What women want: addressing women’s health inequalities

Key
HM:    Helen McKenna
LR:      Professor Dame Lesley Regan
JAC:    Dr Janine Austin Clayton

HM      Hello, and welcome to the King’s Fund Podcast where we talk about the big issues and ideas in health and care.  I’m Helen McKenna, I’m a Senior Fellow here at the King’s Fund.  And for this special International Women’s Day episode, I’m joined by two incredible women who I will ask to introduce themselves shortly.  Together we’ll be looking at women’s health, including how responsive services are or are not to their needs, the extent to which women’s needs are reflected in research and the impact all of this has on diagnosis, treatment, outcomes and of course, on women themselves.  It’s also timely to cover this topic now as the UK Government’s Women’s Health Strategy should be published in the coming months.  And just a quick reminder that if you enjoy our show, please share it with your friends and subscribe, rate and review us wherever you get your podcasts.  It helps others to find us and it helps us to improve the show.

So I’m delighted to welcome Professor Dame Lesley Regan and Dr Janine Clayton, thank you both so much for joining us.  Welcome to the King’s Fund Podcast.  Dame Lesley, can we start with you?

LR:      Thank you for inviting me.  It’s a real pleasure to be here.  I’m an Obstetrician and Gynaecologist, I’m still working on the frontline and I’m based at Imperial College in London on the St Mary’s Campus in Paddington.  I’m the immediate past President of the Royal College of (s.l London 0:01:28) and I’m also the Chair of Wellbeing of Women, the charity that funds research into women’s health, advocacy and education.

HM      Fantastic, thank you.  And Dr Clayton?

JAC:     Delighted to be here.  I’m Janine Clayton.  I’m the Director of the Office of Research of Women’s Health at the National Institute of Health or NIH in the US.  And I’m actually an ophthalmologist by training, I did that for many, many years and actually still see a few patients there.  In that capacity I have the pleasure of working across 27 institutes and centres at NIH and to help coordinate women’s health research and in the incorporation of both sex and gender into research, from a basic laboratory level through translation and clinical and then beyond in terms of implementation.  Excited to be here with you today.

HM      Thank you so much.  Just before we get into the episode proper, I wanted to note that while we’ll often be discussing women as a broad group, women, as I’m sure all our listeners will recognise is not a single homogeneous category.  It refers to a wide range of people, half the population in fact, who have different health concerns and different outcomes, as well as different characteristics, so including disabilities, ethnicity and race, sexuality and gender, social economic status and many, many others, and all of those factors intersect to result in differential impact on health.  So first question to start off with you is that you’ve both dedicated part or much of your working lives to improving the health of women, so I wanted to ask you each what led you down that path?  And maybe Dr Clayton, if we start with you?

JAC:     I got interested in women’s health, as I said, I’m an ophthalmologist and so I was looking at sex differences in eye disease and studying autoimmune eye disease where the immune system really reacts against your own eye tissue.  And many, many of those autoimmune diseases are more common in women than in men.  And in fact I had read a publication, which was a global metanalysis of international studies on blindness and visual impairment.  And two thirds of the world’s blind or visually impaired were women in that paper, that was some time ago.  It’s a little less now, but it’s still over half of the world’s blind and visually impaired are women.  The fact that that could not be explained by women living longer than men, that we did not understand what was beneath that, was just very concerning to me and that’s what got me interested in pursuing that further in women’s health.

And so as I’ve moved forward in my career, it’s been exciting to be able to uncover what’s beneath that and why we see differences in women and men and why we see differences by sex in our animal models of human disease.  We see differences in human disease as well, of course, and how diseases show up in women and men, and we’re learning more and more about that.

HM      Thank you Dr Clayton, and fascinating around some of those stark differences in terms of blindness, for example.  Incredible.  Lesley, what about you?  What led you down this path?

