As I see it . . . Post Reproductive Health 2014, Vol. 20(4) 156–158 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2053369114560319 prh.sagepub.com
As I see it . . . Edward Morris British Menopause Society, London, UK
World Menopause Day, the IMS white paper and the NHS in the UK – No longer banging on a locked door? As I write this commentary, I reflect on the impact of World Menopause Day in the UK. The date, 18 October, was promoted by the International Menopause Society (IMS) worldwide and heavily supported by the British Menopause Society (BMS) throughout the UK. We are indebted to BMS members, our partners, The Royal College of Obstetricians and Gynaecologists (RCOG), Sage Publishing (publishers of Post Reproductive Health) and the media for helping us support the messages in the IMS campaign. The authors of the white paper1 are to be commended for assembling a superb collection of information and presenting a high-quality contemporary view of the state of the art in post reproductive health and how relatively simple interventions performed early in a woman’s life can save lives. The paper eloquently describes the complexities of the effect of various diseases on the menopause along with how the menopause can affect these conditions. Throughout the document, there are frequent references to simple interventions, preventative healthcare measures as well as the place of hormone replacement therapy (HRT) as a strategy for preventing disease. The BMS feels that it is only through high-level campaigns such as this upon publication of the IMS white paper that the authorities worldwide can begin to understand the issues specific to women during the menopause. We did our best to disseminate these messages to all those willing to listen, but I remain concerned that it would appear that few people are listening and those that are do not have the mandate to influence change. In support of my case, please consider the below quotes: Women presenting to their medical providers during the menopausal transition provide a unique opportunity for risk assessment, counseling and the institution of various prevention measures.1
Primary Care Teams invite women on their register, around the time of their 50th birthday, to attend a health and lifestyle consultation to discuss a personal health plan for the menopause and beyond.2
The first quote comes from the IMS white paper published in 2014 and the second comes from the BMS recommendations published in 2011 during the socalled National Health Service (NHS) listening exercise. It is clear to see the marked similarities between the two recommendations, and at the same time, it is clear from those of us working in this area that in the three years since the BMS recommendations were published, there has been little progress towards achieving these seemingly simple aims.
The BMS recommendations2 For those who are unaware of what the listening exercise was, this was an initiative employed by the current coalition government to try to understand the needs of the NHS from the perspective of those providing healthcare following the proposals in the Health and Social Care Bill (2011) before it became legislation in the Health and Social Care Act (2012) as proposed by the then Health Secretary of State, Mr Andrew Lansley. During the listening exercise, the government met with many different stakeholders, including most Royal Colleges, to gather opinion and propose modifications to the Bill. During the listening exercise, the BMS produced its recommendations which described in detail the scale of the problem, highlighting the increasing numbers of menopausal women on a national scale and the major demographic changes in our population that influence chronic disease in later life. Underpinning our recommendations was the desire to suggest that simple non-pharmacological measures along with risk assessment and advice early in the menopause are most likely to have significant longterm influences on morbidity and mortality in these women. We did not suggest expensive treatments, but we merely provided a set of practical measures to steer the NHS towards the attainment of effective
Downloaded from min.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 17, 2015
Morris
157
preventative healthcare. The recommendations were divided into those to influence National Policy and Strategy, Community Policy and Local Healthcare Delivery. Initial feedback was excellent, with positive comments from members and stakeholders alike. However, our greatest pride was the inclusion of our recommendations as an appendix in the RCOG document ‘High Quality Women’s Healthcare’.3 Our key recommendation of a ‘health check’ around the 50th birthday was supported by the RCOG in this paper. This RCOG document was again produced to advise the government during their listening exercise. The key theme within this document was the adoption of a lifecourse approach to the management of women – with a strong bias towards preventative healthcare.
