A recent survey undertaken by NHS Digital ( see footnote 1) found that one in five women had reported symptoms of common mental disorder (e.g., depression and anxiety), compared to one in eight men. Women were also more likely than men to report severe symptoms of common mental disorder. Additionally, the study found that one in five women aged 16-24 had self-harmed at some point; almost double the rate for men of the same age.
Despite these findings, recent press coverage has claimed that women's mental health needs are not being adequately considered by our healthcare systems. Agenda, an alliance of 60 organisations campaigning on behalf of women and girls at risk, submitted a Freedom of Information request to all 57 Mental Health Foundation Trusts in England in April 2016, in relation to the provision of gender specific services to women.
The results of the request (see footnote 2) demonstrated a potential gap in provision of services to women, and suggest that women's needs may not be adequately considered in mental health service planning and delivery. Agenda further suggests that more should be done to support disclosures of past or current abuse by inpatients.
Public sector equality duty
Sex is a protected characteristic under section 11 of the Equality Act 2010. Section 149 of the Act refers to the public sector equality duty, and states that public authorities should have "due regard to the need to advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it". This involves having due regard, in particular to the need to:
- "Remove or minimise disadvantages suffered by persons who share a relevant protected characteristic connected to that characteristic;
- Take steps to meet the needs of persons who share a relevant protected characteristic that are different from the needs of persons who do not share it".
Healthcare bodies therefore have a duty to remove or minimise the disadvantages suffered by women in terms of mental health or to meet the needs of women in mental health care that are different to those of men.
Service strategies and plans
Services should be able to demonstrate that the needs of women are being comprehensively considered in the service planning process. The Department of Health guidance on gender and women's mental health (see footnote 3), states that the delivery of effective women's mental health care services is dependent upon robust planning and commissioning processes, genuine service user and carer involvement, skilled and supported staff teams, a gendered approach to service evaluation and relevant clinical and user-focused research to inform the delivery of appropriate care and treatment.
Consideration should be given to multiagency working, to ensure that social and economic factors that could impact on mental health are effectively addressed (e.g. housing, poverty, social isolation, lone parenthood, experience of violence and abuse, parenting and caring responsibilities). This will require engagement with local authorities who have a responsibility to address social, economic and environmental needs.
Services should consider the need to develop and implement service standards for female service users. This should be a robust process of monitoring and evaluating the quality and appropriateness of care provided for female service users, in both mixed and single-sex settings. A process should also be in place for taking remedial action in response to the findings if necessary.
Service planners and providers further need to ensure that service evaluation and monitoring includes a gender (and ethnicity) dimension so that they can accurately measure whether the needs of women and men are being addressed on an equal basis.
The Department of Health considers that in order to mainstream gender and women's mental health, it must become an integral element in the training of staff and managers at every level. Training could include consideration of the following:
- The social and economic context of women's and men's lives;
- Life experiences that may impact on their mental health (e.g. violence and abuse);
- The interplay between gender and other dimensions of inequality such as ethnicity, age and sexual orientation;
- Differences in the risk and protective factors for mental health in women and men;
- Differences in women and men in presentation and their pathways into services;
- Differences in the treatment needs and responses of women and men;
- The relationship between gender and power inequalities and how this may affect individual service users, staff and the organisations in which they work or are cared for, the day-to-day family, and social and economic realities of women and men's lives.
Abuse disclosure policy
A specific issue which Agenda's FOI request highlighted was that services need to ensure that trained staff are asking service users whether they have experienced domestic violence and abuse.
Recent NICE guidance (see footnote 4) advises that people presenting to frontline staff with indicators of possible domestic violence or abuse are asked about their experience in a private discussion. The guidance highlights the fact that it is likely that mental health services (along with drug/alcohol services or sexual health services) will see more people with indicators of possible domestic violence or abuse than in other settings.
This guidance states that there should be "evidence of local arrangements to ensure that this routine enquiry takes place." Healthcare services should therefore be taking steps to ensure that this routine enquiry is codified into an Abuse Disclosure Policy, or perhaps into their Safeguarding Adults Policy.
The policy must include clear pathways and guidance for staff regarding steps which need to be taken or referrals which need to be made once domestic violence has been disclosed, along with the timescales in which these tasks need to be done, and documentation which needs to be completed. Appropriate support and care pathways for the service user should be identified.
Staff should be trained so they are able to understand the link between women's mental health, trauma and abuse, and should be able to recognise indicators of possible domestic abuse and respond appropriately. Facilities should be available to ask service users about their experiences in private discussions, in an environment in which the person feels safe.
Perinatal mental health care
On 2 December 2014, four days after she had given birth, Charlotte Bevan left hospital and walked to a cliff top with her new-born daughter. Their bodies were found the next day. Charlotte suffered from schizophrenia and her mental health began to deteriorate when she had given birth. An inquest was carried out into Charlotte and her daughter's deaths, and several points of learning were raised.
Firstly, providers of perinatal mental health care should ensure that when a woman with a known mental health condition becomes pregnant there is a multi-disciplinary team meeting to include all or some of the following professionals: GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services, and anyone else deemed to be appropriate.
Secondly, that an appropriate care plan involving all agencies and professionals is drawn up and then widely circulated to those professionals who are involved in the care and treatment of the patient. This is to include: GP, midwife, obstetrician, consultant psychiatrist, care co-ordinator, social services, and anyone else deemed to be appropriate.
Collaborative working across agencies is therefore an essential part of perinatal mental health care provision.
In 2015 the South West Mental Health and Dementia Strategic Clinical Network and the South West Maternity and Children's Clinical Network jointly led a review of perinatal and mental health services across the pathways (see footnote 5). As a result, this year a new training scheme has been launched in South West England asking healthcare organisations to nominate staff to become "perinatal mental health champions", who will then be expected to pass their learning on to other colleagues.
Other organisations in other regions may wish to consider similar schemes in order to ensure that non-medical staff are able to identify and manage mental health issues in pregnant women and new mothers.
For further information on this or any of the points raised in this article please contact Sumayyah Malna, Solicitor or Simon Lindsay, Partner.
- Mainstreaming Gender and Women's Mental Health: Implementation Guidance (September 2003)
- Domestic violence and abuse, February 2016