Women’s Health Strategy call for evidence

Introduction

The Health and Care Women Leaders Network (HCWLN) is an initiative delivered by the NHS Confederation. The network was established in 2015 and is made up of senior and aspiring women leaders, with a range of roles, skills, and backgrounds, working in health and care.

Women make up the majority of the NHS workforce, constituting 77 per cent of NHS staff, and 82 per cent of the care workforce. Women have been a significant presence on the frontline of the health and care service response to COVID-19 in the UK.

About our response

The network welcomes this opportunity to contribute to the development of the government’s Women’s Health Strategy, at a time when the contribution women make to the health and wellbeing of the nation has never been more visible or important. Should Minister of State wish to meet with a selection of our members to discuss our response we would be happy to facilitate a meeting.

The network is responding to theme six in this consultation – understanding and responding to the impacts of COVID-19 on women’s health. We would like to make specific recommendations in the following areas:

• The impact of COVID-19 on the health and wellbeing of women working in health and care.
• The impact of COVID-19 on the way women working in health and care are able to carry out their roles.
• The disproportionate impact of COVID-19 on black, Asian and minority ethnic women working in health and care.

In preparing our response, we have focused on ways that the pandemic has affected the health, wellbeing and working lives of women employed in roles in health and care. We have not explored the impact of COVID-19 on services provided for women, as this is beyond the scope of the network’s remit.

We conclude our response with a series of recommendations designed to improve the working lives of women employees in the health and care sector. Central to these is our core recommendation:

National NHS leaders should develop a Women’s Health Strategy for the NHS workforce, to ensure that the issues identified within this submission are addressed at every level in the health system so that women can progress in their careers in an equitable way.   As an organisation where women make up more than three quarters of the workforce, and whose aim is to improve health, the NHS should be leading in this area.

Impacts of COVID-19 on women’s health

COVID-19 has had a significant impact on women’s lives, from their experience of the working environment to their time spent at home and within their communities. Women comprise 77 per cent and 82 per cent of the NHS and care workforces respectively, meaning women working in health and care have been at the forefront of UK’s response to the pandemic. Female staff have therefore felt its impact particularly acutely, with those from black, Asian and minority ethnic backgrounds (who make up 21 per cent of the NHS workforce) reporting a particularly significant impact on their lives.

The HCWLN has been using surveys to monitor the impact of the pandemic on women working in the health and care sector since the pandemic began. To date, the network has run two surveys of its membership. The first, conducted in June 2020, achieved 1,308 responses from women, while the second, in February-March 2021, was completed by 809 women. In each case, a small number of responses were received from people who did not describe themselves as women and we acknowledge that further work needs to be done to understand their experiences. Our findings reflect the experiences of people describing themselves as women in this analysis.

Women working in health and care have experienced effects both in terms of their health and wellbeing in the workplace, communities and at home, and also in their ability to carry out their professional roles. Specific findings from our survey work are set out below, alongside other research findings that address these two areas of focus.

How has COVID-19 impacted the health and wellbeing of women working in health and care?

The pandemic has affected the health and wellbeing of women working in health and care in numerous ways. Women responding to HCWLN surveys have reported effects on their physical health and wellbeing, their mental health and the burden of caring responsibilities that they face. In addition, the survey identified a degree of vaccine hesitancy among female staff, which may need to be addressed to avoid future health inequity. These issues are explored in greater detail below.

1. Physical and mental health and emotional wellbeing

A significant majority of female respondents to both surveys carried out by the network reported that their job had a greater negative impact than usual on their emotional and physical wellbeing as a result of the pandemic. The proportion of women indicating that their emotional wellbeing had been negatively affected rose by eight percentage points from 72 per cent in June 2020 to 80.5 per cent in February/March 2021.

Sixty-five per cent said their physical health had been negatively affected in February/March 2021, compared with 52 per cent in June 2020. Respondents described experiencing stress, anxiety and pressure, and mentioned fears of burnout, isolation and permanently heavy workloads.

