Chapter 6: Strengthen the role and impact of ill health prevention

When they asked their communities about the most important requirement for living a healthy life, Healthwatch services across the North East consistently found the most common answer was 'access to the help and treatment I need when I want it'. In Gateshead, County Durham, North Tyneside, South Tyneside and Sunderland, 'professionals that listen to me when I speak about my concerns' was the second most popular answer.
(Healthwatch. (2022). Engagement Report for NHS Long Term Plan. What would you do? It's your NHS. Have your say. Northumberland, Tyne and Wear and County Durham.)

To have 'access to help and treatment I need when I want it' requires the medical and research field to know what the best treatment should be. Researchers argue that women are routinely under-represented in clinical trials and that medical research proposed by women, for women, is not allotted the same funding as medical research proposed by men, for men.
(Criado-Perez C (2020). Medically invisible women part one: Caroline Criado-Perez at Digital Health Rewired.)

Without the scientific evidence, assumptions are made that similar medical treatments will work for both sexes. However, Professor Zucker found that women were more likely than men to suffer adverse side effects of medications because drug dosages have historically been based on clinical trials conducted for men.
(Zucker I & Prendergast BJ (2020). Sex differences in pharmacokinetics predict adverse drug reactions in women. Biology of sex differences. 11. Article No: 32)

Given that research has focused on how men react to a health condition, Dr Austin-Clayton argues that 'we literally know less about every aspect of female biology compared to male biology'. As such, women are more likely to be misdiagnosed.
(Austin-Clayton J (2014). Health researchers will get $10.1 million to counter gender bias in studies. New York Times)

An example of this is what is commonly recognised as the classic symptom for heart attacks: a pain in the chest and down the left arm. Although the most common symptoms and signs are the same for both men and women, women can sometimes experience a variety of less 'typical' symptoms including nausea, indigestion, fatigue and dizziness.
(Temple Health. (2020). Heart Attack Symptoms: Are they Different for Men and Women. (opens new window) )

Such misclassification of symptoms can result in worse health outcomes for women.

Less is known about conditions that only affect women, including common gynaecological conditions that can have severe impacts on health and wellbeing. Nationally, it takes on average seven to eight years for women to receive a diagnosis of endometriosis, with 40% of women needing 10 or more GP appointments before being referred to a specialist. Less than 2.5% of publicly funded research is dedicated to reproductive health, even though approximately one in three women will experience reproductive health problems.
(Endometriosis UK. (2022). Endometriosis Facts and Figures.)
(Endometriosis UK. (2022). Endometriosis awareness month launches to tackle the fact 54% don't know about Endometriosis.)
(Public Health England. (2018). Survey reveals women experience severe reproductive health issues.)
(UKCRC. (2015). UK Health Research Analysis 2014.)

Women who may be described as presenting with multiple and complex need often will have experiences that may include homelessness, drug and alcohol misuse, mental and physical health problems, cycles of violence and abuse, and chronic poverty. Often when we talk about women in the terms of their 'need', it suggests that the issues stem from the individual rather than from deficits in the system, or because of trauma or adverse childhood experiences. 

The Lankelly Chase Foundation has adopted the term 'severe and multiple disadvantage', Lankelly Chase Foundation. (2016). The Lives behind the numbers, to describe the clustering of serious social harms such as homelessness, contact with the criminal justice system, substance misuse and mental ill health. The term describes a type of disadvantage that most others do not experience, and which recognises the social nature of disadvantage.
(Duncan M and Corner J. (2012). Severe and Multiple Disadvantage. A Review of Key Texts. Lankelly Chase Foundation)

Acknowledging that people experience multiple social harms is important, as it highlights the intensity of the experience and that the solutions are very different to if there was only one presenting issue.

For some women, experiencing multiple disadvantage means they do not fit neatly into existing services. 

This has led to women who are most in need of support having to struggle to navigate a complex system and either obtain help late or not at all, often falling between the gaps of what is on offer. For example, women are under-represented in official homelessness counts which utilise the concept of 'literal homelessness', which includes sleeping rough, using hostels or other emergency accommodation.
(Fitzpatrick, S., Bramley, G., & Johnsen, S. (2013). Pathways into multiple exclusion homelessness in seven UK cities. Urban Studies, 50(1), 148-168.)