LR:      Well, I was enchanted, I think is the word, with obstetrics and gynaecology when I was a medical student.  I just thought it was such an extraordinary opportunity to look after women across their life course, because I could see that one could have an impact at almost every decade of their lives and I thought that was a real privilege.  And when you’re a very impressionable medical student, delivering a baby, I’m sure Janine will agree with me, is a pretty momentous occasion in your life or event.  But as I was going through my training years, I became really interested in the reasons why women miscarry, which is the commonest complication of pregnancy, and why it is that the textbooks had very little to say about it.  So it wasn’t until about 2010 in fact that I had a bit of a lightbulb moment and I went to a couple of lectures and listened to a few things and was introduced to a few people, who were talking about the importance of understanding that the health that I had been trained to deliver, that it was a really disease intervention model.  Like Janine was saying earlier when she was talking about blindness and particularly for women who tend to go to health services, not always when they’re ill but when they need help with maintaining their lifestyles, doing very normal things like trying to stop having very heavy periods, ensuring they’ve got good contraception, making sure they don’t get cervical abnormalities by going for their PAP smear.  All of these things, indeed pregnancy, you’re not ill when you’re pregnant, well, most women you’re not.  You’re just seeking help and advice from professionals to give you the best outcome.

And then of course there was the whole business about the menopause, which remember I’m the first generation of women who’s going to live longer menopausally than I was reproductive, and that’s not happened before.  As I say, I was very, very lucky to be introduced to a couple of people who were looking at it from a different, much more public health point of view.  And I suddenly thought, “Listen, I’ve got to get much more interested in the life course and the continuum of care and preventing ill health in women”, because they are so important in our society.  Because you mentioned earlier, Helen, they’re 51% of the population but women are extremely generous with the information they’re given.  And you don’t keep the information you’re given about what’s best to do for your health.  You share it with your family, with your community, with your friends, and effectively I think women influence for the better healthcare across society.  So I thought it was so important.

And I realised, and I’m fast forwarding now, that I wasn’t going to be able to change that sort of very patriarchal, “We’re going to do things to you” service unless I got into leadership roles.

HM      Thank you.  This episode is focused on women’s health and maybe some of our listeners are wondering, because certainly in the UK life expectancy for women is considerably higher than it is for men, so what’s the issue, why should we worry about what’s going on in women’s health?

LR:      I think healthy girls and women are the cornerstone of societies and there are all sorts of arguments in every walk of life to confirm that.  That’s number one.  But number two, although women live longer, their quality of life and their ability to remain independent is much poorer.  And one of the reasons I think that has happened is because we focused on disease intervention rather than promoting good health in the future.  I mentioned earlier about my generation of women being the first who will be menopausal for longer.  We used to just wait for women to drift into the menopause, a few of them got lucky and got a bit of help with managing symptoms or various things.  And then we waited for them to have a problem.  And when we asked the members of the general public, women, “What do you think’s going to be your problem?” they all think they’re going to die of cancer.  But of course they’re not, they’re going to die of heart disease and the complications of osteoporosis and frailty.  And the lack of independence that happens after you’ve fractured your hip and been hospitalised and got a chest infection and lost your glasses and feel a little bit uncertain about going out again.  All those sorts of things.

And the other thing we have to consider as well, so firstly they’ve got a poorer quality of life because their services have not been focused and I’m sure Janine’s going to be telling us about the terrible disparities in clinical trials and the gender that’s collected is mostly focused on men, drugs are always excluded women of reproductive age from drug trials – appalling – including the COVID vaccine which is our latest example of how women have been so totally disadvantaged.  But in my own health system in the NHS, what happened as well since 2012 and the Health and Social Care Act being introduced, is that women’s maintenance services have been predominantly grouped together in Public Health England, which meant that there was a sector of funding in the NHS which kept being subjected to financial cuts.  And so I could show you the data and the graphs that show that from 2012 onwards, women who had started off disadvantaged, because they’d not been included in the studies, became progressively and acutely disadvantaged by funding issues.  And because they just weren’t considered, it was always done through a male lens.

