NURS 6551 – Primary Care of Women Assignment.

NURS 6551 – Primary Care of Women Assignment.

This project examines the accessibility of primary care for women in the UK. Women are a
protected group under equalities legislation, and also constitute about 50% of other
protected groups, meaning that they often face a multitude of risk factors.
Women earn almost 20% less than men on average. They also tend to have more unpaid
responsibilities such as caring for children and relatives, and are at higher risk of violence
from partners and family members. NURS 6551 – Primary Care of Women Assignment.Women are also 40% more likely than men to
experience depression. All of these factors interlink, and may be exacerbated by belonging
to a group with comparatively poor health outcomes. Some groups will also experience
additional problems relating to their situation, such as women seeking asylum.
For the first part of the project, personal accounts of accessing GP services were collected,
using an online survey promoted to all UK women regardless of social or ethnic group. The
second part of the research involved holding a series of focus groups for women with
comparatively poor health outcomes.
Results from the survey
– 40% found it ‘hard’, or ‘relatively hard’ to get an appointment. For many, the choice
was between having to miss work without prior notice for a same-day appointment,
and waiting several weeks to be seen. There were similar issues around childcare.
– Many found it stressful to have to convince receptionists of their need for an
– 73% of mothers reported bringing their children into appointments, which is likely to
affect communication, especially about sensitive issues.  NURS 6551 – Primary Care of Women Assignment.
– Only 6% of carers had discussed their caring responsibilities with their GP.
– 62% preferred to see a woman GP about sexual and reproductive health, and some
preferred to see a female GP for any kind of physical examination at all. Some also
preferred discussing their mental health with a woman. But 20% said they cannot ask
for a female GP at their surgery, and 14% did not know if this was possible.
– Stigma, and not being taken seriously, were two of the main reasons why women
had not sought help for a mental health problem. A belief they would only be offered
medication was another concern.
– Prescription charges were a factor for 41% of respondents, when deciding whether or
not to see their GP.
– 69% of the women who had experienced domestic violence did not seek help from
their GP. There seemed to be little trust in the GP’s ability to help. Out of those who
had sought help, two thirds had a positive experience.
Results from the focus groups
Black and Minority Ethnic women
– Several of the BME women we spoke to had bad experiences of not being listened to
by doctors. This was linked with language, and not knowing the correct medical
– The majority felt more comfortable seeing a female doctor, often requesting this
specifically, though this was not always possible. Sexual health and reproductive
health were seen as particularly difficult to talk about.
– Two women who had undergone FGM spoke of highly traumatic experiences of
childbirth, with doctors not knowing what to do. The group said that problems persist,
with embarrassment preventing women affected by FGM from accessing healthcare.
– Some of the younger women had experiences of violence or abuse, but because
they lacked confidence in GPs in general, they did not consider them a potential
source of support.