Research has also found that women tend to make less use of homelessness services, postponing entering the system until sources of informal support have run out.
(Mayock P & Bretherton J. (2016). Women's homelessness in Europe (pp. 127-154). London, England: Palgrave Macmillan)

In 2017, a comprehensive health needs assessment focusing on homelessness and multiple complex need was completed by Gateshead Council. The study identified that although most of those experiencing homelessness are male, the number of women exposed to homelessness is growing, especially within some of the types of homelessness.
(Harland J. (2017). Gateshead Homelessness and Multiple and Complex Needs Health Needs Assessment. Gateshead: Gateshead Council.)

Distinct patterns occur within women's reason and reaction to homelessness compared to that of men. For women the most common are physical or mental health problems and escaping a violent relationship.
(Mackie P (2014) Nations Apart: Experiences of Single Homeless People Across Britain.) 

Interviews with homeless women conducted by Crisis showed that over 20% became homeless to escape violence from someone they knew, Public Health England. (2018). Evidence review: Adults with complex needs (with a particular focus on street begging and street sleeping), and McGrath's participants described coercive and controlling relationships that often included severe violence.
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review))

Health outcomes for women experiencing homelessness are significantly worse, with life expectancy being lower than that of men. 

Women are more likely to be 'hidden homelessness' and engage in coping strategies such as sofa surfing or returning to a relationship to avoid rough sleeping.139 One of McGrath's participants, "Tracey", described the inherent danger associated with sofa surfing: 'Once you owe something, they can take anything'.
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

The Communities and Local Government (CLG) Homelessness Inquiry received evidence that 28% of homeless women have formed an unwanted sexual partnership to get a roof over their heads, and 20% have engaged in prostitution to raise money for accommodation. The evidence identified high levels of vulnerability within the female homeless population, mental ill health, drug and alcohol dependencies, childhoods spent in care, experiences of sexual abuse and other traumatic life experiences are all commonplace. The inquiry also identified that services do not always cater for the specific needs of vulnerable females, so women may be less likely to engage with services.
(Department for Communities and Local Government (2016) Communities and Local Government Committee: Homelessness. Third Report of Session 2016-17.)

McGrath's research highlights how the multiplicity of issues that women face, which compound each other into complex situations, are often faced by services that can only tackle one issue at a time. Key to women's wellbeing is their ability to rely on social networks, which is typically severely impaired.
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

The STAGE project brings together charities (Changing Lives, The Angelou Centre, Ashiana, GROW, A Way Out, Together Women, Basis and Women Centre) to provide trauma informed support across North East and Yorkshire for women who have been groomed for sexual exploitation.
(STAGE (2022) Experiences of accessing healthcare amongst women who have experienced sexual exploitation.)

The STAGE briefing brings together the learning from this work with the aim of influencing systemic change. It highlights that the findings from the experiences of women involved in the study are not isolated occurrences but indicative of wider systemic issues across the health sector that fail to address the needs of women who have experienced significant trauma, discrimination and exploitation. Our systems need to be able to respond to meet the needs of girls and women with severe and multiple disadvantage. 

Evidence from STAGE (2022) shows that women who have experienced sexual exploitation are more likely to experience poor health outcomes and often struggle to access healthcare services because of a lack of recognition or understanding of their needs.
(STAGE (2022) Experiences of accessing healthcare amongst women who have experienced sexual exploitation.)

Similarly to the issues highlighted in McGrath's research, many of the women in the STAGE study reported negative experiences and having to overcome barriers when accessing GP and dental practices. Barriers include identification, cost, accessibility (for example if the women have had to move to escape violence), no recourse to public funds, no fixed abode, in addition to the practicalities of accessing an appointment by ringing the surgery at a precise time, without a phone, or with a pay as you go mobile. For women with complex issues, it may have taken a lot of courage to make that step to ask for help and the experience of making an appointment and navigating a triage assessment by the receptionist can feel like a negative experience. The healthcare issues of this group of women are not easily covered in a 10 minute appointment as it may have been a while since they were able to access services. As a result of these barriers, many women resort to attending A&E departments where often additional barriers may be faced. 

