Connolly, Anne

Dixon, Sharon

Hinton, Lisa

McNiven, Abigail

English

Apollo (Cambridge)

Recent women’s health strategies, published in Scotland1 and announced for England,2 are a welcome recognition that for too long women have lived within health and care systems designed mostly for men, by men.2 Their explicit focus on women’s health needs throughout the life course is sorely needed. Women face significant health inequalities across their lives. Although women typically live longer than men, fewer of those years are in good health.2 Those living in social and economically deprived settings experience even poorer outcomes.3 These inequalities have been exacerbated by the COVID-19 pandemic, including increased period poverty,4 increased domestic violence,5 and women carrying a greater burden of home schooling and unpaid care work.6WHAT COULD (OR SHOULD) THIS MEAN FOR PRIMARY CARE? Primary care needs to be at the heart of any strategy to support and enhance women’s health. GPs are uniquely situated to care for women across their life course. Primary care can (and does) play a central role in supporting women from before menarche to the menopause and beyond. GPs support women who might never need (or want) specialist input from secondary care. However, even where women are supported in secondary care, the GP’s role encompasses care before, during, and beyond periods of specialist or focused secondary care involvement. The GP role includes prevention as well as early intervention including through contraception, pre-conception advice and screening, and menopause management. PROBLEMS WITH RESEARCH IN WOMEN’S HEALTHHistorically, women have been under-represented in trials and research data.7 This has led to a medical understanding of what is usual in health and symptomatology, or in health service development and design, that is male by default and not based on a knowledge of women’s differences and needs.8 A striking illustration of the potential harms of these inequalities is women’s experience in ischaemic heart disease where they are said to experience atypical symptoms of heart disease (that is the symptoms differ to those that men typically experience and describe, which form the basis of medical education and training). The failure to recognise the prevalence of heart disease in women and the different set of symptoms they experience during a heart attack contributes to delays in help seeking and the loss of valuable time in a cardiovascular emergency.9 Alongside the relative lack of representation of women in research of conditions affecting both men and women, conditions that pre-dominantly affect women have been historically under-researched.10 Endometriosis is an important example of this, as a long-term debilitating chronic condition affecting 6%–10% of women, which is significantly under-researched compared with other long-term conditions with comparable incidence (such as diabetes).11 LACK OF RESEARCH ON WOMEN’S HEALTH IN PRIMARY CAREEvidence and resources that understand the role of primary care in women’s health and recognise the complexity of what primary care can and does do, are needed in order to optimise this capability and potential. Women’s health is often narrowly focused on reproductive health but, in primary care, GPs care for all of women’s health needs throughout the whole life course. Evidence and resources that can inform and support holistic and longitudinal care are needed yet currently lacking in many areas of women’s health. In our work on endometriosis12 and female genital mutilation (FGM),13,14 we found that the majority of evidence deployed in primary care is derived from specialist settings and then extrapolated back to the primary care setting, where the populations and needs may significantly differ. Most women across the spectrum of women’s health (before adolescence to menopause and beyond) are cared for exclusively in primary care, with a relatively small number of women referred for specialist care. Those who are referred are more likely to have symptoms that are difficult to understand or manage, or more complex health needs. Using evidence and guidance predominantly derived from specialist settings presents a denominator problem for primary care clinicians trying to determine risk, share decisions, or advise on management options, where the knowledge and evidence relates to a different population from the one they are working with. For example, the National Institute for Health and Care Excellence guidance on endometriosis suggests that referral for specialist care is considered if symptoms are not controlled with first line therapies such as hormonal treatment or non-steroidal anti-inflammatory drugs.15 This leaves GPs facing uncertainty about how to support women with impactful period pain, whose symptoms are well controlled with first line therapies, against the backdrop of widespread reporting of delayed referrals to specialist endometriosis clinics.12 Another example is the predominance of FGM research in obstetric and midwifery settings resulting in a lack of evidence or resources for how GPs might support women with FGM Women’s health and primary care: time to get it right for the life courseEditorials536  British Journal of General Practice, December 2021“… this is an opportunity to call for primary care focused resources, education, and services that will enable GPs to support patients throughout the life course, and across their physical, psychological, and social wellbeing needs.”