It is not widely understood that people who are LGBTQ+ in the UK are more likely to experience physical and mental health problems than the general population. These health inequalities are largely driven by prejudice, discrimination and exclusion, which affect health in two main ways.
Firstly, they increase the likelihood that LGBTQ+ people will be subject to health risk factors, for example, low self-esteem, alcohol, bullying, assault, family rejection and homelessness. Secondly, they affect the ability of LGBTQ+ people to access the right healthcare when they need it. Some people will even avoid seeking healthcare for fear of having a negative experience due to health professionals’ responses to their sexuality or gender. A recent survey by the LGBT Foundation tells us one in five LGBTQ+ people have witnessed homophobic or transphobic remarks by healthcare staff.
These disparities do not only affect the general public and people needing to access healthcare, but they also affect staff working in health and care. Recent NHS Staff Survey data revealed that the LGBTQ+ workforce is at disproportionately high risk of experiencing physical violence from patients, bullying, harassment and/or abuse from colleagues. For example, on the NHS People Promise indicator ‘we are compassionate and inclusive’, the overall score for lesbian and gay staff is 7.1 compared to 7.3 for heterosexual colleagues. The scale of the gap varies by indicator, with the biggest gap between health and wellbeing where the score for heterosexual staff is six compared to 5.6 for lesbian and gay staff. The gaps in experience for transgender staff are even wider and there is also a gap in experience for those identifying as bisexual.
The NHS, along with other health and care organisations, seeks to provide fair access to health and care for all, to improve the health of all parts of the population and to be an inclusive employer. And yet, the data along with feedback from members of the NHS Confederation’s Health and Care LGBTQ+ Leaders Network, exposes that we are still on that improvement journey.
Inclusion framework
The COVID-19 pandemic only served to make things worse for LGBTQ+ people, disproportionately affecting their health and wellbeing and further exacerbating health inequalities. It also served as a catalyst for the NHS Confederation’s Health and Care LGBTQ+ Leaders Network, in collaboration with the NHS Confederation’s Mental Health Network, to develop the LGBTQ+ Inclusion Framework.
The framework supports leaders of NHS and other health and care organisations to better deliver on their role in reducing health disparities, being inclusive employers and creating genuine improvement for LGBTQ+ staff, patients and population. It recommends six key pillars of inclusivity for organisations to build to create and maintain inclusive cultures. These are the principals of the six pillars:
- Visible leadership and confident staff.
- A strong knowledge base.
- Being non-heteronormative and non-cisnormative in everything we do.
- Systematic collection and reporting of data.
- Listening to service users.
- Proactively seeking out partners to co-deliver services.
Leading the way
Visibility matters: having staff who feel confident and who can be their authentic selves really makes a difference. If they feel safe to do so, LGBTQ+ leaders should try to be visible and non-LGBTQ+ leaders should model good allyship. This will help to ensure diversity in the workforce, diversity of leadership and that organisational policy reflects the experiences of LGBTQ+ staff.
Staff should have the opportunity to belong to an LGBTQ+ staff network, ensuring that this diverse group is part of the decision-making process across the organisation. If anyone experiences distress, exclusion and/or conflict in the workplace because they are LGBTQ+, people should be confident that their employer will provide support.
Having a strong knowledge base is also important. This means leaders and staff understanding the specific needs of LGBTQ+ people, the health inequalities they face and the variance of experience between the L,G,B,T,Q and + identities, particularly that of transgender people. Employers can create a safe space for staff to learn about LGBTQ+ experiences and how they can be inclusive, including in terms of intersectionality between protected characteristics.
Another key behaviour is not assuming a person’s gender identity or sexual orientation. Being heterosexual (a person who is sexually attracted to people of the opposite sex/gender) or cisgender (a person whose gender identity corresponds with the sex the person was identified as having at birth) should be considered a possibility, not a default. When designing, commissioning and delivering services and policies, ensuring inclusivity is also considering whether they address the specific needs of LGBTQ+ people.
Collecting data
It is helpful to take responsibility for collecting and reporting data. Proactively seeking specific gender identity and sexual orientation information from all patients and carers, and reporting this to the NHS data sets, can help organisations understand and better meet the diverse needs of their population.
Asking staff about their gender identity and sexual orientation is also important, but its value hinges on employers working to make sure LGBTQ+ people feel confident and safe in sharing that information about themselves. Once data is collected, separating it out for analysis is important – LGBTQ+ people are of course not one homogenous group and good analysis to better understand the issues specific to local LGBTQ+ communities will empower organisations to design more inclusive services and reduce inequalities.
Strengthening delivery
Another pillar is the importance of listening to service users. Organisations have a statutory duty to include service users and community groups in the design and commissioning of services. When co-producing and commissioning services, it is important to include LGBTQ+ voices so they can help to make these services more inclusive for that population. This includes the needs of LGBTQ+ children and young people, particularly around mental health. Organisations can then use that insight to create targeted interventions with measurable outcomes.
Finally, it can be very helpful to proactively seek out partners to co-deliver services. The knowledge and reach of third sector and community organisations closely connected with the local LGBTQ+ population can help ensure that services are being designed or commissioned with diverse local needs in mind.
Actions speak louder than words
Implementing change can be daunting, particularly across an entire organisation. That’s why we have invited a number of health and care organisations to pilot the framework’s pillars. The organisations took our framework, identified areas to start working on and found that small steps can lead to big changes. This is a complex time for LGBTQ+ staff, patients and carers. Health and care leaders want LGBTQ+ staff and service users to know that their best interests are being considered, are at the heart of decision-making and, ultimately, that their places of work and their care settings are safe. To download the LGBTQ+ Inclusion Framework and supporting tools, visit https://www.nhsconfed.org/publications/health-and-care-lgbtq-inclusion-framework Using the pillars of this framework is a way of being more intentional about inclusion.