Written evidence from Department of Health and Social Care and NHS England [WRH0057]

 

 

Introduction

  1. The government welcomes the Women and Equalities Select Committee inquiry into women’s reproductive health.
  2. Improving women’s health is a priority for the government. The Women’s Health Strategy for England, published in 2022, sets out the government’s plans for the next 10 years to boost the health and wellbeing of women and girls and improve how the health and care system engages and listens to all women.
  3. To ensure the strategy reflected women’s priorities, we ran a call for evidence in 2021. This received almost 100,000 responses from individuals sharing their own experience, and over 400 written submissions from organisations and experts. As part of the call for evidence, we also commissioned a focus group study with women across England, undertaken by the University of York and the Kings Fund. This sought to reach groups that were under-represented in the public survey, for example one focus group was specifically with South Asian women.
  4. Through the call for evidence and focus groups, we heard that although women make up 51% of the population, they face obstacles when it comes to getting the care they need and spend a significantly greater proportion of their lives in ill health and disability when compared with men.[1] We also heard that not enough focus has been placed on women-specific issues, and that women are under-represented when it comes to important clinical trials.
  5. Within the Women’s Health Strategy, the priority chapter on menstrual health and gynaecological conditions sets out several ambitions:
  1. The government appointed Professor Dame Lesley Regan in June 2022 as the first ever Women’s Health Ambassador for England to raise the profile for women’s health and to work with us to implement the strategy.
  2. Successes in the first year of implementing the strategy include securing £25 million funding for the expansion of women’s health hubs to improve women’s access to services; reducing the cost of hormone replacement therapy (HRT) through the launch of the HRT prescription pre-payment certificate; and creating a women’s health area on the NHS website to bring together women’s health content and create a first port of call for women seeking information. On 1 August 2023 the National Institute for Health and Care Research (NIHR) announced over £100 million funding to 20 new Policy Research Units, including a new Policy Research Unit dedicated to Reproductive Health which will launch in January 2024.
  3. The government has also launched the Health and Wellbeing Fund 2022-25 on women’s reproductive wellbeing in the workplace. It has awarded almost £2 million across 16 Voluntary, Community, and Social Enterprise organisations who can provide holistic support to women experiencing reproductive health issues (for example, menopause, fertility problems, miscarriage and pregnancy loss, menstrual health and gynaecological conditions) to remain in and return to the workplace.
  4. This September, the government has also announced that £12.4 million has been awarded to six innovative new projects to understand barriers to getting into work. One of the projects is a first-of-its-kind Office for National Statistics (ONS) evaluation which will investigate the impact of endometriosis on women’s participation and progression in the workforce. This vital project will improve our understanding and inform future government policy.
  5. This submission to the Women and Equalities Select Committee’s call for evidence sets out the government’s assessment/evidence on: 

Menstrual health and reproductive health

  1. In 1994, representatives of nearly 180 countries at the International Conference on Population and Development agreed a now widely accepted definition of reproductive health: “A state of physical, mental and social well-being in all matters related to the reproductive system. It addresses the reproductive processes, functions, and system at all stages of life and implies that people are able to have a satisfying and safe sex life, and that they have the capability to reproduce and the freedom to decide if, when and how often to do so”.
  2. This definition is adopted in the reproductive health consensus statement published by Public Health England in 2018. The Women’s Health Strategy also reflects this definition and sets out our ambitions for a system-wide approach to women’s reproductive health based on reproductive wellbeing and supporting individual choice. This means national and local policies and services are centred on women and girls’ needs, and reflect the life course approach, rather than being organised around a specific health issue or the needs of commissioners.
  3. An important part of healthy periods and reproductive health is being free from shame and stigma, and that is why the Women’s Health Strategy has the ambition of tackling taboos and stigmas that surround women’s health and why part of the role of the Women’s Health Ambassador is to raise awareness of these issues.
  4. A period is the part of the menstrual cycle when a woman bleeds from her vagina for a few days. For most women this happens every 28 days or so, but it is common for periods to be more or less frequent than this, ranging from every 23 days to every 35 days. A period can last between 2 and 7 days, but it will usually last for about 5 days. The bleeding tends to be heaviest in the first 2 days. When a woman’s period is at its heaviest, the blood will be red. On lighter days, it may be pink or brown. Regular periods when not on the contraceptive pill indicates a woman has normal cyclical ovarian function. 
  5. While it is normal to experience some discomfort, if a woman or girl begins to have heavy, painful or irregular periods that affect her daily life, she should seek advice from her GP or other healthcare professional. Examples of when a woman or girl may want to see her GP include needing to change a pad or tampon every 1 to 2 hours, passing large clots, requiring multiple layers of protection, flooding at night, fear of leaving home and/or taking time off work or school because of periods.