Refugees and women seeking asylum
– Having had their passport retained by the Home Office made it difficult for these
women to register, as GP practices demanded proof of ID but did not always accept
their Application Registration Card (ARC).
– The women received mixed messages in relation to what healthcare they were
entitled to. They put this down to health professionals’ lack of knowledge, but also
prejudice and discrimination. Many felt that they were treated differently from nonmigrants.
– Several women had found it necessary to call in a third party to negotiate on their
behalf, both in relation to registration and to getting an appointment. They felt they
were being ‘blocked’ by reception staff.
– Several participants spoke of being denied appointments and referred to A&E or
walk-in centres instead.
– Health-related costs were a big barrier to the women, most of whom were destitute.
– Mental health problems were associated with a lot of stigma in this group.
Women living with HIV
– Many participants preferred their HIV-clinic to mainstream health services. They felt
that GPs were lacking in knowledge and experience relating to HIV, and that clinic
staff were more compassionate.
– Confidentiality was one of the main issues for this group and sometimes led to stress
and conflict when receptionists asked ‘intrusive’ questions when other patients could
overhear. There were also issues around taking children into consultations if they
were not aware of their mother’s HIV status.
– 5 out of 8 women in the focus group had experienced domestic violence but had
found it very hard to seek help, because of perceived stigmas of single motherhood
and economic dependency on the partner.
– All the women in this group had experienced mental health problems. Most of them
had sought help, but from their HIV-specialist rather than GP.
LGBT women
– Several women had previous experiences of poor treatment from health
professionals, sometimes having other health problems attributed to their sexual
orientation. For many, the expectation of doctors reacting negatively had become a
deterrent to using health services.
– The focus group and many lesbian and bisexual women who took the general survey
felt that there was very limited knowledge of their sexual health needs. Mainstream
health services were seen as very hetero-normative, for example insisting very
strongly on offering contraception. This left the women with the options of lying about
their relationship, or coming out. Several women in the focus group and the survey
said that they avoid smear tests and sexual health checks for this reason.
– Mental health was another area associated with barriers, as seeking help for
depression or anxiety would invite questioning about the home situation. Not being
able to talk about this had impacted on one woman’s mental health treatment.
– One woman and her partner sought help from their GP to have a child but the doctor
did not know their entitlement, or the referral procedure. Later, they experienced
overt discrimination during the birth when the woman who was not carrying the baby
was refused access to the maternity ward, on the basis of not being a ‘husband or
Women with learning disabilities
– This group of women found registration forms to be inaccessible, jargon-heavy and
requiring information they did not have. Two participants had asked reception staff for
help to fill in the form but were both told this was not possible.
– The women found automated booking systems difficult to navigate and some had
additional problems with dexterity, making it difficult for them to use the phone.
Clarity of speech was another potential problem with phone booking.
– Participants identified several communication barriers relating to GPs’ use of jargon,
and not having access to information in accessible formats, for example about how to
manage a chronic illness, or about contraception. Not being able to make themselves
understood by doctors was another problem. There are potentially serious
consequences if women with learning disabilities cannot make themselves heard, as
they are at high risk of sexual abuse and domestic violence, sometimes from carers.
Women’s support organisations may not be well equipped to support women with
complex circumstances.
– Cervical screening is a potential neglected area of health for this group. Many of the
women found the issue of sexual and reproductive health difficult and embarrassing
to talk about. One had asked several times to see a female doctor for this, but her
request had never been adhered to.
– The women spoke of the ‘postcode lottery’ of mental health services, and the fact
that their low-level disability meant they did not qualify for social worker support.
Many disabled women only have access to mainstream services, which may be
poorly equipped to support them.
The appointment system
 More flexibility is needed in terms of how appointments are offered and how clinics
are scheduled by GPs.
 Audit appointment systems with the help of patient representatives.
 Open up the booking system in order to meet equal access requirements. Online
booking is offered by some practices already and we welcome changes to the GP
contract which will provide all patients with this option in 2014/15. Some respondents
preferred going to see the receptionist in person. Some GP practices also offer a
second chance to book an appointment in the afternoon.
 Offer people with learning disabilities annual health checks, which should include
smear tests and breast checks for women in the relevant age groups. (Currently, the
provision of such checks varies according to area and GP practice.) The Health
Action Plan is another tool that can be used to monitor health.
 Consider reviewing the kinds of questions patients are asked by receptionists when
they call to make an appointment.
 Awareness training for administrative staff about the entitlements of refugees and
asylum seekers, about the Equality Act, and about patient confidentiality.
 In addition to offering a wider range of appointments, consider extended opening
times and operating weekend clinics.
 The responsibility of informal care work should be balanced with the offer of support,
to which carers are legally entitled. Healthcare professionals should raise awareness
of these entitlements in their contact with people who are, or may be, carers.
 Simplify registration procedures to minimise complexity and time demands, including
making all application forms available for download and registering new patients at a
variety of times.
 Consider combining registration with any compulsory health checks. This would also
be an opportunity to offer support with forms, for example for speakers of other
languages or women with learning disabilities.
 Documentation requirements should not be a barrier to registration when passport,
photo ID or utility bills are not obtainable. Insisting on these documents restricts
access to healthcare for groups like asylum seekers, homeless women and members
of the Irish Traveller community.
 In order to adhere to commitments and obligations relating to equal access and the
reduction of health inequalities, NHS England and Health and Wellbeing boards can
work with third sector organisations to provide awareness training for clinical and
administrative staff about the rights of migrants, asylum seekers and refugees, and
NHS obligations towards them, and to act as patient advocates.
 Health and wellbeing boards should consider working with local third sector
organisations to meet equalities standards, including becoming ‘LGBT-friendly,
meeting the needs of patients with HIV, patients with disabilities, speakers of other
languages and others who may struggle to register.
 We welcome changes to the GP 2014/15 contract which will allow GPs to register
patients from outside their practice boundary area, effective from October 2014, as
some patients’ needs are not necessarily met by their local practice.
Effective use of the appointment
 The availability of female doctors should be recognised as a potential access issue
for women as a group of patients. Not meeting this requirement can be a barrier to
accessing care for sexual and reproductive health, and mental health.
 Women should be made aware that they have a choice to see a female health
professional, and requests should be met wherever possible, without additional
 All GP practices should have at least one female doctor in order to meet this need.
 Allocation of time should not be done in a way that inhibits communication about
sensitive issues, or compromises trust between the patient and doctor.
 GPs may need training on how to provide patients with a supportive environment for
disclosure about sensitive issues such as mental health and domestic violence.
 Confidential interpretation services should be commissioned and provided free of
charge to those who require it, in order to meet equalities commitments about equal
access as provided for by the Equality Act 2010, the Human Rights Act 1998 and the
NHS constitution. Face-to-face interpretation is preferable, but phone services may
help to address the issue of small communities where confidentiality could be
compromised. Female interpreters should be made available to women wherever
 Awareness needs to be raised among patients about entitlement to interpreter
services, for example using strategically placed posters in GP practices.
 Midwives and other healthcare professionals should have awareness of the protected
period for pregnant asylum seeking women, allowing them to advocate on their
behalf if necessary.
 The Royal College of General Practitioners recommends ensuring that patients with
learning disabilities have their individual communication needs outlined in their
patient notes. They also recommend longer appointment slots for patients with
Learning Disabilities.
 NHS England is currently working towards implementing an Information Standard for
accessible information for patients with disabilities, which means that health and
social care organisations will be required to provide information to patients in a
format that they can understand. GP practices will need to ensure they comply with
this new standard when it is implemented.
 NHS England should consider following the Scottish example: in order to meet the
requirement to accessible information, as per the NHS Scotland’s rights-charter,
NHS Scotland now supplies accessible easy-read maternity books from CHANGE, to
all expectant mothers with learning disabilities.
 NHS England should consider commissioning training for healthcare providers on
how to work more accessibly, how to adapt practices and communication to become
more inclusive. In recognition of equalities duties and in line with the ‘No decision
about me, without me’ agenda, commissioners and providers should consider
seeking advice on implementation from women with learning disabilities themselves.
 GP practices, pharmacies and other NHS organisations should support public
awareness of low income schemes by providing forms and advice.
 Free prescriptions for vulnerable migrants should be retained and the HC1 form (the
application form for the HC2 certificate) routinely be provided by GPs, pharmacists
and other healthcare providers.
Prejudice and discrimination
 Healthcare professionals need training in order to become more confident and
comfortable dealing with LGBT women patients, becoming more aware of their
needs, and knowing how to eliminate discriminatory practices.
 A recent CQC inspection reveals that 1 GP service in 8 has no set complaints
procedure. Official complaints can be a valuable tool for quality assurance.
Complaints should be dealt with according to a set process which is open, accessible
and supportive. Awareness can be created using information leaflets and posters.
 In respect of the above, however, it also needs to be recognised that bad
experiences may lead to avoidance rather than active engagement. For this reason,
alternative methods for evaluation and feedback should also be explored by NHS
organisations in order to reach seldom heard groups.
 You cannot improve what you do not measure. Public health data should be genderdisaggregated and contain information about protected characteristics. Questions
about sexual orientation need to be asked in sensitive ways and the reasons for
collecting this data explained.
 Further to the above, GP practices should be required to audit their success in
meeting the needs of aforementioned groups via questionnaires/ patient’s group
feedback, and make improvements where necessary.
 Underlying reasons as to why BME and refugee and asylum seeking women tend to
report worse health experiences needs to be explored further. Such treatment
appears to be discriminatory, and against the Equality Act 2010 and the NHS
Constitution. For example, it is unacceptable to refer patients to A&E for nonemergencies, and investigation may be needed into the extent of this problem and
how to address it.
 Reception staff should be offered training on patient confidentiality, helping them to
deal with concerned patients.
Mental health problems
 The course of action outlined by the Department of Health in order to achieve ‘true
parity of esteem’ between mental and physical health should be carried out;
investigating the scale of the problem, and implementing maximum waiting times for
treatment of mental health problems.
 GPs need training on how to provide a safe and non-judgemental space for
disclosure about mental distress. Having one GP per practice specially trained in
mental health, and putting this information out to patients, is an option.
 The risk of mental health problems like PTSD in the asylum seeker group should be
recognised by health professionals, including how cultural issues may affect
perceptions of mental health.
Gender-based violence
 Work on FGM should reach outside of the maternity setting and be subject to set
referral pathways, which should include advocacy support. In the case of younger
girls, it should be incorporated into existing child safeguarding frameworks.
 A recent CQC inspection showed that 12% of surgeries do not know the correct
procedures for safeguarding children and vulnerable adults, such as women with
learning disabilities. This needs to be addressed.
 Health professionals should recognise that intimate partner violence also happens in
same-sex relationships and adapt standard forms and procedures accordingly.
 Patients should be made aware that their GP services can be a first step towards
getting help with gender-based violence. Information from women’s organisations,
such as posters and leaflets, should be placed in waiting areas. Equally, information
should be available in community settings such as libraries, pharmacies and
community organisations.
 We concur with the NICE recommendation that strategic partnerships, such as
Health and Wellbeing boards identify all local services that deal with domestic abuse
and map them against the Home Office/AVA ‘Coordinated Community Response
Model’. Services should also be mapped in order to identify other local specialist
organisations such as Rape Crisis Centres, BME VAWG specialists and community
based organisations that work on LGBT women, disability and other protected groups
or groups with comparatively poor health outcomes.
 GP surgeries should draw on existing models of promising practice, such as the IRIS
project, and the GP champions Youth Inclusion Project, which have improved
collaboration between the voluntary sector and primary care through prompts for
clinical enquiry, care pathways, practice – based clinical leads, and VAWG experts
based in GP surgeries.
 Consistent and standardised training or guidelines are needed for health
professionals about how to identify the signs of gender-based violence, the impact of
gender-based violence and responding appropriately. GPs should work in
partnership with specialist voluntary sector organisations to develop appropriate
referral pathways that also ensure confidentiality and safety in situations where
women may disclose gender-based violence. This should also include knowledge
about issues relating to asylum-seeking women and their entitlements in genderbased violence situations where their asylum claim is linked to the perpetrator of
violence. Knowledge should be updated along with changes in legislation and policy,
so that GPs can provide the vital support that women in this situation need.
 We concur with the 2013 intercollegiate recommendation that ‘all new patient
registrations in primary and secondary care, including A&E of young girls/women,
should include detailed enquiry about country of origin. If the family is from FGM
practising community, document any presence of FGM to establish a baseline for
monitoring and sharing information with the relevant agencies.’
 We concur with the Alberti Review recommendations, including the one that ‘NHS
staff should be made aware of the issues relating to violence and abuse against
women and children, and of their role in addressing those issues, including how to
broach the issue sensitively and confidently with patients’.
General recommendation
 This report has flagged up several areas in which NHS providers can potentially fail
to meet the needs of their patients. In order to meet equalities duties and public
health duties to the local community, NHS organisations should identify where
service delivery falls short of their equalities commitments, for example using the
NHS Equality Delivery System EDS2.
Part 1 – Context
1.1 Aim of the project
This projetct, commissioned by the Women’s Health and Equality Consortium, examines the
accessibility of NHS primary care services, from the point of view of UK women.
The aim of this project is to explore potential barriers to healthcare, both for women in
general, and for women who experience comparatively poor health outcomes, in order to
contribute to an understanding of how these may be addressed.
1.2 Rationale for this project – Why women?
Women are a protected group under UK Equality Legislation. Women also constitute roughly
half of all other protected groups, such as people with disabilities, Black and Minority Ethnic
(BME) people and lesbian/gay/bisexual and transgender people1
, and may therefore face
multiple disadvantages.
There is evidence that women experience significant inequalities in health outcomes
compared to men.3,4 Whilst the biological differences between men and women undoubtedly
play a role (including, but not limited to, factors relating to childbearing) the focus of this
report will be on the wider concept of gender, defined by the World Health Organisation
(WHO) as ‘the socially constructed differences between women and men, including
expectations of roles and responsibilities, as well as differences in patterns of employment
and unpaid work’.5
The impact of social circumstances on health is well documented, and the need to address
inequalities is recognised in UK health policy. The Department of Health mandate to the
NHS states its responsibilities to the public as follows:
“The Government’s ambition for excellent care is not just for those services or
groups of patients mentioned in this document, but for everyone regardless of
income, location, age, gender, ethnicity or any other characteristic. Yet across these
groups there are still too many longstanding and unjustifiable inequalities in access to

