Challenge 9.2

Why does this Challenge need to be solved?

Over 50 per cent of Scotland’s Population will experience the menopause and while a minority may not experience any symptoms, many more will find that it impacts their lives and a significant proportion will experience severe and negative impacts affecting their personal and professional lives. This infographic from the British Menopause Society provides an overview of the prevalence of symptoms.

With rising awareness, expectations have changed:  in the past menopause was just something to struggle through, now there is a recognition that clinical management or other types of support is needed in many cases. However due to historic stigma driving limited engagement, NHS menopause services have not been developed at a level that meets the needs of the population. The consequence is that too many women cannot access the type of menopause care of support they need, when they need it. The impacts for women are varied; from their relationships and careers; to the long-term medical implications of delayed treatment and/or support can have a significant negative impact on quality of life, relationships and careers from short term menopausal symptoms, like hot flushes, night sweats, mood changes, anxiety, etc., but can also have a negative impact on longer term health from increased risks of osteoporosis and cardiovascular disease. Young women experiencing premature ovarian insufficiency, may also have an increased risks of Alzheimers dementia.

There are 3 sections to the challenge which are summarised here and then set out in more detail below, respondents are not required to address all three components;

Identifying and Understanding Symptoms and  Options for Support

Each woman’s experience of menopause will differ significantly and while awareness of menopause is increasing there is not currently a way to provide women with a personalised understanding of their own menopause and to help them find options for support whether through clinician supported medical care or other types of support, that are relevant to their own specific symptoms, when they need it.

The options for support could range from lifestyle or self-help measures through to medical interventions such as hormone treatment or other types of treatment such as Cognitive Behavioral Therapy. A woman’s decisions about support or treatments will be based on both the specific symptoms experienced; their medical history; and their personal preferences about the types of support or treatment they wish to engage with.

Self Help and Work Place

Whether a woman is seeking medical care for her menopause symptoms or not there are a range of self-help measures which can be critical to managing symptoms.  These self-help measure can sometimes fall into the category of “simple but not easy” measures to implement on areas such as diet, sleep and exercise.  However women can be left feeling unsupported when generic advice  or guidance is offered. Approaches to supporting women to implement self-help measures through more directive intervention or personlised plans are invited.

In addition, it has been highlighted working women often report it is most difficult to manage their symptoms in the work place. Therefore it is important women are supported in approaching their employers about conversations to help manage symptoms as part of self-help measures.

Accessing Medical support 

In addition if seeking medical support from a health care professional, it can be hard for women to; identify the different options for accessing medical support, have conversations with healthcare professionals presenting a record of the symptoms which might be required and advocate for their own needs. It is also hard for health care professionals with short appointment slots to gather significant amount of history from a women about her symptoms and wider medical history to make a full assessment. Furthermore delays in referrals to specialists are happening as a result of incomplete information about symptoms or medical history and secondary care specialists appointment slots mean much of appointments can be spent gathering information rather than discussing support or treatment options.

Overall we are seeking ways to improve access to personalised menopause support for all women ensuring that disabled women, women from minority ethnic communities and women lower income groups. 

The scope of the challenge is intentionally wide, and includes how to provide women with reliable, validated and personalised NHS information and support; through to the challenges in managing the referral and follow up process between primary and secondary care providers. We have set out the challenge in three sections, applications which can address part of the Challenge are welcome.

It is not expected that one response will necessarily cover all aspects of the Challenge, respondents can focus on a specific part or parts of the challenge as long as they demonstrate how the component they are addressing would create an impact on at least one of the Challenge outcomes. Furthermore, detailed background can be provided on specific components of the challenge both through additional materials and during the subsequent stages of the process.

Please see below further details on each section of the challenge summarised above.

Understanding menopause symptoms of options for support

Each woman’s experience of menopause will differ significantly and while awareness of menopause is increasing there is not currently a way to provide women with a personalised understanding of their own menopause and to help them find options for support whether through clinician supported medical care or other types of support, that are relevant to their own specific symptoms, when they need it. Not all women will seek clinical support for their menopause symptoms, however the first step for most women in managing menopause is accessing information. Access to information can help women to both understand their personal symptoms (and even steps that can be taken before symptoms develop) and the choices they can make about the types of support that may be relevant. However there are a range of issues associated with providing quality validated personalised information which this challenge is seeking solutions to address as set out below:

1. Lack of personalised information: there is currently no NHS resource which provides women with a personalised understanding of the menopause symptoms they individually may be experiencing. There is good NHS content within resources, such as NHS inform, however the information from NHS is not personalised in terms which allow women to understand how their specific symptoms might relate to menopause. This can include a need to understand aspects of a women’s wider medical history.