The IMS white paper1 This paper has just been produced by the IMS and is a welcome additional support to the BMS and its aims for post reproductive care. The contents of the document cover an extremely high level of detail and careful analysis of the available data. The paper starts with a description of the epidemiology of menopause and chronic disease with a global perspective. Then, it discusses the influence of insulin sensitivity, metabolism and the challenge of obesity on numerous aspects of postmenopausal health along with practical interventions. Coronary heart disease (CHD), one of the prime reasons for the Women’s Health Initiative (WHI) study is placed in a contemporary context with a clear discussion around the main contentious issues of the impact of HRT on overall CHD risk. This section also includes an evaluation of the optimal timing of HRT administration for CHD prevention, also known as the ‘window of opportunity’ hypothesis. Other areas of clarity from this article come from the authors’ discussion around pharmacological and nonpharmacological measures that affect outcomes in osteoporosis prevention, cognitive function, Alzheimer’s disease and cancer prevention strategies. The final sections of this paper provide a welcome and eloquent debate, using the most up-to-date data, on the place of HRT as a preventative intervention in this age group of women. Overall this article, as well as being an excellent read should be considered required reading for anyone practising in this area of healthcare. Whilst it is not designed for the specifics of any single health system, it contains most of the current information to allow a fully evidence derived basis of a preventative care package for women after the menopause, whatever the country.
With all this data why are not things changing in the UK? This question is perhaps the main issue and my main concern. From a postmenopausal perspective, the last decade has been a perfect storm for the issues raised in this article. To explain my theory, I feel the components that have contributed negatively to the care of these women in recent years are: . The WHI and Million Women Study publications and the consequent withdrawal from management of the menopause. . Economic recession in the UK which has resulted in a redesigned healthcare system in post reproductive women that is more reactive than proactive, thus less fit for purpose for preventative care. . Sustained lack of correct and current knowledge of the place of HRT in the management of the menopause – mainly in those that deliver care and more importantly those that commission and design services. In the UK during 2011 and following the government listening exercise, I feel that the tools produced by the BMS and RCOG have yet to be widely employed in post reproductive women in spite of widespread dissemination by both organisations. I strongly believe that these highly practical documents should be revisited, with particular attention to the simple, practical measures that come without recourse to pharmacology. What could be simpler than the BMS key recommendation from 2011? What we asked was that these women attended their general practitioner at a fixed point in their life to assess their overall health and make simple recommendations that could not only extend their life but also improve their quality of life and possibly their utilisation of precious NHS resource later in life. This advice received a mixed reception – largely revolving around the lack of funding for such an initiative. At the BMS, we tried to emphasise the fact that a modest degree of investment now could reap rewards later. What is clear is that commissioners at present do not have pathways and standards to help them commission such a service. We at the BMS would be quite prepared to help them.
Hope for the future The good news in this area is that the National Institute for Health and Care Excellence (NICE) is currently preparing a guideline covering the management of the menopause. The BMS is delighted that this is happening – it is likely to produce a high-quality analysis of the
Downloaded from min.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 17, 2015
158
Post Reproductive Health 20(4)
available evidence with the aim of developing standards of care and recommended systems for the delivery of this care. The BMS is of course stakeholders in the process and we are fortunate that past chairs of the society are in the guideline development group. In addition, the extra push from the IMS with World Menopause Day and the similarity of the messages helps us in the UK to validate the facts that simple methods of preventative healthcare are key. However, it is refreshing to see the use of HRT being considered as a preventative strategy once again – something many of us have continued to believe after 2002. Finally as a UK specialist society, we are indebted that the RCOG continues to support the call for improved care through a life-course approach. In his support of World Menopause Day in an RCOG Press release, the President, David Richmond said: With the increase in lifestyle diseases such as obesity, diabetes and stress-related disorders, we need to ensure that as healthcare professionals, we take every opportunity we can to counsel women on what they need to do now so that they can go on to living longer and healthier lives. This will include diet, alcohol advice, exercise and weight management. The promotion of health is crucial throughout life and even more so in this period of life.