Gynaecological conditions

  1. Gynaecological conditions are conditions that affect the female reproduction organs, for example, heavy menstrual bleeding, premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), endometriosis, adenomyosis, fibroids and polycystic ovary syndrome (PCOS). 
  2. Heavy menstrual bleeding is when a woman loses 80ml of blood or more in each period, has periods that last longer than 7 days, or both. PMS is the name for the symptoms women can experience in the weeks before their period. Most women have a degree of PMS at some point, but a small number of women may experience more severe symptoms of PMS known as PMDD. Symptoms of PMDD are similar to PMS but are much more intense and can have a much greater negative impact on a woman’s daily activities and quality of life. Treatments for these conditions can include taking hormonal medicine, such as the combined contraceptive pill.
  3. Endometriosis is a condition where tissue similar to the lining of the uterus (womb) starts to grow in other places, such as the ovaries, fallopian tubes and outside the reproductive tract in the pelvic or abdominal cavity or even farther afield. The only way to confirm the diagnosis of endometriosis is by performing a laparoscopy – an operation in which a camera is inserted into the pelvis via a small cut through the navel. Due to the invasive nature of this diagnostic procedure and the need for general anaesthetic, it may be better to offer medical treatment for mild symptoms and reserve a laparoscopy for women with more debilitating symptoms who usually require surgical removal of endometriosis tissues by laser of diathermy. 
  4. Adenomyosis is a condition where the lining of the uterus starts growing into the muscle in the wall of the uterus which may lead to intense pain. Medical treatments that can help with any symptoms include oral hormonal medication and long-acting reversible contraception (LARC) devices inserted into the uterine cavity.
  5. Fibroids are non-cancerous growths that develop in or around the uterus. They are a frequent cause of heavy bleeding, pain, fertility problems and pressure symptoms on other organs such as the bladder or bowel.
  6. PCOS is a common condition that affects how a woman’s ovaries work. The 3 main features of PCOS are irregular periods, excess androgen production which may contribute to acne and increased hair growth, and the appearance of multiple cysts of the ovary at ultrasound examination.

What we heard in the call for evidence for the Women’s Health Strategy

  1. Nearly 100,000 people in England responded to the call for evidence public survey. Gynaecological conditions were the topic respondents most wanted us to include in the strategy (63% of respondents selected this). Menstrual health was the fourth most selected topic (57% selected this), but it was the top choice of topic for those aged 16 to 17.
  2. Fewer than 1 in 5 respondents said they have access to sufficient information on menstrual wellbeing (17%), and fewer than 1 in 10 said the same about gynaecological conditions such as endometriosis and fibroids (8%). On average, 71% of respondents reported feeling comfortable talking to healthcare professionals about gynaecological conditions, but this dropped to 60% among respondents aged 16 to 17.
  3. We heard concerns that women had not been listened to in instances where pain is the main symptom – for example, being told that they were exaggerating their pain, that heavy and painful periods are a ‘normal’ part of being a woman, or that they will ‘grow out of them’ once they get pregnant and have a baby. Women also told us about speaking to doctors on multiple occasions over many months or years before receiving a diagnosis for conditions such as endometriosis. 
  4. Linked to diagnosis times, many responses called for better education for healthcare professionals and improved service provision.
  5. The focus groups found that women in the youngest age groups (18-24) and in the mixed-aged South Asian group felt menstruation was a priority for women’s health, whilst women aged between 25-44 prioritised reproductive disorders, fertility and perinatal health, and women aged 45-64 prioritised menopause. Periods were extremely painful for some women, affecting their ability to carry out day-to-day activities and their mood. Young women voiced that they did not know what was ‘normal’ or ‘what to expect’ making it difficult to know when to seek help with regards to menstrual health.  
  6. The written submissions from organisations and experts covered similar themes to the public survey, as well as additional themes such as tackling period stigma, better education for healthcare professionals, easier access to services, and more focussed research and evidence. Some written submissions thought that gynaecological conditions were frequently overlooked or not fully understood by healthcare professionals. For example, although heavy menstrual bleeding is a symptom, not a diagnosis, many clinicians are not confident differentiating between heavy periods without any specific underlying medical condition and heavy periods which are indicative of conditions such as fibroids, endometriosis, PCOS or pelvic inflammatory disease.

