By Matthew Morgan (Clinical Senior Lecturer, Institute of Clinical Sciences)
Under the Equality Act 2010 it is illegal to discriminate against someone at work, in education or when accessing a public service on the grounds of their sexuality or because they are a transgender person. Therefore, everyone having contact with the NHS as a patient, employee or student should be confident that being open about their sexuality or transgender status won’t result in receiving adverse treatment from healthcare providers or being subject to bullying or discrimination by colleagues, employers or educators.
I am an out gay (nearly) middle-aged white cis-gendered man working as an NHS consultant. I have experienced the NHS as a student, trainee doctor and patient. I believe the experiences of LGBT+ people in the NHS have improved significantly since I was a student in the early 1990s and certainly compared to colleagues’ experiences during the early years of AIDS in the 1980s. Until recently, from my privileged position, I would have said that the LGBT+ experience in the NHS was not an issue any more. However, over the last few years, working with students and my own experiences as a patient, I have realised that the LGBT+ experience of the NHS is often still far from ideal.
LGBT+ patients, staff and students frequently report anxiety about coming out to healthcare staff because of concerns about negative reactions, not feeling able to challenge heteronormative assumptions (assuming everyone is straight) or concerns about confidentiality. This is particularly an issue for staff and students who are relatively low in the institution hierarchy and those having to integrate into multiple unfamiliar teams over short periods of time (eg. agency staff, junior doctors and students). LGBT+ clinical staff and students also need to decide whether to be open about their gender and sexuality with patients. This is potentially a particularly fraught area for staff involved in delivery of intimate care.
Are LGBT+ people right to be concerned? Unfortunately the evidence suggests they are. Reports of LGBT+ phobic remarks by NHS staff are relatively common. Experience of direct discrimination appears to be less common but is reported by a significant minority of staff and patients. In 2015 the House of Commons Women and Equalities Committee concluded “…the NHS is letting down trans people, with too much evidence of an approach that can be said to be discriminatory and in breach of the Equality Act.”
The culture of the NHS as experienced by LGBT+ people reflects the attitudes and beliefs of the people who staff the NHS. Although attitudes towards LGBT+ people have improved over the last few decades LGBT+ people are not universally accepted in UK society. However, NHS organisations cannot merely reflect prevailing UK cultural norms – they have a duty to deliver services, employment and training without discrimination. For the experiences of LGBT+ people to improve the culture of the NHS must continue to change and that change must be actively led. NHS organisations have policies to support LGBT+ people; the difficulty is ensuring that these policies reflect the organisational culture from the Chief Executive at the top to the most vulnerable and least powerful staff and patients. For LGBT+ staff, students and patients to feel able to come out in the NHS they need to be confident they will be supported.
“Remember: it is the organisation’s responsibility to come out as LGBT friendly, rather than the individual LGBT person…” (Supporting lesbian, gay, bisexual and trans people with cancer, p. 8)
Education is important in helping NHS organisations demonstrate they are LGBT+ friendly. Equipping staff with the knowledge and skills to care for and support LGBT+ patients should be a priority in undergraduate education and continuing professional development. Inclusivity in the NHS needs to be visible; whether that be appropriate posters and information in public areas, events such as supporting LGBT history month or individual acts such as wearing rainbow lanyards. One student commented about their placement “…LGBTQ History Month boards up everywhere! That was really good to see and to be seen, and to know that somewhere in the hospital, there was someone who knew you were there. There was also a paeds nurse with a big rainbow badge on and regards of whether or not they were LGBTQ, it was nice to see someone supporting us so openly.”
One barrier to change is students and staff not feeling empowered to challenge LGBT+ phobic comments and discrimination. At Birmingham Medical School we routinely ask all our medical students about their experience of any discriminatory and unprofessional behaviour in their placement evaluations. Their reported experience is similar to the nationwide experience of junior doctors. We also ask students how confident they are that either the Medical School or the placement would deal appropriately with any reports they make. Initially a significant minority of students lacked confidence that we would respond appropriately. We have taken several approaches to supporting our students. Just asking them about their experience has improved their confidence that we will deal with issues they raise. We have introduced new communication skills training to help them develop ways to appropriately challenge more senior staff and we are working with the University on developing a simple unified reporting system to allow students to raise concerns as well as explaining how concerns are dealt with. One issue we have yet to fully resolve is how to inform students what action we have taken in regards to specific concerns in a way that does not breach confidentiality.
The experience of LGBT+ people in the NHS has improved in recent years but often still falls short of what I want for my patients, colleagues and students. I believe that the vast majority of staff in the NHS want to deliver the best possible care for all patients and to support their colleagues and students. To create an inclusive culture requires effective training and education for all staff and students; supporting patients, their families and carers, staff and students in raising concerns and challenging unprofessional and non-inclusive behaviour; working with representation groups to understand the barriers to openness and to create visible support for LGBT+ people. Finally, patients, staff and students should be regularly asked to report their experiences to monitor whether LGBT+ supportive policies are reflected throughout the culture of NHS organisations.
Acknowledgements: The staff and students of local LGBT+ networks who gave me their advice and opinions to contribute to this article.
Note: LGBT+ rather than any of the longer current acronyms has been used to improve readability and does not indicate any intention to exclude any group of people.