Research conducted by HCWLN sister network the BME Leadership Network found black, Asian and minority ethnic backgrounds staff were reported to be more likely to take high-risk roles, including working in frontline COVID-19 wards, due to fear that their contract may not be renewed or shifts reduced, especially if they were agency staff or had a vulnerable immigration status. Institutional racism was suggested by BME Leadership Network members as a reason for more staff from black, Asian and minority ethnic backgrounds working on the front line or in COVID-19 wards compared to white colleagues. ^[1]

Survey findings in relation to mental health corresponded with findings from other research. For instance, a study involving 2,600 healthcare workers employed by ten trusts in the West Midlands found post-traumatic stress symptoms in almost a quarter (24.5 per cent) of respondents, with more than a third (34.4 per cent) reporting clinically significant symptoms of anxiety and more than 3 in 10 (31.2 per cent) reporting depression. ^[2] Women were found to be more likely to report post-traumatic stress disorder and anxiety symptoms. A separate study into the presence of a range of probable mental disorders among staff at three London NHS trusts, involving 4,378 participants, also found women, nurses and younger staff tended to have poorer outcomes than other staff, except in the case of alcohol misuse. ^[3]

Female staff with long-term conditions experienced a greater negative impact on their physical health and emotional wellbeing, felt less safe sharing concerns with managers and had a poorer experience of remote working compared with those without long-term conditions, suggesting the pandemic has taken a heavier toll on staff with poorer overall health.

2. Burden of caring responsibilities

Women surveyed by the network in June 2020 reported having taken on an average of 11.22 extra hours each week of non-work caring responsibilities, but had only reduced their working hours to take account of these extra responsibilities by 1.44 hours each week. By the time of the most recent survey, in February/March 2021, this had increased to 12.81 hours per week. The total number of hours women spent each week on non-work caring activities rose from 17.73 hours to 19.67 hours (this figure includes non-work caring activities that women were undertaking before the pandemic).

Respondents with children under 18 reported being far more involved than usual in non-work caring responsibilities, compared with the period before the pandemic, presumably related to the prolonged closure of schools. There was a statistically significant association between the number of children that respondents had caring responsibilities for and the total number of hours per week involved in non-work caring responsibilities, increased hours per week involved in non-work caring responsibilities beyond pre-pandemic levels and working reduced hours. One participant responding in June 2020 said: “Managing a full-time job with conflicting priorities, home schooling, supporting family in the UK and [abroad] takes a toll. It’s financially difficult and emotionally draining.”

This finding is reflected in analysis carried out under the Independent Review into Gender Pay Gaps in England. The review found that ‘the lion’s share’ of the seniority gap between men and women doctors and the lower level of experience among women hospital and community health service doctors, is accounted for by a combination of family and structural factors, with workplace culture also playing a substantial role in accounting for the lower level of experience among women GPs.

The review states: ‘Overall, our results suggest that it is the interaction between women’s family responsibilities and an unsympathetic career structure which leads to lower levels of experience and less favourable career paths for women.’ ^[4]

Although our survey did not ask women specifically about their household income, it is likely that women who are sole carers will face greater financial burdens as a result of their caring responsibilities. Women with lower incomes, such as those who are at the bottom of health and care pay scales, face experiencing economic hardship as an additional stressor on top of their work and caring responsibilities. This is likely to affect black, Asian and minority ethnic backgrounds disproportionately because of the existence of an ethnicity pay gap in the NHS.

Analysis carried out by the Nuffield Trust in 2021 found that for four major staff groups – staff supporting doctors and nurses (such as secretaries and ward clerks), nurses and health visitors, managers and senior managers, and consultants – pay gaps favoured white staff, and black British men earn less on average than any other group in the NHS. ^[5]

3. Vaccine hesitancy

85.4 per cent of women surveyed had received at least their first dose of a COVID-19 vaccine at the point when fieldwork was undertaken in February/March 2021, suggesting a large proportion of the female health and care workforce should be protected against the virus at the time of writing (June 2021). However, four per cent of respondents reported that they had decided not to have the vaccine. This suggests that more work may be needed to improve vaccine confidence among female staff. Separate research has found that in the UK, vaccine hesitancy is associated with younger age, female gender, lower income, and ethnicity. ^[6]

How has COVID-19 impacted the way women working in health and care are able to carry out their roles?

Responses to our surveys show that women have experienced particular challenges during the pandemic in relation to their working lives. Significant numbers of women reported not feeling safe when sharing personal concerns with a manager, experienced problems accessing suitable personal protective equipment throughout, and described negative home working experiences. Unfortunately, a small number of women told us that factors in their home made working from home problematic for their safety. Women also reported working extra unpaid hours roughly equivalent to one working day per week on average during the pandemic period. In many cases, a higher proportion of women from black, Asian and minority ethnic backgrounds reported these problems than white women.

Since our survey was predominantly completed by women, we do not have available data to assess whether women have been more severely affected than men by these issues. However, the most recent NHS staff survey found females were significantly more likely than males to report having felt unwell as a result of work-related stress in the previous 12 months and to have come into work despite not feeling well enough in the past three months.