Our work to improve care for gynaecological conditions

Access to primary care

  1. Primary care is often the first point of contact for women and girls experiencing menstrual problems. We are committed to making it easier and faster for patients to get the help they need from primary care, and the measures in our ‘Delivery Plan for Recovering Access to Primary Care’ (published in May 2023) will support practices with additional funding, build capacity and cutting bureaucracy. This includes funding care navigation training for all practices to give practice staff the skills to direct patients to the most appropriate member of the wider practice team, making sure patients get the care they need more quickly and helping to build relationships between patients and care providers.  

Women’s health hubs

  1. Women’s health hubs will play a key role in improving care for common gynaecological and urogynaecological conditions. Expanding women’s health hubs across England is a key commitment in the Women’s Health Strategy, with an initial aim to see at least one hub within every integrated care system (ICS). We are investing £25 million in women’s health hubs and this money is being distributed across England, with each Integrated Care Board (ICB) receiving £595,000 over 2023/24 and 2024/25 to meet local women’s health and wellbeing needs.
  2. Women’s health hubs bring together healthcare professionals and existing services to provide integrated women’s health services in the community, centred on meeting women’s needs across the life course. These include menstrual problem assessment and treatment, including for heavy, painful or irregular menstrual bleeding, and care for conditions such as endometriosis and PCOS; menopause assessment and treatment; and contraceptive counselling and provision of the full range of contraceptive methods including LARC fitting for both contraceptive and general gynaecological purposes, for example, LARC for heavy menstrual bleeding and menopause management.
  3. As outlined in the core specification for women's health hubs, hub models aim to improve access to and experiences of care, improve health outcomes for women, and reduce health inequalities. Hubs often work at the interface between primary and secondary care. They provide intermediate care, where services are more advanced than typically seen in primary care but are for health issues which do not necessarily need a referral to secondary care. This means that women who access care in hubs may not have to travel to a hospital or be referred into secondary care services, reducing waiting lists and other barriers to diagnosis and treatment. Another aim for hubs is to optimise the skills of multidisciplinary teams through joint working and training opportunities. This can result in better care for women and ensure they are listened to about their experiences. 
  4. Our initial goal is for there to be at least one women’s health hub within each ICS. The funding is not intended to provide full population coverage, but rather proof of concept to support further expansion, as we will need much greater expansion to deliver high quality care for all women. Existing women’s health hubs and associated benefits are mapped in the early evaluation of women's health hubs, which DHSC commissioned from the National Institute for Health and Care Research-funded Birmingham, RAND Europe and Cambridge Rapid Evaluation Centre. An interim report was published in October last year, and the final report is expected to be published this year.

Contraception

  1. In addition to the importance of preventing unplanned pregnancies, contraceptive methods play a vital role in the management of many common menstrual and gynaecological problems such as heavy menstrual bleeding and endometriosis. Hormonal contraception is an important treatment option for endometriosis as it can help relieve symptoms and be used over long periods of time, thereby avoiding the need for surgery with its associated risks. We are working to improve access to contraception, including through women’s health hubs. Evidence captured in the early evaluation of women’s health hubs shows that introducing a LARC service is often the first building block for women’s health hubs and is highly cost effective.
  2. To improve access to contraception in pharmacies, the NHS England pharmacy contraception service enables community pharmacists to provide ongoing management of routine oral contraception initiated in GP surgeries or a sexual health service. This will allow women greater choice when considering continuing their current contraceptive methods. Women are also able to purchase the progestogen-only pill over the counter after consultation with a pharmacist, following the MHRA reclassifying the medicine desogestrel in 2021.

