Revolutionising access to treatment for women’s health problems

1. The problem

A urinary tract infection (UTI) is a debilitating, though usually short-lived, illness which burdens the individual, the NHS and the economy. UTIs overwhelmingly affect women. Moreover, many women suffer from recurrent UTIs (more than one incidence per year). For large numbers of women, over a lifetime, UTIs are as familiar as coughs and colds, though much more acute and crucially, much more difficult to get treatment for.

To illustrate these points, in one Lancet study ( 83.3% of the cases of UTI were in women. 20.8% of the women aged 18-64 had more than one UTI per year; 2% had 3 episodes in a year. It cites a national study in which 3% of women over 15 reported 3 UTIs in the previous year.

As a bacterial infection, UTIs are treated with antibiotics. UTIs are the second most common reason for antibiotic prescribing. NICE guidelines acknowledge the risk of antimicrobial resistance – but the fact is, antibiotics are the cure for UTIs. The NHS website says there is no evidence that over-the-counter sachets and cranberry products clear up UTIs. Without treatment UTIs can develop into kidney infections, which fully incapacitate the patient and may require hospital care.

In the above study, same-day antibiotics were prescribed for 85.7% of cases, rising to 89% of cases in women aged 18-64. These antibiotics are extremely effective: no further antibiotics were prescribed in 95.9% of cases.

Despite the prevalence and severity of UTIs among women, for each and every incidence of UTI that requires antibiotics it is necessary to see the GP to get a new prescription. These appointments create costs for individuals and for the NHS.

Using a study ( that looked at how women dealt with UTIs we can calculate the cost of GP appointments in England for women with UTIs. With 11% of women contracting a UTI in a year, of 25,369,600 adult women in England, 2.79m contract a UTI. With 65% of those contacting their GP, this leads to 1.81m appointments per year. Multiplied by the cost of a GP appointment, which is given by the NHS as £30, gives the total cost as £54.4million per year.

This figure is certainly less than the total cost to the NHS of UTIs given that some women contact out of hours doctors or go to A&E (5% and 4% of women respectively, according to the study).

Avoiding these appointments, and moving more quickly to the end result of a prescription (which is needed in the vast majority, 86%, of cases) would

• Drastically reduce demand for GP appointments, resulting in a better experience for people contacting their GPs

• Free up GPs for other work

• Allow women to fill their prescription and begin treatment sooner, therefore feeling better and returning to normal life sooner

• Mean women were less stressed because they would feel confident that they can access effective treatment from the moment they notice a UTI

• Reduce administrative burden and inconvenience for unwell patients

• Potentially result in women who were deterred from getting an appointment by the difficulty of getting a GP appointment receiving treatment sooner

• Potentially result in fewer numbers of women getting a kidney infection from not having access to treatment, with knock-on effects for the NHS

2. The proposal

The proposal is for a digital service (e.g. via the NHS App) that enables women with a UTI to seek an immediate or near-immediate prescription for antibiotics 24/7 and without having to attend a medical setting.

This would need to be co-designed with users of the service and medical professionals, but would probably include these steps

• Establishing the identity of the person e.g. NHS number

• Self-declaration as needing of antibiotics for a UTI, possibly by answering questions about symptoms

• Screener questions to filter out cases where a direct generic prescription is inappropriate e.g. pregnant women

• Prescription is automatically generated, or validated by a trained professional

• User receives confirmation and is told when their prescription will be ready at their local pharmacy

Possible negative effects of this proposal centre around inappropriate prescriptions, abuse of the system and overuse of antibiotics by individuals. These can be tackled within the design, for example:

• A limit on the number of prescriptions an individual can receive in a certain time period, with an automated check to determine this.

• A red flag trigger to show up obvious attempts at abuse such as weekly requests.

• Behavioural-science-informed design to nudge towards honest behaviours, such as asking women to make a declaration that they need the medicine and are not making the request on behalf of anyone else.

• Limitations on how the service is accessed – for example it could be invite-only “for next time” after women have seen a doctor for a UTI

• Temporal or geographic limitations to the service being put in place to manage any incidents of antimicrobial resistance, with users directed to go to their GP instead

• Screener questions that rule out more serious conditions, or triage users in some way that directs them to appropriate healthcare, if that is not a direct prescription for antibiotics.

A digital service like this would cost a fraction of the money spent on GP appointments for UTIs. Even if medical validation or spot checking was required, this could be integrated into remote healthcare work (NHS 111), and it would not have to be done by a GP. Consideration should also be given to whether an algorithm could be created that could ‘make decisions’ about antibiotics prescribing using geographic, user-entered and other data – but it is not certain that this sort of data is available.

3. Possible further uses

The proposal is focused on women because UTIs are a common, acute yet straightforward problem for women. It might be possible for men to use the service as well, depending on the medical complexities of UTIs in men.

Perhaps in future a service like this could be extended to other treatments, if there are any others that cannot be sold over the counter despite being both critical and frequent.

4. A note on discrimination

The question of access to antibiotics is important and can elicit strong views. Medical concerns about antimicrobial resistance are legitimate. However, women bear the brunt of the status quo, suffering from repeated painful infections for which antibiotics are the only proven medication. Therefore, this proposal for easier access to antibiotics for UTIs must be considered in the context of gender inequality and systematic historic misogyny. In recent years health leaders have acknowledged that women’s health issues have been systematically overlooked and that women’s reports of pain and inconvenience have been disregarded. We are only just starting to see attempts to understand the costs of women’s health issues to individuals, to society and to women’s economic activity. Serious problems sometimes require large-scale and radical solutions.