‘Herstory’: the barriers facing women in health and care

In 1929, Virginia Woolf created a tragic fictional character – Judith Shakespeare, the twin of William Shakespeare. In her essay ‘A room of one's own’, Woolf concluded that even had Judith had the same talent as William, she wouldn’t have been able to succeed as he had. She believed that the treatment of women by society prevented many female writers from achieving their potential.

Fast forward to 2014 and the announcement of the HSJ's ‘Inspirational women in health’ list. Two colleagues from The King’s Fund and I were included in this list, and at least one third of the women named have been coached by, or attended development programmes run by, me or my colleagues. This prompted me to revisit in my head the tale of Judith Shakespeare and to relate it to my 16 years’ experience of working with women in health.

When I moved from developing and coaching individuals in the commercial sector to the world of the NHS, women made up 77 per cent of the workforce – they still do, and hold only 37 per cent of board positions, and just over 30 per cent of NHS chief executive roles. In this context, the NHS Confederation has set the goal of having 50 per cent more women on all NHS boards by 2018 – an unambitious target given the benefits attributed to having greater diversity in leadership.

Leaders across health and care agree that much more needs to be done to address the low representation of women in senior medical leadership roles. It has taken 214 years for the Royal College of Surgeons to elect a female president, for example (Miss Clare Marx took over this role on 10 July). And of course, it is not only in terms of gender that there is a mismatch between the composition of those at the top of organisations compared to staff and the patient population: the black and minority ethnic population is largely excluded from senior positions, both as NHS managers and as NHS trust board members.

In the late ‘90s some suggestions were made for women’s lack of success at achieving senior leadership roles, including:

  • ‘women have a lower sense of motivation’
  • ‘they fear success’
  • ‘they have a low sense of competence’
  • ’they tend to attribute failure to themselves and successes to external factors’.

These suggestions have their origin in traditional motivation theory – mostly written by men.

Against this, when I review the many achievements of women on HSJ’s ‘Inspirational women’ list, I and colleagues at the Fund who have in one way or other touched the careers of these women noticed that many strive to overcome the many obstacles to career progression – balancing working lives with their responsibilities as carers or parents, undertaking extra study at night and/or second jobs. Many women in health today seem able to adapt, to negotiate and renegotiate their job role. However, there are three areas that continue to act as individual or collective barriers to progression for women.

First, gender stereotyping, which some women feel has been with them from school age, affects their inner dialogue when making choices about their working lives and certainly contributes to ‘wobbles’ in their confidence and self-belief.

Second, the cultural expectations (as in Judith Shakespeare’s time) women have of themselves and that others have of women still act as a significant barrier to progression.

And finally, many organisations have either inadequate or absent career planning and talent spotting as part of an overall strategy.

One powerful element in any culture is the stories that are told. A list such as the HSJ’s can offer evidence that women in health can achieve their potential and also presents positive role models. And the celebration of those successes in itself contributes to creating a culture of an expectation of achieving potential. Here at the Fund we recognise the need to continue to support the successes of the many women we have worked with over the years – both as part of our women-only Athena programme and through our wider work developing individuals and organisations. Indeed, we hope that this leads to a recognition of the success of all the women who make up 77 per cent of the NHS workforce. 

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#42335 Kathryn Colas
Chief Exec
Agents of Change

Well said! Personally, I have been reluctant to make a particular case for women (each on their merits, etc). I've changed my mind recently. We must make a case to raise awareness of the myths and stereotyping that continue to pervade the workplace and detract from true talent and I wouldn't be doing my job properly if I didn't add in the benefits to the workplace of acknowledging hormonal health and menopause.

#42336 Vijaya Nath
Assistant. Director
The King's Fund

Ditto and when writing this blog I was mindful that a number of women who are carers and patients needs are not directly addressed. In addition the invisible barriers for women who experience different health states at different times as described by you. Women who have ' invisible ' disabilities e.g hearing loss face unconscious and conscious bias.Hopefully, raising these issues creates more awareness/ dialogue and in turn this will contribute to the shift we need to see in enabling all to achieve their potential .

#42337 Dr Karen Castil...

Great blog Vijaya - well done! Although we are making slow progress in the UK as recently illustrated by FTSE 100 companies increasing the number of women on FTSE Boards, we still have much to do in the NHS. The relativities relating to the number of women employed in the NHS and the number of women in senior leadership positions remain disappointingly disparate.

In terms of your point about gender stereotyping, I would urge both women and men to read the recent report from KPMG "cracking the code" (PDF available on the KPMG website). Their research does a great job in busting some of the popular myths about women in the workplace and creates a more neutral ground on which we can have the conversation about how we can better support women to "lean-in" to NHS leadership positions. Their research offers a gender intelligent approach to developing corporate leaders and improving the talent pipeline.
Thanks again! Karen

#42338 Vijaya Nath
Assistant Director
The King's Fund

Thank you Karen for signposting further information and for your personal efforts in helping us as a leadership community (both male and female ) shape a better future for women as leaders in health and care.

#42342 Jill Parnham
Operations Director
Royal College of Physicians

A truly thought provoking blog Vijaya, thank you. One of the highlights of being an Athena participant was being exposed to wonderfully inspiring women, not only some of those named by the HSJ's ‘Inspirational women in health’ list but also Baroness Blood and Baroness Neuberger to name but two. Since then I've also had the privilege of listening to Aung San Suu Kyi speak at the World Innovation Summit for Health. What strikes me more than anything else about these women is not their confidence (which they exude in bucket loads), not their self belief or strong moral compass but their risk taking abilities, their continued drive in adversity and utter determination. I am not only inspired, but am thoroughly aspired to push the boundaries of these traits and remind myself of them daily.