Access to diagnostics and secondary care

  1. For some symptoms or conditions, access to diagnostics or more specialist care is needed. For example, using ultrasound or hysteroscopy to investigate symptoms of PCOS, fibroids or heavy menstrual bleeding, and the only way to definitively diagnose endometriosis being via laparoscopic surgery.
  2. Waiting times can be a barrier to diagnosing and treating gynaecological conditions. Gynaecology waiting lists increased the most in percentage terms of all elective specialities between February 2020 and September 2022, increasing by 192% to 550,000 patient pathways. Since then, they have continued to steadily increase in line with the rest of the waiting list, and in June 2023 there were almost 600,000 patient pathways waiting for diagnosis or to start treatment for a gynaecological condition.
  3. The Delivery Plan for Tackling the COVID-19 Backlog of Elective Care, published in February 2022, set out plans to reduce waiting times and improve patient experience for patients across all specialty areas, including gynaecology and urogynaecology. To support elective recovery, the government plans to spend more than £8 billion from 2022/23 to 2024/25, in addition to the ringfenced Elective Recovery Fund envelope of £2.8 billion in 2023/24.
  4. The delivery plan set out the principles to minimise the impact of waiting long periods of time for treatment on patients, the public, NHS staff and health inequalities. This includes a focus on equity of access, experience and outcomes for the most deprived. The delivery plan committed to further developing the healthcare inequalities improvement dashboard, which measures, monitors, and informs actionable insight to make improvements to narrow health inequalities. This dashboard supports systems to pinpoint disparities in waiting times based on ethnicity and deprivation, enabling the NHS to take action.
  5. DHSC has also worked with NHS England to provide support to trusts with the longest and most challenging waiting lists. As a result, we have virtually eliminated long waits of two years or more and significantly reduced waits of 78 weeks or more which has helped address these inequalities in waiting times.
  6. Community Diagnostic Centres (CDCs) will play an important part in tackling the backlogs of people waiting for diagnostic tests, which includes check-ups, various tests and scans for patients on gynaecological pathways, for example, ultrasound, phlebotomy and hysteroscopy to investigate heavy menstrual bleeding or post-menopausal bleeding. The 2021 Spending Review includes £2.3 billion to roll out up to 170 CDCs by March 2025, expanding and protecting elective planned diagnostic services. This investment is delivering up to 17 million tests by March 2025, having added the capacity for 9 million more per year once they are all fully operational. As of early September, there are 116 CDCs currently operational which have delivered over 5 million additional tests since July 2021, including larger, standard and hub models.
  7. Dedicated and protected surgical hubs that conduct planned procedures only are another important part of tackling elective backlogs by increasing capacity. These might exist within a hospital as a distinct unit or ring-fenced theatre, or they may be located at a separate site. Surgical hubs focus on providing high-volume low-complexity surgery, such as hysteroscopies for women not suitable for outpatient clinic procedures and laparoscopies for suspected endometriosis. There are currently 93 surgical hubs operational across the NHS in England, with 46 of these conducting minor gynaecological procedures. 
  8. The NHS England Getting it Right First Time (GIRFT) programme is supporting surgical hubs. Through its High-Volume Low Complexity programme, the GIRFT programme is working with systems and regions to assist the NHS recover performance in elective services and reduce the backlog of patients. Gynaecology is one of 6 specialties being prioritised through this programme. By the end of March 2025, there will be 51 additional surgical hubs operating in the NHS, though not all of these will carry out gynaecological procedures.
  9. NHS England is also updating the service specification for severe endometriosis, which defines the expected standards of care. Following their review of the specification, NHS England will shortly be seeking comments on the revised draft from relevant organisations and individuals. The final service specification will be published before the end of March 2024.

NICE guidelines and education for healthcare professionals

  1. NICE guidelines represent best practice and healthcare professionals are expected to take them fully into account in the care and treatment of individual patients. NICE has published several guidelines on women’s health topics, and a number of NICE’s guidelines are supported by patient decision aids that have been produced to help women understand the options that are available to them. NICE is currently updating a number of its women’s health guidelines, including on endometriosis, fertility, and menopause. NICE has also recently been asked by NHS England to develop a guideline on PCOS. Any new proposals for guidance will be considered through the new prioritisation process that NICE is establishing.
  2. NICE is also establishing a new women’s and reproductive health topic suite to create new guidance and update existing guidance in a more responsive, swift and flexible way with a standing committee dedicated to this topic. NICE are aiming to establish the new suit by April 2024.
  3. At undergraduate level, higher education institutions develop the curricula content that enables their medical, nursing, midwifery and allied health professional students to meet the regulators’ outcome standards. Regarding doctors, the General Medical Council (GMC) will be introducing the Medical Licensing Assessment for the majority of incoming doctors, including all medical students graduating from academic year 2024/25 and onwards. Within this assessment are a number of topics relating to women’s health including fibroids, endometriosis and urinary incontinence. This will encourage a better understanding of common women’s health problems among all doctors as they start their careers in the UK.
  4. Women’s health is also embedded in the Royal College of General Practitioners’ (RCGP) curriculum for trainee GPs, including gynaecology, sexual health and breast health. The RCGP, Royal College of Obstetricians and Gynaecologists (RCOG), and the Faculty of Sexual and Reproductive Health (FSRH) have recently launched a web-based women’s health library, which provides educational resources and guidelines on women’s health that are relevant to GPs and other primary healthcare professionals.

