

●        Create male-friendly spaces - many of the spaces mentioned above feel more male-friendly than traditional health services which are often focused on those who use them most - women and children. Male-friendly spaces don’t judge men or see them as potential trouble and are safe even for saying the ‘wrong’ thing.

●        Speak men’s language - language that doesn’t blame the man or imply individual weakness[27]. It’s easier to admit to feeling ‘stressed’ or in a ‘difficult situation’ (caused by external factors) than to being ‘depressed’, ‘anxious’ or having ‘problems’ (which some may see as caused by internal failings). Services should have clear, solution-focused objectives and use practical, fact-based language.

●        Create a shoulder-to-shoulder, ‘team’ environment - men appear to respond better when they feel part of a team in which their contribution and expertise is respected rather than to a hierarchical, one-way ‘doctor knows best’ discourse.

●        Are positive about men - men are more likely to do something because it makes them feel good about themselves than be cajoled into doing it because they’ve been made to feel bad. For example, weight-related programmes which focus on positives like sport and fitness rather the negatives of being obese.

Given the stigma for men around admitting to problems (especially around mental health) and in asking for help (ie using traditional health services), part of an effective strategy might be to better support and evaluate community projects, voluntary sector and other services provided by third parties which look less like traditional ‘state’ services.

However, as mentioned, traditional services need to be opportunistic and take advantage of men when they are there. For example, services to new parents are almost entirely targeted at mothers. Engage fathers. As well as being better for the baby and fairer for the family (why is it all down to mum?), it is an opportunity to engage with men around health at a time when the evidence suggests they may be more receptive. Similarly, if a man is using a service, make the contact count. Having a blood test? Take blood pressure as well.

Reaching men at higher risk of isolation and poor mental health

There is good evidence that linking up with institutions and organisations which men have greater awareness of (and perhaps greater trust in) than state institutions is effective - sports teams, sports clubs, community clubs and societies, barbers, leisure establishments etc.

Many of these sorts of projects can be enormously valuable for the men reached by them. They need to become part of a long-term community offer, not a short-term project. Better to support community, voluntary and campaigning organisations with genuine roots than parachute in a project that ends when the funding ends.

Reaching different population groups

Our central recommendation of going where men are applies to all population groups of men. Go where disabled men are. Go where minority ethnic men are. Go where disadvantaged men are. Key to doing this effectively will be co-creating material and co-designing services with the groups of men for whom they are intended.

Trust in the state and state institutions (such as the NHS) is often lowest amongst these groups. To take an example from the pandemic once again, this lack of trust was evident in the higher rates of vaccine hesitancy amongst minority ethnic groups.[28] Because of trust issues based on historic exclusion and discrimination, support for voluntary sector organisations targeting those in greatest need will be particularly important here.

Endnotes