McGrath's participant "Beckie" stated: "Services are invisible. So hard to find". "Carrie" commented: "You have to keep telling your story over and over. Why can't they keep it all on file?".
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

High staff turnover was an issue, as women valued relationships built with individuals and were unwilling to retell their story or start again with someone who did not know them. To help address some of these barriers, staff at the Queen Elizabeth hospital in Gateshead are trained in identifying women who are experiencing severe and multiple disadvantage and require a trauma informed approach. This can be identified from the moment that someone books into the department. In addition, within A&E there is a 'Peer Navigator' post linked to the Alcohol Care Team, who can provide more specialised trauma informed support and ensure safeguarding pathways are followed, with referrals to community services where needed.

Awareness and understanding of complex issues, such as sexual exploitation, has been identified as making a big difference in the way women are treated, managed and supported. 

For this group of women, their presenting physical health problems are often viewed by health professionals as due to their 'life choices'. Where women have been subjected to exploitation, gynaecological issues are very common, but barriers to access services may be felt from fear of judgement, repercussion or re-traumatisation. Healthcare provision provides an opportunity to ask explorative questions to identify vulnerability, rather than seeing contraception, although it is important, as the only solution. 

57.1% of the women supported by STAGE had a dual diagnoses of substance misuse and mental ill health. Women who experience addiction often struggle to access the mental health support they need, yet the underlying cause of both the poor mental health and addiction is often unresolved trauma. Therefore, it is vital that women can access trauma responsive support. Many women experiencing complex and multiple disadvantage may require mental health services. However, the STAGE report identifies concerns that women may in fact be experiencing post-traumatic stress disorder (PTSD) rather than personality disorder and are therefore possibly being mis-diagnosed. Being labelled as having emotionally unstable personality disorder is felt by women to be a dismissive diagnosis, which they feel unable to challenge.
(STAGE (2022) Experiences of accessing healthcare amongst women who have experienced sexual exploitation.)

In Gateshead, the need for trauma-based interventions is widely recognised, and we are fortunate that Recovery Connections, (one of the organisations that make up the substance misuse service, Gateshead Recovery Partnership) have accessed funding to embed specialist trauma counsellors within the substance misuse treatment system. McGrath's participant "Carrie" reiterated the importance of this: "We need the help with what we're going through now to be able to deal with what's happened in the past. You can't deal with the past if you don't deal with the present".
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

The national 10-year drug strategy, 'From harm to hope: A 10-year drugs plan to cut crime and save lives',142 and subsequent increased investment in substance misuse treatment systems provides the opportunity to consider how the needs of women with severe and multiple disadvantages can be better met and barriers to service access can be overcome. This may be through women's specific sessions or venues, an assertive outreach approach or innovative delivery of healthcare services focussing on women's health. 

Nationally, diagnoses of sexually transmitted infections (STIs) fell by 7% from 2013 to 2017. There has been a significant decline in new HIV diagnoses, thanks to a sustained long-term effort and more recently the introduction in some areas of PrEP2. There has also been a fall in genital warts, due to HPV vaccinations, and chlamydia, since the introduction of the chlamydia screening programme. However, trends for syphilis and gonorrhoea have increased.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

In Gateshead, our detection rate for chlamydia is higher in females - 1,610 per 100,000 - than males - 1,052 per 100,000. Interestingly, the female rates are lower in Gateshead compared with North East and England but are substantially higher for males living in Gateshead when compared with the North East and England. The difference in the rates by gender could be because more females are coming forward to be tested.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

In Gateshead, the conception rate for under 18s is higher than the national average, but lower than regional rates. For under 16s, the rate is higher in Gateshead than the national average but similar to regional rates. The percentage of children born to teenage mothers (12-17 years old) is also higher in Gateshead compared to the national average. There are however a very small number of children born to teenage mothers in Gateshead (20 in 2020/21), so any small change can disproportionately increase the percentage reported.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

Contraceptive service engagements 2020 (Office for Health Improvement and Disparities. (2023) Public health profiles.)