2. Lack of personalised options for support: not all women will seek support for their menopause symptoms. For women who do the options for support could range from lifestyle or self-help measures through to medical interventions such as hormone treatment or other types of treatment such as Cognitive Behavioral Therapy. A women’s decisions about support or treatments will be based on both the specific symptoms experienced; their medical history; and their personal preferences about the types of support or treatment they wish to engage with. In addition some support option may be localised in nature (such as in-person peer support groups or specialist pharmacy based services).

3. NHS Validated Information. While awareness on Menopause has been raised in recent years and there is content available across various platforms and apps, that content is not always either NHS validated or reliable. Therefore any approach need to be based on reliable NHS approved information.

4. Equality of Access:  there is evidence that menopause services are accessed less by those on lower incomes and by women from minority ethnic groups. In addition Menopause can affect some, intersex, non-binary and transgender men, approaches to providing information which are inclusive and help address the inequality of access to treatment are sought through this challenge.

Lack of personalised and directive Self Help: both for women who go on to seek support and for women with more mild symptoms of Menopause there are various “self-help” and lifestyle changes which can help with managing symptoms. There is a lack of NHS validated resources to bring together the types of support that could be relevant such as on sleep, diet and exercise in a personalised way. In addition generic advice on such lifestyle measures can be difficult for women to implement. Through this challenge we are seeking solutions which can provide a personalised approach to directing women to a combination of personalised advice and/or other technology solutions to help them to implement lifestyle measures or manage specific symptoms. This should also help sign post women to clinical care options where self-help measures are not meeting needs of women.

1. Identifying relevant self-help measures: often generic information on self-help measures focuses on particular types of symptoms (such as hot flushes) however this types of self-help is only relevant to women who experience those specific symptoms. These self-help measures are also often part of the measures recommended when seeking medical support. However women can be left feeling unsupported when generic advice  or guidance is offered, particularly when it is difficult to implement in the context of other personal or work life pressures.

2. Active Self Help Management: Self-help measures can sometimes fall into the category of “simple but not easy” measures to implement on areas such as diet, sleep and exercise. There are a range of both established and emerging technologies in this area that can help, from fitness and menstrual cycle tracking tools to the use of wearables to help manage hot flushes. However these types of tools are not typically focused on women from the point of view of management of menopause symptoms. Approaches to supporting women to implement self-help measures through more directive intervention using such technologies or the development personalised plans are invited.

3. Self-Help and the work place: In addition to helping women find support that supports to help manage symptoms generally, it has been highlighted working women often report it is most difficult to manage their symptoms in the work place and while awareness generally has improved  there is evidence that stigma seems to play a significant ongoing role in women’s  difficulties with symptoms in this context. It is estimated that 70% of women going through the menopause did not disclose menopause symptoms as the real reasons for absence from work.  While employers policies will vary (with some introducing more progressive approaches to helping employees)  there is a lack of consistency in the approach of employers. Therefore it is important women are supported in approaching their employers about conversations to help manage symptoms. This could include providing a clear understanding of what their rights are in the work place and who to speak to, advice what types of measures might be considered as part of supporting women to manage their symptoms in the workplace that is relevant to the specific symptoms a women is experiencing, sign posting to peer support communities or other support. The information available currently can be too generic or focus on specific symptoms (such as hot flushes)

4. Ongoing Stigma There can also be stigma in family and social settings and sign posting of peer support groups are fragmented.

Accessing Care through the NHS

For Women seeking clinical support for their menopause symptoms there are a range of complex challenges in accessing services whether that is initially accessing GP services (primary care) or for those referred to specialists (secondary care). The challenges set out below focus on the challenges in terms of accessing Menopause care specifically within the scope of existing resources. There is wider work underway through the Women’s Health Plan to address areas such has training for Primary Care providers and specific initiatives (such as pilots for community pharmacy led support) that may increase capacity of services. However, this challenge focuses on how to get women the right support, from the right place at the right time within existing, albeit constrained, resources.

1. With limited capacity and challenges in the appointment booking systems for GPs women can find it hard to get an initial appointment. One factor can be that not all reception staff are trained to know the other options (such as a Practice Nurse or Advanced Nurse Practitioner) for primary care support. In addition there are some symptoms which can be treated with over the counter medicines at a pharmacist and pilots for community pharmacy menopause clinics for wider prescribing are underway in some regions. Women looking to access an appointment with a Health Care Professional may not know the options available to them either in general terms or specific options locally. This challenge would welcome solutions which can help women identify options for primary care support including, options for appointments with different health care practitioners, over the counter medications and/or other local services (such as community pharmacy clinics as and where they exist).