Mental health support

  1. Mental health support is an important aspect of ongoing care for menstrual problems and other common gynaecological disorders, and we have heard concerns that it is frequently overlooked or ignored. Mental health was the fifth most popular topic selected for inclusion in the Women’s Health Strategy call for evidence. Just 3 in 5 respondents (59%) said they felt comfortable talking to healthcare professionals about mental health conditions; this was lower than when discussing their general physical health concerns (85%) and specific women’s health topics such as menstrual wellbeing (77%) and the menopause (64%).  
  2. The NHS Long Term Plan commits an additional £2.3 billion a year for the expansion and transformation of mental health services in England by March 2024 so that an additional two million people, including women with reproductive health issues, can get the NHS-funded mental health support that they need. The NHS recognises that two thirds of people with a common mental health problem also have a long-term physical health problem, and integrating NHS talking therapies with physical health services can provide better support to this group of people and achieve better outcomes.
  3. The Five Year Forward View for Mental Health, NHS England’s plans for mental health from 2016 to 2021, committed to increasing access to evidence-based psychological therapies for people living with long-term physical health conditions.
  4. Additionally, long term conditions services are continuing to grow and develop. All ICB are expected to commission NHS Talking Therapies services which are integrated into physical healthcare pathways.
  5. The COVID-19 mental health and wellbeing recovery action plan set out NHS England’s work to prevent, mitigate and respond to the mental health impacts of the pandemic during 2021/22 - supported by £500 million additional funding to accelerate the expansion and transformation of mental health services. This included accelerating key commitments in the NHS Long Term Plan, investing £110 million to expand Talking Therapies (formerly IAPT) and other adult mental health services along with the community mental health framework, and £111 million to grow the mental health workforce to deliver these and other commitments.
  6. Perinatal mental illness affects up to 27% of new and expectant mothers and covers a wide range of conditions, with depression and anxiety being the most common. As well as being crucial to new mothers, new-borns and their families, perinatal services can play an important role in ensuring mental health is integrated into overall healthcare at the earliest possible stage of life. The NHS Long Term Plan builds on the commitments outlined in the Five Year Forward View for Mental Health to transform specialist perinatal mental health services across England. We aim to ensure that by 2023/24, at least 66,000 women with moderate/complex to severe perinatal mental health difficulties will have access to specialist community care from pre-conception to 24 months.  

Maternity Care

  1. In March 2023, NHS England published the Three-Year Delivery Plan for Maternity and Neonatal Services. The plan states that all women will be offered personalised care and support plans. Personalised care and support plans should cater for women’s individual circumstances, including existing gynaecological conditions and the outcome of any previous pregnancies. For pregnant women with an acute or chronic medical problem, timely access to specialist advice and care throughout the various stages of their pregnancy and postnatal period will be available from the new Maternal Medicine Networks (MMN).    
  2. There are 14 MMNs that have been established and are operational across England. MMNs need to have arrangements in place that ensure women are able to participate in decision-making at every stage of their care and that their personalised care plans are informed by the maternal medicine multidisciplinary team. Postnatally the MMN should provide a written summary and detailed discussion with new mothers including detailed personalised plans for follow-up, ongoing physician input, appropriate contraception and information regarding future pregnancies, if applicable. This is an important opportunity to help women understand the potential implication of their medical disorder on their health and wellbeing at a later stage in their life course and to introduce preventative lifestyle measures where needed.
  3. MMNs are not a gynaecological initiative, however gynaecology is listed as a co-dependent service in the national specification so there is already an expectation that maternity and gynaecology will link up for management of these conditions in pregnancy.
  4. Personalised Care and understanding individual experiences are an important part of maternity care. NHS England are committed to ensuring that all women have a Personalised Care and Support Plan in place and can make informed decisions about their care through fully understanding the risks, benefits and consequences of the choices they have. 
  5. NHS England are currently promoting and increasing provision of Perinatal Pelvic Health Services. These aim to improve the prevention, identification and access to investigate tests, medication and essential physiotherapy for common pelvic health issues both antenatally and postnatally. Perinatal Pelvic Health Services make an important contribution to the care and support of women suffering from these very common postnatal disorders such as urinary incontinence, urinary frequency and urgency due to bladder instability, faecal incontinence and pelvic organ prolapse. Full rollout across England is expected by March 2024.

