Guidance

Women's health hubs: cost benefit analysis

Updated 21 March 2024

Applies to England

Executive summary

Women’s health hubs bring together healthcare professionals and services to provide integrated women’s health services in the community, centred on women’s needs across the life course. They aim to address fragmentation in service delivery to improve women’s health access, experiences and outcomes.

Based on this analysis, the benefits of implementing women’s health hubs outweigh the costs due to the increased access and improved experience for women, high return on investment for contraceptives, the number of groups benefitting from hubs and the limited set-up and running costs required.

Longstanding issues with the existing provision of women’s health services were reported in the Women’s Health Strategy: Call for Evidence and in feedback from local systems. Issues include fragmented commissioning of women’s health services and a lack of service integration.

In March 2023, the government announced £25 million for women’s health hub expansion. This will support integrated care boards (ICBs) to introduce at least one women’s health hub in areas where they do not currently exist or expand hubs to wider geographical areas in places where they are already established.

Existing hub models

Existing hub model footprints vary, with different models covering a range of populations. For this analysis, the footprint of a hub is assumed to cover a primary care network (PCN). PCNs cover a population of around 30,000 to 50,000 people and there are currently 1,263 in England. Although some hubs cover a larger footprint (up to 9 PCNs), these have developed over time, and so this analysis has been developed on the assumption hubs are initially implemented at a single PCN level.

There are a range of hub models across England, which can be challenging when defining and evaluating hubs. While only a small number exist, the variety of approaches seen in England is in part due to local population needs (for example, a focus on contraception in younger populations, or menopause in older populations), but also the funding arrangements and coordination possible at the local level.

Core components of a women’s health hub

The Department for Health and Social Care (DHSC) (working with stakeholders) has identified some services to illustrate potential core components of a hub. These include:

• menstrual problems, assessment and treatment
• menopause assessment and treatment
• contraceptive counselling
• provision of the full range of contraceptive methods (including long-acting reversible contraceptives (LARCs)) for both menstrual problems and prevention of pregnancy
• preconception care
• breast pain assessment and care
• pessary fitting and removal
• cervical screening

It should be noted that this is not necessarily the current standard offer in existing hubs, and that hubs may start with one or two services and expand their service offer over time.

Cost benefit analysis

Routine data sources and existing hub models in England provide some evidence on hubs to develop this analysis. We have not identified any full social cost benefit analyses of women’s health hubs previously undertaken. While most costs and benefits have been quantified in the analysis (albeit with uncertainty), some unquantified elements remain. Consideration should be given to both the quantified and unquantified elements.

Analysis presented here demonstrates that there are some upfront costs associated with establishing hubs, including:

• initial training and backfill costs
• initial equipment
• project management
• IT integration
• virtual appointments
• assessment of, and engagement with, the local population to understand needs

Additional ongoing costs include:

• additional costs of increased workforce and equipment
• room rental
• potential costs of increased demand
• ongoing operational costs
• potential displacement of workforce

The main benefits include:

• improved access for women and reduced disparities in access to healthcare, quality of care and health outcomes
• reducing unplanned pregnancies
• reducing pressure on secondary care by transferring appointments into hubs
• increased cervical cancer screening uptake
• improved staff training and morale
• wider economic benefits
• emotional benefits for women

Under the central scenario, for every £1 spent on implementing a PCN-sized hub, there are estimated to be £5 of benefits. This estimate does rely in part on some evidence-based assumptions about the improvements in services that can be achieved through hubs and in particular reduced waiting times for care. Therefore, a range, capturing best-case and worst-case scenarios, is presented to reflect uncertainty in estimates and assumptions, and is summarised in table 1. When considering the national picture under the central scenario, the net present value is £7.3 billion if a hub is implemented in each PCN, or £0.2 billion if one PCN-sized hub is implemented in each ICS.

The summary below table 1 shows the costs and benefits of introducing hubs, categorised by whether they are quantified or unquantified. This helps to provide an overall picture of the costs and benefits applicable to women’s health hubs. More detail on each aspect is provided in the chapter on ‘Cost benefit analysis assumptions’.

Table 1: hub cost benefit analysis summary (real 2022 to 2023 prices, discounted)

Over 10-year appraisal period	Central scenario	Best-case scenario	Worst-case scenario
Sum of costs	£2m	£1m	£3m
Sum of benefits	£7m	£9m	£5m
Net present value	£6m	£8m	£2m
Benefit cost ratio	5	13	2

Summary of quantified and unquantified costs and benefits

Quantified costs:

• training (implementation)
• initial equipment costs (implementation)
• project management (implementation)
• workforce (delivery)
• equipment (delivery)
• room rental (delivery)

Unquantified costs:

• IT integration (implementation)
• assessing population needs (implementation)
• increased demand (delivery)
• ongoing operational costs (delivery)
• displacement of workforce (delivery)
• virtual appointments (delivery)

Quantified benefits:

• improved quality of life for women
• shifting LARC appointments to primary care
• reduced menopause-related absence
• reducing unplanned pregnancies
• increased cervical cancer screening

Unquantified benefits:

• better experiences for women
• emotional impacts for women
• reduced pressure on services
• reducing short-pregnancy intervals
• increased access to treatment and services
• wider economic benefits
• improved staff morale

Introduction to cost benefit analysis

Cost benefit analysis in DHSC

The Green Book, published by HM Treasury, sets the overall framework for appraisal of government policies, programmes and projects. This includes the approach to assessing value for money through social cost benefit analysis. A social cost benefit analysis involves weighing up costs and benefits in economic terms, which involves looking at the financial costs and savings, as well as the less tangible social impacts or social value generated by an intervention (and, where possible, converting them into monetary values). It also aims to monetise all costs and benefits to society, where possible. In the case of DHSC and the NHS, social value is mainly generated through improved health outcomes, and costs and savings to the health and care system.

The purpose of this cost benefit analysis

This cost benefit analysis is to inform local health systems and support their development of women’s health hubs. The potential costs and benefits to the various levels of the health system are summarised in the hub’s value for money analysis. The analysis also presents the example net present values of implementing one hub per primary care network (PCN),^{[footnote 1]} or implementing one PCN-sized hub per integrated care system (ICS).^{[footnote 2]}

This paper has been produced to illustrate the associated costs and benefits of implementing women’s health hubs, to consider their value for money. To do so, it sets out DHSC’s understanding of how much costs differ to the existing women’s health services (for example, not through hubs), by estimating the cost to set up and deliver hub models.

The picture of women’s health services across England is complex, given the different ways in which services are funded, commissioned and delivered. This cost benefit analysis has been produced using the best possible understanding of this picture, and the best data available at the time, including administrative data, survey data, evaluation evidence, focus group data and case studies. Where evidence gaps have been identified, primary research has been used to fill some of these. As with any analysis there remains a degree of uncertainty and, in this case, that applies to the current cost of women’s health service provision and the potential costs and savings associated with the implementation of women’s health hubs. Where necessary ranges are presented, and an explanation is provided to reflect this uncertainty.

Background on women’s health hubs

The case for change

Improving access and reducing wait times

Although women in the UK live longer on average than men, the evidence shows they spend a greater proportion of their lives in ill health or disability when compared with men. Based on evidence from the government’s ‘Women’s Health Strategy: Call for Evidence’, and feedback from local systems, there are a number of issues with women’s health services. These include the fragmented commissioning (for example, some by local authorities and some by the NHS) and a lack of service integration, where women are required to attend a range of different services which do not provide holistic care for the issues they face. These are all issues that women’s health hubs will aim to address.

The Endometriosis APPG Inquiry report found that in 2020 over half (58%) of approximately 11,000 survey respondents diagnosed with endometriosis visited their GP 10 or more times and one-fifth (21%) visited doctors in hospital 10 or more times prior to diagnosis. Even though most cases of endometriosis require a secondary care referral, some symptomatic management for less severe cases may be able to be undertaken in a hub (where surgery is not deemed appropriate). This would improve access and reduce pressure on secondary care referrals.

In addition, gynaecological services waiting times in secondary care are some of the longest in comparison to other services, varying from 10 weeks to 26 weeks across integrated care boards (ICBs), with a national average of 16 weeks.^{[footnote 3]} If women with heavy menstrual bleeding or severe menopause symptoms were able to access treatment from women’s health hubs, this would likely improve waiting times for treatment in these cases.

