Addressing the gender divide

pharmafile | May 20, 2004 | Feature | |   

A recent report by the Equal Opportunity Commission (EOC), Promoting Gender Equality in Health, has highlighted a significant omission which may impact on the overall provision of care to particular groups of patients.

Their report shows that gender is an important determinant of health outcomes and should be taken into consideration when designing health services, stating that the government won't meet its objectives in areas such as heart disease "unless it adopts different health strategies and targets for women and men".

Gender blindness is causing national initiatives to fall short of intended targets. But it should be made clear that in this article, gender is used as a representation of male and female and their relation to the bigger picture, rather than discussing specific gender debates.

The NHS is evolving fast and patient choice and empowerment are increasingly important in the government's vision for the service.

Yet recent debates have suggested that further consideration of patient needs are crucial for the appropriate and successful delivery of healthcare. It is surprising that the Department of Health (DH) has not considered the implications of gender specific health initiatives in the past as certain conditions and diseases affect men or women exclusively.

Perhaps it is the bigger picture that has been considered and not gender details? This is not to suggest that the government has ignored gender in the past, although it seemed to have a heavy bias towards women to the exclusion, and some would say detriment, of men.

Men have never been ones to shout about gender bias; they have never needed to as the discussion of gender is traditionally reserved for women. Men do not readily engage in discussions on gender, nor are men traditionally disposed to talking about their bodily functions, whereas women have a culture of health awareness and openness, when it comes to health issues affecting their access to healthcare and health information.

Female gender agenda

The focus on a particular gender agenda is biased towards women. While searching for men's and women's health on the DH website, there were 33 matches for men's health and 289 for women's, showing the emphasis placed on women's health initiatives.

Men's health initiatives seem to concentrate on youth rather than the 40-plus age group where the incidence of specific male health issues occur most.

To illustrate the gender bias in healthcare here are a few questions for the male readers. When you walk into a GP surgery, or a hospital clinic, what types of magazines make up the majority of the general reading material? When you go to the GP, what services make up the majority of the advertising? What is the typical sex of the receptionists in healthcare?

The answer is of course female, and while not being a criticism of the latter question, it does pose questions of access and encouragement to accessing healthcare in the UK. GP surgeries are the gatekeepers and the main point of access for 85% of the population to healthcare, demonstrating where the priority needs to be focused.

The Men's Health Forum (MHF) has examined the government pharmacy review, A Vision for Pharmacy, concluding that it is gender blind. They see that community pharmacies are an ideal location for men to access or initiate healthcare. The MHF briefing states that "part of the problem is that most pharmacies do not allocate space for confidential consultations and their product displays often give the impression that they are a service primarily for women".

They also reach a similar conclusion regarding explicit services for men in that men are marginalised when it comes down to health promotion and services. A one-size-fits-all approach clearly does not address the realities of disease incidence, and gender streaming should be actively perused and not sidelined as a superficial option.

April saw the implementation of the new GMS (nGMS) contract which seeks to improve the working conditions (and pay) of GMS doctors, and the improvement of patient care through patient access in an environment which reflects the local population needs. Of the 1,050 points available for PCOs to aspire to, 50 of these are for access to care.

But nowhere in the contract does it specify a gender-relevant approach to improving access, merely a 'commitment' by PCOs to making improvements in this area. Nor are gender divisions considered in reaching the aspirational clinical domains. It represents a missed opportunity to promote gender streaming in health provision. The Office for National Statistics (ONS) collect data on the use of health services by gender, showing which services are accessed by which gender group. As expected, women access GPs 40% more than men and in-patient numbers are similar.

GP visits

If you look at the time spent with a GP by gender, between the ages of 15 and 65, men spend less than half the time with a GP compared to women. Of course the figures are somewhat distorted by the fact that women may have additional health issues such as pregnancy. Nevertheless, it does identify that while men access GP services less than women, during consultation they are given even less time by their GP. Further research would be needed to find out why.

These figures should be seen in the context of wider health issues for men and women. Life expectancy of men from birth to death is lower than women, and men are three to four times more likely to commit suicide than women, especially in the 25 to 44 age range. The Samaritans take over 10% more calls from men than women. The information so far shows that the NHS does not adequately consider the importance of gender determinants of health.

The Viagra effect

A watershed occurred in one aspect of men's health, ably assisted by soccer hero Pele. Since the launch of Viagra in 1998, a once taboo subject has had salient press and health promotion on a scale previously unheard of for a men's health issue.

Although Viagra was not the only treatment for erectile dysfunction (ED), it was the first drug which highlighted a condition which affects 15% to 20% of men, with physical and mental consequences. Since the launch of Viagra, due to reporting, there has been a two to threefold increase in the annual incidence of ED between 1998 to 2000 for men aged between 40 and 79, indicating that some of the boundaries on this topic have been removed.