Menopause

  1. Menopause is when your periods stop due to lower hormone levels. It usually affects women between the ages of 45 and 55 but it can happen earlier. Common symptoms of menopause include vaginal dryness, dyspareunia (pain during or after sex) and recurrent urinary tract infections. These symptoms can be improved with local or systemic HRT.
  2. The menopause is a priority area within the Women’s Health Strategy, and the government and NHS are implementing an ambitious programme of work to improve menopause care so all women to be able to access the support they need. 
  3. The NHS England National Menopause Care Improvement Programme is working to improve clinical menopause care in England and reduce disparities in access to treatment. The NHS is also developing an education and training package on menopause for healthcare professionals. 
  4. HRT is the most effective treatment for perimenopause and menopause symptoms due to low oestrogen levels, and NICE recommends that it is safe and effective for most women. We have reduced the cost of HRT prescriptions through a bespoke HRT prescription pre-payment certificate (HRT PPC). Between 1 April and 31 August, there have been 377,024 HRT PPCs purchased, meaning patients are paying a one-off charge equivalent to 2 single prescription charges (less than £20) for all their prescriptions for a year. The HRT PPC definition was amended on 31 May and two further products came into scope; Livial and Intrarosa.  

Raising awareness and providing information

  1. Raising awareness and providing information for women and girls about their health is a priority for delivering the strategy. We want women and wider society to easily equip themselves with accurate information about menstrual health and gynaecological and urogynaecological conditions.
  2. In July 2023 we launched a new women’s health area on the NHS website, which brings together over 100 health topics, and will be a first port of call for women seeking health information. The women’s health area provides information on a range of health issues including periods, gynaecological conditions, fertility and cancers. We have added new pages on adenomyosis and HRT medicines, and provided updated content on menstrual period management and female cancers.
  3. NHS are tracking a range of metrics to help us understand how people are using the new women’s health area, what content is most useful and whether it is meeting the objectives we set out to achieve overall. Since launch, around 4,000 people have visited the women’s health area each week, with most people continuing to look at content relating to menopause and vagina and vulva health. We also continue to receive feedback via a survey published on the page and from this we can see that people are looking for information about symptoms and diagnosis of a range of conditions.
  4. The introduction of compulsory Relationships, Sex and Health Education (RSHE) in state-funded schools from September 2020 marked an important milestone by increasing knowledge of female health issues. Pupils are being taught the facts about key areas of women’s health across the life course, including menstruation, fertility, contraception, pregnancy and the menopause. The Department for Education is currently reviewing the RSHE statutory guidance and hopes to publish revised guidance in 2024 following a period of public consultation this autumn.

Research and evidence

  1. Research is important for improving our understanding of what causes different conditions, how they affect individuals, and effective treatments and other support. The DHSC commissions research through the NIHR. The Women’s Health Strategy sets out our commitments to boost research into women’s health issues and for improving the participation of women in all research.
  2. Between April 2022 and July 2023, the NIHR invested £53 million into research on women’s health. The NIHR have also approved funding for an additional 18 projects on women’s health, expected to start by April 2024. Across their full duration, these projects value a total of £8.5 million. 
  3. Through the NIHR, DHSC has commissioned several research studies into important gynaecological conditions, including:
  1. Beyond studies with an explicit focus on a given condition, the NIHR is funding the development of clinically validated medical algorithms for self-triage of gynaecological health. The NIHR has also funded a project to develop and evaluate statistical methodology to combine different outcomes into a single, patient-centred definition of 'success of treatment', to support the production of high-quality, thoughtful and efficient trial designs in clinical gynaecology. 
  2. On 1st August 2023 the NIHR announced over £100 million funding to 20 new Policy Research Units including a new Policy Research Unit dedicated to Reproductive Health. The unit will launch in January 2024 and is led by University College London. The unit will undertake research on policy areas such as menstrual health, gynaecological conditions, menopause and pelvic floor. Policy Research Units create a critical mass of experts for research in priority areas for health and social policy and provide both a long-term resource for policy research and a rapid-response service to provide evidence for emerging policy needs.