Figure 1: average referral to treatment (RTT) waiting times for incomplete pathways by treatment function and % within 18 weeks (as of March 2023)

The chart shows the average waiting times in weeks for each treatment area. Gynaecology has the fourth longest waiting time of 24 specialties. The range of values are from 8 to 17 weeks and gynaecology is 16 weeks.

Approximately 15,000 secondary care attendances are associated with menopause-related conditions and 85,000 attendances relate to pessary procedures. Provision of menopause treatment and pessary services are proposed as potential core services for hubs. Moving a number of these attendances to a hub setting may give cost savings, if there are similar cost reductions to those for LARC procedures, as detailed in the section on ‘quantified benefits’ below. As mentioned, benefits will be felt through reducing secondary care waiting times and therefore pressures on secondary care services.

In 2021 the ‘Women’s Health Strategy: Call for Evidence’, which nearly 100,000 women in England responded to, found just 40% of respondents said they can conveniently access the services they need in terms of location and 24% said the same in terms of timing. One of the main suggestions respondents put forward to improve this was joined up provision of women’s health services through hubs and drop-in clinics, for example:

Increase the number of specific women’s health and community gynaecology clinics. So many women’s health issues can be managed conservatively and holistically by specially trained GPs and community gynaecologists or sexual health healthcare professionals. Cheaper and much better than sending all women to hospital as outpatients.

Improving incentives

There is currently an issue with incentives for setting up hubs which may exacerbate this issue. Setting up hubs, and the costs associated with doing so, often falls to local authority and NHS commissioners (former CCGs), while the largest benefits are felt by women and then secondary care providers (and may not be felt immediately). In addition, separate funding streams for contraceptive services (local authority funded) and gynaecology services (NHS funded) means more coordination and collaborative commissioning would be required to streamline services.

As seen in some areas, some payments to GPs for providing contraceptive services had to be increased to improve uptake and make fitting long-acting reversible contraceptives (LARCs) commercially viable. To date, the establishment of hubs has been driven by committed individuals and has been dependent on good relationships at local level.

Hubs, or the need for integrated or holistic commissioning of sexual and reproductive health (SRH) services, were also advocated for by a number of organisations and experts who responded to the call for evidence, such as professional representative groups, key academic stakeholders, MPs and private companies. They are seen as a way of trying to improve the coordination and integration of services in a local area to deliver them in a more efficient and person-centred way.

Alignment with broader NHS strategy

Hubs align with the NHS Long Term Plan, which aims to “provide alternative models of care to avoid up to one-third of outpatient appointments”. Planning and developing the hub model will introduce interventions to improve care for women so they will be seen by “the right person, in the right place, first time”. Hub models aim to address fragmentation of services by breaking down the barriers between institutions, teams and funding sources that can affect access to women’s healthcare. They fulfil the Long Term Plan’s objectives to create a health service that is:

• more joined-up and coordinated in its care
• more proactive in the services it provides
• more differentiated in its support offer to individuals

Hubs also align with the direction of travel set out in the Health and Care Act 2022, in particular promoting person-centred care, empowering local health and care leaders and systems, and breaking down silos between the NHS and local authorities. The 4 key objectives of each ICS are to:

• improve outcomes in population health and healthcare
• tackle inequalities in outcomes, experience and access
• enhance productivity and value for money
• help the NHS support broader social and economic development

Similarly, the Fuller stocktake report of primary care and ICSs led by Dr Claire Fuller, makes a series of recommendations for local and national health and care leaders, and articulates ideas about the future shape of care, including the further development of ‘integrated neighbourhood teams’ (similar to a PCN level population) in order to build a new, more effective health service designed with the communities to fit their needs. Similarly to women’s health hubs, this approach focuses on delivering coordinated care at a local level in order to deliver better outcomes.

Definition of women’s health hubs

Women’s health hubs bring together healthcare professionals and services to provide integrated women’s health services in the community, where services are centred on women’s needs across the life course. They are understood as a model of care working across a population footprint. For example, hub models can integrate cervical screening with other aspects of women’s healthcare such as long-acting reversible contraception (LARC) fitting or removal. Hub models involve partnership working across the NHS, local authorities, and the voluntary and community sector, and are collaboratively or jointly commissioned. They are delivered in the community, often working as an intermediate level between primary and secondary care.

Hubs are not necessarily a specific place, and often make use of existing facilities, such as GP surgeries, as well as digital provision like virtual triage or consultations. The delivery of services will often take place at PCN level to ensure services are accessible to the populations they serve. However, there are also opportunities for working at system level to set strategic direction and where there are benefits of scale, such as agreeing minimum standards and consistent care pathways across a system, metrics and evaluation, digital transformation and workforce development.

Hubs are not:

• replacement for primary care
• replacement for secondary care or specialist services where that is required
• one size fits all

Further detail on the definition and aims of hubs is provided in the core specification document accompanying this cost benefit analysis.

The 10 aims of women’s health hubs

Hub models’ primary aim is to coordinate and integrate women’s health services in the community. By doing so, they aim to achieve a number of outcomes. These can be described in terms of the different groups that hub models are looking to benefit.

Aims for women and girls:

• better access to services, including preventative healthcare and early intervention, and reduced unmet need for healthcare

• improved patient experience, with care being delivered in one appointment where possible

• improved health outcomes and reduced health inequalities

• improved access to health information, in a range of formats, and supported patient self-management where appropriate

Aims for the workforce: 

• optimising the skills of multi-disciplinary teams (MDTs) through joint working and training opportunities

• improved workforce experience and retention

• improved communication and partnership working between primary, community and secondary care

Aims for the health and care system:   

• greater efficiency, through care delivered at the right time, in the right place, and by the right person; fewer unnecessary secondary care referrals; and collaborative commissioning to make best use of resources

• more integration and partnership working between health system partners - NHS, local authorities, the voluntary and community sector, and patients - so that services better meet the needs of women and girls

• better collection and use of data by commissioners and providers to understand women’s health needs and improve service provision and outcomes

Hubs already in existence

An evaluation of hubs, conducted by the Birmingham, RAND and Cambridge Evaluation (BRACE) Centre identified 17 women’s health hubs across the United Kingdom, with 13 in England.^{[footnote 4]} Though a range of examples of integrated women’s health models have been identified, these are the hubs meeting the BRACE definition, which was developed collaboratively with stakeholders including women. The evaluation also identified areas that had integrated community gynaecology or LARC services in place but did not meet their working definition of a women’s health hub.

As models are developed to meet the needs of their local population, in the complex context of existing women’s health services and commissioning structures, it may also be that some integrated women’s health services, potential hubs or developing hubs were not identified in the evaluation. Similarly, given the funding announced for the expansion of women’s health hubs, it is expected that additional hubs will have been established since the evaluation was conducted.

Services provided by hubs

There is no one-size-fits-all approach, as hub models must be tailored to local population needs and should meet women’s health needs across the life course. Evidence from existing hubs show that hub models often start with an initial service offer which is expanded over time - with a long-acting reversible contraception (LARC) service often the first ‘building block’.

Core services that could be included in a hub model are:

• menstrual problems’ assessment and treatment
• menopause assessment and treatment
• contraceptive counselling and provision of the full range of contraceptive methods including LARC fitting for both contraceptive and gynaecological purposes
• preconception care
• breast pain assessment and care
• pessary fitting and removal
• cervical screening
• screening and treatment for sexually transmitted infections (STIs), and HIV screening

Hubs may provide additional services within their offer, depending on the local population needs. These are listed in the core specification guidance. This analysis considers the costs and benefits of the core services listed above.

Theory of change

Based on these services, a women’s health hub logic model has been developed following a review of relevant literature, previous engagement with stakeholders across the system, and the work of the BRACE evaluation team. It represents, in a simplified way, a hypothesis or ‘theory of change’ about how an intervention works, and how it achieves the desired impact.

Under the current system, women are being referred to secondary care for some conditions (like heavy menstrual bleeding) which can mean longer waiting times (see figure 1 above).

