Meeting women's reproductive health needs better in the emerging landscape

In this month’s eFeature of the Sexual Health, Reproductive Health & HIV Policy eBulletin, Dr Sue Mann, Consultant in Women's Health at Homerton University Hospital and Medical Expert in Reproductive Health at Public Health England (PHE), puts the spotlight on women’s reproductive health. She looks at new policy opportunities and system reforms on the horizon and considers how we can better meet the reproductive health needs of women in the emerging landscape.

Impacts of the pandemic on reproductive health

There is no doubt it has been a tough 18 months for everyone everywhere. Health services have been challenged to the limits and access to support and services for non-essential care has fallen to virtually zero. For the 51% of the population who are women, the scale of their reproductive health need is hard to quantify. Anecdotally, we have heard women say that they have been unable to reach the care that they sought and remain in control of their reproductive destiny – either not managing to get the contraceptive methods they need or conversely have their Intrauterine device (IUD) or implant removed so they can conceive. The reproductive rights of women are more under threat now than ever and whilst the needs of women during usual times lack visibility, in recent times they have been altogether absent and unheard.

New opportunities on the horizon?

On a brighter note, as we hopefully emerge, at least to a degree, from the pandemic, 2021 promises some key opportunities for women’s health. Health Improvement in Public Health England (PHE), which addresses reproductive health from the healthy population perspective, will become part of the Office for Health Promotion in the Department of Health and Social Care (DHSC). As such it represents a move to embed prevention and promotion at the heart of national policy making. Both a new Sexual and Reproductive Health Strategy and a Women’s Health Strategy in 2021 offer an opportunity to consider women’s reproductive health across the life course and in its entirety. At the same time, the development of Integrated Care Systems and a move to place based care represent a new opportunity for system reform. The changes signal a shift in emphasis to review population health needs and address inequalities rather than purely maintaining the focus of health and healthcare on a disease-based model. This is the backdrop to the development of the new strategies and will undoubtably shape the direction of travel in how they play out.

Surfacing the hidden realities through data

So what is next? Work published by PHE in 2018 on Reproductive Health paved the way for considering reproductive health as a public health issue. The strategies will pick up on the foundations laid for reproductive health and set the direction of travel for women going forward ensuring that issues that have previously fallen through the cracks will remain on the surface. Nonetheless people who are not counted often do not count and women are as yet largely “unheard” through the data. Many of the issues that keep them off work or affect their relationships, their ability to parent or their general wellbeing are not quantified. The London School of Hygiene and Tropical Medicine has been commissioned by PHE to develop a Reproductive Health survey tool which covers the full range of women’s experiences of reproductive symptoms and support from services and the wider community. This survey will be conducted nationally and will be the first to quantify in real time what is happening on the ground.

In addition, PHE has been looking more widely at measurement. Through consultation and developing consensus with women themselves, service providers, commissioners and policy makers, a set of 24 indicators have been collated. These will provide an overview of the health of women in a population, support decision making and help to measure trends in the burden of ill health for women which have been hitherto unmeasured. Some of these are already up and running, but many are ambitious, and this year will kick off the early stages of developing a set of new measures which will enable population need to be fully represented in the future.

Improving access to good equitable reproductive healthcare

But how to improve delivery on the ground. Negative experiences and barriers to accessing good care have been rehearsed and re-rehearsed in Reproductive Health. Women often report going from pillar to post to different providers for their cervical smear and contraception, or their Intrauterine system (IUS) for menorrhagia compared with their IUS for contraception. The pathways to care are often a matter of luck and some women require a lengthy journey in and out of different services. More recently, solutions for integrating different aspects of care have been evolving in a limited and sporadic way. Some areas have focused on provision of contraception (commissioned by local authority) in post pregnancy settings (commissioned by CCGs and NHS); others have focused on providing cervical screening in sexual health services.

General Practice has often found it more challenging to meet the full range of need. Contraception is provided by General Practices as part of the General Medical Services contract. However, this does not include Long-Acting Reversible Contraception (LARC), which is separately commissioned through local authorities via a range of contracting methods, but often holding onto the old Local Enhanced Service Contracts. Many practices do not have capacity to deliver the full range of contraception themselves and development of women’s hubs with inter-practice referrals as a solution has been happening but is largely unrecognised. Commissioners with a drive to find solutions have been wrangling with the resulting complex commissioning arrangements which will cement the join-up of the system.

So, welcome to the emerging new integrated and collaborative structures including integrated care systems, integrated care partnerships and primary care networks (the smallest of the family which represent population footprints of 30-50,000). Facilitated by the potential of new integrated models of commissioning and provision, low and behold, we have an emerging system that has knitted together for itself. The system is ripe for developing localised solutions where one general practice can serve others, so that no one general practice has to hold all the solutions and the governance arrangements of PCNs speak to a wider local arrangement. Much of the development of PCNs has been focused on long term condition management and reaching complex patients. This could be just the change that the system has been waiting for truly improving access to good equitable reproductive healthcare.

Published in the May 2021 edition of the Sexual Health, Reproductive Health and HIV Policy eBulletin. The content of all eFeatures represents the views and opinions of the authors. FSRH and coalition partners do not necessarily share or endorse the views expressed within them.