The Equality Act, 2010. For a summary, see for example
2 WHEC, 2013, Better Health for Women – How to incorporate women’s health needs into Joint Strategic Needs
Assessments and Joint Health and Wellbeing Strategies, available at
ibid., Annex A
Health inequality is defined by NICE as “Differences in health experiences and outcomes between different
population groups, depending on socio-economic status, geographical area, age, gender and ethnicity”
S. Payne, 2009, WHO Policy Brief 12, How can gender equity be addressed through health systems? Available
services, in the quality of care, and in health outcomes for patients. The NHS is a
universal service for the people of England, and NHS England is under specific legal
duties in relation to tackling health inequalities and advancing equality. The
Government will hold NHS England to account for how well it discharges these
The Health and Social Care Act 2012 also places a duty on the Health Secretary to ‘have
regard to the need to reduce inequalities between the people of England with respect to the
benefits that they can obtain from the health service.’7
The relationship between socio-economic status and health is not merely a matter of the
very poor being more susceptible to illness, which could have been explained by lifestyle
factors alone. Research by Marmot and others has found that health status declines with
each decline in socio-economic status, making a strong case for focussing on ‘the broader
structure of social economic condition’ rather than on poverty alone.8
More recent research
has corroborated these views.9 There is evidence that the current recession, with the
associated cuts to public spending, welfare and healthcare budgets10 has disproportionately
affected single parents and women 11 and, according to authoritative sources, ‘will likely
widen health inequalities considerably’.
One of the intended functions of this document and its recommendations is to support NHS
commissioners, providers, and others responsible for meeting their Public Sector Equality
Duty (Equality Act 2010), under which equal consideration must be given to the needs,
experiences, outcomes and aspirations of people with protected characteristics under
equalities law.

6 Department of Health, 2013, ‘The Mandate – A mandate from the Government to NHS England: April 2014 to
March 2015’, available at
The Health and Social Care Act, 2012
M. Marmot, 1997, as quoted in M. Denton and V. Walters, 1999, ‘Gender differences in structural and
behavioural determinants of health: an analysis of the social production of health’, Social Science & Medicine, 48,
See for example: M. Marmot, 2010, Fair Society, Healthy Lives, The Marmot Review – Strategic Review of
Health Inequalities in England Post-2010, available at; and K Pickett, R Wilkinson, The Spirit Level – Why Equality is Better for
Everyone, Penguin UK, 2010
10 The Royal College of GPs reports that, although over 90% of patient contacts with the NHS take place in
general practice, its share of the NHS budget is only 9%. Investment in real terms fell from £8,865m in 2009/10,
to £8,459m in 2012/13.
11 S. Himmelweit & D. Elson, Women’s Budget Group, 2013, The Impact on Women of Budget 2013 – A budget
for inequality and recession, available at
12 According to Jessica Allen, deputy director of the UCL Institute of Health Equity and former Project Director of
the Marmot Review: ‘Health inequalities continue to widen across England, made worse by the economic climate
since 2008 and by welfare reforms. Our analysis demonstrates that the combination of recession and austerity
will likely widen health inequalities considerably.’, Feb 2013)
13 For a list of bodies this duty applies to, see for example
1.3 Defining access
According to international human rights standards, every human being is ‘entitled to the
enjoyment of the highest attainable standard of health conducive to living a life in dignity’,
and this includes equal access to healthcare
14. Access can be quite a blurry concept in
places like the UK, where health care is free at the point of use for the vast majority of users.
For this reason, our definition of access here refers not only to physical access, or actual
use, but also to the availability of suitable services at a personal cost which is acceptable to
the user.15 It also requires an appropriate level of information, for example about entitlement,
provision and location of facilities.16
Accessibility, i.e. potential access, is less observable than actual use, but equally important.
17 In order to include this aspect, we will be asking questions about women’s experiences of
making and getting appointments, but also about the factors that influence their decisions
about whether or not to seek help.
The concept of access should also include the notion of effective use of services. This takes
into account aspects of quality such as the ability to communicate need and receive
information effectively. Information needs to be accessible to the user and this may entail
translating to other languages, or using picture support for patients who do not read.
Receiving poor quality care, whether this is to do with communication or something else (for
example being stigmatised on the grounds of sexuality, or treated with prejudice because of
ethnicity) is both an access problem in itself and can become a deterrent to seeking help in
the future. One aspect of effective communication is time. Angus18 found that ‘many authors
reported women’s complaints about limited opportunities for fruitful communication during
appointments with physicians. A commonly identified problem was insufficient time allotted
for appointments, which truncated discussion of health issues; some women found primary
care providers were unable to discuss details of specialty care and treatment’.
Barriers to healthcare therefore include both supply-side features like policies and processes
and even physical issues like location, as well as social and economic issues like the
inability to afford prescription charges or taking time off work. It also includes factors that
impact on the doctor-patient relationship, such as prejudice and stigmatisation, which have a
detrimental impact on trust and communication.

14 UN Committee on Economic, Social and Cultural Rights (CESCR), General Comment No. 14: ‘The Right to the
Highest Attainable Standard of Health’ (Art. 12 of the Covenant), 11 August 2000, E/C.12/2000/4, available at
15 Based on the definition used in M. Goddard and P. Smith, 2001, ‘Equity of access to health care services –
Theory and evidence from the UK’, Social Science & Medicine, Volume 53, Issue 9, 1149–1162
16 This is in accordance with – article 12 b of the International Covenant on Economic, Social and Cultural Rights,, which states that Health facilities, goods and
services have to be accessible to everyone without discrimination, within the jurisdiction of the State party. This
includes non-discrimination, physical accessibility, economic accessibility (affordability), and information
accessibility, including confidentiality.
17 M. Goddard and P. Smith, 2001, op.cit.
18 J.E Angus et al, 2012, ‘Beyond barriers in studying disparities in women’s access to health services in Ontario,
Canada: a qualitative metasynthesis’, Qualitative Health Research 23(4):476-94
1.4 Factors underpinning women’s health inequalities
The factors that underpin women’s health disadvantage include (but are not limited to):
 Factors relating to women’s economic disadvantage
 Factors relating to women’s caring roles
 Factors relating to gender-based violence
1.4.1 Economic disadvantage
UK women earn an average of 19.7% less than their male counterparts
. Women are also
more likely to be poor in terms of lacking two or more necessities, earning below 60 per cent
median income, experiencing subjective poverty and receiving Income Support.
The Marmot Review in 2010 found a lower level of attendance of cancer screening services
in lower socio-economic groups, ultimately affecting treatment options and prognosis.
Patients in lower social strata (variously defined by occupation, level of deprivation and
overcrowding in the local area, as well as individual economic circumstances) have also
been found historically less likely to take part in preventative programmes such as cervical
screening and childhood immunisation.23
Disentangling the various factors affecting health-seeking behaviour is not a straightforward
matter. However, it is possible that some low-income individuals avoid (or do not prioritise)
non-urgent treatment following a calculation of upfront cost versus potential long-term
benefits. Although healthcare is free to most people in the UK24
, and associated expenditure
(transport, phone calls and prescription charges, for example) comparatively low, cost is
relative to income and should not be disregarded as a factor.
25 It is also true that people who
experience poverty may have ‘chaotic lifestyles’, due to the demands of living on a low
income and negotiating with various service providers and authorities, such as benefit
Caring responsibilities are often an additional factor for women on top of other
The majority of working people take time off to see a doctor – In a recent survey by the
Patients’ Association, more than 3 in 4 respondents reported having to do this, and for more
than half (58%), this amounted to a full day or more.
27 Having to request (potentially unpaid)
time off can be a problem for anyone, but perhaps especially for lower income individuals in