There is also some unmet need in society, where women who suffer from the conditions outlined in the hub core services do not, or cannot, currently access the care they need for various reasons. The implementation of hubs, and the associated additional workforce costs, aims to increase capacity and availability for treating the conditions within the hub service offer. More efficient and streamlined treatment through hubs will also support this aim without further additional resource. Therefore, the hubs aim to reduce secondary care referrals and reduce unmet need, however the extent of the impacts on each are uncertain (see ‘Unquantified delivery costs’ below in section ‘Cost benefit analysis assumptions’).

Policy objective and economic case for hubs

DHSC’s policy objective is to incentivise and support areas to either introduce women’s health hubs in areas where they do not currently exist or expand hubs in places where they are already established. Expansion of existing hubs may be either to a wider geographical area, or to increase services to align with the core services mentioned. In March 2023, the government announced £25 million for women’s health hub expansion in order to achieve this objective, and enable women across the country to benefit from better access to care for essential services for issues such as menstrual problems, contraception, pelvic pain and menopause care.

The intended outcome of the fund is to accelerate the development of new women’s health hubs between 2023 to 2025 to benefit women across England and help to ease pressures facing the NHS. The purpose of this cost benefit analysis is, therefore, to present the value for money case of implementing women’s health hubs.

Economic case for hubs

There is a misalignment of incentives for setting up women’s health hubs, as the costs and benefits fall upon different groups. The costs of setting up hubs often fall to local authority and NHS commissioners, while the key benefits are felt by women and secondary care providers. The funding announced aims to improve this by reducing the initial cost barrier to local health systems.

The current system can also lead to inefficiencies and lower uptake of services such as LARCs or menopause support due to the challenges in accessing those services. Therefore, introducing hubs nationally aims to improve efficiency through the specialisation of healthcare professionals. This is because a few healthcare professionals in each area will have greater knowledge of the core services offered and so can treat women quicker and, where possible, combine services into one appointment.

Finally, there may be further positive knock-on effects as there is evidence to suggest that specialisation of GPs can help to improve retention and morale of staff, by offering alternative career paths. Improving staff retention can improve efficiency through lower operational costs, by reducing the costs of recruiting and training new staff.

Cost benefit analysis assumptions

Key assumptions

This section presents DHSC’s estimate of the costs and benefits of implementing and delivering an individual women’s health hub covering a PCN footprint. It provides an indication of the scale of costs as an example, covering the ‘core services’ outlined in the ‘services provided by hubs’ section.

Key assumptions have been made to develop this analysis, all of which may vary when it comes to implementation and delivery, so conservative assumptions have been made in this analysis. These include:

• implementation is assumed to be in 2023 to 2024 and delivery from 2024 to 2025 for the purposes of this analysis
• the footprint of a hub covers a PCN for the purposes of this analysis - however, it is recognised that neighbouring PCNs could share governance resources (while still delivering locally), to create economies of scale and reduce costs, as seen in some existing hubs
• assumes average female population in each PCN area with average population demographics that require all core services (LARCs, menopause, pessary fitting, STI testing and cervical cancer screening)
• assumes part-time (0.5 full-time equivalent (FTE)) for staff working in the hub as the central scenario, but a range is provided from approximately 0.2 FTE to 1 FTE
• all appointments are assumed as in-person within this analysis, whereas some existing hubs utilise virtual appointments
• assumes additional workforce, venue space and equipment are required and available to deliver the services, rather than integrating existing resource, as has been utilised in existing hubs
• core services are assumed to be LARCs, heavy menstrual bleeding, menopause, pessary fitting, STI testing, cervical cancer screening, breast pain, and pre-conception advice
• inflation over the 10-year period is assumed to be in line with the GDP deflator (and Office for Budget Responsibility (OBR) longer-term forecasts) for most aspects, except for workforce, which uses OBR average earnings growth forecasts over the next 5 years
• improving access to LARCs is assumed to generate a spike in demand in year 1 and then remain steady, given the long-acting nature of them. This means averted pregnancy or birth costs only span the first year, while the knock-on impacts to government (for example, reduced childcare, child health, educational) costs span the full 10-year appraisal period to varying levels
• backfill costs of a week’s GP salary have been assumed to cover training (in addition to course costs). However, GPs also have a regular training allowance so backfill costs may not be required if they can do women’s health training within this, but this will vary by local area

There are several key costs and benefits where robust quantification has not been possible but are nonetheless important to consider.

Overall, cautious estimates have been made for benefits and best-case and worst-case scenarios of the value for money of a hub have been presented too. This is to reflect some of the uncertainty in these estimates and the generalised assumptions that have had to be made to produce the analysis. In addition, the central scenario essentially assumes new resources are required in all aspects (such as workforce, equipment or room rental).

Adaptations to the approach could be made as has been seen in some existing hubs, for example:

• some operations using existing resource
• hubs achieving faster waiting times (increasing quality-adjusted life year (QALY) benefits - see ‘Quantified benefits’ below)
• utilising virtual or group appointments (reducing cost)
• generating economies of scale by managing multiple hubs across neighbouring PCNs

All these could further strengthen the value for money case.

To reflect this uncertainty, best and worst-case scenarios are provided. The key assumption changes are summarised in table 2 below. For assumptions which do not have high and low options as easily available, a 20% increase or decrease in costs has been applied accordingly. Where a minimum level is required, the costs in the best-case scenario are assumed to be the same as the central scenario.

Table 2: key assumption changes under the best-case and worst-case scenarios

Assumption	Best-case scenario	Central scenario	Worst-case scenario
Initial training and backfill costs	Training cost same as central Assume no backfill cost (within regular GP allowance).	Assume one person trains on each aspect. Assume backfill cost is one week of GP salary.	Double training cost (bigger team). Assume backfill cost is 2 weeks of GP salary.
Initial equipment costs	Same as central	Assumed cost based on evidence from hubs survey	Double cost (bigger team)
Project management costs	0.5 FTE, as assumes streamlining across PCNs	Assume one FTE, paid the same as a GP	Add 20% to cost
Workforce costs	Team of staff all on 0.2 FTE	Team of staff all on 0.5 FTE	Team of staff all on one FTE
Equipment costs	Same as central	Assumed cost based on evidence from hubs survey	Double cost (bigger team)
Room rental	Half cost if streamlined across PCNs/use virtual appointments	One room rental	Double cost (bigger team)
Quality of life for women	75% of QALY benefits included	50% of QALY benefits included	25% of QALY benefits included
Replacing LARCS in SC	Same as central	DHSC estimate of benefit	Reduce by 20%
Less menopause related absences	Same as central	External research on benefits	Reduce by 20%
Increased cervical cancer screening	Same as central	External research on benefits to NHS	Reduce by 20%
Return on Investment for LARCs	Same as central	Replication of PHE approach to estimating benefits	Reduce by 20%

Detail on the approach to calculating each of these costs and benefits has been provided in the following sections, including key limitations to those estimates.

Quantified implementation costs

Training and backfill

To start operating women’s health hubs, it is expected that some GPs, nurses, or other healthcare professionals will need additional training to deliver services such as LARC fitting and pessaries.

The costs presented are based on training for LARCs, and specialist training for menopause, for example. In addition, pessary fitting qualification is recommended to be obtained through competency certification, as per the UK clinical guideline for best practice in the use of vaginal pessaries. This cost is modelled on the basis each training type will be completed initially once per hub to have specialist expertise in each area. However, depending on the hub model being implemented, some areas may require more healthcare professionals to train in these areas.

The costs for backfilling clinicians while on training for hubs is assumed to be equivalent to a week of a GP salary under the central scenario. For the best-case scenario this is assumed to be zero because it would be assumed the training is carried out within their regular training allowance, while the worst-case scenario captures 2-weeks’ salary to capture a hub with a wider training requirement. This is conservative, because in some cases it could be a nurse or other healthcare assistant who does some of the training.

Initial equipment cost

This estimate is based on costs provided by existing hubs. This may include items such as an exam couch, chair and laptop. These are the basic items necessary for hubs to offer the ‘core services’. Some hub areas may already have access to this equipment, whereas others may also need to invest in other basic items such as desks or printers, a cost of which has not been accounted for.