“Evidence and resources that understand the role of primary care in women’s health and recognise the complexity of what primary care can and does do, are needed in order to optimise this capability and potential.”beyond their reproductive years and through the menopause.14Where potential gaps in care are identified, all too often the conclusion is that GPs lack knowledge and awareness, and that increasing these would improve care.12 However, our work on endometriosis demonstrates GPs are rarely working with a lack of knowledge, but rather engage with complex and nuanced considerations. They are already balancing multiple possibilities and involved in complex shared decision making with women based on knowledge about known uncertainties and the challenges at the primary to secondary care interfaces.CONCLUSIONThese new women’s health strategies offer opportunities to put primary care at the heart of enhancing women’s health throughout the life course. But to achieve this we need evidence and knowledge developed with, from, and for primary care. We need to ensure that the services and resources developed in response to these strategies do not become too symptom or condition specific, risking compartmentalising women’s lives and bodies into organs, conditions, and phases of life. Instead, this is an opportunity to call for primary care focused resources, education, and services that will enable GPs to support patients throughout the life course, and across their physical, psychological, and social wellbeing needs. Within primary care, there are opportunities to identify and mitigate against health inequalities in women’s health, which would benefit all of society. Primary care’s huge strength is being there for the journey. It would be a missed opportunity if the conclusion and outcome of these consultations defaulted to an explanation of ignorance and to pillorying GPs to simply know more. Instead, we urge policymakers to positively utilise the wisdom and experience of GPs and patients, in research and consultation, to support an effective and meaningful women’s health strategy inclusive of primary care. Sharon Dixon, GP and Researcher, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.Abigail McNiven,Senior Qualitative Researcher, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.Anne Connolly, GP, Bevan House Healthcare, Bradford; Chair, Primary Care Women’s Health Forum; Clinical Champion, Royal College of General Practitioners Women’s Health.Lisa Hinton,Senior Research Associate, The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge.Open accessThis article is Open Access: CC BY 4.0 licence (http://creativecommons.org/licences/by/4.0/). FundingLisa Hinton, Sharon Dixon, and Abigail McNiven’s work on endometriosis in primary care, including this editorial, were funded by the National Institute for Health Research (NIHR) School for Primary Care Research (project number: 403). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Lisa Hinton is based in The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge. THIS Institute is supported by the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK.ProvenanceCommissioned; externally peer reviewed. Competing interestsAnne Connolly has received funding for lecturing, which is documented in full on www.whopaysthisdoctor.org. All other authors have declared no competing interests.DOI: https://doi.org/10.3399/bjgp21X717713trials. J Clin Invest 2003; 112(7): 973–977.8. Perez CC. Invisible women: exposing data bias in a world designed for men. London: Penguin Random House, 2020.9. The Lancet. Cardiology’s problem women. Lancet 2019; 393(10175): 959.10. It’s time to expand the definition of ‘women’s health’. Nature 2021; 596(7870): 7.11. As-Sanie S, Black R, Giudice LC, et al. Assessing research gaps and unmet needs in endometriosis. Am J Obstet Gynecol 2019; 221(2): 86–94.12. Dixon S, McNiven A, Talbot A, Hinton L. Navigating possible endometriosis in primary care: a qualitative study of GP perspectives. Br J Gen Pract 2021; 71(710): e668–e676.13. Dixon S, Hinton L, Ziebland S. Supporting patients with female genital mutilation in primary care: a qualitative study exploring the perspectives of GPs’ working in England. Br J Gen Pract 2020; DOI: https://doi.org/10.3399/bjgp20X712637.14. Dixon S, Duddy C, Harrison G, et al. Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations. BMJ Open 2021; 11(3): e039809.15. National Institute for Health and Care Excellence. Endometriosis: diagnosis and management. NG73. 2017. https://www.nice.org.uk/guidance/ng73 (accessed 5 Nov 2021).ADDRESS FOR CORRESPONDENCESharon DixonNuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK.Email: Sharon.dixon@phc.ox.ac.ukBritish Journal of General Practice, December 2021  537“… we urge policymakers to positively utilise the wisdom and experience of GPs and patients, in research and consultation, to support an effective and meaningful women’s health strategy inclusive of primary care.”REFERENCES1. Scottish Government. Women’s health plan: a plan for 2021–2024. 2021. https://www.gov.scot/publications/womens-health-plan/documents (accessed 5 Nov 2021). 2. Department of Health and Social Care. Women’s health strategy: call for evidence. 2021. https://www.gov.uk/government/consultations/womens-health-strategy-call-for-evidence/womens-health-strategy-call-for-evidence (accessed 5 Nov 2021). 3. Raleigh V. What is happening to life expectancy in England? 2021. https://www.kingsfund.org.uk/publications/whats-happening-life-expectancy-england (accessed 5 Nov 2021).4. Plan International UK. Menstrual Health Day: global period poverty and stigma getting worse under lockdown. 2020. https://plan-uk.org/media-centre/menstrual-health-day-global-period-poverty-and-stigma-getting-worse-under-lockdown (accessed 5 Nov 2021).5. Szilassy E, Barbosa EC, Dixon S, et al. PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic (PRECODE): protocol of a rapid mixed-methods study in the UK. BMC Fam Pract 2021; 22(1): 91.6. Modi N, Hanson M. Health of women and children is central to covid-19 recovery. BMJ 2021; 373: n899.7. Schiebinger L. Women’s health and clinical 

Women's health and primary care: time to get it right for the life course.

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Women's health and primary care: time to get it right for the life course.

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