19 These categories are taken from WHEC, 2013, Better Health for Women op.cit.
20 ONS, 2012, ‘Annual Survey of Hours and Earnings’. Based on median hourly earnings for all employees, both
full-time and part-time. Available at
21 Women’s Budget Group and the Joseph Rowntree Foundation, 2008, Women and poverty
Experiences, empowerment and engagement, available at
22 M. Marmot, 2010, op. cit.
23 M. Goddard and P. Smith, 2001, op. cit.
24 Excluding certain categories of migrant, and UK nationals living abroad
25 M. Goddard and P. Smith, 2001, op. cit.
26 Judicial College, 2013, ‘Equal Treatment Bench Book’, available at The issues
are discussed in relation to how they may affect court attendance. Arguably, similar issues come into play
regarding making and keeping health appointments.
27 C. Hall, 2013, Primary Care Review Vol 2, Primary Care – Access Denied? The Patients Association, available
precarious employment situations. A Canadian study of low-income migrant women found a
link between this type of work, and delays in seeking healthcare. The same was true of selfemployed women without access to paid sick-leave.

Goddard and Smith (2001) found that, although economically disadvantaged people were
more likely to consult their GP about certain problems they were less likely to be referred to
specialist treatment.29 It is possible that poorer patients are unable to make as effective use
of services as their wealthier peers. The same meta-study found that middle-class
individuals generally spend more time with their doctor, asking more questions and getting
more information.
30 Other studies have found a positive relationship between gender, age
and class, and the quality of communication between patient and healthcare provider.
1.4.2 Women’s caring roles
There are around 6 million carers (for a child or adult, who may be sick or disabled) in the
UK. 60% are women32
. Women’s socially constructed gender role is more likely to include
expectations of the roles and responsibilities associated with unpaid work such as
housework and caring, 33 and within families, caring responsibilities are more likely to fall on
the partner who has less earning potential outside of the home.

Although the caring role can be personally rewarding, it is also associated with a range of
issues relating to health, such as poverty, isolation and discrimination, as well as physical
problems like high blood pressure (associated with stress) and musculoskeletal conditions
(associated with heavy lifting).
35 According to research from the OECD, carers are about
20% more likely than non- carers to have mental health problems and female carers are
more likely than men to be at risk of poverty as a result of their role.36
The government recognises in relation to its Carers Strategy that ‘carers often neglect their
own health and need advice to maintain their wellbeing’, and that carers often lack both time
and social support.37 The informal nature of their work can mean that they are effectively ‘on
call’ at all times, unable to take time off in order to access healthcare. This is well illustrated
by the following quote:

28 J.E Angus et al, 2012, op. cit. (Canadian healthcare is free at the point of use, much like the UK NHS)
29 M. Goddard and P. Smith, 2001, op. cit.
30 ibid.
31 J.E Angus et al, 2012, op. cit.
32 Health and Social Care Information Centre, 2010, Survey of Carers in Households – England, 2009-10 ,
available at
33 S. Payne, 2009, op. cit.
34 F. Colombo et al, 2011, ‘Help Wanted? Providing and Paying for Long-Term Care’, Health Policy Studies,
OECD Publishing, available at
35 HM Government, 2010, Recognised, valued and supported – Next steps for the Carers Strategy, available at
36 F. Colombo et al, 2011, op. cit.
37 HM Government, 2010, Recognised, valued and supported, op.cit
“I am supposed to be having my cataracts done but I just can’t because who will care
for Mum?”
The unpredictability of the demands associated with care work can also make it difficult to
arrange a suitable GP appointment ahead of time.

Many carers are eligible for special assistance, such as Carer’s Allowance, respite services40
and yearly health checks and vaccinations. They also have a legal right to a needs
assessment by social services, and GPs are often the entry point to all of the above.
However, many do not identify with the label of ‘carer’, and therefore do not seek or receive
any support.
41 This may be especially likely to affect women whose gender-role involves
caring as a societal expectation.
“I’m not recognised as a carer. In China you wouldn’t say I’m a carer, you
automatically care ‘because you should’ … It’s the Chinese family way, our culture.”
For similar reasons as those described in relation to caring, mothers may neglect their own
health, potentially having to juggle health appointments for themselves and their children
with work and childcare or school hours. Single parents, over 90% of whom are women43
are more likely to be low earners and be affected by welfare cuts,
44 and research suggests
that single mothers have ‘poorer functional health than women living as part of nuclear
families’45, possibly because they often have full or main responsibility for childcare whilst
not being supported financially by a full-time earner.
1.4.3 Gender-based violence
According to the National Institute for Health and Care Excellence (NICE), at least 1.2 million
women and 784,000 men between 16 to 59 years of age in England and Wales experienced
domestic abuse in 2010/2011. This is 7.4% of women and 4.8% of men. At least 29.9% of
women and 17.0% of men in England and Wales have experienced it at some point in their
lives, though the real figures are likely to be higher due to under-reporting of this kind of
crime. 46 Although some sufferers are male, severe and repeated episodes and sexual
violence are much more likely to be perpetrated by men towards women.47 According to UK
figures, around half of all female homicide victims are killed by a partner or ex-partner. This
is also true of about 5% of men. Prevalence of domestic violence is greater among young
women (under 24 years), and those who have a long-term illness of disability (including
HIV), placing them at multiple disadvantage.48