So we now know that girls in our society in Central London, one of the most affluent cities in the world, who can’t go to school on a monthly basis because they can’t afford period products.  And many of them, extraordinary, they don’t know what these periods are when they start.  And there’s women who are leaving their workplace in their 50s, not because they want to stop working but because they can’t cope with their menopause transition and they don’t feel able to talk about it.  There are so many examples of things that are just so important across the lifestyle.  Another good example is, although we sort of led the way in cervical screening and preventing cervical cancer, we have now got a 20-year all-time low in uptake of cervical smears.  And that’s not because women refuse to go or because they’re too embarrassed, it’s because they can’t get appointments.

So one of the things that I think we really have to understand is that you can’t get healthy societies if you don’t allow the people living in them easy, direct access to the services they need.

HM      Dr Clayton, from your perspective, why should we be worried about women’s health?

JAC:     So the health of women, the way that I think about it is very consistent with Dame Lesley’s.  It’s a head-to-toe approach, everything that affects a woman from head to toe; reproductive female specific and beyond.  And so we also have a life course perspective that we use as well and so if you think about that, health inside and out, it’s both your genetic risk, things that are happening within your body, as well as exposures.  So that could be a toxic exposure to a chemical because you live near a chemical plant or air pollution consequences.  Or it could be a toxic relationship where you are exposed to violence, intermittent partner violence, domestic violence, and we see some very disturbing data there, especially during the pandemic, with increases in gender-based violence.  And the consequences of that violence and its real effect on health, diagnosis of hypertension for example, anxiety and depression.  So trauma, violence and those exposures I think is something very important to consider.  That health span that Dame Lesley mentioned, women do live longer years than men, but they don’t live healthier in those years.  They spend more of their years with disability, with multiple chronic diseases, not just a single disease.  Women have what we call multimorbidity, multiple conditions, and so I also want to share that women as they’re going into their pregnancies, they are not as healthy as they were in the past.

We’re seeing many, many more women with hypertension at younger ages and they don’t even know that they are hypertensive, they don’t know they have high blood pressure.  They don’t think they’re at risk for it, right, and so that going into the pregnancies, they’re more often overweight and so we see women are less healthy, even at younger ages.  The health of women determines the health of society, we need to be ensuring that women who make 80% of healthcare related decisions receive the healthcare that they need and deserve.  And of course all women are not alike, we have women of diverse backgrounds and different educational levels, and they have health concerns that may be different.  And we see health disparities in their outcomes.  In fact in the US, worse outcomes for African American women, three times great than for white women, worse outcomes for American Indian Alaskan native women, two times those of white women.  Women, because they manifest disease differently, they sometimes go undiagnosed or misdiagnosed.

And heart disease is a big example.  Even our Gold Standard tests like a coronary angiogram, the test that we use to look for obstructions, narrowing, blockages in the arteries, the large arteries in the heart, that test, that Gold Standard was developed for the pattern of disease that we see more commonly in men.  Because that was the male lens as Dame Lesley mentioned through which we saw everything.  And so we thought that would be fine for women, but data now show that women manifest diseases differently, for example, women are more likely to have microvascular heart disease affecting the small blood vessels in the heart.  Why that’s important is because that doesn’t show up on a coronary angiogram.  So a woman may come to the Emergency Room with vague symptoms, which women are more likely to have as well; shortness of breath, fatigue, “I just don’t feel right”, weakness, without chest pain and they may be dismissed as having anxiety or just having a cold or being stressed and not get the diagnostic test that they need.

Or the clinician may say, “Okay, let’s do an angiogram or recommend you for an angiogram”, and it shows up as normal, and they may not dive further because they don’t understand, they need to look if a woman has a symptom and says, “Something is not right with my body.”  We know our bodies the best, we are the Number One expert on our own body.  And if you say to a clinician, “Something’s not right, it’s different”, we need to look until we find out what that is.  And unfortunately we know too often women’s voices are just not heard.  Women’s symptoms are dismissed and that is a problem.

HM      Janine, you mentioned women not being listened to and I think that helpfully brings us on to – we spoke to a young woman called Shakira Fernandu about her experience of navigating Outpatient Mental Health Services.  She’s a young South Asian woman and she very kindly and generously shared her experience with us.