Urogynaecological conditions

  1. Urogynaecology is an important subspecialty of gynaecology. It covers services that provide assessment, investigations and treatment for women with recurrent urinary tract infections, urinary incontinence, vaginal prolapse, bladder pain, fistulas and pelvic floor injury after childbirth including faecal incontinence. It links with obstetrics, urological and colorectal services.
  2. Pelvic organ prolapse is when one or more of the organs in the pelvis, including uterus, rectum (lowest section of bowel) or bladder, slip down from their normal position and bulge into the vagina.
  3. Urinary incontinence is the unintentional passing of urine. It is a common problem thought to affect millions of people. There are several types of urinary incontinence, including:

What we heard in the call for evidence for the Women’s Health Strategy

  1. In the call for evidence informing the Women’s Health Strategy for England, 16% of some 100,000 respondents to the public survey selected pelvic health as a topic for inclusion in the strategy, making it the 11th most popular topic. Furthermore, 55% of respondents selected fertility pregnancy, pregnancy loss and postnatal support as a topic which should be included, making it the second most popular topic. This response option is likely to include incontinence and/or pelvic prolapse following childbirth.
  2. Many of the themes raised in relation to gynaecological conditions are also relevant for urinary incontinence and vaginal prolapse. For example, respondents to the call for evidence cited vaginal prolapse as a condition where they didn’t feel listened to by healthcare professionals. We also heard testimony about people not feeling supported by healthcare professionals and getting ‘no answers’ on incontinence issues.
  3. Organisational responses spoke about the normalisation of urogynaecological symptoms, including issues such as incontinence and pelvic organ prolapse being viewed as something to be accepted after childbirth. They shared reports of women not feeling heard during and after pregnancy, including not being given sufficient care when reporting issues including pelvic organ prolapse. We also heard about a lack of high-quality information available to the public on maternal physical health after pregnancy and childbirth, including pelvic floor disorder and the safety of and alternatives to transvaginal mesh as a treatment option.
  4. Organisational responses also reported that healthcare professionals do not consistently ask women in later life about incontinence, and women are often reluctant to disclose such symptoms due to embarrassment or not knowing that treatment is available.

Our work to improve care for urogynaecological conditions

Primary care, diagnostics and secondary care

  1. The standard care pathway for urogynaecological issues begins with a consultation with primary care, and then treatment from secondary care as required.
  2. For pelvic organ prolapse, symptoms can usually be improved with pelvic floor exercises and lifestyle changes, but sometimes medical treatment is needed. A pelvic organ prolapse patient information leaflet has been produced by RCOG to support patients with information and aims to help better understand their health and their options for treatment and care.
  3. A diagnosis of urinary incontinence is made following history taking and physical examination. Further testing may be required such as assessing residual urine, use of bladder diaries and urodynamics. Treatments can include lifestyle interventions, physical therapies e.g. pelvic floor muscle training, medication or surgical management.
  4. NHS England is working to improve services for pelvic floor dysfunction. The NHS Long Term Plan set out a commitment to “ensure that women have access to multidisciplinary pelvic health clinics and pathways across England”. NHS England is currently rolling out Perinatal Pelvic Health Services (PPHS), to improve the prevention, identification and treatment of pelvic health problems before and at least one year after birth, and ultimately reduce the number of women living with pelvic floor dysfunction postnatally and in later life. PPHS are currently being implemented by two-thirds of integrated care systems, with all ICBs responsible for commissioning a PPMS by March 2024. Key objectives of these services include to increase the number of pelvic health physiotherapists nationally and to streamline referral pathways across England so that all women have timely access to best practice perinatal pelvic health care in with NICE guidance. Currently 28 out of 42 ICBs have been implementing PPHS as either an Early Implementer or Fast Follower. 
  5. The NICE guideline on pelvic floor dysfunction: prevention and non-surgical management provides advice for health care professionals including how to help women to reduce their risk of pelvic floor dysfunction and recommended interventions to treat symptoms. The guideline also recognises that physiotherapy is important for the prevention and treatment of pelvic floor problems relating to pregnancy and birth.
  6. For more severe pelvic floor dysfunction, surgical management may be needed. Following the recommendation from the Independent Medicines and Medical Devices Safety (IMMDS) Review there has been a national pause in place on the use of vaginally inserted mesh to treat pelvic organ prolapse and the use of tape or sling to treat stress urinary incontinence. However other surgical and non-surgical treatments remain available. For instance, the surgical treatment for severe pelvic floor dysfunction is an autologous sling. The non-surgical treatment is pelvic physiotherapy.
  7. NHS England’s Specialised Women’s Clinical Reference Group is reviewing the service specification for specialised complex surgery and treatment options for urinary incontinence and vaginal and uterine prolapse (16 years and above). The review of the specification will report back in January 2024.