Project management cost

To organise the implementation of hubs, there will be some level of project management role required. This role will include bringing together and coordinating various stakeholders, as well as identifying population needs, mapping out patient pathways, mapping out staff training needs and organising training, and changing how services are commissioned. There is added complexity due to responsibility for different parts of the pathway being split between the NHS and local authorities, and care currently being delivered in a number of settings - for example, primary care, secondary care and specialist sexual and reproductive health (SRH) services.

This cost assumes the salary of a GP as this has previously been the case in some existing hubs, and it is likely some clinical expertise will be required as part of setting up the hubs. This cost may be lower as some areas may join up to streamline the implementation of hubs and create economies of scale, or where the role is more administrative and does not require a clinician to undertake it.

Unquantified implementation costs

There may be additional implementation costs that have not been able to be quantified within this analysis, which have been explained below.

IT integration

There are some costs associated with IT infrastructure used to manage the hubs and patient data. For example, implementing a hub may require changes to IT systems to enable shared records and intra-practice referrals. Regardless of the IT system used, achieving interoperability requires coordination across GP practices and sites. An example of how this can be achieved is provided by the Primary Care Women’s Health Forum’s interoperability guidance. This aspect is also dependent on whether any existing work for integrating IT systems has already been undertaken in any areas.

Assessment of and engagement with local population to understand needs, raise awareness, seek feedback

There may also be costs of consultation and engagement with the local population to understand their needs from services, raise awareness of new services, and seek feedback on the implementation of hubs. There may also be costs of evaluating the effectiveness of new service provision. This exercise may be undertaken on a larger scale than the footprint of a hub that this analysis has assumed (bigger than a PCN-size area), if it seems appropriate to the local population or geography, which may reduce these costs per hub.

Quantified delivery costs

Workforce costs

Understandably, there are workforce costs to ensure delivery of hub services. The estimate provided includes the cost of a GP, administrator, healthcare assistant, a consultant, and a nurse. Most of these costs have been sourced from the Agenda for change pay rates. While a project management role has been included in implementation, this analysis does not include an ongoing leadership role above and beyond the clinicians listed above, as some hubs are led by a consultant or GP who also works at the hub.

As with most of the assumptions made, there is some degree of flexibility in these costs depending on the level of service provided or required in each local area and approach adopted. This flexible nature has been captured by the best and worst-case scenarios outlined under the ‘key assumptions’ section. While the central estimate assumes the professionals costed each work 0.5 FTE within the hub, the best-case and worst-case scenarios assume they each work 0.2 FTE and 1 FTE, respectively. These workforce assumptions have been partially informed by workforce information reported by hub leads to the BRACE Women’s Health Hub Evaluation team.^{[footnote 4]} However, there is uncertainty in the current number of appointments relating to women’s health in primary care in particular, to understand existing demand.

These costs are assumed to cover the range of core services listed in ‘services provided by a hub’ section, as a broad assumption, rather than costing out each individual service due to the uncertainty in demand for each element. In addition, these costs may be lower if areas are able to use schemes such as the Additional Roles Reimbursement Scheme (ARRS) which uses wider healthcare professionals to provide services at a lower cost to primary care (for example, pharmacists or nursing associates).

Equipment costs

This reflects the regular equipment costs required to run hub services, such as additional devices for contraception or examination. These costs were provided as an example from an existing hub in the recent survey (see annex A), which covers an area of one PCN, so may differ if the footprint of a hub is larger or smaller.

Room rental

There are many places a hub can be located, the most common being in GP practices. The most important factor is that they are in the community, easily accessible to the women they serve. As per the recently conducted evaluation by BRACE, some hubs are located in hospital settings, sexual health clinics, community NHS trusts and can even be pharmacy based. It is therefore difficult to appropriately quantify the cost of facilities or physical space a hub operates from, but an estimate has been made based on the most common space.

This estimate was provided as an example from an existing hub as a response to a recent survey^{[footnote 4]} but has been cross-checked against average GP surgery costs to provide additional assurance. By including this cost, it also means the analysis captures the opportunity cost of the space (where existing space is used for a hub, that space could have instead been utilised for other healthcare services).

Unquantified delivery costs

Increased demand

There may be increased demand from previously unmet need, which is not captured here, if hubs offer services which would previously require a secondary care referral (for example, LARC fitting), and through increasing overall appointment capacity. This could lead to increased costs of extra appointments for women who visit hubs who previously would not have been to their GP, due to the improved process and access. There would also be the cost of additional devices - for example, if improved access increased take-up of LARCs. However, some of this may be offset by a reduction in longer-term appointments if women are seen earlier and avoid a worsening of symptoms.

In addition, should the hub offer additional services, such as cervical screening, there would be additional costs if uptake is higher, which are estimated to be around £30.76 per screening. In 2021 to 2022, 69.9% of the 5.12 million women invited to cervical screening were screened at the national level. If improved access via hubs leads to uptake increasing by 10 percentage points (so uptake is 80%), an additional 512,000 women (nationally) would be screened at a cost of £15.7 million. While these costs are assumed to be captured within the workforce and equipment costs at the hub level, the medium and long-term benefits of doing so are presented below in ‘Quantified benefits’.

The additional workforce and equipment costs assumed in this analysis are based on evidence from existing hubs, which in theory should capture unmet demand in those areas (if awareness is high enough). However, it is not certain if these assumed costs will fully meet any unmet need that comes forward as a result of hubs providing clearer and/or easier access to services at the national level. This is because there is uncertainty in the current amount of unmet demand, the likelihood that introducing hubs will increase demand and the current number of appointments relating to women’s health in primary care (to give indications of existing demand). Therefore, this remains an unquantified cost within this analysis.

Ongoing operational costs

A project manager role has been costed in the overall workforce costs in implementation. However, further potential ongoing costs such as management, laboratory, medicine and any additional equipment costs, aside from those accounted for in implementation equipment, have not been quantified in this analysis. Some of these will be transferred from other settings, such as from secondary care.

Displacement of workforce

Implementing women’s health hubs may lead to some displacement or de-prioritisation of existing services to allow training and/or specialisation of GPs and delivery of the hubs. However, this potential opportunity cost will depend on local decisions relating to how hubs are implemented and delivered. Upskilling GPs could mean some women may be treated at their first GP appointment rather than needing to be referred to a hub (and through increased general awareness), which could streamline appointments in that aspect and mitigate some of the displacement effect.

Virtual appointments

Stakeholder engagement with existing hubs has highlighted that some appointments have been offered virtually, and some as virtual group consultations. This is because some improvements to health can be made based on advice alone before treatment. An existing hub provided evidence of improvements in understanding and health (for example, mental health and/or fatigue) for conditions such as menopause through offering virtual group consultations (see annex A). If some appointments are offered virtually, this will reduce costs as room rental may not be required and it may also improve accessibility.

Quantified benefits

The benefits of hubs fall to a range of groups in society, first and foremost women (particularly of reproductive age) and their families, the NHS, wider government and employers. Some benefits apply to women as well as the NHS and wider government, while others benefit one group more than others. This section outlines the key benefits of women’s health hubs which have enough evidence to quantify.

Improved quality of life for women

The largest benefit of introducing hubs is to women. By providing improved access to treatment compared with the current system, women could benefit by reaching an improved state of health with reduced waiting times. This benefit can be quantified by using the QALY approach. This approach assumes an average improvement in health scores for the assumed number of women due to be treated by hubs for a sample of conditions (heavy menstrual bleeding, menopause and pessary fitting).

It is assumed that under the current system the average gynaecology referral times are 16 weeks in England (see figure 1 above), and hubs should be able to see patients within 6 weeks (a 10-week improvement in wait times). It is likely the waiting times for hubs will be shorter than 6 weeks and closer to the 2 to 3 week wait times for primary care. However there could also be an initial spike in demand from improved access, so 6 weeks has been used as a conservative estimate.

For the purposes of this analysis, improvements to pain and/or discomfort, usual activities and anxiety and/or depression are assumed to happen as a result of treatment for the conditions included, following clinician review of the approach. Tables 3 to 5 below summarise the assumed improvements to EQ-5D scores (an approach to measuring health states - see EuroQol: results from a UK general population survey) for each health condition, where level 1 represents perfect health, level 2 some problems and level 3 severe problems.