1. Support in the workplace during COVID-19

In the February/March 2021 survey, almost three in ten female respondents (29.4 per cent) said they did not feel safe sharing their personal concerns about the pandemic with their manager – a slight increase from 26.3 per cent in June 2020. While it is reassuring that the majority of respondents felt able to share concerns, it is troubling that a large minority do not.

Respondents from black, Asian and minority ethnic backgrounds felt less safe sharing their personal concerns with managers than white respondents, as did respondents with adult dependents, compared with those with no dependents. This suggests that more work may be required to ensure that the work-related support needs of those in minority groups and with additional caring responsibilities are addressed. 

There were also in June 2020 some reports of poor behaviour amplified by the pandemic among some leaders, including claims of bullying, sexism, racism and threats. This finding is reinforced by BME Leadership Network research, where participants, both managers and clinicians, reported that bullying and harassment were a fact of life for many black, Asian and minority ethnic backgrounds employees. ^[7]

2. Challenges of working from home

Half of women working in health and care responding to the survey who were able to work from home described a positive experience (50 per cent in February/March 2021 and 51.8 per cent in June 2020). Benefits highlighted included opportunities for flexible working and time savings from not having commute. However, around a quarter (23 per cent in June 2020 and 25 per cent in February/March 2021) reported a negative experience, with some citing concerns including feelings of isolation and a lack of connection with colleagues.

Some participants in the June 2020 research mentioned feelings of resentment from colleagues unable to work from home, physical discomfort from working in an environment not designed to be a workspace and confusion from management over who should be allowed to work from home.

It is important to note that women in patient and service user-facing roles will have been less able than those in managerial roles to work from home during the pandemic period. Therefore, the option of home working may not have been available to some women, which is likely to have posed additional challenges when unpaid caring responsibilities are taken into account (see section above; Burden of caring responsibilities).

3. Domestic violence risks

Worryingly, a small proportion of women (2.6 per cent in June 2020 and 1.7 per cent in February/March 2021) said there were factors in their home that made working from home problematic for their personal safety. Proportionally more staff from black, Asian and minority ethnic backgrounds reported not feeling safe at home. One respondent said: “My partner is always emotionally abusive, but during the period of self-isolation, they became physically abusive.” This person said their manager had been supportive, but this highlights a need for managers to consider safety issues associated with home working, and to ensure information on domestic violence support is available to all staff.

4. Unpaid working

Survey respondents reported working an average of 7.14 extra unpaid hours per week in June 2020 and 8.46 extra in February 2021. Female staff from black, Asian and minority ethnic backgrounds reported working more unpaid hours than white women, reporting greater reductions in their paid working hours and increased non-work caring responsibilities. One possible explanation for this is that these women had reduced their paid hours to take into account non-work caring responsibilities, but had ended up working more unpaid hours, perhaps to compensate for reduced paid hours while still doing the same job.

This implies women from black, Asian and minority ethnic backgrounds may have experienced a worse detrimental impact on working life and opportunities for earnings and career progression as a result of the pandemic. In June 2020, respondents on higher salaries also reported working more unpaid hours than those on lower salaries. 

5. Availability of personal protective equipment (PPE)

When the first survey was undertaken in June 2020, 4 in 10 respondents (40 per cent) reported that PPE was available in the sizes needed and that appropriate training had been given to all staff who needed it. But 29 per cent did not agree that PPE was available in the sizes needed and 22 per cent did not agree that appropriate training had been given to all staff.

There were comments about problems with availability and sizing of PPE, including in accident and emergency settings. One respondent said staff were wearing extra-large gowns when most needed a small or medium.

By February 2021, the picture was better, with 16 per cent disagreeing that PPE was available in all sizes and 13 per cent disagreeing that appropriate training had been given to all staff. However, the fact that in February 2021, a significant proportion of respondents were still unhappy with PPE provision and training indicates that more work is needed in this area. Staff providing frontline care are at heightened risk, and research has shown an individual’s perception of having inadequate equipment can be associated with post-traumatic stress disorder, poorer health and increased reporting of emotional health problems. ^[8]

6. Stress and presenteeism

Findings from the NHS Staff Survey published in March 2021, and covering the period between October and December 2020, included that female NHS staff were 14.1 per cent more likely than males to report having felt unwell as a result of work-related stress in the previous 12 months. Women were 9.5 per cent more likely to have reported coming into work despite not feeling well enough in the past three months.