SF:       Hi everyone, I’m Shakira Fernandu.  I am a South Asian British Sri Lankan woman living in London.  I’m currently a Postgraduate Research student at the University of London.  So I have a diagnosis of schizoaffective disorder, which is for those of you who don’t know, pretty put as a combination of schizophrenia and bipolar.  So you have the so-called psychotic symptoms of schizophrenia but also the mood swings of bipolar and you can have those at the same time.  I don’t like to be cynical about these things but I can’t help think that had I been male and tall, had I been white maybe, it’s quite possible that I would have been treated differently and believed a bit more about my own experiences.  That’s not to say that men don’t have huge inequalities in accessing mental health services or entering them, but I do think there was this kind of idea that because I’m female, I’m presenting in a certain way, it must just be stress, it must be hypochondria, things like that.  And it took over a year to get a diagnosis, so actually I was given medication and therapeutic interventions that weren’t appropriate for my phenomenon of hearing voices.  And I can’t help thinking it’s the perception of women as (s.l potentially 0:17:16) melodramatic or not knowing their own experiences.  I can’t help think looking back in retrospect that that played a part in how long it took me to get a diagnosis.

Stress is a big trigger for my psychosis, as is lack of sleep, so if I’ve had a particularly all‑night trying to cobble together notes for the psychiatrist, only to be misunderstood and then have to fight my corner or them trying to put me on different meds or whatever, that has a knock-on effect on my sleep for the next day, which then can cause the voices to get louder, which can then lead to kind of suicide attempts, which can then lead to not being so coherent, which then leads to being misunderstood even more.  And so it kind of becomes a vicious cycle and it’s very hard to break that.  And it’s very hard to keep up enough energy and the will to fight on.  There’s this perception that if you’re a woman and you’re really trying to get heard, you’re either seen as difficult or over-demanding or a hypochondriac.  So I think there are these narratives that need to change, there are these narratives that need to shift.

HM      Lesley, Janine, is there anything in Shakira’s very moving and troubling story that stood out to you there?

LR:      What struck me is the clarity and the insight that she has and recognising that she wasn’t listened to.  She also described being able to work through her dual diagnosis sometimes and then being almost flawed by it other times or it knocked her over almost unexpectedly.  It brings an important point about the issues that women face and we have to face up to the fact, I think, that there are two big areas of disadvantage and mental health does not have parity of seen with physical health.  And we have to do something about ethnicity and diversity and understanding what the needs are of particular groups of people in society, and in this case women, and she was explaining that she’s a South East Asian woman and Janine has already referred to the terrible disparities in maternity outcomes.  We have similar ones in the NHS where nobody has to pay to go and have a baby, but black women are four times more likely to die during pregnancy or the first year after their baby’s born than white women.  And Asian women are twice as likely to die in the UK.  So we can’t just put this down to genetics or whatever, it’s about all of those social determinants of disease which comes back to the point that I was making at the beginning.  And that is that the other two thirds of health that aren’t sorted out by medicine are sorted out by the social determinants of disease.

The consequences of where you live or where you were educated, where you were born, where you grew up, what your mother was like, most of them it’s depression.  But there are some more acute episodes.  In my experience, the acute episodes get looked after quite well because they are scary, the families recognise that something terrible, sometimes tragic things happen, but there’s a massive platform underneath this of postnatal depression, which you can then translate in the IQ and the behavioural engagement of children by the age of four or five.  They are behind the milestones that the baby of a mother who’s not been depressed has reached.  So that’s a terrible thing to have knowledge about and us not as a society to want to try and redress the balance.  So I think it’s about redressing the balance, so talking about all these taboo subjects.  As a gynaecologist, I’ve always been absolutely amazed that almost every girl and woman that you and I know will have 12 periods a year for nearly 40 years of her life.  And yet it’s only very recently that people have been able to talk about periods or the menopause.  And yet these are inevitabilities of womanhood.  And they are so important as well because they are the basis of our evolutionary development, aren’t they, those reproductive years.

And then to counter that, I would also say that when you talk to most politicians and policymakers about women’s health, they immediately think that you’re talking about maternity.  But being pregnant is actually a very, very small interval in most women’s life.  There’s an awful lot more of her life that needs looking after and maintaining to high standards if we really want to achieve good health.