Changing the way we deliver care Guidelines have many uses in medicine – from practical tools to make sure all the steps are followed in the care of a patient with a very specific diagnosis to a guideline produced with the aim of leading to organisational change. I believe that whilst the menopause guideline will have pathways and tips to help with day-to-day management of the menopause, it is the design of quality standards in care that will allow organisational change. As most of us will know and very simply put, to effect high-quality change, you need the following: . A good understanding of the starting point . A clear set of aims (the destination) . Persistence First, I think it is fair to say that no one could accuse the BMS medical advisory committee and many of the
staff and members of the society of lacking in persistence! Second (as outlined above), I think we all have a clear idea of our destination. Third, and most importantly in my reading around the IMS White Paper, I do not think we all have a clear understanding of our starting point here in the UK. There are few papers from the UK that have clearly explained the problems in a fashion from which a commissioner could benchmark their local service and then design a service fit for purpose.
Someone did listen On the NICE website and looking into the history of the commissioning of the Menopause guideline in the ‘Timeline’ section of the guideline, I found the following quote: On the 7 June 2012 the Department of Health formally requested the National Institute for Health and Clinical Excellence to prepare a clinical guideline on the diagnosis and management of menopause.
I am now convinced that in 2011, the BMS and RCOG were most probably listened to. The Department of Health decided to commission the guideline, and this was temporally related to the publication of our documents. We should therefore be proud that our lobbying had an effect. We should embrace the BMS ‘Mind the Gap’ campaign to prepare ourselves for the guideline by spreading the knowledge that we have now to prepare our colleagues and patients for the burst of activity that will accompany the publication of the NICE guidance. With the right preparation beforehand, I hope very much that we as a specialist society can continue to lobby the NHS to provide the best care for our patients to allow them to live a longer, healthier life. References 1. Lobo RA, Davis SR, De Villiers TJ, et al. Prevention of diseases after menopause. Climacteric 2014; 17: 540–556. 2. British Menopause Society Council. Modernizing the NHS: observations and recommendations from the British Menopause Society. Menopause Int 2011; 17: 41–43. 3. RCOG. High quality women’s health care: a proposal for change. London: RCOG Press, 2011.
Downloaded from min.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 17, 2015
As I see it . . . Edward Morris British Menopause Society, London, UK
World Menopause Day, the IMS white paper and the NHS in the UK – No longer banging on a locked door? As I write this commentary, I reflect on the impact of World Menopause Day in the UK. The date, 18 October, was promoted by the International Menopause Society (IMS) worldwide and heavily supported by the British Menopause Society (BMS) throughout the UK. We are indebted to BMS members, our partners, The Royal College of Obstetricians and Gynaecologists (RCOG), Sage Publishing (publishers of Post Reproductive Health) and the media for helping us support the messages in the IMS campaign. The authors of the white paper1 are to be commended for assembling a superb collection of information and presenting a high-quality contemporary view of the state of the art in post reproductive health and how relatively simple interventions performed early in a woman’s life can save lives. The paper eloquently describes the complexities of the effect of various diseases on the menopause along with how the menopause can affect these conditions. Throughout the document, there are frequent references to simple interventions, preventative healthcare measures as well as the place of hormone replacement therapy (HRT) as a strategy for preventing disease. The BMS feels that it is only through high-level campaigns such as this upon publication of the IMS white paper that the authorities worldwide can begin to understand the issues specific to women during the menopause. We did our best to disseminate these messages to all those willing to listen, but I remain concerned that it would appear that few people are listening and those that are do not have the mandate to influence change. In support of my case, please consider the below quotes: Women presenting to their medical providers during the menopausal transition provide a unique opportunity for risk assessment, counseling and the institution of various prevention measures.1
Primary Care Teams invite women on their register, around the time of their 50th birthday, to attend a health and lifestyle consultation to discuss a personal health plan for the menopause and beyond.2
The first quote comes from the IMS white paper published in 2014 and the second comes from the BMS recommendations published in 2011 during the socalled National Health Service (NHS) listening exercise. It is clear to see the marked similarities between the two recommendations, and at the same time, it is clear from those of us working in this area that in the three years since the BMS recommendations were published, there has been little progress towards achieving these seemingly simple aims.