People who self-described or preferred not to report their gender showed much worse levels of wellbeing and lower satisfaction in relation to work in the staff survey, suggesting a need for further work to ensure staff understand the specific needs of LGBTQ+ people, the health inequalities they face, and the variance of experience between the LGBTQ+ identities – particularly that of transgender people. ^[9]

7. Impact of national policy

The NHS People Plan sets out the NHS’s workforce strategy for 2020/2021. It includes ambitions to improve staff wellbeing and flexible working. Examples include psychological support, Schwartz Rounds and workplace ‘wobble rooms’, as well as increased support for working carers via the carers’ passport. The plan also includes a requirement for employers to ensure staff have access to and training to use appropriate PPE, home working support and risk assessment, including for black, Asian and minority ethnic staff. ^[10] Similarly, the NHS People Promise, a pledge, emphasises staff wellbeing, support and inclusivity. ^[11] But neither the plan nor the pledge make direct reference to the fact that the NHS workforce is predominantly female.

Disproportionate impact of COVID-19 on black, Asian and minority ethnic women working in health and care

Female staff from black, Asian and minority ethnic backgrounds were more involved than others in non-work caring responsibilities, saw greater reductions in their working hours and at the same time were working more unpaid hours than white women (see section above; Unpaid working). Although it is better to consider different ethnic groups separately to recognise different cultural and social factors that affect different groups, the number of respondents from minority ethnic backgrounds was too low to allow for comparison between different minority groups.

The findings suggest a disparity in demands on women outside of work in relation to ethnicity and implies the detrimental impact on working life and opportunities for earnings and career progression may be worse for women from black, Asian and minority ethnic backgrounds.

Steps taken by employing organisations in the NHS to support workers during the pandemic

Employing organisations in the NHS have taken significant steps to support their staff during the pandemic.

At a national level, the NHS has provided dedicated confidential support via phone and text message using mental health trusts and professionals, a bereavement support helpline, and online resources, guidance and webinars. Helplines specifically designed to help black, Asian and minority staff manage anxiety and stress levels have been created in recognition of the disproportionate impact of COVID-19 on these groups.

At a local level, employing organisations have put in place regular listening sessions, opportunities to connect with teams and leaders using technology, risk assessment and financial support. Where staff are working on site, rooms have been set aside for staff to use for resting, along with people to talk to.

Other local initiatives have included wellbeing hours, interventions to minimise isolation in home working and shielding staff, supporting line managers to have open conversations with staff and creating spaces for staff to share their experiences of the pandemic, such as living history projects.

However, it is not clear that all employing organisations have specifically considered how the pandemic has affected their female workforce and put in place provisions specifically to support the needs of this group. More could be done both locally and nationally to address the particular needs of female workers during the next phase of the COVID-19 recovery.

Although in recent years NHS organisations and arm’s length bodies (ALBs) in health have been increasing the proportion of women occupying senior roles, research conducted for the HCWLN in 2020 found that 150 more executive and non-executive female directors (including 40 more female medical directors and 50 more female chief finance officers) would be needed to reach gender balance across NHS trust and ALBs boards in England. [12] Further work to address these deficits is likely to provide a benefit by increasing the proportion of women in board-level leadership roles and therefore in a position to identify and address workplace issues disproportionately affecting women.

Conclusion

Surveys carried out by the HCWLN during the pandemic period indicate that COVID-19 has had a significant impact on both the health and wellbeing of staff working in health and care, and also in the way they are able to carry out their roles.

Negative impacts on health, wellbeing and working lives

Our research indicates that women face significant pressure because of the extra burden of caring and family-oriented tasks that they tend to bear, as well as experiencing negative impacts on their health and wellbeing as a result of their experiences of the pandemic.

Women may not feel sufficiently able to share personal concerns with managers and may experience discrimination and bullying. For black, Asian and minority ethnic backgrounds women, this is a particular problem. This risks introducing a barrier for women wishing to access support via the workplace in response to specific challenges they face stemming from their experience of working through the pandemic. Moreover, some women have been placed at greater risk of domestic violence because of the shift to home working during lockdown periods; this is an issue that all responsible employers will want to consider.

Women also face risks relating to poor availability of PPE equipment in the correct sizes. Responses to our surveys suggest this problem is in the process of being rectified, but is still not completely resolved.

Exacerbating existing challenges

Often, for instance in the case of unpaid caring responsibilities, the pandemic has exacerbated issues that were already affecting women in significant numbers prior to the COVID-19 outbreak. The pandemic also seems to have had a greater impact on black, Asian and minority ethnic female staff in some cases, with larger proportions of female staff in these groups raising concerns than white staff in some areas.

These challenges did not come into existence with the arrival of COVID-19 and will not disappear once the pandemic is over. However, the post-COVID-19 recovery period does present an opportunity for leaders to build back better with policies and approaches that recognise the specific needs of the female health and care workforce.