HM      Thank you, Lesley.  And Janine, I’d be interested in hearing your reactions to Shakira’s story and also what you think needs to change for women to feel more listened to and supported by services and the health system?

JAC:     So I certainly was really struck by Shakira’s eloquent presentation of her symptoms and her bravery to speak up.  You have to be your own best advocate for your own health because no‑one else will.  I so agree with Lesley’s comments about the fact that mental health is not seen as part of overall health.  It’s seen as somewhat less than, there’s still a significant stigma associated with mental illness, and so people feel uncomfortable coming forward.  Until we understand the brain is just like any other organ and things can go wrong and we have to understand that and support everyone in being as healthy as possible, mental health is an aspect of brain health.  It’s behavioural health and we know in fact that our behaviour and our social determinants of health that Lesley mentioned are more responsible for our health outcomes than our genes.  We have no problem talking about our genetic risk, but we are at risk because of our social determinants of health where we live, work and play, educational background.  And our traumatic exposures.

So I mentioned intermittent partner violence before and I want to mention it again here.  Violence and trauma, sexual trauma, any kind of trauma, these factors build up over time and cumulative trauma is associated with increased risk for depression and anxiety.  And we know rates of depression and anxiety are greater in women than in men.  They manifest differently in women than in men.  Women respond to the treatments for these conditions differently, so we need to understand that better.  Substance use which can go along with mental illness, we see differences in women and men and their patterns of use, and in the likelihood that different interventions will work.  Even as straightforward as smoking cessation, the interventions work differently in women than in men.  Women metabolise nicotine faster than men do and so some of the nicotine replacement treatments don’t work as well in women as they do in men.  So that might be important.

It's not to say we won’t try those, but it means that if a clinician is aware of that, they would move on to the next treatment faster in a woman than in a man.

HM      Thank you so much Lesley and Janine.  We’re going to take a quick break now and we’ll hear more from our guests in a moment, so stick with us.

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Welcome back.  I wanted to touch on some of the issues around the data and research, because we’ve talked about obviously some of the negative experiences that women have when trying to access healthcare, but as you’ve both pointed out, we know that the inequalities start well before women make it to their doctor’s surgery.  So women are routinely underrepresented in clinical trials and medical research proposed by women for women is not allotted the same funding as medical research proposed by men the evidence suggests.  And over the last few years, greater attention has been called to what is described as a gender data gap, which I think has its origins in this idea that male bodies are somehow the default and with little to no analysis of sex or gender differences.  And both of you have touched upon this in your answers already.

But Janine, can you tell us a bit more about this and how it impacts on health outcomes for women?

JAC:     So of course even though we in the US have legislation, we have laws that say “You must include women in NIH supported clinical research.”  And women indeed are generally included.  And in aggregate, over half of the participants of NIH funded clinical research studies are women, but that’s not all of the studies.  We have studies that are supported by pharmaceutical companies and other funders, so even though we see great progress and inclusion, I’m sad to say that fewer than one third of those Phase 3 clinical trials, those big studies that are designed to inform treatment decisions that are made every day by clinicians, less than one third of those have the results for women and men recorded separately in the scientific literature.  So it’s almost as if those women were not even there.  We’re not getting the full benefit of women’s inclusion in those clinical studies, and in some cases for a randomised control trial, for example, women are undertaking risk to be enrolled in the study.  Risk without the promise of benefit, I have real ethical concerns about the fact that the data never see the light of day in terms of the scientific publication, because that is what the clinician needs to inform his or her decision when you or I are sitting in front of them with a new diagnosis.  They don’t have sex and gender aware data on which to make a sex and gender aware treatment decision.

This is a hole in our foundation.  You highlighted the fact that women’s health as a topic and women’s research that’s put forward by women in this space is less likely to be funded, so there are differential funding rates, and there are also differential citation rates.  Women’s work is less likely to be cited, women from underrepresented backgrounds, women of colour, we know have even more concerns in this space.  So research has the power to change care and it has, but until we consider sex and gender at every step of the way, until it’s as automatic as stopping at a stop sign, we have not done enough.