Improvements in health states assumed for each condition captured in QALY analysis

Table 3: menstrual bleeding - before and after treatment

EQ-5D dimension	Heavy menstrual bleeding, before treatment	Heavy menstrual bleeding, after treatment
Mobility	Level 1	Level 1
Self-care	Level 1	Level 1
Usual activity	Level 2	Level 1
Pain and/or discomfort	Level 2	Level 1
Anxiety and/or depression	Level 2	Level 2

Table 4: menopause - before and after treatment

EQ-5D dimension	Menopause, before treatment	Menopause, after treatment
Mobility	Level 1	Level 1
Self-care	Level 1	Level 1
Usual activity	Level 2	Level 1
Pain and/or discomfort	Level 2	Level 1
Anxiety and/or depression	Level 2	Level 1

Table 5: pessary fitting - before and after treatment

EQ-5D dimension	Pessary fitting, before treatment	Pessary fitting, after treatment
Mobility	Level 1	Level 1
Self-care	Level 1	Level 1
Usual activity	Level 2	Level 1
Pain and/or discomfort	Level 1	Level 1
Anxiety and/or depression	Level 2	Level 1

One QALY is estimated to be worth £70,000 (based on DHSC and HMT Green Book guidance). The improvement in health state (using EQ-5D scores) is then calculated over the reduced wait time (10 weeks pro-rated). Under the central scenario, 25% of these benefits are captured in the cost benefit analysis. The best-case and worst-case scenarios then include 50% and 10% of these benefits, respectively. These assumptions on the proportion of benefits included in the analysis reflect the uncertainty in these elements of the calculations:

• the start and end states of health in tables 3 to 5 (which is also dependent on any previous treatment if applicable)
• the number of women treated by each hub due to varying PCN size
• whether the treatment delivers the improvement in health assumed in tables 3 to 5
• the reduction in wait time (may be shorter and/or longer depending on hub availability and local secondary care referral wait times)

The Royal College of Obstetricians and Gynaecologist (RCOG) noted that more than 75% of women reported that their symptoms had worsened while on the gynaecology elective waiting list, an element which is not factored into the QALY calculations. Improving access to the right care through hubs aims to avoid this. In addition, hubs may also flag symptoms of other conditions sooner (for example, women’s cancers) so that they can be referred to secondary care for treatment. This benefit would be especially large if found among women who would not have gone to a GP prior to hubs.

Fitting, removing and replacing LARCs in a hub instead of secondary care

Hubs reduce pressure on services such as referrals to secondary care and GP appointments if women’s health needs are met more quickly, and if multiple issues can be streamlined into one appointment. The ‘Women’s Health Strategy: Call for Evidence’ found that of women who had been ignored by healthcare professionals, 56% said this was in the context of seeking referral to a specialist.

This benefit assumes 50% of LARC procedures (for gynaecology purposes) are undertaken in hubs instead of in secondary care. While this could be considered a transfer from secondary care to primary care, LARC procedures in the community (price taken from primary care) can be done at a lower cost than in secondary care settings. For example, the individual appointment cost savings for LARC fittings give a 68% reduction (£270 to £87). Secondary care cost is based on the NHS National Tariff workbook costs for intrauterine device (IUD) procedures as an outpatient. Hub costs are based on GP cost of £90 per hour, which is the highest potential labour cost in primary care setting.

While we assume 50% of appointments are transferred to hubs as the central scenario, this assumption is uncertain, so the table below shows the range of cost savings of providing IUD fittings in primary care settings as opposed to secondary care. This is presented at the national level, based on the 22,322 IUD procedures in England that occurred in 2021 to 2022.

Table 6: proportion of appointments transferred to primary care from secondary care

Percentage	Expenditure in secondary care	Expenditure in primary care	Secondary care savings	Net savings
10%	£4.7m	£0.2m	£0.5m	£0.4m
20%	£4.2m	£0.3m	£1.1m	£0.7m
50%	£2.6m	£0.8m	£2.6m	£1.8m
100%	£0	£1.7m	£5.2m	£3.6m

In addition to this, there are also the averted secondary care procedures that LARC provision could avoid (see ‘Reducing pressure on services’ below).

Fewer absence-related costs due to severe menopause symptoms

This estimate was provided in previous research into menopause and economic participation. It is considered a conservative estimate considering only working women aged 50 to 54 suffering the most severe symptoms. The national estimate has been converted into 2022 to 2023 prices and divided to represent the scale of benefits within a single PCN. If appointments were streamlined and women were able to access treatment and more specialist support for menopause sooner, this could reduce the economic impacts of absence on employers and the wider economy. This estimate is based on less absence-related costs due to severe menopause in the UK.

For additional context, in England there are 4.5 million women aged between 50 and 60 of which an estimated 3.1 million are in the workplace. It is important to appreciate that, in addition to absenteeism and presenteeism, leaving the workplace as a result of symptoms has significant economic costs. A survey by Benenden Health found that employees on average miss 4 days a year to medical appointments which equates to £437 per person. If that was the case for even 50% of the 3.1 million women in work aged 50 to 60, that would equate to £439 million in costs to the wider economy. Getting women with conditions such as menopause seen sooner to resolve their symptoms and streamlining appointments can reduce these wider economic costs.

Reducing unplanned pregnancies

Some GPs or other healthcare professionals may only have limited training in contraception options and, combined with availability constraints, this may be a reason why LARCs could be under-used. Some sources suggest that up to 50% of GPs believe themselves to have inadequate knowledge of contraceptives such as implants. Improving access to LARCs through hubs could improve uptake, leading to the benefit of reducing unplanned pregnancies.

Currently, 45% of pregnancies and one third of births in England are unplanned or associated with feelings of ambivalence. In addition, 20% of women who reported not wanting to get pregnant do not currently use contraception (unpublished pilot of women’s reproductive health survey commissioned by Public Health England).

According to the Office for National Statistics conceptions dataset, in 2020 (most recent data available) 25.3% of conceptions in England lead to an abortion. However, this varies by age group and region, as higher rates of abortion tend to be seen in more deprived communities, and where LARC rates are lowest. The unit cost of an abortion can range from £450 for under 9 weeks gestation to £3,600 when surgical abortion is required over 20 weeks gestation.

Increasing access to LARCs will most likely lead to increased uptake among the female population in a local area. As a result of reducing unplanned pregnancies, this has benefits for the NHS (healthcare costs) and wider government (non-healthcare costs).

Savings on healthcare costs include:

• maternity services costs - immediate cost reduction of not having to provide maternity services
• abortion costs - preventing unplanned pregnancies will reduce the number of abortions required
• birth costs
• miscarriage costs
• ongoing child healthcare costs

Savings on non-healthcare costs include:

• education costs
• welfare costs
• children in care costs - cost reduction of not providing other non-healthcare related services for a child across the life course

These were considered in the Return on Investment (ROI) estimates for funding LARC provision in primary care by Public Health England (PHE). Using conservative assumptions, the estimates found that investment into LARC in primary care yields a 1:9 benefit to system over 10 years. The costs included consumables, overhead and training costs while the benefits include the health and non-health benefits mentioned above (including the abortion costs mentioned).

Women would also benefit over their life course from avoiding unplanned pregnancies due to improved access of LARC fitting, due to the significant cost and impact of having a child. Considering the cost savings as listed above, PHE estimate the savings to government per averted pregnancy, across both healthcare and non-healthcare sectors, to be £23,976 over a 10-year period. Cost saving per averted birth is estimated at £65,276 over a 10-year period.

Increased cervical cancer screening uptake

By improving availability and access to cervical cancer screening, this benefit assumes an increase in uptake from 78% (current rate) to 85% in England, due to that being the most recent estimate available.

The latest data available in 2018 found that 80.3% of cervical cancers are diagnosed at stage 1 or 2. While this is within the top 10 early detected cancers, the rates could be even higher with improved uptake of cervical cancer screening. If hubs were able to offer screening at the same time as another appointment, this may increase uptake through improving access and convenience for women. There may also be increases in uptake through opportunistic testing.

A 2014 study commissioned by Jo’s Cervical Cancer Trust looked at the impacts of additional screening for cervical cancer. The research showed that increasing cervical screening rates in women up to 85% (they were 78% in 2014) could save £9 million per year and increasing up to 100% could save the NHS £12.1 million per year. This is because it is more expensive to treat cervical cancer at later stages (early stage or pre-cancer treatment can cost as little as £500, while treatment at later stages can cost as much as £25,000). While the introduction of the HPV vaccine will aim to reduce abnormal tests, there will still be cases avoided through screening.

