Working alongside clients with multiple and complex needs (MCN) / multiple disadvantage has shown us that the vast majority have a physical health problem or problems. Many have a combination of long-term chronic conditions such as liver cirrhosis, hepatitis C, diabetes and circulatory diseases. The female clients we have worked with have more complex and chronic conditions compared to men. A number of factors contribute to this, including the impact of domestic abuse and violence, as well as the stress on the body from rough sleeping. The average life expectancy nationally of homeless people is low – for men this is 47 years of age, for women this is 43 years of age.
Our recent research into the deaths of people facing multiple disadvantage who were supported by Fulfilling Lives South East (FLSE) over the past seven years, supported national research findings that individuals facing multiple disadvantage are more likely to experience premature death compared with the general population (Aldridge, 2018). With some of the most complex cases, FLSE had the highest mortality rate across the national programme. Restricted access to healthcare is a recurring theme in our casework.
This recent research captured in our How can we avoid treatable or preventable deaths of people facing multiple disadvantage? found that:
• Of all the Fulfilling Lives South East clients who died in hospital of preventable or treatable conditions; 75% were women (6 clients), compared with 25% who were men (one client).
• Of all the FLSE female clients who died, 100% were from preventable or treatable causes in hospital, without inquest or further investigation.
• The average age when clients died was slightly higher for women (42 years), compared with men (41 years)
What does this mean about healthcare for women who face multiple disadvantage? As women, do they experience additional levels of health inequalities?
Our project believes that women facing multiple disadvantage are more likely to have more complex health issues and are more at risk of premature death. Our client work suggests the healthcare system struggles to meet their needs even more so than men facing multiple disadvantage. Our case studies highlight the complex trauma experienced by women who received support from across FLSE, culminating in very complex health needs. This evidence clearly illustrates why women’s specific healthcare services are paramount and could ultimately reduce or prevent premature deaths of women facing multiple disadvantage.
The National Women’s Health Strategy
In June 2021 FLSE fed into the government’s ‘Women’s Health Strategy Review’. It was recognised by the Secretary of State for Health and Social Care that, “For generations, women have lived with a health and care system that is mostly designed by men, for men.”
In response, we recommended support for:
• Women only spaces in healthcare settings, such as sexual health clinics.
• Specialised healthcare services for women with MCN.
• Making appointments should be flexible (not only online or phone) and offer walk-in clinics.
• The frailty score should be used for women (and men) with MCN to offer healthcare services more quickly, using the ‘Edmonton Frail Scale’ (Rolfson et al., 2000).
• Making trauma-informed approaches training compulsory to all healthcare professionals.
• Improved coordination of support services for those with comorbid mental health and substance misuse conditions.
We have further fed into the discussion about the future Women’s Health Strategy. At the end of 2021, the Government released details of its Vision for the Women’s Health Strategy for England, informed by feedback received in the call for evidence.
We have reflected on this Vision as a team and welcome some of its strategic intentions, particularly to shape services by taking a ‘life course approach’. However, there are some areas we feel need strengthening to better meet the needs of women with MCN. We have shared these reflections with the Maria Caulfield MP for Lewes who is leading the development of the Women’s Health Strategy.
Key reflections on the Vision for Women’s Health Strategy include:
Women’s Voices: We are happy to see the acknowledgement of stigma and taboo in the new Vision document but we strongly feel that trauma informed training needs to be rolled out across the healthcare system, not only in connection with Violence Against Women and Girls specific services/aspects of the healthcare system.
Healthcare Policies and Services: We welcome the life course approach of the vision document but feel that links between services are missing, especially when it comes to some of the potential links between the Mental Health Act, Mental Capacity Act, the VAWG Strategy and the Women’s Health strategy. We would like to see resource being directed to link us these strategies at a national level.
Information and Education: In our experience, women experiencing MCN are linked in with a variety of systems and services: the prison system, alcohol and substance misuse services, adult social care, domestic abuse and the physical and mental health services. The one commonality though is women are left feeling that these systems operate in isolation and information is not being shared. We would like to see training on trauma informed approaches to promote shared language and approach to healthcare services that could enable a less siloed approach between physical and mental health as well as the wider NHS services, adult social care and the third sector.
Health in the workplace: We would encourage greater attention on supporting the health and wellbeing of those with experiences of MCN in the workplace and see this support as an enabling factor, helping people with lived experiences re-enter the workplace as well as supporting their health and wellbeing.
Research, evidence and data: Due to the high complexity of clients, we call for an open-ended, tailored and individualised approach. We believe that the healthcare system unfortunately is not always prepared to support women who experience MCN or reach out and include them in research studies. FLSE would welcome a new, more collaborative and inclusive way of working to enhance the reach of research because historically women experiencing MCN have been under-represented in data and research as such are often missed out of policies and strategies.
Our best hopes for women’s health
In our experience, the key to providing better healthcare to women experiencing MCN is accessibility and flexibility. This is also supported by the King’s Fund ‘Interventions to tackle health inequalities need to reflect the complexity of how health inequalities are created and perpetuated, otherwise they could be ineffective or even counterproductive.’
FLSE is based in Brighton and East Sussex which means that our clients have worse health outcomes due to coastal inequalities, than in other areas as explained by Chief Medical Officer Prof.Chris Whitty’s annual report 2021.
Nonetheless, we hope that our recent contribution to the call for evidence for the Women’s Health Strategy will contribute to a better system for women experiencing MCN.
That is why our best hopes for the Women’s Health Strategy are that:
- MCN is recognised as a population category in itself, alongside disabilities and minorities.
- There is recognition that some of the listed priorities (such as gynaecological health) can be traumatising or re-traumatising for women who have experienced certain forms of abuse and women experiencing/who have experienced MCN. As a result, high quality trauma informed training needs to be provided to all healthcare staff (incl.GP receptionists) and that the training includes the voices of lived experience.
- The different strategies (such as VAWG, Mental Health Act, Mental Capacity Act) are linked together and find a systemic way to collaborate more efficiently.
- The life course approach to include social determinants of health, as well as more joined up working, so that we move away from a focus on singular health issues, towards more joined up approaches to complex health conditions such as coexisting conditions mental ill health and substance use.
Rebecca Rieley, Systems Change Lead
Michaela Rossmann, Systems Change Officer
For further information about Fulfilling Lives work in this area, please contact:
Rebecca Rieley, Systems Change Lead:
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