2. Once a woman accesses a GP appointment (or an appointment with another healthcare provider) the time available is often too short to gather all the relevant background information on symptoms for GPs to consider in recommending treatment or advice. In addition in can be hard for women to keep track of the different symptoms they are experiencing and have a record of these ready for discussion with the GP. This (along with the problem below) can result in women struggling to get support through the GPs without multiple visits, exacerbating pressure on the already constrained resources. This is a critical aspect to the challenge.

3. GP and Primary Care training on Menopause is also affected by historic stigma and myths. The media has overinflated perceived risks of HRT and there has been severe lack of menopause training for all health care professionals. For example (while it is only one type of menopause care) there is evidence of significant variation in the prescribing rates for HRT between GP practices. There are initiatives underway under the Women’s Health Plan to develop training on Menopause for primary care providers however this can mean women need to be well prepared with NHS validated information for their appointments with Health Care Providers and equipped to advocate for their own needs. Approaches to solving this aspect of the challenge that can help develop understanding of where training and support is most needed would be welcome.

Accessing Secondary Care

For women who need to be referred into secondary care there are another range of challenges associated with the referral process. These can result in significant further delays in women accessing the specialist support they need.

1. There can be delays in the referral process as a result of incomplete referral information which needs to include medical history such as any cancers, up to date BMI, Blood Pressure, other medications and the background in terms of the individual’s specific symptoms. Where background information has not been provided in advance of a secondary care appointment the appointment time is often used gathering the information without enough time to provide the advice to patients.

2. There is significant variation regionally in waiting lists for treatment with some regions have 4 month waiting lists and other 18 Month waiting lists. There is no additional resource to provide additional capacity into secondary care therefore approaches which might include ways to make the most of limited secondary care menopause services both within and across health boards would be welcome.

3. Women who are receiving clinical menopause care often require regular follow up. This follow up might not require an appointment with a secondary care consultant or GP but can include requirements for a range of different monitoring from blood pressure to blood tests. This follow up can often be delayed resulting in delays to repeat prescribing or follow up treatment.

Data

The availability of data in Menopause and menopause care is limited as a result of historic under investment. There are limited data available both on existing services available and on take up of those services. There are some data on prescribing of HRT and on waiting lists for secondary care but none on numbers of women presenting at primary care services seeking menopause related care. The above graph includes data on variation in prescribing rates of HRT for some GP practices in Ayrshire and Arran. While it only shows HRT prescribing specifically and other types of menopause care are available it highlights that there is a significant variation between practices with roughly a 20% difference in prescription rate as a % of registered patients. Approaches to solving the challenge which can improve the data on the accessibility of information and services and the health outcomes for women are invited.

This challenge aims to develop solutions which could be adopted by the NHS to improve Menopause care overall. However, it is acknowledged that any approach to developing a solution which is effective at a population level will require more narrow specific use cases as part of developing and testing the solution. In addition to working with the clinical teams within NHS Greater Glasgow and Clyde and NHS Ayrshire and Arran on Menopause Care and the NHS Scotland Innovation “Test Beds”, there are options for engaging with specific groups to develop the solution including The NHS Scotland [NHS A&A/GG&C] workforce. The challenge sponsor team have engaged with their local HR teams who are very supportive of the challenge. Furthermore the newly developing Accelerated National Innovation Adoption (ANIA) pathway is a potential route to fast-track solutions into the healthcare frontline on a ‘Once for Scotland’ basis if the technology is proven to meet specific criteria.  

How will we know the Challenge has been solved?

Data

• Improved data on menopause care services and outcomes for women

• Reduced number of days absent from work due to menopause (primary outcome)

• Accurate menopause data covering primary care, secondary care and prescriptions.  

Information and Self Help

• Access to validated menopause information and personalised care for all women in Scotland when they need it

• Increased usage of NHS validated information (including website hits)  

Accessing Primary Care & Secondary Care

• Increase in number of women with appropriate access to the appropriate services (primary outcome)

• Improved wellbeing measures in women aged 45+ collected from the Scottish Health Survey and other user feedback surveys (primary outcome)

• Reduced inequalities of prescribing rates and access (primary outcome)

• Shorter waiting lists

• Review of data from solution developed to ensure that we are developing our understanding of need, increasing our understanding of personalising risk, increasing our understanding of improvements of QoL/symptoms (wearables)

• Use AI to ensure that solution is updating and relevant

Who are the end users likely to be?