This is a growing issue, as the latest data shows the uptake of cervical screening has continued to decrease, dropping to 69.9% in 2021 to 2022. It should be noted that, due to available research and data, the benefit to the NHS is based on a 7 percentage point increase in uptake, while the indicative costs (see ‘Unquantified delivery costs’ below) are based on a 10 percentage point increase in uptake. There is also a benefit to the quality of life of women by being diagnosed earlier not captured in these figures.

Unquantified benefits

Better experiences for women

In the ‘Women’s Health Strategy: Call for Evidence’, many women also noted that a lack of knowledge of women’s health issues in primary care made it difficult to get treatments:

I very much do not have access to the healthcare I need at a convenient time or location. The general knowledge and expertise about women’s reproductive health in particular is so poor in average primary care that I have repeatedly had to be referred to a particular clinic or treatment centre for what should be routine healthcare. These often require significant waiting times and travel to a particular centre.

In addition to having access to the right care at the right place, improving this process should reduce the need for women to explain health problems multiple times within the system to get to the treatment they need.

Emotional impact on women

Many respondents spoke about the challenges with the current system in the Women’s Health call for evidence. Dealing with long waiting times, or not being referred for women’s health issues and continuing to deal with symptoms, can be a distressing experience for women.

Hubs hope to reduce waiting times, with some existing ones already showing evidence of this, by providing the right level of care in the right setting. While the QALY benefits look at improvements in health state as a result of reduced waiting times, they do not capture the additionally important emotional component.

Where streamlining can be done in hubs, this can also lead to fewer intimate examinations for women (such as fitting IUD at same time as cervical cancer screening). By combining appointments, certain groups of women (like those with caring responsibilities) are also more likely to attend a single appointment rather than multiple appointments in different locations. This, in turn, reduces inequalities in women’s health. The adoption of hubs may also help to reduce the stigma preventing women from accessing the care and support they need.

Reducing pressure on services

Some of these benefits have been captured as part of the analysis - for example, through the reduction in secondary care referrals. However, there will likely be additional benefits not captured when it comes to reducing pressure on services. This is because when hubs integrate services in one place, women may be able to have multiple issues treated at once (for example, menopause and contraceptive fitting in one appointment, or cervical cancer screening and IUD fitting) which reduces the need for multiple primary and/or secondary care appointments. This would subsequently help to reduce the waiting lists for secondary care in particular.

In addition to this, if there were higher LARC uptake in hubs, there would be reduced primary care appointments for repeat contraceptives (such as pill prescriptions) or prescribing emergency contraception, where these methods have been replaced with LARCs.

Further, across England, data shows 23% of heavy menstrual bleeding spells result in an operation in secondary care. Based on the assumption that appropriate management in a hub (such as fitting LARCs) averts referrals and some operations, this would reduce waiting lists for secondary care and provide additional potential savings through management in a hub instead. Pessary fittings and severe menopause treatments are further core services within hubs that could reduce secondary care referrals.

Finally, some treatment for menstrual health problems may require STI testing - for example, post-coital bleeding. If a hub could offer this service on site, it will further reduce the need for additional referrals and appointments.

Improved access to treatments or support

Many benefits to women stem from improved access to treatments and support through hubs. They may provide quicker access to specialists, reduced travel time and improved self-management. In turn, this may then reduce the need for women to turn to private care to get the advice or treatment they need.

The Women’s Health Strategy: Call for Evidence (see ‘Access to services’) found that many women wanted services joined up through women’s health hubs as a way to improve their access to services. Generally, numerous women noted their support for women’s health hubs and clinics, because they felt it provided quicker and more direct access to professionals with expert knowledge in women’s health and women-specific health conditions. One respondent said:

Increase the number of specific women’s health and community gynaecology clinics. So many women’s health issues can be managed conservatively and holistically by specially trained GPs and community gynaecologists or sexual health healthcare professionals. Cheaper and much better than sending all women to hospital as outpatients.

There is also the potential benefit of reduced travel time for women if they are treated in hubs rather than referrals to secondary care. While 90% of people live within 3.9km of their GP surgery, around 70% of people live within 10km of an A&E setting. This indicates the distances to travel to hospital settings are likely to be higher on average, so avoiding secondary care referrals could be hugely beneficial for some women. Reducing this travel time also has impacts on time off work for appointments, where required.

Improving access to treatment may avoid women feeling the need to pay for private treatment because they are not able to get the advice they needed from their GP or wait a long time for referrals to secondary care. A 39% year-on-year increase in the number of people self-paying for treatment in the fourth quater of 2021 has been linked to long waiting times in the NHS.

Improved access can also improve self-management by giving women the information they need earlier in their care journey. Virtual group consultations mentioned previously which are run by some existing hubs (see annex A) can be testament to this.

Reduced likelihood of short interpregnancy intervals

Women’s health hubs could also be used to support women postnatally by providing LARCs. Fitting LARCs postnatally will provide additional benefits, as short interpregnancy intervals (less than 12 months) are associated with increased maternal and foetal and infant risks for women aged 20 to 34 years and for women 35 years or older at index birth. Women could also be educated on the importance of longer interpregnancy intervals at women’s health hubs. This reduces pressure on NHS services responding to these complications.

The PHE return on investment (ROI) tool was also applied to funding LARC provision in maternity settings (to reduce the likelihood of short interpregnancy intervals). When discounted by DHSC analysts the ROI of LARC in maternity settings was £22.22 per £1 spent, more than double the ROI of when LARCs are used in the general population of women. However, while hubs will accommodate postnatal women, they may not all be based in or near maternity settings, so this benefit has not been included in the cost benefit analysis. This would also avoid any double counting with averted births or pregnancies already captured in the analysis.

Improved access to contraception, especially in post-natal settings, can help reduce short birth intervals which, as mentioned, are associated with a higher chance of maternal and neonatal deaths or injury. More adverse outcomes at birth may then increase the chance of clinical negligence costs. The average cost of a maternity claim (including compensation and legal costs) is around £293,000. However, if the harm leads to brain injury at birth the average cost of a claim is around £9.4 million. This would be considered a secondary impact of the hubs, and due to there not being strong enough evidence for the impact of hubs on short pregnancy intervals, this impact has been excluded from the cost benefit analysis.

Wider economic benefits

While the benefits of reducing menopause-related absences have been included in the cost benefit analysis, the benefits may stretch further than this. The ‘Women’s Health Strategy: Call for Evidence’ found that 62% of women said a health condition or disability had impacted their experience in the workplace, with 26% saying it impacted their earnings and 22% saying it meant they stopped work earlier than they had planned. Many women spoke of their experiences of painful periods, baby loss and menopause being key challenges they faced in the workplace. Many respondents to the Call for Evidence noted that it was very challenging to get time off work for women’s health appointments.

This aligns with research internationally in the United States which estimated that about 600 million working hours or 2 billion dollars are lost annually because of period pain if adequate relief is not provided. Similarly, in Japan it was estimated that economic losses due to period pain totalled $4.2 billion annually. 

By providing the right care for women at the right time, the impact on work and the economy is likely to be improved. For women in work, this might benefit them and their employers through:

• less time off for appointments if streamlined and combined
• less absence from work or presenteeism if a solution is reached faster
• if treatment is provided for conditions, such as painful periods or menopause, more women may enter the workforce and/or less women may leave the workforce

It should be noted that additional benefits to the wider economy or wider government are captured within aspects such as averting unplanned pregnancies, as this can have a positive impact on aspects like welfare costs and employers.

Improved staff training and morale

There is qualitative data to suggest that being able to fit LARCs, or having extended roles in women’s health issues, makes primary care workers feel well equipped and motivated in their role. This is because they feel more knowledgeable to treat women in a primary care setting instead of referring to secondary care. This can then lead to increased staff retention, role satisfaction and wellbeing. As well as providing care closer to home, appropriate training and experience ensures healthcare professionals are not only able to treat in primary care, but they are also able to provide more holistic care to women.