Yes, it has taken 214 years for the RCS to elect a their first female President. The Royal College of Physicians, founded in 1518, is now on its third female President (Professor Jane Dacre) and describes itself as 'a thoroughly modern organisation'. For the first time in the history of the RCP, a female President and Chief Executive Officer (Patricia Wright) hold office at the same time.

#42343 Vijaya Nath
Assistant Director
The King's Fund

Jill it is good to hear from Athena Alumni .We know from the work that you and colleagues are tackling,that influencing the system to support your successes and those following you is crucial.
We need men and women to work together to promote more women to achieve their potential . Colleagues at The RCP & RCS have this opportunity at this point of their respective organisations 'histories' to work with their new Presidents in leaving a different legacy to tomorrow's medical & surgical work forces and in turn to our patient populations.

#42345 Loretta Outhwaite
Chief Finance Officer
NHS Isle of Wight CCG

Great blog Vijaya. Whilst I work in a CCG where women leaders are in the majority, it's certainly not the case at senior levels in NHS Finance. I am co-lead for a workstream within the NHS Future Focused Finance programme which is looking at Diverse Leadership. We'll be exploring what's encouraging & holding people back from all minority groups, then looking at how this can be addressed. I hope that we can perhaps work with yourselves & other interested parties on this, to help motivate & empower colleagues.

#42346 Penny Newman
Director of Service Integration
Colchester Hospital University NHS Trust

Thanks Vijaya - very well put. The NHS is missing a trick by not recognising the zeitgeist of addressing "second generation bias" and the under representation of women in senior leadership roles. The business case is made and changes in the private sector should have catalysed us into action, given women are the majority not minority of NHS workforce.

Some good progress now on BME by the Equality and Diversity Council - why not the same for women? http://www.england.nhs.uk/2014/07/31/tackle-race-inequality/

Women doctors are amongst the most poorly represented at Board level or equivalent (which measures the pipeline like A&E throughput), with differentiation also occurring between specialties i.e. far more female GPs than surgeons. Despite many national reports, little has been done to address this so far. What is needed is a concerted effort and system change rather than avoidance to make the best of the medical leadership and talent now available and address a paternalistic culture.

Judith Shakespeare's hypothesis has been conformed by a recent RCT- assessment of CVs for a post in science by male and female assessors were rated lower on starting salary, hire ability, competence and access to mentoring on female name alone.

#42419 Helen Cherry
Community RN Network Nursing - mobile working support
NHS Trust - London

Hi Vijaya great read saw this shared on twitter. Being a health
professional who is deaf I have one more to add to list too - those of us who are women with disabilities; women within diverse spectrum of disabilities inclusive of deaf, blind, neuro, cognitive conditions acquired or from birth. At times this is huge elephant in the room and too hard basket for many to think through.

Add to that I am a woman who is blond, blue eyed, deaf - well you can imagine the 'unconscious bias' and sometimes out right in my face out loud remarks……. mind you I always prefer those that say it out loud as its an excellent opportunity to 'educate' the error. I believe we have even really tipped the edge of negative unconscious bias assumptions and judgements and what impacts them. It is complex as unconscious bias and how we make judgements are not always negative in outcomes.

People see me as a city girl as I love living in London, however I grew up on a farm amongst the folk I grew up with it was only our physical strength that 'dictated' what we did on the farm we all worked together as a team make and female and but the way I am stronger than I look!!

So just putting it out there another angle is inclusion of women with diverse disabilities creates another layer in this dialogue. I wonder how many hold senior positions when developing confidence, enabling ourselves in leadership within environments which still haven't fully embraced disabilities.
Loved your writing

#403609 jennifer rhodes

Dear Vijaya,

I just completed a dissertation on why there are not more women in executive leadership positions in healthcare. As you have stated women are vastly in the majority in the healthcare industry, yet continue to be significantly under represented in the executive suite. It appears to be baffling. My research (although small and masters level) showed that women choose to be the ones to step back from their career versus their spouse. (My target audience were all very well educated of a minimum bachelor`s level degree to PhD, and all worked in healthcare). This did not correlate to a lack of ambition, or lack of confidence, or lack of wanting to succed in their career fields, this belief is simply not correct. There are many, many reasons why women choose to step back, and i found it to be a somewhat convoluted 'story'. Some of the reasons are societal expectations, gender stereotyping, and the glass ceiling. There is one factor that i feel is of significance, and that is the male oriented work day, and organization structures. The workplace is very convenient to the male employee who only has one job, not so much for the women who has dual roles, and two jobs, of which the second job starts when the woman gets home. A male oriented work structure does not facilitate women advancing to executive leadership position.

Please note, this is a very brief synopsis of this subject - too brief.
My dissertation answered a lot of questions that i have had for many years about healthcare, specifically in the hospital setting. I have always been confused as to why is it so disorganized, and how detached the internal systems are from one another. There is a distinct lack of cohesiveness within the hospital system as a whole. It correlates directly to poor leadership. The current leaders are men, and have been men in the past. I am absolutely pro-women advancing to leadership positions - we have all the tools and more to succeed .

#403622 jennifer rhodes

Gosh...i apologize for some of my poor grammar above. I don't have my glasses - weak excuse i know!!

#407897 Vijaya Nath
Assistant Director
The King's. Fund

Jennifer , thank you for taking the time to leave this comment .
Your observation that ' A male oriented work structure does not facilitate women advancing to executive leadership position.' , is the challenge certainly in advancing Medical Leaders especially in certain specialities eg Surgery.Do keep in touch and hope we catch up in person in 2015.

#432362 Liz hepplewhite
GP Board member

Having been on an excellent Women as Leaders course at Cranford University and met some very able women in really challenging jobs it's apparent that sexism is alive and kicking in Health and private business alike.The misconception by younger women that we don't need to be Feminists because it's all sorted out now is depressing to say the least!

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