38 ibid.
39 S. Payne, 2009, op. cit.
40 For example, short breaks can be prescribed to carers at risk of burnout.
41 HM Government, 2010, Recognised, valued and supported, op.cit.
42 ibid.
43 E. Bloomer, 2012, The impact of the economic downturn and policy changes on health inequalities in London,
UCL Institute of Health Equity, available at
44 ibid.
45 M. Denton and V. Walters, 1999, ‘Gender differences in structural and behavioral
determinants of health: an analysis of the social production of health’, Social Science & Medicine, 48, 1221-1235
46 NICE, 2014, op.cit.
47 ibid.
48 ibid.
The Government recognises gender-based violence as violence directed against a woman
because of her gender, or because it affects women disproportionately.
49 In addition to
domestic violence, the definition encompasses different forms of violence against women
and girls including FGM and so-called ‘honour based’ violence, in recognition of the fact that
different forms of violence are manifestations of expressions of patriarchy and gender
inequality. The risk is higher during pregnancy, at which time the violent partner often begins
or escalates the abuse50
. It is common for women in this situation to experience feelings of
shame, and to be strictly controlled by their partner,51 and these are some likely reasons why
disclosure in the healthcare setting is rare52
. Another potential barrier to getting help is
caused by economic dependence. Women are more likely than men to be reliant on a
partner’s income, for reasons relating to lower earnings potential and the caring role. For a
woman who lacks the means to support a family, disclosure of the abuse could mean
53 Gender-based violence is also associated with depression and anxiety54
potentially presenting affected women with multiple barriers to getting help.
1.5 Mental health as a neglected issue
This report considers both mental and physical aspects of health to be of equal importance
in terms of care and treatment. This, however, is not necessarily the experience of sufferers.
Recent research from The Centre for Economic Performance’s Mental Health Policy Group
found that three quarters of an estimated 6,000,000 people with anxiety and depression go
untreated, and that 65% of surveyed GPs stated that they were ‘rarely’ able to provide
patients with specialist psychological therapies (such as cognitive behavioral therapy)
within two months.
55 There is no maximum waiting time for mental health treatment in the
NHS Constitution, as the 18-week limit does not apply here.56
In acknowledgement of these problems, the Department of Health has set out the following
goals in order to attain ‘parity of esteem’ between mental and physical health:
‘Too often, access to services for people with mental health problems is more
restricted and waiting times are longer than for other services, with no robust system
of measurement in place even to quantify the scale of the problem. The Department
of Health and NHS England are committed to ending this and believe that
implementing new access and/or waiting time standards is vital in order to have true
parity of esteem. We expect NHS England to work with the Department of Health and
other stakeholders to develop a range of costed options in order to implement these

49 A. Golding & A. Duggal, 2011, Commissioning services for women and children who experience violence or
abuse – a guide for health commissioners, Department of Health, available at
50 NHS, Health A-Z, Pregnancy and Baby, ‘Domestic Abuse’, available at
51 E. Crawford et al, 2009, ‘Women’s Understanding of the Effects of Domestic Abuse: The Impact on Their
Identity, Sense of Self and Resilience – A Grounded Theory Approach’, Journal of International Women’s
Studies, Vol 11, Issue 2
52 WHO, ‘Gender and women’s mental health’
53 ibid.
54 ibid.
55 Centre for Economic Performance / LSE, 2012, How mental illness loses out in the NHS, available at
56Department of Health, 2013, ‘The Handbook to the NHS Constitution’, available at
standards starting from April 2015, with a phased approach depending on
affordability.’  NURS 6551 – Primary Care of Women Assignment.
Women are about 40% more likely than men to experience depression and 60% more likely
to suffer from an anxiety disorder, 58 but despite this many never seek professional help. A
2010 survey by the women’s organisation Platform 51 found that 29% of the young women
respondents who had experienced mental health problems had refrained from seeking
professional help. Reasons given included fear of being judged as over-emotional,
expectations of not being taken seriously and not wanting to waste doctors’ time.
Whilst these concerns may reflect the way mental health problems affect health-seeking
behaviour, for example causing sufferers to become introverted, they may also provide some
insight into these young women’s experiences of the doctor-patient relationship, and their
views of doctors as potentially judgemental and lacking in time and patience. According to
the WHO, ‘Communication between health workers and women patients is extremely
authoritarian in many countries, making a woman’s disclosure of psychological and
emotional distress difficult, and often stigmatized.’60 It may be a mistake to assume that such
problems do not exist in the contemporary UK context.
1.5.1 Mental health and the factors underpinning women’s health disadvantages
Mental health problems sometimes overlap with the marginalising social factors described
earlier. Recent research made links between indebtedness and poor mental health61
, and
figures from the Royal College of Psychiatrists suggests that as many as half of all adults
who have personal debt may be suffering from some form of mental health problem62
As has been discussed previously, unrelenting caring responsibilities are associated with
both poverty and mental health problems in some circumstances. Gender-based violence is
another known cause of depression and anxiety in women. Women are at higher risk of
being abused by a partner, and for reasons relating to caring and earnings; they are also
more likely than men to be reliant on their partner’s income. For women who experience
gender based violence, financial and material dependence can be a barrier to seeking help.
1.6 Factor increasing women’s vulnerability
Many additional factors can increase women’s vulnerability and exacerbate health
inequalities. This study considers five groups of women who experience comparatively poor

57Department of Health, 2013, NHS Mandate, op. cit.
58 D. Freeman & J. Freeman, The Stressed Sex – Uncovering the Truth About Men, Women and Mental Health,
OUP, Oxford, 2013
59 Platform 51, 2010, Women like me – Supporting wellbeing in girls and women, available at
60 WHO, Gender and women’s mental health,
61 Fitch et al, 2011, ‘The relationship between personal debt and mental health: a systematic review’, Mental
Health Review Journal, Vol 16, Issue 4
62 Royal College of Psychiatrists, ‘Debt and Mental Health’
health outcomes: BME women, refugees and women seeking asylum, women living with
HIV, LGBT women, and women with learning disabilities.
1.6.1 BME women
The Race Equality Foundation reports that, although it is known that BME individuals face an
increased risk of experiencing socio-economic deprivation which affects their health, this
does not sufficiently explain disparities in health outcomes, and that the ‘direct and indirect
experiences of racism in everyday life’ needs to be included as a factor.
63 The healthcare
system can exacerbate existing problems in various ways, for example through inaccessible
services, unmet needs, poor communication, and negative service experiences. Such
experiences are commonly reported by BME patients, and not confined only to recent
migrants or those with limited command of the English language.64 One example relates to
the Irish Traveller community, who report open prejudice and discrimination when attempting
to access GP surgeries, often accessing healthcare only through A&E as a result.65
Figures from the Department of Health indicate that patients from BME groups were more
likely to report negative experiences of care, especially in the primary care setting, and
especially relating to issues around ‘access and waiting’, and wanting ‘better information and
more choice’.
66 A series of focus groups by WHEC, Women Care and RED on the health
experiences of women from a range of BME backgrounds found that an ‘overwhelming
majority’ of women reported difficulties in getting an appointment with their GP when they
needed one, and almost all women from Bangladeshi backgrounds said that this was true for
One problem for BME women relates to communication: A majority of the women in the
aforementioned focus groups had encountered language and communication barriers, even
when using interpreting services. Many had experienced difficulties accessing these
services. Some had also been given wrong information, for example about test results, from
68 The common practice of using a family member (for example a child or
husband) as a translator is problematic because it compromises confidentiality and places
restrictions on the kind of issues that can be raised, in all likelihood excluding disclosure of
gender-based violence or sexual health issues. Some linguistic communities are also
relatively small and close-knit, which can compromise confidentiality if the interpreter knows
the patient or her family personally.  NURS 6551 – Primary Care of Women Assignment.

63 S. Salway et al, 2013, High Quality Healthcare Commissioning: Why race equality must be at its heart, Race
Equality Foundation, Better Health Briefing 27, available at
64 ibid.
65 J. Atterbury, 2010, Fair Access for all? Gypsies and Travellers in Sussex, GP Surgeries and Barriers to
Primary Healthcare, Friends, Families and Travellers (FFT), available at
66 Department of Health, 2009, Report on the self reported experience of patients from black and minority ethnic
groups, available at
67 WHEC, August 2013 Briefing: Enablers and barriers to wellbeing – experiences of BME women in Manchester,
available at
68 ibid.
Language proficiency has been shown to be lower for women than men in migrant
communities, and this is especially true for older generations
, which means that older
migrant women run a particularly high risk of experiencing language barriers when using
healthcare. The Office for National Statistics (ONS), in the 2011 Census, found a strong link
between English language proficiency and health. 88% of the population who had a mother
tongue other than English, but who were ‘proficient’ in English reported ‘Good’ general
health, whereas the same was only true for 65% of the population deemed as ‘Nonproficient’ in English.70
Specialist services can mitigate some of the barriers that BME women face, providing a safe
and appropriate space for BME women to disclose and access support for gender-based
violence, access language support and to advocate for women. According to a report from
the Department of Health’s Mental Health Policy Division, ‘there is clear evidence that an
approach of working in partnership with BME communities and voluntary sector
organisations leads to earlier and more effective interventions, and enables activity to
support good mental health to be more effectively targeted at the most vulnerable groups’.
Imkaan also reports that 87% of black and minority ethnic women would prefer to be
supported a BME-specific women’s service if they were to seek help for issues around
gender-based violence.72 However, nine out of ten local authorities do not provide specialist
services to BME women, and those which currently exist are threatened by funding cuts.