Value for money summary

Financial impact of a hub

Based on the assumptions outlined in the previous chapter, this section summarises the financial estimates for implementing a women’s health hub within a PCN. Tables 7 and 8 below are presented in nominal terms, to represent the financial impact of a hub, broken down by the costs and benefits expected to occur. The first 3 years are captured in the tables for presentational purposes, as future year costs and benefits (2026 to 2033) are the same as 2024 to 2025, but simply inflated over time. The 10-year total captures the full period from 2023 to 2033, which includes the implementation costs presented in 2023 to 2024 and the delivery costs and benefits from 2024 to 2033.

As mentioned in the assumptions section, table 7 sets out the conservative assumption that workforce and rental costs will be additional. However, this will depend on implementation decisions and local arrangements. In practice, existing hubs have been seen to repurpose existing resources - both in terms of workforce (such as existing staff delivering enhanced services in their existing sessions) and estate (like using empty rooms without charge). If new hubs follow a similar approach then these would be opportunity costs, rather than additional financial costs, so would be considerably lower than the estimates below. A best-case scenario is presented in the value for money section, which will be closer to the costs of this type of hub approach.

Table 7: estimated total financial costs of women’s health hubs (in £000’s)

	2023 to 2024	2024 to 2025	2025 to 2026	Total over 10-year period
Initial training and backfill costs	3	0	0	3
Equipment initial cost	2	0	0	2
Project management	60	0	0	60
Workforce costs	0	172	175	1,893
Equipment costs	0	10	10	104
Room rental	0	10	10	104
Total costs	65	187	190	2,124

Table 8: estimated total financial benefits of women’s health hubs (in £000’s)

	2023 to 2024	2024 to 2025	2025 to 2026	Total over 10-year period
Quality of life for women (QALY benefit)	0	540	545	5,843
Fitting LARCs in hub not secondary care	0	2	2	17
Fewer menopause related absences	0	8	8	89
Increasing cervical cancer screening	0	9	9	95
Return on investment for LARCs	0	909	388	6,227
Total benefits	0	1,468	951	12,271

Value for money summary

This section summarises the total costs and benefits of implementing a hub, where the hub is assumed to cover the footprint of a PCN. The figures in table 9 are presented in real 2022 to 2023 prices and have been discounted in line with Green Book principles for cost benefit analysis (QALYs have been discounted using the 1.5% rate as per DHSC guidance).

While the costs presented in tables 7 and 8 represent the costs and benefits actually incurred by ICBs, the value for money estimates below are real, discounted costs, which is why they are different. Real costs remove the impact of inflation over time, so they are presented in today’s prices (2023 to 2024). Discounting aims to account for the fact that money spent in the future is preferred to money being spent now.

A 10-year appraisal period has been used to produce these figures. The net present value is how much an investment is worth over the 10-year appraisal period, discounted to today’s value, whereas a benefit cost ratio indicates the return on investment (for example, a ratio greater than one is expected to deliver a positive return).

Table 9: value for money of one PCN-sized hub

Over 10-year appraisal period	Central scenario	Best-case scenario	Worst-case scenario
Sum of costs	£2m	£1m	£3m
Sum of benefits	£7m	£9m	£5m
Net present value	£6m	£8m	£2m
Benefit cost ratio	5	13	2

When scaling up to give a national view, the benefit cost ratio remains consistent, as the costs and benefits for each hub would be assumed to remain consistent. However, economies of scale are more likely to be accessed at this point, so the value for money would likely strengthen.

For context at the national level, if a hub was developed in every PCN, the net present value would be £7.3 billion under the central scenario, and £2.5 billion or £10 billion under the worst and best-case scenarios, respectively.

For the central scenario, this essentially means society is estimated to be better off by £7.3 billion over the 10-year period. This is distributed across the benefits listed in the table, not just the direct cost savings for the NHS alone but also quality of life benefits for women (for example).

Alternatively, if one PCN-sized hub was developed in each ICS (so not full population coverage), the net present value would be £0.2 billion under the central scenario, and £0.1 billion to £0.3 billion under the worst and best-case scenarios, respectively. As some hubs already exist (although only a small number), the costs of implementation at the national level are expected to be lower than what is presented here.

Monitoring and evaluation

DHSC aims to collect data from hubs on particular metrics to monitor the success of the funding allocated to this policy. This will also help to inform any future evaluation of hubs where data gaps currently exist (such as the unquantified costs and benefits in this analysis).

Some hubs may wish to collect further metrics to develop their own evaluations. The types of metrics that could be collected to consider the impact of a hub could be:

• qualitative data on patient or staff experiences
• detailed activity metrics, such as appointment numbers or women treated by service
• number of appointments that combine services (for example, LARC fitting and STI or cervical cancer screening)
• reductions in secondary care referrals and waiting times
• waiting times for both triage and treatment
• wider population metrics like LARC fitting rate (per 1,000 women in the area), teenage pregnancy rates, STI rates and cervical screening rates
• unintended impacts of hubs (for example, impacts on primary care)

Limitations

While an attempt has been made to quantify the majority of costs and benefits associated with women’s health hubs, there is not enough evidence to provide a fully quantified cost benefit analysis at the local or national level. This is due to the varying nature of what hubs provide, the small number in operation and scarcity of data in some areas.

In addition, some benefits may be difficult to attribute to hubs (like reducing waiting times), as other policies (such as those to reduce the elective backlog) will also be impacting upon the same metrics. It can also be difficult to derive exact expenditure on women’s health services due to commissioning sitting across local authorities and the NHS and the use of block contracts in secondary care. It can also be challenging to quantify impact on health inequalities. However, all unquantified costs and benefits have been listed and detailed and should be taken into consideration when setting up and delivering hubs.

The main assumptions behind the cost benefit analysis are presented in the ‘key assumptions’ section. However, typical costs that hubs will face will range depending on:

• the size of the hub (including the size of workforce, how many women it is serving)
• hours of service opening
• how many staff work as part of the hub and which staff are delivering the services - for example, a nurse trained to fit IUDs will be cheaper than a GP
• any increased demand experienced - for example, from offering services which would previously require a secondary care referral, and through increasing appointment capacity
• local population demographics and health needs, like a larger student population requiring more contraceptive provision, or an older population requiring more menopause and incontinence and/or prolapse care

While substantial stakeholder engagement and research has been undertaken, there may be unintended consequences for local health systems not captured in this analysis. However, clarity on the pathways and educating the whole system on the purpose of women’s health hubs should aim to reduce these. While this analysis captures increased uptake of certain elements (such as LARCs or cervical screening), there is always a possibility that some of this increase could have occurred under the current system.

Further, more detailed, limitations for specific costs and benefits have been provided under each element in ‘Cost benefit analysis assumptions’.

Conclusion

There is a complex existing landscape of commissioning women’s health services and there is a diversity of existing services and hub models. This means it is difficult to identify, with certainty, accurate quantification for the overall costs and benefits for the national implementation of women’s health hubs. Based on existing evidence, engagement with operational hub models, and using available data to make informed assumptions, an estimate of the costs and benefits of implementing and delivering women’s health hubs has been made. This has been presented in the section ‘Value for money summary’ as the nominal costs relevant to those introducing hubs (where they have been able to be quantified).

The costs and benefits have then been summed over the 10-year appraisal period and the figures converted into real (2022 to 2023), discounted prices. The central scenario benefit cost ratio is estimated to be 5, while the worst and best-case scenarios are 2 and 13, respectively.

Given the positive social net present values for the implementation of women’s health hubs, the policy is assumed to provide good value for money with the benefits outweighing the costs. This is because the benefits of hubs impact on a substantial proportion of the population, with opportunities to streamline in the health service, and often with limited implementation and ongoing costs. There are also additional unquantified benefits which strengthen the case for investment.

While there are limitations with the analysis noted in the previous section, a conservative approach has been taken (such as new resource costs for workforce and/or venues and cautious benefit estimates) to mitigate some of the uncertainty around the varied hub models. This is because it is most likely that alternative approaches may offer cost savings, such as using existing venues, offering virtual appointments, or gaining from economies of scale by managing multiple hubs across neighbouring PCNs.

Annex A: summary of existing women’s health hub survey responses

DHSC surveyed some existing hubs to aid understanding of current approaches and provide insights to inform the cost benefit analysis. The responses to this survey are summarised below.