The BMS recommendations2 For those who are unaware of what the listening exercise was, this was an initiative employed by the current coalition government to try to understand the needs of the NHS from the perspective of those providing healthcare following the proposals in the Health and Social Care Bill (2011) before it became legislation in the Health and Social Care Act (2012) as proposed by the then Health Secretary of State, Mr Andrew Lansley. During the listening exercise, the government met with many different stakeholders, including most Royal Colleges, to gather opinion and propose modifications to the Bill. During the listening exercise, the BMS produced its recommendations which described in detail the scale of the problem, highlighting the increasing numbers of menopausal women on a national scale and the major demographic changes in our population that influence chronic disease in later life. Underpinning our recommendations was the desire to suggest that simple non-pharmacological measures along with risk assessment and advice early in the menopause are most likely to have significant longterm influences on morbidity and mortality in these women. We did not suggest expensive treatments, but we merely provided a set of practical measures to steer the NHS towards the attainment of effective
Downloaded from min.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 17, 2015
Morris
157
preventative healthcare. The recommendations were divided into those to influence National Policy and Strategy, Community Policy and Local Healthcare Delivery. Initial feedback was excellent, with positive comments from members and stakeholders alike. However, our greatest pride was the inclusion of our recommendations as an appendix in the RCOG document ‘High Quality Women’s Healthcare’.3 Our key recommendation of a ‘health check’ around the 50th birthday was supported by the RCOG in this paper. This RCOG document was again produced to advise the government during their listening exercise. The key theme within this document was the adoption of a lifecourse approach to the management of women – with a strong bias towards preventative healthcare.
The IMS white paper1 This paper has just been produced by the IMS and is a welcome additional support to the BMS and its aims for post reproductive care. The contents of the document cover an extremely high level of detail and careful analysis of the available data. The paper starts with a description of the epidemiology of menopause and chronic disease with a global perspective. Then, it discusses the influence of insulin sensitivity, metabolism and the challenge of obesity on numerous aspects of postmenopausal health along with practical interventions. Coronary heart disease (CHD), one of the prime reasons for the Women’s Health Initiative (WHI) study is placed in a contemporary context with a clear discussion around the main contentious issues of the impact of HRT on overall CHD risk. This section also includes an evaluation of the optimal timing of HRT administration for CHD prevention, also known as the ‘window of opportunity’ hypothesis. Other areas of clarity from this article come from the authors’ discussion around pharmacological and nonpharmacological measures that affect outcomes in osteoporosis prevention, cognitive function, Alzheimer’s disease and cancer prevention strategies. The final sections of this paper provide a welcome and eloquent debate, using the most up-to-date data, on the place of HRT as a preventative intervention in this age group of women. Overall this article, as well as being an excellent read should be considered required reading for anyone practising in this area of healthcare. Whilst it is not designed for the specifics of any single health system, it contains most of the current information to allow a fully evidence derived basis of a preventative care package for women after the menopause, whatever the country.
With all this data why are not things changing in the UK? This question is perhaps the main issue and my main concern. From a postmenopausal perspective, the last decade has been a perfect storm for the issues raised in this article. To explain my theory, I feel the components that have contributed negatively to the care of these women in recent years are: . The WHI and Million Women Study publications and the consequent withdrawal from management of the menopause. . Economic recession in the UK which has resulted in a redesigned healthcare system in post reproductive women that is more reactive than proactive, thus less fit for purpose for preventative care. . Sustained lack of correct and current knowledge of the place of HRT in the management of the menopause – mainly in those that deliver care and more importantly those that commission and design services. In the UK during 2011 and following the government listening exercise, I feel that the tools produced by the BMS and RCOG have yet to be widely employed in post reproductive women in spite of widespread dissemination by both organisations. I strongly believe that these highly practical documents should be revisited, with particular attention to the simple, practical measures that come without recourse to pharmacology. What could be simpler than the BMS key recommendation from 2011? What we asked was that these women attended their general practitioner at a fixed point in their life to assess their overall health and make simple recommendations that could not only extend their life but also improve their quality of life and possibly their utilisation of precious NHS resource later in life. This advice received a mixed reception – largely revolving around the lack of funding for such an initiative. At the BMS, we tried to emphasise the fact that a modest degree of investment now could reap rewards later. What is clear is that commissioners at present do not have pathways and standards to help them commission such a service. We at the BMS would be quite prepared to help them.