One potential consequence of the lack of targeted support is that female genital mutilation
(FGM) goes unnoticed and untreated. FGM, which is recognised as torture by the UN74
, is
an act of violence against a girl or woman’s right to bodily integrity which can lead to death
or disability and often causes complications and related health problems75
– both physical
and mental76
. According to estimates from 2001, 66,000 women resident in England and
Wales in 2001 had undergone FGM and over 23,000 under the age of 15, from African
communities, were considered being at risk of, or potentially having undergone FGM.
Research has shown that women and girls are unlikely to disclose FGM and related health
problems outside of maternity services, and there is very limited understanding of the issue
in the mainstream.78 Additionally, health services do not have consistent mechanisms for
encouraging disclosure or referral, for example through routine enquiry.
79 A lack of

69 A. Szczepura, 2005, ‘Access to health care for ethnic minority populations’, Postgraduate Medical Journal,
2005, 81:141–147.
70 ONS, 2013, Detailed analysis – English language proficiency in England and Wales: Main language and
general health characteristics, available at
71 M. Wilson, 2009, Delivering Race Equality in Mental Health Care: a review, Department of Mental Health
Policy Division, available at
72 Imkaan, 2011, The road to sustainability: A review of Black, Asian, Minority Ethnic and Refugee organisations
working with women on health and gender based violence in England, Executive Summary, available at
73 ibid.
74 RCM, RCN, RCOG, Equality Now, UNITE, 2013, Tackling FGM in the UK: Intercollegiate Recommendations
identifying, recording and reporting, available at
75 ibid.
76 ibid.
77 ibid.
78 S. Roy et al, 2011, The Missing Link: a joined up approach to addressing harmful practices in London,
Imkaan, available at
79 ibid.



understanding and knowledge on how to respond appropriately amongst health and social
care professionals are also barriers to women who experience other forms of gender based
violence, including forced marriage.
80 At the same time, it is important for health
professionals to recognise that women from BME backgrounds also experience more
common forms of gender-based violence, such as domestic violence.  NURS 6551 – Primary Care of Women Assignment.
1.6.2 Refugees and women seeking asylum
Refugees and women seeking asylum may experience many of the same problems as other
BME women, but they also face a number of unique barriers relating to their legal status,
and to the complexities surrounding their entitlement to care.
No patient applying to register with a GP can be turned down on the basis of race, gender,
social class, age, religion, sexual orientation, appearance, disability or medical condition.81
Currently, GPs have discretion to register refused asylum seekers and undocumented
migrants. GPs are not required to check the immigration status of patients joining their
practice, and patients have no obligation to provide evidence to this effect
. However, the
situation is subject to change, as charging will soon be extended to the primary setting and
to all non-EEA migrants applying for more than six months leave to enter the UK
Restricting access to free healthcare, even if some individuals and conditions are exempt, is
also likely to become a deterrent for anyone who struggles to provide evidence of their
entitlement, for example members of the Irish Traveler community, something which the
government also acknowledges.84
Hospital care, including maternity care, is subject to a different set of rules: women who have
an ongoing asylum claim or an appeal pending are not chargeable anywhere in the UK. In
England, refused asylum seekers are subject to charging, unless they are in receipt of Home
Office support, but in the rest of the UK they are not. There are recent news reports of
destitute women avoiding antenatal care and giving birth with no professional involvement
due to the fear of owing thousands of pounds they have no way of paying back.85 However,
there are no plans to exempt pregnant women from charges. There are also plans to extend
charging to emergency treatment for some migrants. Although care will not be denied to
those who cannot pay, the prospect of incurring a debt will be a deterrent.
According to the British Medical Association ‘there exists a degree of uncertainty amongst
some health professionals regarding the entitlements in place for asylum seekers and

80 Imkaan, 2011, The road to sustainability, op.cit.
81 See for example: Royal College of General Practitioners Position Statement, January 2013, ‘Failed Asylum
Seekers / Vulnerable Migrants and Access to Primary Care’, available at
82 BMA, 2012, ‘Access to healthcare for asylum seekers and refused asylum seekers – guidance for doctors,
available at
83 The Immigration Bill, 2013-14, Chapter 2, Clauses 33 and 34.
84 Department of Health, 2013, Sustaining services, ensuring fairness – Government response to the consultation
on migrant access and financial contribution to NHS provision in England, available at
85 D. Taylor, 2013, ‘NHS charges putting pregnant migrant women in danger’, The Guardian, 27 November,
available at
refused asylum seekers and their responsibilities with respect to treating and referring these
groups’86, and this is reflected in the fact that women in this group often have trouble
registering with a GP.
87 Refugees and people seeking asylum may also lack information
about the UK system and their rights within it88, and these issues are also likely to be
exacerbated when new charges are introduced.
Another important barrier for this group relates to documentation. Evidence to the Joint
Committee on Human Rights from 2007 from the support organisation Project: London
revealed that asylum seekers are unable to access healthcare due to demands for very
specific forms of official documentation, such as passports, utility bills, bank statements or
rental agreement as proof of address. Due to unstable living arrangements, no access to
bank accounts, and their passports being retained by the Home Office, asylum seekers are
very unlikely to possess any of this.89
Project: London also reported that because there is no legal requirement to provide
identification or proof of residency when registering with a GP, there is some scope for them
and other organisations to influence the process through negotiation and advocacy.90
Nevertheless, the many individuals who do not have access to such support still have to
negotiate barriers relating to language and communication, lack of information, and lack of
documentation.  NURS 6551 – Primary Care of Women Assignment.
Asylum seekers and refugees have often experienced trauma, such as torture or rape, in
their country of origin and are at increased risk of mental health problems
. Rape and
sexual violence against civilian women in conflict zones is identified as the most common
cause of Post-Traumatic Stress Disorder (PTSD).
Survivors may also suffer stigmatisation
after the event93
– According to the US National Centre for PTSD, some women feel such a
strong responsibility to protect their family from this stigma that they remain silent about the
trauma. 94 This makes it extraordinarily difficult for these women to seek help, especially as
PTSD is also associated with avoidance behaviour. 95 Women also run a higher risk of being
subjected to coercion, entrapment and sexual exploitation once in the asylum system
, and
barriers to a good doctor-patient relationship, such as a lack of trust, or communication
problems are also barriers to getting out of such a situation.