The need for hubs described in the areas surveyed

There was general consensus that hubs have been needed in order to:

• improve access to women’s health services through providing care closer to home with more accessible appointment times
• reduce pressures on secondary care services and waiting lists
• improve outcomes for women and reduce socio-economic inequalities in provision of women’s health services

A patient’s journey for accessing women’s health services was described as ‘confusing and lengthy’ in one response, with secondary care waiting times for gynaecology and menopause clinics at approximately 18 months in some areas. Hubs were described as needed in order to simplify and shorten the patient journey, and also reduce waiting times and pressures on secondary care.

Multiple responses also mentioned that hubs have been needed in their areas due to clinicians lacking knowledge and training in women’s health services, alongside a variation in GP expertise in women’s health. Hubs have been noted as important in reducing potential ‘postcode lottery’ effects and increasing equality in access. Additionally, one hub noted that they provide opportunity for upskilling wider community and primary care staff in women’s health services.

Another response detailed that their hub was needed due to a noticeable increase in provision of private menopause and women’s health clinics. Some patients turn to private care due to long waiting times and can end up continually paying for prescriptions that they have not be able to access from their GP.

One response mentioned their hub was additionally needed in order to implement the Women’s Health Strategy.

Populations served by existing women’s health hubs

The most common population being served by the existing hubs who provided responses is one PCN, with populations varying between 39,000 to 47,000.

One response detailed that they currently have 3 hubs operating across 2 PCNs, alongside weekly clinics in an additional community site which serves 6 PCNs. They estimate that over 2023 they will have directly supported 2,250 women with their current hub model and aim to roll out PCN-based clinics across their wider population.

Another hub detailed that their community gynaecology service covers multiple PCNs, and an approximate population of 354,000. However, women living outside of this region are able to access Level 3 contraceptive services, with this wider total population being estimated at 787,000.

Services available to this population before women’s health hubs

In one response, it was noted that referrals were made by GPs to secondary care general gynaecology and a small community gynaecology service, commissioned by their clinical commissioning group (CCG). There were inter-practice LARC referrals which were GP Confederation-tariff based, and LARC fitting also took place at sexual health clinics. This was also the case within other hubs.

One hub detailed that their area had Level 3 contraceptive services which provided a range of LARC procedures, alongside staff training, which is now commissioned by the local authority. Their community gynaecology service had also been set up with the aim of reducing secondary care pressures.

Another hub detailed that pessary procedures and cervical smears were delivered by GPs or nurses. However, a lack of training, high costs of training, and a lack of funding meant they felt these services were under-provided. For cervical smears in particular, this hub noted that meeting national uptake targets and engaging women within their area had been difficult.

In multiple areas, it was noted that both gynaecology clinics and menopause clinics were delivered in secondary care and had long wait times of between 18 and 24 months. One hub also detailed that early pregnancy advice was also delivered within a secondary care setting.

Approaches to women’s health hubs and changes to current system

Within their responses, existing hubs provided information on their workforce, the services they offer and conditions they provide treatment for, their current models and opening times, and their commissioning structure.

One hub detailed that they currently have:

• 2 community sexual and reproductive health (SRH) consultants (one FTE)
• one community SRH associate specialist (0.4 FTE)
• one community SRH trainee (0.2 FTE)
• one GP with special interest in women’s health (0.5 FTE)
• one healthcare assistant (0.5 FTE)
• one project manager (0.5 FTE)

This hub suggested that for a PCN-sized hub, the workforce structure could be a consultant (0.2 FTE), speciality doctor (0.5 FTE), a project manager (0.5 FTE) and 6 healthcare assistants.

All responding hubs provided most, if not all, of the following services:

• LARC procedures
• heavy menstrual bleeding and other bleeding problems
• cervical smears or cervical cancer screening
• pessary procedures for incontinence and prolapse
• menopause treatment

Other services that were noted across existing hubs include:

• STI screening and treatment
• polycystic ovary syndrome
• pregnancy advice and referral
• pre-conception counselling
• ultrasound scanning
• vulval pain
• pre-menstrual syndrome
• women’s health counselling and psychosexual treatment
• cervical polyps
• difficult or complex LARC or cervical smear procedures

One hub also detailed the governance and management services that they have developed. This includes improving physical access and parking availability, awareness of potential child exploitation or female genital mutilation, assisting Age UK in the delivery of menopause awareness, and building a business relationship with Bayer UK to have a LARC trainer.

Across the hubs, appointments are available both face-to-face and by telephone. Patients are usually referred by their GP. However, one hub noted that they allow self-referral for their LARC services. Some hubs also offer evening and weekend appointments, which is improving access for women with work and family commitments. Opening times vary from 2 weekday evenings and a Sunday afternoon in one hub, to 5 to 6 days a week within another. In some hubs, appointments can be for multiple services at once in a ‘one stop shop’ format.

One hub also provides virtual group consultations for menopause treatments, which have been reported as very successful in improving outcomes (as detailed under ‘Evidence of improved outcomes’ below).

More than one hub also provides training opportunities for their staff, allowing them to upskill and improve expertise in women’s health.

The responding hubs were mainly commissioned by their CCGs or ICBs or their local authority. However, one hub noted they had less interest from their ICB in doing so.

Costs of setting up and running hubs

The data provided by existing hubs was varied in scope and content. One hub has received yearly investments for the first 2 years of their PCN pilot hub, mostly from their CCG (now ICB).

Another hub provided their yearly staff costs for their community gynaecology service, which serves around 2,000 patients a year, seen within 4 to 6 weeks. These costs are approximately £190,000 in total. This hub also provided detail on the type of staff, such as consultant, nursing bands and administrative staff, required to run the hub.

One hub provided their operational costs over a 2-month period, their estimated cost savings (through reducing GP appointments and secondary care referrals), and a 6-month projection of costs, savings and income generation projection.

For the 2-month period, their estimated costs of providing the services were approximately £8,500 in total. On the other hand their GP appointment cost savings were estimated to be £7,500 over a 2-month period, and secondary care referral savings of approximately £2,000, it should be noted that these costs may not be representative of every hub, due to the limitations mentioned in the main document.

Further developments to hubs planned

Existing hubs are planning future expansion and investment in order to cover a wider footprint. One hub noted they are planning substantial investment for the next 2 years to roll out their model across more PCNs.

One response detailed that their hub is wanting to track patient socio-economic indicators based on postcode and to collect more data on potential cost savings as their hub continues to develop.

Evidence of improved outcomes

All responses from existing hubs detailed that they collect patient feedback on their services, which provide evidence of outcomes improving. One hub provided a log of patient feedback within their response, which was extremely positive overall. Women felt that their GPs and nurses were helpful, informative, friendly, quick and efficient. In their response, one hub provided patient feedback they had gathered on their provision of virtual group consultations for menopause. Across all metrics, such as hot flushes, anxiety and/or depression and tiredness, women rated themselves as being less bothered by these symptoms after 3 months of attending the consultations. Women also felt like they had greater understanding of the menopause after the group consultations, and this was all achieved without treatment.

One hub provided statistics on secondary care referral reductions, evidencing the potential for hubs to reduce pressures on secondary care services. This hub saw a reduction in secondary care referrals of 7%, while the wider geographical area saw a 23% increase in referrals.

Another hub detailed the various metrics they have been using to measure outcomes improving, and these include the number of women attending the clinic, waiting times between GP referral and hub appointment, the number of secondary care referrals, staff feedback, postcode and demographic information. This hub has also been improving access and outcomes for women through providing interpreters for non-English speakers where needed, through offering screenings for domestic violence, and through using outreach teams to encourage LARC provision.

1. Primary care networks (PCNs) are a group of GP surgeries. PCNs build on existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home. ↩

2. Integrated care systems (ICSs) are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. Following several years of locally led development, recommendations of NHS England and passage of the Health and Care Act (2022), 42 ICSs were established across England on a statutory basis on 1 July 2022. ↩

3. An integrated care board (or ICB) is a statutory NHS organisation which is responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services within the ICS. ↩

4. At the time of publication of this document, the BRACE evaluation report was unpublished and undergoing NIHR peer review, therefore findings cited may be subject to change. However, an interim evaluation report has been published. ↩ ↩² ↩³