Hope for the future The good news in this area is that the National Institute for Health and Care Excellence (NICE) is currently preparing a guideline covering the management of the menopause. The BMS is delighted that this is happening – it is likely to produce a high-quality analysis of the
Downloaded from min.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 17, 2015
158
Post Reproductive Health 20(4)
available evidence with the aim of developing standards of care and recommended systems for the delivery of this care. The BMS is of course stakeholders in the process and we are fortunate that past chairs of the society are in the guideline development group. In addition, the extra push from the IMS with World Menopause Day and the similarity of the messages helps us in the UK to validate the facts that simple methods of preventative healthcare are key. However, it is refreshing to see the use of HRT being considered as a preventative strategy once again – something many of us have continued to believe after 2002. Finally as a UK specialist society, we are indebted that the RCOG continues to support the call for improved care through a life-course approach. In his support of World Menopause Day in an RCOG Press release, the President, David Richmond said: With the increase in lifestyle diseases such as obesity, diabetes and stress-related disorders, we need to ensure that as healthcare professionals, we take every opportunity we can to counsel women on what they need to do now so that they can go on to living longer and healthier lives. This will include diet, alcohol advice, exercise and weight management. The promotion of health is crucial throughout life and even more so in this period of life.
Changing the way we deliver care Guidelines have many uses in medicine – from practical tools to make sure all the steps are followed in the care of a patient with a very specific diagnosis to a guideline produced with the aim of leading to organisational change. I believe that whilst the menopause guideline will have pathways and tips to help with day-to-day management of the menopause, it is the design of quality standards in care that will allow organisational change. As most of us will know and very simply put, to effect high-quality change, you need the following: . A good understanding of the starting point . A clear set of aims (the destination) . Persistence First, I think it is fair to say that no one could accuse the BMS medical advisory committee and many of the
staff and members of the society of lacking in persistence! Second (as outlined above), I think we all have a clear idea of our destination. Third, and most importantly in my reading around the IMS White Paper, I do not think we all have a clear understanding of our starting point here in the UK. There are few papers from the UK that have clearly explained the problems in a fashion from which a commissioner could benchmark their local service and then design a service fit for purpose.
Someone did listen On the NICE website and looking into the history of the commissioning of the Menopause guideline in the ‘Timeline’ section of the guideline, I found the following quote: On the 7 June 2012 the Department of Health formally requested the National Institute for Health and Clinical Excellence to prepare a clinical guideline on the diagnosis and management of menopause.
I am now convinced that in 2011, the BMS and RCOG were most probably listened to. The Department of Health decided to commission the guideline, and this was temporally related to the publication of our documents. We should therefore be proud that our lobbying had an effect. We should embrace the BMS ‘Mind the Gap’ campaign to prepare ourselves for the guideline by spreading the knowledge that we have now to prepare our colleagues and patients for the burst of activity that will accompany the publication of the NICE guidance. With the right preparation beforehand, I hope very much that we as a specialist society can continue to lobby the NHS to provide the best care for our patients to allow them to live a longer, healthier life. References 1. Lobo RA, Davis SR, De Villiers TJ, et al. Prevention of diseases after menopause. Climacteric 2014; 17: 540–556. 2. British Menopause Society Council. Modernizing the NHS: observations and recommendations from the British Menopause Society. Menopause Int 2011; 17: 41–43. 3. RCOG. High quality women’s health care: a proposal for change. London: RCOG Press, 2011.
Downloaded from min.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 17, 2015