HM      Thank you, Janine, and just hearing you say, “I’ve read it before”, but just hearing you set this stuff out, it’s shocking actually.  Lesley, I wanted to ask you, because my understanding and correct me if I’m wrong, is that the UK is actually behind the States in terms of research requirements, in terms of spitting out data for male and female participants?

LR:      Sadly, yes, you’re right.  A recent example was the COVID vaccine trials where pregnant women were excluded or the messages to women in the UK were so muddled, that they have been excluded.  We now have a situation with the Omicron variant whereby the only young women on Intensive Care or getting intensive therapies now are pregnant women who are unvaccinated.  So it’s been a very, very recent example of how disadvantaging women has really, really quite fatal outcomes.  But yes, it’s been an enormous problem, and one of the things that I wanted to mention to you, Helen, was when I was at the RCOG, we produced this report and we started off by doing a survey of almost 4000 girls and women across the UK and finding out what their problems were accessing health.  And they highlighted problems with mental health, highlighted the problems of being unable to access health maintenance services, simple things; contraception, abortion care, smears, mammography, all those sorts of things.  And during that time period I was able to persuade the then Secretary of State for Health to set up a taskforce.

And we addressed all sorts of taboo areas, but we didn’t just have doctors and healthcare professionals coming to those roundtables, we had agencies across society.  So with domestic violence we were talking to Police and Social Services and educationalists and then of course the current Government has set out a call last year for evidence for what should be in a Women’s Health Strategy, and they were inundated with submissions.  And the idea is that they’re going to develop a Women’s Health Strategy in the Spring of this year and they’re going to appoint a Women’s Health Ambassador to lead that strategy.  So I really hope that the UK Women’s Health Strategy and this new ambassador that will be appointed are going to go some way to contribute to that and (s.l get it to a better place 0:31:07).

HM      Thank you, Lesley, and actually you’ve helpfully brought us on to the final question around women in leadership and the voices of women in scientific research and beyond.  So obviously addressing and tackling the gender data cap can seem, and is, I think a daunting and complex task I think you’re both encountering in your own work.  And it’s predicated on change in so many different institutions, from research to medical education, and that also relies on representation and women in those institutions first of all being there, and then leading the way and calling out bias.  So I just wanted to reflect on that with you both, given the important roles that you each hold.  How does it feel to be a woman confronting these issues and how easy is it for you to be, I guess, making the case?

LR:      I don’t think it is easy, particularly insomuch as that if you make your point very strongly, you’re often accused of being bossy or shrill or even hysterical.  So women’s contributions and the way they present themselves and their viewpoints are judged in a different way to those of men.  What can I say?  I am an incurable optimist because otherwise I can’t get up in the morning and get on with my life, but I do believe that when you include women in these important decision-making roles, and particularly in leadership roles, that you just have a fairer, more equitable outcome; either societal or educational or health or research, I think women are particularly good at being able to recruit a whole load of people with possibly quite polarised viewpoints and get them to talk to each other.  And I’m not going to use the word “compromise” but find some middle way that you can all move forward.  But so often they don’t apply for the job or they don’t put themselves forward because they’ve got a very, very large dose of imposter syndrome.

Now I think we’ve all got a bit of imposter syndrome, but I think it’s really important to overcome it.  And I also think that asking people for advice and help is something that women tend not to do as well as men, or they don’t look for mentors and people to support them along the way, and that’s what does make the difference I think.

HM      Thank you, Lesley.  So Janine, Lesley has fought against I think being called “shrill” and “bossy” and all the rest, what’s it been like for you?

JAC:     So certainly agree.  It’s not been easy but nothing worth doing ever is.  And one of my mentors, who was the first African American President of the American College of Surgeons in the US, taught me in medical school, his favourite motto was “equanimity under duress.”  And as a surgeon, I’m an ophthalmologist, I took that on a lot doing surgery.  You’re the captain of the ship, you need to be in control, you need to demonstrate equanimity.  But it’s helped me throughout every aspect and I’ve been very fortunate to have role models and mentors and sponsors along the way, Dame Lesley mentioned the importance of mentorship and getting mentors from different sectors and different types of mentors who can help you in different things.