	Gateshead	North East	England
Total prescribed long-acting reversible contraceptives, excluding injections, rate per 1,000 females	36.2	28.9	34.6
Under 25s individuals attend specialist contraceptive services rate per 1,000 (females)	119.8	106.5	97.6
Total abortion rate per 1,000	15	16.4	18.9

Engagement with sexual health services in Gateshead has historically been good and above national and regional averages. In 2020 during the pandemic, there was a significant, but expected, decline in face-to face attendances, although we did see an increase in service demand remotely. 

Gateshead also has a lower abortion rate compared with the North East and national figures.

When we consider sexual health and reproductive health, the responsibility is usually on the female rather than the male.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

91% of under 25s attending specialist contraceptive services in 2020 were females.

Cervical cancer is largely a sexually transmitted disease but the onus of control is on women, despite men being equally likely to spread the strain. Between 2018 and 2020 the age standardised rate of cervical cancer registrations in the North Integrated Care Partnership was 7.4 per 100,000 population. This is lower than the national average of 9.3 per 100,000 population.
(NHS Digital. NDRS. (2022). Cancer Data: Incidence and Mortality 2018-2020.NHS - cancer data (opens new window))

This is lower rate is likely because of early diagnosis due to high cervical screening coverage, especially in younger ages.

74.6% of women aged 25-49 have had a cervical screen in Gateshead, compared with 68.0% nationally.
75.5% of women aged 50-64 have had a cervical screen in Gateshead, compared with 74.7% nationally.
Office for Health Improvement and Disparities. (2023) Public health profiles.

On the advice of the Joint Committee on Vaccination and Immunisation (JCVI), a HPV national vaccination programme was introduced in 2008 to protect adolescent females against cervical cancer. At that time, a three dose schedule was offered routinely to secondary school Year eight females (aged 12 to 13) alongside a catch up programme targeting females aged 13 to 18.

In September 2014 the programme changed to a 2-dose schedule based on evidence that showed that antibody response to two doses of HPV vaccine in adolescent females was as good as three doses. The UK Health Security Agency recommended that the first dose be given at any time during year eight, with the second dose being given a minimum of six months after the first, with the recommendation the second dose should be given in year 9 for operational purposes.
(UKHSA. (2022). Human papillomavirus (HPV) vaccine coverage estimates in England: 2020 to 2021)

From September 2019, males aged 12 and 13 became eligible for HPV immunisation alongside females, based on JCVI advice. This is the first year that males in year 9 have been offered the HPV vaccine. Gateshead has good uptake of the HPV vaccine, although more needs to be done to encourage males to have the vaccine, both nationally and locally.

HPV vaccination coverage one dose (12-13 year olds)	Gateshead	North East	England
Male	70.8%	62.9%	71%
Female	80.3%	69.1%	76.7%

HPV vaccination coverage two dose (13-14 year olds)	Gateshead	North East	England
Female	83.6%	72.9%	60.6%

* It appears that vaccination uptake for two doses is greater than for one dose due to different cohorts being compared. In 2020/21 (likely due to the disruption arising from Covid-19) more females received their first dose in year nine rather than year eight. As second doses can be given as little as six months apart, a higher number of females were able to be vaccinated with a second dose in year nine.

Since 2002, the rates of dementia and Alzheimer's among women aged 85 and over have been rising. 

From 2002 to 2015 there was an increase of around 175% in dementia as the cause of death in women aged 85 and above.
(Allen J & Sesti F. (2018). Health inequalities and women - addressing unmet needs. BMA.)

The prevalence of dementia is higher in women than men. Evidence suggests that women with dementia have fewer visits to the GP, receive less health monitoring and take more potentially harmful medication than men with dementia. Furthermore, women were found to be at particular risk of staying on antipsychotic or sedative medication for longer, probably due to the lower number of appointments where their treatment can be reviewed.
(Allen J & Sesti F. (2018). Health inequalities and women - addressing unmet needs. BMA.)

 Age standardised mortality rate - Dementia and Alzheimer's disease, by gender. Gateshead vs England (rate per 100,000)
(ONS. (2022). Mortality Statistics - underlying cause, sex and age. (Accessed from NOMIS).)

Within the North of Tyne and Gateshead Integrated Care Partnership (covering Northumberland, North Tyneside, Newcastle and Gateshead), there are 4,147 people on the dementia register. This equates to a prevalence of 0.77%, which is largely in line with the England average of 0.72%. Of those aged 65 years and above, 64% are female.
(NHS Digital. (2022). Recorded Dementia Diagnoses, September 2022.)

