By Katherine Ripullone and Kate Womersley
From 2019, the NHS will refuse hundreds of thousands of operations, as part of cost-cutting measures. What’s been less well publicized than the ‘17 blacklisted ops’, is how restriction and discontinuation of these procedures by NHS England will disproportionately affect women.
This gender bias is not a new trend. Funding cuts to the NHS have affected more women than men – a point well made in a paper from The London School of Economics last year: ‘Government cuts are putting women’s health, women’s bodies and their babies at risk,’ the author writes. ‘The pressure on NHS services affects women disproportionately … as patients and as workers in the NHS. Women made up 55.2% of hospital admissions in 2015, and 77% of the NHS workforce are women’.[1]
The NHS claims that the latest cuts aim to save £200m by stopping “risky”, “outdated”, “ineffective” and “unnecessary” procedures, and to bring practice in line with the Royal Colleges’ ‘Choosing Wisely’ campaign.[2] A ‘grin and bear it’ approach is suggested to patients, and NHS seniors are underlining the public’s shared responsibility for protecting NHS funds and not asking for these operations.
The NHS cuts announcement in June was met with mixed responses. The British Society for Surgery of the Hand (BSSH) is concerned about unforeseen side-effects from not carrying our procedures, side effects which could cost more than the projected savings. For example, refusing carpal tunnel release surgery could increase days of work lost to individuals with the condition. The BMA says that guidelines are already in place to regulate who receives the 17 procedures, and so the cuts are excessive.
So, which operations are being cut? No ‘exclusively male’ procedures are on the list, while three exclusively female procedures have been included: dilation and curettage for heavy menstrual bleeding, breast reduction surgery, and hysterectomies for heavy menstrual bleeding. While not gender-specific, other procedures, including varicose vein surgery, carpal tunnel syndrome release procedures and haemorrhoid surgery are performed more often on female patients than on men (the conditions that these procedures treat have a greater incidence amongst women).
Online, women have noticed the gender inequalities regarding who will end up not getting surgery. On the forum mumsnet there is a discussion running, entitled ‘NHS stopping 17 routine operations – is it sexist/unfair?’ which offers insight into how NHS statements about the intentions behind the cuts impact patients’ lives. “They aren’t stopping as many ‘mens’ ops as women’s in my view,” says contributor Sarahjconnor. “For many women it is already a major, major fight to get a hysterectomy,” she continues. “How much harder are they going to make it? I really have the rage over this!”
“I am appalled that women will be denied these operations. They don’t have a hysterectomy for fun,” says NonSuchFun. “I know someone with truly enormous breasts who has been denied a reduction but this really impacts her health. Exercise is difficult, her whole posture leans backwards to compensate for the weight of her breasts so no surprise she gets back problems” (surgery for back pain is also a surgery to be cut back). JustLikeBefore notices that “varicose veins (Although some men get them) mainly effect women” and “when you compare the things on the list together, the pain and effects on normal life, seem disproportionate, to women to just get on with it.”
Other Mumsnet users see the cuts as yet another chapter in the devaluation of women’s health, and underappreciation of female suffering. They share stories about the benefit they gained from these supposedly “ineffective” surgeries: keepingbees reflects that her hysterectomy for heaving bleeding “was genuinely life changing and meant I could continue to be a tax payer.” Nonsuchfun agrees. She was “so glad” to have haemorrhoid surgery, because before, the “[b]leeding meant I couldn’t safely wear light coloured trousers… All completely better now.”
NHS England’s claim that the 17 conditions can be more effectively addressed with preventative or lifestyle approaches should be met with scepticism. While crucially important and deserving of greater attention, well-researched lifestyle medicine is in its infancy. With regards to weight loss – which is associated with haemorrhoids, varicosities, back pain, and heavy menstrual bleeding (all symptoms or conditions affected by the new cuts) – doctors don’t yet have a sufficient evidence base, reliable guidelines or adequate community resources to rely on these approaches for patients. gallicgirl on Mumsnet worries that “the NHS isn’t great at preventative medicine so I doubt there will be access to nutritionists and physiotherapists.” Whilst non-interventionist approaches may be safer, they must be shown to be effective and available if we are to rely on them as feasible alternatives to surgery.
More worrying still is the opaque process of prioritization regarding certain groups of patients over others. In response to the cuts, Sarahjconnor adds that “Women and children’s pain seem less important than men’s from what I see.” Steve Powis, NHS England’s medical director, told the The Times that he is “confident there is more to be done”; these cuts are just “the first stage” in the cull of “futile” treatments.“ He goes on: “we are also going to ask ‘Are there other procedures and treatments we should add to the list?’”
But which professionals and which members of the public are going to be asked? Who gets to say which procedures, and therefore which patients, are more important than others? We cannot let women be the ones who inevitaby lose out when austerity bites again.
[1] https://wbg.org.uk/wp-content/uploads/2016/12/WBG_Budget2017_Fullresponse-1.pdf
[2] http://www.choosingwisely.co.uk/i-am-a-clinician/recommendations/#1528715940309-e6054b7d-ff3d