This is just one of many conditions related in part or full to men but shows it is possible to highlight men's health issues in a positive way. Men are not given a forum to voice health issues; the cards are firmly stacked against them, a perceptual and actual barrier exists.

Despite the focus on patient involvement in various NHS organisations, there is an ominous gap in the attention paid to gender. The seminal NHS Plan published in 2000, which laid the bedrock for NHS reforms mentions gender only in respect to

challenging discrimination. Gender is worryingly silent in the remainder of the document. This lack of specificity highlights the minor role gender plays in NHS reforms, despite it being directly related to certain disease categories.

Gender in cancer care

In the NHS Cancer Plan (2000), the aim for prostate cancer is 'to empower men to make their own choices' and provide information on the risk of prostate cancer. So far, this aspect of the cancer plan is not as apparent as screening for other cancers specific to gender or not.

Funding for prostate cancer treatment is diverted to trials on treatments whereas breast cancer funding continues to be invested in treatment pathways, screening machines and health prevention information. It is the media which has driven the impetus for prostate cancer knowledge not the NHS: the lessons from ED are appropriate for this cancer. The additional funding for cancer treatment since 1997 indicates that prostate cancer is paid lip-service, while the most common cancers  continue to receive publicity and funding for prevention and treatment.

Additionally, NICE has also been slow to appraise technology for the treatment of prostate cancer. NICE has published guidance on Improving Outcomes in Urological Cancers but nothing on pharmacological treatment regimes. In contrast, four pieces on guidance for breast cancer have been issued. I am in no way denigrating funding and/or treatment appraisals for specific cancers, but merely remarking on the quiet absence of other diseases which have a common occurrence. The question needs to be asked: "What is driving the policy for disease importance?"

The gender initiative should not be solely focused on the male agenda, although clearly there is a lag. According to the DH, colorectal cancer, gender unspecific, has a slightly higher incidence in males whereas diabetes mellitus has a marginally higher incidence amongst females. The reasons for the disparity of colorectal cancer may come down to diet and a reluctance of men to seek advice at the early stages of the disease – a frightening fact which indicates the necessity of a service which caters for this inequality.

Certainly, other factors compound the data: for instance social and economic status, which merely adds to the call for a sound debate on the factors influencing health inequalities, which must include gender, as the social class agenda has been debated to death. For colorectal cancer, the projected 2001 figures indicate that the gap between males and females may be widening slightly. Surely an opportune moment for the health service to jump on the gender bandwagon.

Why do we need a gender agenda? It is not enough for healthcare providers to initiate this agenda however much they are autonomous in local healthcare delivery. The initiative must come from the DH. The existing paradigm is that the DH sets the priorities or targets and the local providers decide how best to deliver them in relation to local priorities, demographics and epidemiology. Primary care perceptions are ultimately shaped by Whitehall.

The DH has to realise that gender is as much an element of healthcare access to and by the patient, as are health inequalities. Gender compounds the existing health inequalities making it an element of the sum of all healthcare provision. However, it does need to be a national campaign, learning from past successes, which permeates to the local provision of healthcare.

What should pharma do about the gender debate?

One aspect which the pharma industry has been called to champion is disease portfolio brand management which moves away from drug branding.

This aspect of promotion indicates where a company can influence an overall agenda which contains a portfolio of drugs. Tied into this debate is how healthcare providers manage their salient priorities which are based on influences such as NSFs, NICE and the GMS contract.

The priority for the providers of healthcare is to achieve these targets relevant to the local population. If pharma can alert these providers to the need for gender relevancy in certain disease management categories, then inequalities, once identified, can produce more efficient and appropriate outcomes. Disease audits should take into account the gender debate, not as an exclusive aspect of healthcare, but an important consideration in healthcare planning.

The report from the EOC shows that gender cannot be ignored. If the outcome is to reduce disease complications and prevent future conditions, gender should be seen as part of the overall sum. Providers of care may see the gender debate as irrelevant or insignificant compared to the wider provision of healthcare and health promotion. To ignore this factor in delivery and outcomes has a cost – inequalities in health are there to be equalled out.

Viewing the patient under a universal umbrella does not see them in the categories which they function in. Social class, ethnicity and epidemiology are common elements in healthcare debate, but until services are realigned to consider the poor access of men and the bias of health promotion towards women, inequalities will continue to exist and impact on health outcomes. We should be pushing for the gender agenda to be more obvious to those who plan and deliver care.

Gender streaming can only lead to a more patient-centred perspective, the bedrock of the current health debate from the government. Disease prevention must take into account gender as it does social inequalities.

There remains a chronic lack of male-centred health debate, and while this should in no way be at the expense of women, the imbalance needs to be addressed.