Hospitals that score poorly on feedback from female patients could soon see their budget cut under a plan unveiled in April by Wes Streeting, the UK's health secretary. Branded "patient power payments", the scheme would tie a slice of hospital income to women's experiences of care, a measure designed to end what Streeting himself has called an "appalling culture of medical misogyny" in England's National Health Service.
The instinct behind the policy is understandable. Women's anger is real, well founded and widely overdue for a serious answer.
The current backlog experienced by women is the clearest summary of the problem. Nearly a quarter of a million women are on waiting lists for gynaecological care in England. This number has roughly doubled since 2018 and grown faster than any other clinical speciality's waiting list.
In a survey of more than 100,000 women , half said their pain had been disregarded and overlooked. In the UK today, obtaining a diagnosis of endometriosis (a painful condition affecting roughly one in ten women) now takes an average of nearly nine years and roughly ten visits to a GP.
This is a cultural sickness. Whether the right response is to dock money from overburdened hospitals is a different question.
Pay-for-performance schemes for hospitals have a long and somewhat chequered history abroad. A US review found that American hospitals serving the poorest patients paid roughly 10% of all penalty dollars under Medicare's quality programmes while taking home only 5% of the bonuses. Research has also found that such programmes risk widening inequality by diverting funds from hospitals that care for the sickest patients.
The surveys themselves are not without bias. Female, Asian and black doctors score lower on patient experience ratings than their white male peers, even when the care is identical. These scores often pick up charm, confidence and continuity rather than clinical quality.
The problem with importing this logic into England is that the hospitals most likely to score the worst are already in the worst shape.
Patients in deprived areas tend to be sicker and develop multiple long-term conditions up to seven years earlier than those in wealthier neighbourhoods - factors that drag satisfaction scores down without necessarily reflecting poor clinical care.
Hospitals serving patients in the most deprived areas recorded the steepest fall in finances last year, and the NHS as a whole is carrying a deficit above £1 billion, with more than 20,000 roles needing to be cut just to balance the books.
The inverse care law
Strip cash from hospitals with the longest waits, the hardest caseloads and the smallest budgets, and the women least well served to start with will find their care worse, not better. That is what the inverse care law , first set out in 1971, predicts: good healthcare is scarcest where it is needed most, and scarcer still where market pressures dominate.
The doom loop is easy to foresee: a struggling hospital loses funding because its ratings are poor; it cannot adequately recruit or retain gynaecologists; waiting times lengthen; ratings drop further; more money disappears.
The question, then, is what would actually work.
Do other policies show more promise? Between 2023 and 2025, England funded women's health hubs - one-stop community clinics offering contraception, menopause care and help with period problems and pelvic pain under one roof. Evaluations led by Rand Europe reported shorter waits, fewer hospital referrals and better patient experience. Dedicated funding for the hubs has not been renewed and many face being scaled back or closed in 2026.
A deeper fix might be found within medicine itself. Much of modern practice was built around male bodies, and women were largely excluded from clinical trials until the 1990s , leaving drug doses, pain research and disease criteria mostly calibrated around men.
The textbook heart attack symptom of crushing chest pain is one more likely to be experienced by men. This is one reason why women are around 50% more likely than men to be given the wrong diagnosis when having a heart attack.
Women reporting abdominal pain are routinely sent through slow general clinics rather than dedicated gynaecology services. Resetting those defaults costs relatively little and tackles the bias at its source.
The reality is that this problem is bigger than any one solution can deliver. Women are dismissed in consultations, wait years for routine gynaecology and are misdiagnosed for conditions from endometriosis to heart attacks - issues that need clinical time, training and steady staffing, not budget cuts.
Obstetrics and gynaecology has among the worst vacancy rates in the English health service. One in five obstetricians and gynaecologists plans to leave the NHS within five years and nurses are quitting the profession at record rates . A scheme that cuts the budgets of struggling hospitals threatens to speed the exodus driving the problem in the first place.
"Patient power payments" has the appeal of borrowing the language of consumer choice. It reframes our cultural failure as a marketplace one. But a marketplace will always reward customers with the most power to walk away. And punish the hospitals left to look after the women with the least.
Philip Broadbent receives funding from the Wellcome Trust 223499/Z/21/Z
