The Women's Health Strategy

The latest event organised by the Progress Educational Trust (PET) gathered a panel of speakers to provide insight into progress made one year after the much anticipated UK Government publication of the Women's Health Strategy for England.

Sarah Norcross, director of PET, opened the conversation with a reflection on the lack of progress made since the publication of the Strategy in July last year (see BioNews 1152). She explained that amid the initial excitement, PET expressed reservations about how the well-intentioned goals in the Strategy could be achieved in practice (also BioNews 1152). A year on, such concerns have been validated.

First to speak was Professor Geeta Nargund, co-founder and medical adviser at Ginsburg Women's Health Board and lead consultant for reproductive medicine at St George's University Hospitals. She began by setting the scene for women's health in the UK, describing, among other statistics, that the UK has the largest gender health gap in the G20, and the 12th largest gap globally. Against this background, the Strategy contained welcome proposals including mandatory women's health training for all new doctors from 2024, funding to create 'one-stop shops' in community settings, removing non-clinical criteria for accessing fertility treatment, and improving transparency to tackle the IVF postcode lottery.

Despite these proposals, it was unclear how the UK Government intended to put the Strategy into practice.

Professor Nargund then discussed various issues with IVF funding, concluding that in light of the economic value of an infant born in the UK being potentially in excess of £700,000, the cost of IVF treatments should not be borne by the Department of Health and Social Care alone. Instead, the cost should be spread across other parts of Government that would benefit from population growth such as the Treasury, the Department for Work and Pensions, and the Government Equalities Office. Professor Nargund used an MBRACE report to illustrate the shocking disparity in maternal health outcomes across ethnic minorities. Black women are 3.7 times more likely, and Asian women 1.8 times more likely, to die during childbirth than white women. This was accompanied by an overview of the adverse economic impact on the economy of inadequate menopause support.

Professor Nargund concluded by suggesting a need for collaboration across government departments, the NHS, the voluntary and private sector, and local communities, as well as an intersectional approach to removing barriers.

The second speaker was Nickie Aiken MP, Member of Parliament for the Cities of London and Westminster, who is proposing the Fertility Treatment (Employment Rights) Bill in Parliament and has launched the related Fertility Workplace Pledge. She mentioned how important it is that the Women's Health Strategy mentions fertility treatment, but said that this was not enough. She urged cooperation, to ensure that those undergoing fertility treatment feel supported, and can have a conversation with their employer without fear of losing their job.

Next to speak was Isaac Barnswell, research and policy officer at Stonewall and leader of the IVF for All campaign. He began by explaining the significant financial cost of intrauterine insemination (IUI) for female same-sex couples. One year on, despite the Strategy promising to remove additional financial barriers to IVF for female same-sex couples in England, progress has been slow. Stonewall's research indicates that:

• 93 percent of Integrated Care Boards (ICBs) are falling short of the Strategy's target, forcing female same-sex couples who need IVF to pay thousands of pounds for private treatment before becoming eligible for NHS services.
• 19 percent of ICBs do not even meet the requirements of 2013 NICE Fertility Guideline, and require up to 12 self-funded cycles of artificial insemination.
• Only five out of 42 ICBs have policies officially under review.
• Only three ICBs do not require female same-sex couples to pay for artificial insemination before accessing IVF.

In light of this, Barnswell presented Stonewall's three key recommendations.

1. Equal access to NHS treatment across all ICBs, reinforced by the updated NICE Fertility Guideline which is due to be published in 2024.
2. The Secretary of State for Health and Social Care taking responsibility for ensuring full implementation of the Strategy's commitments, and ending the postcode lottery.
3. A clear timeline for the implementation of the Strategy.

Picking up on the theme of barriers to access for same-sex couples, and LGBTQ+ people more generally, was Laura-Rose Thorogood - founder of LGBT Mummies and of Proud Foundations, mother of four children via IUI/IVF treatment, and co-author of research in the journal Healthcare concerning increasing use of IVF by same-sex female couples.

Explaining flaws in the Strategy itself, Thorogood explained that having recommendations in a Guideline rather than a mandatory policy allows ICBs to evade responsibility for ensuring equal access, on the grounds of budgetary constraints. The Strategy itself also fails to use inclusive language, meaning that various groups of people are unnecessarily excluded from it.

In the face of these challenges, Thorogood explained that many in the LGBTQ+ community seek alternative pathways for pregnancy, such as home insemination. However, even in this context the NHS often refuses access to medication that may assist with conception, thereby adding a further impediment to having a family.

Thorogood then turned to the physical, psychological and financial impacts of a lack of funding. She gave examples of individuals getting into debt by taking out multiple credit cards or borrowing from family to fund fertility treatments. Moreover, a lack of NHS support means that those undergoing home insemination experience risk of STDs from donors and lack of support over other potential complications. Parental legal issues are also a significant hazard for those pursuing alternative pathways.

The final speaker was Dr Raj Mathur - chair of the British Fertility Society, and lead for reproductive medicine at St Mary's Hospital in Manchester. He analysed four fertility-related commitments in the Strategy:

• 'Work with NHS England to review and address the current geographical variation in access to NHS-funded fertility services across England to ensure all NHS fertility services are commissioned in a clinically justifiable way.'
• Explore mechanisms to publish data nationally on provision and availability of IVF' and 'improve information provision regarding fertility over the next two years'.
• Remove non-clinical access criteria to fertility treatment, such as one partner having a child from a previous relationship, to create more equality in access to fertility services.'
• Ensure that when it comes to same-sex couples, 'there is no requirement for self-funding and the NHS treatment pathway for female same-sex couples will start with six cycles of artificial insemination, prior to accessing IVF services if necessary'.

Having set out these commitments, Dr Mathur agreed with his fellow panellists that little has been done to fulfil these goals. However, he noted that some improvement has been made in individual ICBs, citing the North East and North Central London ICBs (covering a population of approximately 3.6 million) which introduced improved IVF policies following a consultative process (see BioNews 1148 and 1152). Recognising the importance of understandable policies to good healthcare, he commended the new London policies as being unusually well written in plain English, and urged other ICBs to follow suit.

Dr Mathur concluded NHS clinicians would like to see the implementation of the NICE Fertility Guideline, which has been achieved in Scotland and some parts of London, and hoped to see the removal of social criteria and the delivery of promises made to same-sex couples. Finally, he noted that the wider context of fertility needed to be considered, including the health of men and trans people.

The lively Q&A that followed covered much ground, beginning with a discussion of how fertility policies are often difficult to understand. Thorogood noted that this is an additional barrier to access, and rendered many unsure of what they are entitled to. Norcross added that according to a recent PET report, GPs too are often confused about whether their ICB complies with the NICE Guideline (see BioNews 1190).

The panellists also covered how funding shortages and the NHS staffing crisis affect the implementation of the Strategy. Professor Nargund claimed that there is currently much resource wastage in the NHS, and reallocation of such resources is an easy step that can be taken towards addressing the funding gap.

There was a general consensus that fertility is one of the key issues in women's health, with the panellists noting the multiple economic and social advantages associated with having a family. Dr Mathur also emphasised that the appointment of a Women's Health Ambassador could serve as a powerful message to the health system in itself, helping to raise the profile of fertility issues. Overall, it was clear from the event that much more needs to be done. in order to turn the Women's Health Strategy into a reality.

PET is grateful to the British Fertility Society and Merck for supporting this event.