86 BMA, 2012, Access to healthcare for asylum seekers and refused asylum seekers, op.cit.
87 See for example: R. Feldman, 2013, When Maternity Doesn’t Matter – Dispersing pregnant women seeking
asylum, Maternity Action, available at
88 BMA, 2012, Access to healthcare for asylum seekers and refused asylum seekers, op.cit.
89 Parliamentary Joint Committee on Human Rights, 2006-07, The treatment of asylum seekers: tenth report
session, Vol. 02, available at
90 ibid.
91 P. Nyiri, 2012, ‘A specialist clinic for destitute asylum seekers and refugees in London’, The British Journal of
General Practice, 62(604): 599–600
92 US Department of Veterans Affairs, National Centre for PTSD, ‘Rape of Civilian Women in a War Zone’,
available at
93 ibid.. See also T. Sideris, 2003, ‘War, gender and culture: Mozambican women refugees’, Social Science &
Medicine, Vol. 56, Issue 4, 713–724
94 US Department of Veterans Affairs, op. cit.
95 US Department of Veterans Affairs, National Centre for PTSD, Symptoms of PTSD, Available at
96 Crawley et al, 2011, Coping With Destitution: Survival and livelihood strategies of refused asylum seekers
living in the UK, Oxfam, available at
Pregnant asylum seekers and refugees have some of the worst pregnancy outcomes in the
UK and are often ‘late bookers’ with maternity services
. Although NICE recognises them as
a group experiencing ‘complex social factors’, warranting special care provisions,98 pregnant
women, like other asylum seekers, are subject to routine dispersal, which entails being
moved suddenly to a different area, often away from partners and any existing social support
networks. Apart from expensive duplication of effort, such as re-taking blood tests to ensure
they are correct, it also causes problems relating to signing up with a new GP and
maternity service with each move, and potential loss of information about sensitive issues.
Issues like mental health and domestic violence are not stored in handheld notes100 and
women may not be prepared to disclose such information several times, to a person with
whom no prior relationship exists. A ‘protected period’ of four weeks either side of delivery
exist in the government’s official guidelines, although the same guidelines contradict
themselves by also recognizing the importance of six weeks postnatal care, and mentioning
the fact that women seeking asylum may give birth earlier than estimated by UK standards.  NURS 6551 – Primary Care of Women Assignment.
Asylum seekers and refugees are some of the most socially excluded people in the UK.
Home Office support is subject to a destitution requirement
102 and paid at a rate below that
of state benefits such as Income Support. As has been discussed earlier, poverty and
economic disadvantage are associated with worse health and less participation in public
health programmes. Cost is also a barrier to treatment if money for prescriptions is not
1.6.3 Women living with HIV
Thanks to modern drug regimes, people living with HIV can have normal lives and women
can give birth to healthy children with the help of antiretroviral therapy. Despite medical
advancements, however, HIV is still surrounded by stigma and ignorance, and people living
with the condition often report a lack of trust in GPs, and a low uptake of mainstream primary
care services.103 Women’s physiology makes them more susceptible to HIV infection104
Women from conflict areas are also at increased risk if they have been subjected to
systematic sexual violence, as are women who are involved in prostitution, or engaging in
transactional relationships in which they may have little control over the use of protection.

97 R. Feldman, 2013, op.cit.
98 NICE, 2010, Clinical Guidance 110, ‘Pregnancy and complex social factors’, available at
99 R. Feldman, 2013, op. cit.
100 ibid.
101 R.Feldman, 2013, op.cit, p: 64
102 See for example UKBA, Home Office, ‘Assessing Destitution’, available at
103 A. Namiba & A. Anderson, 2010, Primary Care Access: How General Practice Can Better Respond to the
Needs of People Living with HIV, Positively UK, available at
104 See for example, T.C Quinn, 2005, ‘HIV/AIDS in Women: An Expanding Epidemic’, Science, Vol. 308, No.
5728 pp. 1582-1583
A survey of people in East London living with HIV, showed that nearly one third of all
respondents had experienced discrimination because of their health condition, and almost
half of these instances involved a GP, dentist or other health care professional.
105 This is
against the law under the discrimination under the Equality Act 2010 which incorporates the
Disability Discrimination Act (2005) and includes people with HIV.
GP practices usually require new patients to fill in a form stating their existing health
problems, sometimes asking specifically about HIV. As mentioned previously, all people in
the UK have the right to register with a GP regardless of race, gender, social class, age,
religion, pregnancy or maternity, sexual orientation, appearance, disability or medical
condition. Nevertheless, there are reports of patients being excluded from GP practices after
disclosing their condition.106
Perhaps justifiably then, some people choose not to disclose, which can compromise the
quality of care – knowing about existing diagnoses and medications is important for doctors
in order to treat patients safely and effectively. Even when patients do disclose, Positively
UK reports that GPs do not have much knowledge on HIV drugs and possible interactions
and there is anecdotal evidence that women who attend mainstream services often have
their unrelated health complaints attributed to HIV/AIDS, or medications and the needs
they have in other areas of their lives may be overlooked. NURS 6551 – Primary Care of Women Assignment.
For these reasons, HIV clinics often end up providing primary care to patients who are
reluctant to attend mainstream primary care services. However these clinics may not be fully
equipped to provide general healthcare.
Another barrier for this group relates to confidentiality. In 2012-2013 85% of respondents to
the GP Patient Survey said that other patients can overhear what they say to their GP’s
receptionist. Whilst 57 % did not feel that this was a problem, 25 % were not happy about it.
109 Patients with stigmatised conditions such as HIV are likely to feel more strongly than
others about this, as many have not disclosed the condition even to their families. A study
carried out in East London showed this to be especially true of African heterosexual women
and men, who reported high levels of HIV-related stigma, and were less likely to have told
friends, family and partners.
Stigmatisation is a barrier in itself, especially if it deters people from seeking help. It is also
associated with high levels of stress and anxiety, which can contribute to poor mental health.
Research indicates that people living with HIV have a higher prevalence of mental health
problems than the general population.111 As we have seen, women are already more likely
than men to develop anxiety and depression, and women with HIV are therefore at an
exceptionally high risk.  NURS 6551 – Primary Care of Women Assignment.

105 J. Elford, 2009, ‘HIV and primary healthcare: disclosure and discrimination’, Primary Health Care Research &
Development, 10: 281–283
106 A. Namiba & A. Anderson, 2010, op. cit.
107 ibid.
108 R.L Carr & L.F Gramling, 2004, ‘Stigma: A Health Barrier for Women With HIV/AIDS’, Journal of the
Association of Nurses in AIDS Care, Vol. 15, No. 5
109 The GP Patient Survey, 2013, Summary Report (June 2012 publication), NHS England, available at
110 J. Elford, 2009, op. cit.
111 A. Namiba & A. Anderson, 2010, op. cit.
Gay men (and men who have sex with men) are the largest group of HIV positive people in
the UK and African women are the second largest. Both of these groups may experience
multiple disadvantages associated with sexual orientation, gender, race and socio-economic
status as well as ‘HIV-phobia’ when accessing mainstream services
112 A 2008 UK study of
HIV positive BME people linked race and HIV status with poverty, indicating that 40% of
Black African heterosexual men and women with HIV were experiencing severe economic
hardship, and that this group ‘consistently reported more difficulties in relation to
employment, income and housing’. The nature of this relationship is not entirely clear, but
the research suggests that HIV affects economic activity and causes individuals to become
lost from the labour force,113 placing this group at higher risk of poverty. There are also
additional overlaps with other potential disadvantages relating to ethnicity, language and
migration status, which have been discussed in previous sections of this report.
Recent international research suggests an increased risk of gender-based violence for
women living with HIV both as a ‘cause’ and ‘consequence’ of having the condition.114 As we
have seen, gender-based violence often begins or worsens during pregnancy, which is a
crucial time for a mother with HIV to receive antiretroviral treatment, advice and support for
the benefit of herself and the unborn baby. Violence can cause women to retreat from health
services due to stigma, fear and economic dependence

1.6.4 LGBT women
The NHS constitution states:
‘You have the right not to be unlawfully discriminated against in the provision of NHS
services including on grounds of gender, race, disability, age, sexual orientation,
religion, belief, gender reassignment, pregnancy and maternity or marital or civil
partnership status.’
Research from the national charity Stonewall does however indicate that lesbian, gay and
bisexual people experience discrimination from health services. Lesbian women are twice as
likely as gay men to expect poor treatment from local services,
117 and figures from a 2007-
08 report indicated that half of lesbian and bisexual women did indeed have negative
experiences with healthcare in that period.  NURS 6551 – Primary Care of Women Assignment.
118 Recent research of 253 women found that
whilst 64% of gay men had positive experiences of coming out to their GP, the figure was
20% lower for lesbian and bisexual women.119 Stonewall also reports that seven out of ten