It is estimated that there are 2,668 patients aged over 64 years with dementia in Gateshead. 1,936 of these have a recorded diagnosis of dementia, which amounts to a diagnosis rate of 72.6%.
(NHS Digital. (2022). Recorded Dementia Diagnoses, September 2022.)

Of the 26,854 patients on the dementia register in the NHS North East and North Cumbria Integrated Care System, 2,090 have a prescription for anti-psychotic medication. Just over 20% of these have a psychosis diagnosis.
(NHS Digital. (2022). Recorded Dementia Diagnoses, September 2022.)

It is important to understand what prevents or delays the onset of dementia. A study of socioeconomic position as a risk factor for death due to dementia showed that in women there is an association between leaving full-time education at a younger age and dementia-related death, which is not evident in men.
(Brayne C, Ince P, Keage H et al. (2010). Education, the brain and dementia: neuroprotection or compensation? EClipSE Collaborative Members. Brain. 133:8, p2210-2216.)

It has also been identified that excessive alcohol consumption over a lengthy time period can lead to brain damage, and may increase the risk of developing dementia.
(Alzheimers Society. (2022). Alcohol and Dementia)

Non-communicable diseases (NCDs) are the number one cause of death and disability in the world.

NCDs are non-infectious illnesses that cannot be spread from person to person, such as cancers, cardiovascular disease, diabetes and mental health disorders. These often result in long-term health consequences and create a need for long-term treatment and care. Many NCDs can be prevented by reducing common risk factors such as tobacco use, physical inactivity and unhealthy diets. Alcohol, for example, is linked to seven types of cancer.
(Balance North East. (2022). Alcohol and Cancer)

Lung cancer has the biggest impact on life expectancy for women in Gateshead and although lung cancer mortality rates have increased over time for females, they are now starting to reduce. Mortality rates for lung cancer are lower for females, at 75.7 per 100,000 compared with 94.3 per 100,000 for males (2017-19).

Mortality rate from lung cancer (three year range,) directly standardised rate - per 100,000 (Office for Health Improvement and Disparities. (2023) Public health profiles.) 

This may be partly explained by the smoking prevalence trend for both females and males (males from the passive smoking impact). Smoking prevalence is coming down for females at a faster rate than it is for males.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

Smoking prevalence in adults (18+) - current smokers (APS)(Office for Health Improvement and Disparities. (2023) Public health profiles.)

The under 75 mortality rate from respiratory disease that is considered to be preventable is remaining stable for males, but appears to be increasing for females.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

Under 75 mortality rate from respiratory disease considered preventable (2019 definition) (Female three year range)
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

Mortality from liver disease that is considered to be preventable has increased recently for females, but has remained quite stable for males. It is concerning that hospital admissions for alcohol specific conditions have been rising for females living in Gateshead, whereas a small decrease is observed nationally.
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

Hospital admissions for alcohol specific conditions (female)Directly standardised rate per 100,000
(Office for Health Improvement and Disparities. (2023) Public health profiles.)

It is important to consider the whole system and the underlying root causes and wider infrastructure when addressing health conditions. This will enable real change to occur with improved outcomes.(Office for Health Improvement and Disparities. (2023) Public health profiles.)

Changing Lives is an organisation that supports people who experience multiple disadvantage. 
Their focus consists of four pillars of practice - 

• Women and Children 
• Housing 
• Recovery 
• Employment

Changing Lives' work with women falls into three sub areas:

• Adult women who have been groomed for sexual abuse through exploitation and women who exchange sex for money 
• Women who have experience of the criminal justice system 
• Domestic abuse - refuge, IDVA and ISVA services and family services, supported by an experienced domestic abuse workforce for those who are refused other provision because of complexity of need.

In regard to inequalities experienced by women, an important aspect is the premature deaths of women who experience multiple disadvantage, which was highlighted in a recent report, 'Make The Link: The premature deaths of women experiencing abuse and exploitation' (November 2022).
(Changing Lives. (2022). Make the link: The premature deaths of women experiencing abuse and exploitation. A briefing by Changing Lives.)