So it’s been really one of the most heart-warming parts of my job is to expand family friendly policies, to develop new programmes, to provide funding for individuals who experience what we call qualifying life events, like childbirth or adoption, to receive additional funding from NIH and their grant to pay for individuals to come in and support their time while they go out and come back in.  And talking about the culture that needs to change in academia, so that we have high rates of sexual harassment in medicine, and biomedicine is higher than other fields.  And even students are subject to sexual and gender harassment, so a culture of accountability where we make clear our policies on harassment, NIH has made advances in this space.  It really cannot be up to the women to fix this problem that we did not create.  So as we end here, until we can include everyone and benefit from the entire armamentarium of our intelligence, we have work to do.  And we envision a future for science where women and particularly women of colour are represented equitably across the biomedical enterprise and we can, in the end, all reap the diversity dividend and improve health for everyone.

HM      Thank you, Janine, and I couldn’t agree with you more about the vast benefits of diverse representation.  Benefits that go across the board and the impact it has and yet at the same time, while this has been an optimistic podcast from you both, there just seems to be so much more work to do, a huge mountain to climb ahead of us.  I know you’re both climbing that mountain and thank you for all the work that you do and you’re making that difference, there’s a huge amount more still to do, so we stand behind you.  Unfortunately, because there’s so much more we can cover, that’s all we’ve got time for today, but I want to say thank you so much to our two fantastic guests: Professor Dame Lesley Regan and Dr Janine Austin Clayton.  Thank you both so much for your time.

LR:      It’s been such a pleasure to talk to you, Helen.

JAC:     My pleasure to be here, thank you so much, Helen.

HM      Before we go, I’m just going to handover to our producer for this episode, Emma Sheffield.

I2:        Hi, yes.  So Helen, don’t you have some news you’d like to share with our listeners?

HM      Yes, this is embarrassing.  So this is my last episode of the podcast because I have a very exciting new job and so I’m going to be leaving the Fund.  I’m going to work as Chief of Staff to the Chair in Common for Barking, Havering and Redbridge University Hospitals NHS Trust and Barts Health NHS Trust.  And the Chair in Common is Jacqui Smith and I’m really very, very excited about the new role and about getting to work obviously with Jacqui Smith and all the people I’m going to meet at both Barking, Havering and Redbridge University Hospitals Trust and also Barts Health Trust.  I’m super excited, but I’m also going to really miss the podcasts and it’s been such a privilege to do this on a monthly basis for a few years now.  And the Podcast Team, including you, Emma, Ian Ford, Sarah Murphy, Charlotte Wickens [ph] and Jonathan Holmes, you’ve all been so important in terms of being the people who make this happen on a monthly basis.  And it couldn’t exist without you.  I get to have these amazing interviews with amazing guests and talk about really interesting topics, so it’s been such a privilege and I’m just going to miss this a lot.  This is the last time I’ll be with you.

I2:        This is the last one, yes.  Our long-time listeners will know that Helen hosted the very first episode of the King’s Fund Podcast.  We will really miss your voice on the show, as well as your creative input, and the Production Team wish you all the very best in your new role.

HM      Thank you for everything that you have given to the Podcast, Helen.

Thank you, Emma, and thank you to the whole Podcast Team and all our listeners and all our guests.  It’s just been such a privilege, so please continue to listen and check in to the podcasts.  I will be listening on a monthly basis and I can’t wait to hear the future episodes from afar.  Thank you.

So you can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast.  And you can get in touch with us via Twitter @TheKingsFund account, we’d love to hear from you.  Thank you also to our Podcast Team for this episode, Charlotte Wickens, Emma Sheffield, Shilpa Ross [ph] and Sharon Jones.  The show is edited by The Spoken Media.  Don’t forget to subscribe, share, rate and review this episode wherever you get your podcasts.  And of course, thank you for listening, we very much hope you can join us next time