112 ibid.
113 J. Elford, 2009, op. cit.
114 Sophia forum, Violence as a cause or consequence of HIV for women in England – a feasibility study
regarding a potential national investigation, 2012, available at
115 Sophia Forum, 2012, op. cit.
116 NHS, 2013, ‘The NHS Constitution – the NSH belongs to us all’, available at
117 N. Miles, 2011, How to Engage Gay People in Your Work, Stonewall, available at
118 R. Hunt & J Fish, 2008, Prescription for Change – Lesbian and bisexual women’s health check 2008,
Stonewall, available at
119 L. River, Director of Age of Diversity and an Ambassador for Opening Doors London, Presenting research at
the National LGB&T Partnership Lesbian and Bisexual Women’s Event – London 2012
lesbian and bisexual women got inappropriate comments from healthcare workers when
they told them about their sexual orientation.
The risk of encountering homophobic or prejudiced attitudes, which according to these
figures appears to be considerable, can affect health-seeking behaviour and lead to
avoidance of sexual health services and other healthcare. A report from 2008 found that
sexually active respondents who had not disclosed their LGBT identity to their GP were less
likely to have ever had a sexual health check, especially women, who often believed that
they did not need it.121 29% of gay men in this survey had accessed sexual health services
in the last six months, whereas this was only true of 8% of lesbian women122. 64.1% of
transgender respondents to a different survey had never visited a sexual health clinic123
which is especially problematic as an international study of transgender women showed
them to be 49 times more likely to have HIV, compared to a reference group.
Research, health promotion and targeted services for LGBT women’s health are sparse
compared with what exists for gay men.
125 Many LGBT women also view mainstream
services as heterosexist, homophobic and discriminatory. NURS 6551 – Primary Care of Women Assignment.



There appears to be a lack of knowledge and information about sexual health needs, on both sides. For example some
lesbian and bisexual women do not think they need cervical screening, sometimes having
been told this by health professionals.
126 This goes against official NHS advice which states
that Human papilloma virus (HPV) can be transmitted during sex between women, and that
screening should be offered.
127 With regards to maternity and fertility for female same-sex
couples, health professionals may have very little previous experience. NICE has only
recently outlined the entitlements of same-sex partners in official guidelines.128
Lesbian women run a higher risk of developing eating disorders, and self-harming. An
American study links this to the pressures of concealing sexual identity, the threat of hate
crime, discrimination and stigmatisation129
. Lesbian and bisexual women also have higher
rates of smoking, alcohol use and recreational drug use than the general population.130
Bisexual women have been found to be at especially high risk of mental health problems and

120 R. Hunt & J Fish, 2008, op. cit.
121 K. Browne & J. Lim, 2008, Count Me In Too – LGBT Lives in Brighton and Hove, Additional findings report,
available at
122 ibid.
123 S. Keeble, 2013, Transgender Sexual Health in Birmingham: Needs assessment, Birmingham LGBT
124 ibid.
125 L. River, 2012, Op. cit.
126 L. River, 2011, Appropriate Treatment – Older lesbian, gay and bisexual people’s experience of general
practice, Age of Diversity and Polari, available at
127 NHS, 2009, NHS Cervical Screening Programme – ‘Cervical screening for lesbian and bisexual women’,
available at
128 Since 2013, NICE Clinical Guideline 156, ‘Fertility Assessment and treatment for people with fertility
problems’, paragraph 1.9.1 recommends physicians to consider intrauterine insemination for people in same-sex
129 Department of Health and Human Services USA, 2009, ‘Frequently Asked Questions, Lesbian and Bisexual
health’, available at
130 M. King & E. McKeown, 2003, ‘Mental health and well-being of gay men, lesbians and bisexuals in England
and Wales’, Mind, available at
suicidal ideation, both according to international and UK figures
. As we have seen, many
women feel vulnerable when asking for help with mental health, and this could be an even
bigger problem if there is also an expectation of discrimination or homophobic treatment.
Lastly, there are few targeted services available for lesbian, bisexual or transgender women
experiencing intimate partner abuse. Research from the United States indicates that
transgender women are especially vulnerable to sexual exploitation and abuse. 132
1.6.5 Women with learning disabilities
“Promoting equality and equity are at the heart of NHS England’s values – ensuring
that the organisation exercises fairness in all that it does and that no community or
group is left behind in the improvements that will be made to health outcomes across
the country.”  NURS 6551 – Primary Care of Women Assignment.
133 (NHS England)
The Royal College of GPs points out that several formal enquiries134 in the UK have found
that people with learning disabilities have comparatively worse health outcomes than the
general population, yet they are less likely to access healthcare.135
Research indicates that
the quality of service for women with learning disabilities is highly dependent on the personal
attitudes of health professionals. 136 For example, prejudiced attitudes about disabled
women’s lives (i.e. the belief that they do not have intimate relationships) can lead some
health professionals to overlook the need for cervical screening, family planning and sexual
All women between 20 and 64 years of age should be called for cervical screening by the
NHS, but research shows that women with learning disabilities are less likely to take part in
cervical screening programmes. One study found that women in this group were 45% less
likely to do so in 2008-2009. 138
According to CHANGE, mainstream sexual health services are not well resourced to support
young people with learning disabilities, and generally lack of accessible-format information

131 M. Barker et al, 2012, The Bisexuality Report: Bisexual inclusion in LGBT equality and diversity, The Open
University, Centre for Citizenship, Identity and Governance, available at
132 S. Keeble, 2013, op. cit.
133 NHS England, 2014, About us, Equality and diversity, available at
134 For example Mencap’s 2007 report Death by Indifference, and the 2010 Parliamentary and Health Services
Ombudsman report Health Inequalities and People with Learning Disabilities in the UK
135 M. Hoghton and the RCGP Learning Disabilities Group, 2010, A Step-by Step Guide for GP Practices: Annual
Health Checks for People with a Learning Disability, available at
136 M. Brown et al, 2010, ‘Equality and access to general health care for people with learning disabilities: Reality
or rhetoric?’ Journal of Research in Nursing 2010 15: 351, and S. Harrison et al, 2004, ‘Valuing people:
Developing health visiting practice for people with learning disabilities’, Practice Development in Health Care,
3(4) 210–215
137 See for example S. Broughton and K. Thomson, 2000, ‘Women with learning disabilities: risk behaviours and
experiences of the cervical smear test’, Journal of Advanced Nursing, 32(4), 905-912
138 D.P.J Osborn et al, 2012, ‘Access to Cancer Screening in People with Learning Disabilities in the UK: Cohort
Study’, the Health Improvement Network, available at
material, for example using easy-read formats supported by pictures.
139 Sex education can
also help to define boundaries in personal relationships, something which could be
especially important for women with learning disabilities, who face a much higher risk of
violence and sexual abuse than other women.
Women with learning disabilities have historically been deprived of their mothering role and
their right to a family life. A case study by CHANGE suggests that this still persists to some
extent and that women may not be getting the information needed to make informed choices
about abortion.141 The Royal College of Midwives reports that ‘disabled women have
identified insensitivity and poor understanding of the nature of their disability in relation to
pregnancy as key factors in their maternity care’.
As has been discussed previously, mental illness is more common in women, and tends to
be under-diagnosed. People with learning disabilities have a higher incidence of mental
health problems compared to the general population, and early symptoms are often
misattributed by doctors as relating to the disability.
143 This means that women in this group
are both at higher risk, and may experience more barriers to treatment.
Apart from the aforementioned problems with inaccessible written information, patients with
learning disabilities may also experience verbal communication barriers. They may have
trouble describing their symptoms, and health professionals may be using clinical jargon
which is difficult to understand.  NURS 6551 – Primary Care of Women Assignment.
Many people with learning disabilities also have physical disabilities and may not be able to
drive or use public transport. This affects how flexible they can be when booking an
appointment, as they may have to ensure the availability of a support worker or transport
service. Building access is also a potential barrier for wheelchair users, as Care Quality
Commission (CQC) inspections found in 2013 – 24% of GP premises were deemed unsafe
or unsuitable for reasons which included the absence of disabled access. NURS 6551 – Primary Care of Women Assignment.

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