The data from this report showed how 61 women with multiple disadvantage had died before age of 40 - many of these deaths were recorded as drug related deaths or unknown cause.

Some of the deaths have been linked to domestic homicide reviews, where huge inequality and lack of understanding were shown for the women - all of whom were exposed to domestic abuse and had a history of trauma and/or violence. All of this points to the fact that services collectively are not meeting the need of these women in the right way to stop them dying prematurely. And though this is not intentional, we must do better as the life expectancy for this group is far below average.

Another inequality that is experienced by the group of women that our services work with, is the access to justice. Many of the women have been repeat victims of sexual exploitation and yet the perpetrators are not held to account for this, as the cases are not referred to the CPS and most often never get to trial. Women with complex issues are viewed by the criminal justice system as unreliable witnesses, and as a result the crimes against them go unpunished. Although there have been some high-profile cases that have had more traction within the criminal justice system, for the majority this is the picture. 

For this to change it is important that the women are understood from a safeguarding perspective. They need to be fully understood by services to get the help that they need and that requires services to be trauma informed. It is difficult for these women to reach out for help and support if their previous experiences of engaging with services have been negative. If services do not have a positive response and come across as judgmental, this is just not good enough. We recognise that doing things in a different way can be really challenging, but we have to find the right way to do this, otherwise we are letting down the most vulnerable women in our communities The message that a different approach is needed has been highlighted through Safeguarding Adults Reviews, Domestic Homicide Reviews for example.

An example of this is letters for appointments. They just don't work for women who are experiencing complex issues. Personal engagement and persistence (with boundaries) are much more effective and building the kind of relationship that will make a difference to the women. 

One of the projects I am involved in is the STAGE partnership. The partnership is led by Changing Lives and made up of seven organisations who work with women across the North East and Yorkshire. 

The project consists of operational delivery of services, but the learning achieved via this work aims to make recommendations, via briefing papers, to influence policy. The partnership has an influencing group consisting of key members such as Jess Phillips MP, Kate Davies from NHS England, Baroness Hilary Armstrong and Dame Vera Baird.

The work undertaken by the partnership has led to a legal definition for adult sexual exploitation being finalised. It is hoped that the definition will form part of the new Victims Bill.

The partnership includes organisations who work with women from the black and minoritised sector working alongside Changing Lives to ensure that the women have their voices heard. To understand more about the nature of exploitation for this group, what is happening, and how exploitation differs for different groups.

Exploitation training and a STAGE toolkit are available to help organisations identify and respond to those who may have experienced adult sexual exploitation.

What more needs to be done?

There are real opportunities for the police to do more to support women with multiple unmet needs who have been the victims of exploitation. They are in a position where they are responsible for so much, as they are the gateway to access to justice for this group. For example, having specialist dedicated officers in each area employed to work on VAWG who have had training on legal frameworks.

The Adults Sexual Exploitation definition, and how it impacts on legislation such as The Care Act, will be a key turning point in having women's needs met as it will allow women to be seen as a victim who needs support, rather than being seen as complex and hard to engage. Our current processes do work for women who are not experiencing complex issues - but those who have experienced complex trauma in their life fall between the gaps and as such, we are failing them.

We also need more refuge space, or dispersed accommodation with intensive support. Not just for victims of domestic abuse, but safe space for all vulnerable women, as at present we are placing people into unsafe spaces. Women are often turned away from existing provision as they are seen as too complex. 

I also sit on a national women's working group and a discussion within this group is about how access to drug and alcohol treatment can be improved for women. The hope from this group is that when commissioning drug and alcohol treatment services, a dedicated option for women could be considered. Whether this is a separate offer or thought given to how women's specific organisations can work with treatment providers to improve the offer. It is important to note that the willingness to work together is there across the partnerships.

Through my work at Changing Lives, I feel that it is my role to challenge the system constructively to look at these issues in a different way and to work with partners to find the solutions. Within the work that I am a part of, I feel that I am able to strengthen the voice of the women. Without this advocacy, our most disadvantaged women will always be seen as being the problem, instead of a vulnerable, misjudged victim with unmet need.

Recommendation 1. Giving every child the best start in life