• Women experiencing menopause or perimenopause or seeking information

• Healthcare professionals - primary and secondary care, clinical nurse specialists, community pharmacists

• Pharmacies and Community Hubs

• Employers

• Mental Health Services

Has the Challenge Sponsor attempted to solve this problem before?

No. There are non-NHS validated approaches to tackling aspects of the challenge.

Are there any interdependencies or blockers?

• Respondents will benefit from understanding the requirements for developing technology products which qualify as a medical device.

• IT compliance (security) and data / information governance.

• Integration with NHS systems, data, and pathways such as GP practice management systems (e.g. EMIS) Referrals (SCI Gateway), Secondary care patient referral, vetting, appointing and management systems (e.g. TrakCare), and decision support (e.g. Right Decision Service).

• Complex NHS systems and data landscape and involved national strategies (e.g. Digital Health & Care Strategy, Health and Social Care Data Strategy) and local strategies (e.g. NHSGGC Digital Health & Care Strategy)

• Consideration to be given to language barriers, accessibility, digital literacy and access to IT. Low literacy is a barrier- we often want women to read large volumes of information.

• Ethics Committee Review

Will a solution need to integrate with any existing systems / equipment?

NHS Clinical systems (more details can be provided if helpful and examples provided above).

Depending on nature of the solutions NHS Boards and Test Beds may be able to bring access to innovation enabling infrastructure such as existing systems integration points. 

Improve access to data and digital technologies built around citizen choice and control including Digital Front door

Any technologies or features the Challenge Sponsor wishes to explore or avoid?

The following technologies should be explored:

• Personalised risk calculators

• Wearables to collect data e.g. on sleep, flushes

• Facilitation of data sharing between the patient, primary care (including community pharmacy), and secondary care

• Measurement of ‘softer’ inputs e.g. exercise, healthy eating, reducing alcohol – essentially increasing the profile of prevention/self-care approaches so women both embrace this aspect but also do not feel they are being ‘fobbed off’ with something non-medical

• Technology to prevent women having to read large volumes of information and to present information in an interactive way.

• AI for translation for those for whom English is not the first language.

• Use of AI to facilitate online Cognitive Behavioral Therapy for hot flushes

What is the commercial opportunity beyond a CivTech contract?

The commercial opportunities associated with solutions to this Challenge include other health sectors nationally and internationally. However there is a significant additional market given the challenges for women in managing Menopause symptoms in the workplace. There is limited data but some estimates indicate between 10-20% of women will leave the workplace due to menopause symptoms. Given recruitment and retention implications, some employers have already taken steps to introduce policies and support for women during menopause. Other customers could include insurance companies.

Who are the stakeholders?

• Women and their families

• The Women’s and Children’s Health Innovation Senior Leadership Group, chaired by Neil Patel, Consultant Neonatologist and Clinical Lead for West of Scotland Innovation Hub. This group have been closely involved with the development of this challenge from the outset.

• Clinical Directors and Leads for Gynaecology and Sexual and Reproductive Health, NHS Ayrshire & Arran and NHS Greater Glasgow & Clyde

• Women’s Health Champion and the Women’s Health Plan Policy Leads, Scottish Government

• Chief Scientist (Health) and the Chief Scientist Office, Scottish Government

• NHS Scotland Innovation Hubs

• Digital Health & Care Policy Leads, Scottish Government

• The ALLIANCE

• Reproductive Health and Childbirth Research Network

Who’s in the Challenge Sponsor team?

Subject matter experts:

• Esther Aspinall, Consultant in Public Health Medicine, NHS Ayrshire & Arran

• Katrin Bjornsson, Menopause clinical and strategic lead for Sexual and Public Health, NHS Ayrshire & Arran

• Jenifer Sassarini, Consultant Gynaecologist and Obstetrician, NHS Greater Glasgow & Clyde

Innovation support, including access to the NHS Scotland Regional Test Beds which will support successful applicants to take forward their projects (including access to data, Information Governance, access to patient pathways). 

• Craig Bell, Innovation Project Manager, West of Scotland Innovation Hub

• Suzanne Graham, Programme Lead, CSO Innovation Team, Scottish Government

What is the policy background to the Challenge?

Women’s Health Plan Women's health plan - gov.scot (www.gov.scot)