Specialist mesh centres

  1. To support women who have experienced adverse impacts from mesh surgery, NHS England has established nine specialist mesh centres. These centres are in operation across England, ensuring that women in every region with complications of mesh inserted for urinary incontinence and vaginal prolapse get the right support. Each mesh centre is led by a multi-disciplinary team to ensure patients get access to the specialist care and treatment that they need, including pain management and psychological support. NHS England is updating the service specification to treat patients (both male and female) with a range of rectopexy complications, which include rectal prolapse and obstructive defecation.

Work to improve care for gynaecological and urogynaecological conditions

  1. Furthermore, the work set out in the previous section ‘our work to improve care for gynaecological conditions’ also applies to urogynaecological conditions as well. For example, our work to improve primary care provision and the expansion of women’s health hubs will make it easier and faster for patients to get the support they need in the community. The Delivery Plan for Tackling the COVID-19 Backlog of Elective Care sets out plans to reduce waiting times and improve patient experience for patients across all specialty areas, including urogynaecology. The dedicated women’s health area on the NHS website provides information on pelvic health and bladder and urinary health. Improving provision of Perinatal Pelvic Health Services will better support women suffering from bladder instability, faecal incontinence and pelvic organ prolapse. The NIHR have funded a significant amount of research into reproductive, gynaecological and urogynaecological health including recurrent urinary tract infections and pelvic pain.

Research and evidence

  1. Much of the earlier research section above is also relevant to urogynaecological conditions. For example, the new reproductive health Policy Research Unit will undertake research into urogynaecological conditions.
  2. In addition, the NIHR has commissioned several research studies in this area, including a qualitative study of people’s experiences of urogynaecology services. NIHR researchers spoke to 74 individuals across the UK about urogynaecological conditions. The study found that having an urogynaecological condition had an impact on emotional wellbeing, with many of the women reporting feeling emotional and tearful because they no longer felt like the same person. Women reported sex, intimacy and romantic relationships being deeply affected by their conditions, and those with children reported missing out on doing activities together. Women also reported everyday activities being more difficult and their conditions affecting work life and money. The women interviewed expressed appreciation for healthcare professionals and the NHS, but many found navigating healthcare services was challenging. Some women described healthcare staff being dismissive, difficulties in arranging appointments and frustration when it felt like nothing was happening. Healthcare services for urogynaecological symptoms could seem to be patchy, inconsistent, or unavailable. The final report is undergoing peer review and is expected to be published this year.
  3. We have also recently commissioned, through the NIHR, a £1.6 million study to develop a patient reported outcome measures (PROM) for prolapse, incontinence, and mesh complication surgery. The new questionnaire will help women to report how these surgeries have affected their quality of life.

Conclusion

  1. The government and NHS are committed to improving the way in which the health and care system listens to women’s voices and boosting health outcomes for women and girls. Over the 10-year course of the Women’s Health Strategy, the government and NHS England are delivering several programmes of work to improve women’s reproductive health, and particularly the care and experience of women who have gynaecological and urogynaecological issues.
  2. The government recognises the importance of the issues being considered by the Women and Equalities Select Committee as part of this inquiry and looks forward to continuing to work with the Committee.

 

September 2023

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[1] We received a very large volume of responses to the call for evidence and therefore the results represent significant and helpful evidence on the views of women. While this is the case, the results are not a nationally representative survey and therefore are only representative of those who responded. Where we refer to the views of women, and how these vary by age, ethnicity and other characteristics, this cannot be taken to represent all women in England in those groups. Results of the ‘Women’s Health – Let’s talk about it’ survey - GOV.UK (www.gov.uk)