Since women make up such a large proportion of the health and care workforce, employers have a significant opportunity to show leadership in improving the experience of women in work and supporting their health and wellbeing more broadly, in the immediate response to COVID-19 and beyond. As a large-scale UK employer, with a significant HR infrastructure, the NHS has an opportunity to show leadership in this area. Yet, to date, NHS workforce policy strategies have not focused on understanding or articulating the specific needs of the female workforce.

Towards a Women’s Health Strategy for the NHS workforce

The network therefore sees it as essential that the concerns we have outlined in this response are taken into account during future workforce planning activities. We are calling for the development of a Women’s Health Strategy for the NHS workforce, to identify and describe the specific challenges that women in the health and care workforce face, and to propose ways of addressing these so that women experience greater equity at work.

The NHS should be the exemplar employer for women’s health for two related reasons. Firstly, more than three quarters of the workforce is female, meaning policies that address the specific challenges faced by female workers have the potential to improve the health of a significant majority of NHS staff. Secondly, as this submission demonstrates, the health and care working environment has posed specific challenges to women, particularly during the pandemic. As an organisation whose purpose is to improve health, the NHS has a responsibility to remove workplace barriers to better health and wellbeing.

As part of the strategy, and in part so that the challenges facing female staff are better addressed in future, there should be a specific focus on ensuring women are able to progress to leadership roles, ensuring that leaders and key decision makers better reflect the diversity of the workforce. The strategy should also focus on making improvements for women who are the most marginalised intersectionally as an early priority.

We note the need for further evidence and insight into the needs of all women in order to shape a comprehensive health strategy. Women’s experiences both in relation to and outside the Equality Act 2010 protected characteristics should be considered, for instance in relation to women with disabilities, older and younger women and those living in rural areas. 

Recommendations

The HCWLN has made the following recommendations in light of its female members’ experience of working in the health and care sector through the COVID-19 pandemic:

Flexible working

• Requests to work flexible/reduced hours should always be accommodated unless there are exceptional reasons why this is not possible.

Health and wellbeing

• Managers should pay particular attention to the physical and emotional health needs of female staff with children during the pandemic.
• Staff should be discouraged from working unpaid overtime and encouraged to maintain good work-life boundaries, particularly when working from home and for staff with children.
• Organisations should prioritise the appointment of a wellbeing champion, and the national wellbeing offers should be extended to all across health and care and continue beyond this immediate crisis.
• NHS England and NHS Improvement should ensure the continuation of all wellbeing support and psychological support that will be needed by those on the frontline.
• Managers should support workers to speak up about personal concerns in relation to the pandemic, being mindful that black, Asian and minority ethnic backgrounds staff and staff with adult dependants may find it particularly difficult to share their concerns, and signposting to alternative speaking-up channels.
• Managers must work with female staff with long term conditions to ensure mental and physical health support is geared to their specific needs, that they feel able to speak up and that those who work remotely are supported to do so.

Workplace safety

• PPE must always be available in all sizes, and appropriate training in using PPE must be given. If suitable PPE is not available, workers need to know how to speak up and to be encouraged to do so.
• Managers should create a culture where workers feel able to speak up about their personal safety at home and, where concerns are shared, staff should be proactively helped to seek support.

Home working

• Organisations should review their home working policies, and ensure staff have access to the appropriate equipment and that safety assessments are undertaken.
• Domestic violence information and support services should be made available to all staff working across health and care.

Equality of opportunity

• Government, national bodies and individual employers should ensure that the childcare and other caring responsibilities of female staff do not hinder their careers.
• Employers must ensure that all women have equitable access to career progression opportunities, and should understand the vital contribution these women are making and the additional demands on their time both during the pandemic and in general.
• The experiences of women from black, Asian and minority ethnic communities appear to be consistently worse, and in some instances compounded by racism. Government, national bodies and individual employers should resource and redouble efforts to eliminate racism within the workplace, including through responding to the issues raised here and by ensuring staff from black, Asian and minority ethnic backgrounds are empowered to speak up.

National priorities

• Government and national bodies should pay specific attention to the impact the pandemic has had on women working in health and care. Investment and policy focus should be targeted at addressing the needs of this group, which comprises more than three quarters of the health and care workforce.
• This should include investment in ongoing, tailored mental and physical health support and investment in recruitment to allow for flexible working and ease the burden on women.
• National NHS leaders should develop a Women’s Health Strategy for the NHS workforce, to ensure that the issues identified within this submission, and issues requiring further follow-up, are addressed at every level in the health system so that women can progress in their careers in an equitable way. The issues identified in this report cannot be fully addressed without having a targeted strategy to eliminate racism.