3Leadership and creating policy that results in measurable improvement
31.Disparities in health and social care outcomes can be tackled, but this requires commitment from across the health and social care sectors. We saw no evidence that suggested service-providers and policy-makers are unwilling to provide an equal service to LGBT people and, indeed, we have heard numerous examples of individual health and social care providers delivering excellent, person-centred care to their LGBT communities. We have also heard that there are a number of barriers to full inclusion that relate to strategic leadership and accountability and that without improvements in this area the effectiveness work to tackle health and social care disparities will be limited.
The role of national and local leaders
32.LGBT-inclusion is rarely seen as a distinct issue to be considered and championed by senior leaders. This can manifest itself either in the outdated idea that “inclusion” means treating everyone the same regardless of specific needs48 or in the loss of LGBT-specific interventions within the more general work on “equality, diversity and inclusion”.49 We are hopeful that this issue will be addressed through the ongoing drive to provide “person-centred care”.
33.In an attempt to ensure that all staff take individual responsibility for equality issues, strategic leadership on LGBT inclusion within NHS services can be lost. As Wendy Irwin from the Royal College of Nursing told us:
What we often hear is that there is no clear leadership on this issue, so this desire that it is everybody’s business is fine, but in practice it becomes nobody’s business because there isn’t someone holding people to account over, “Well, we see that in this community those health inequalities are widening, sharpening, broadening, deepening.” Who is responsible for changing outcomes on that? It is not always at all clear who is responsible.50
34.NHS England has an Equality and Diversity Council whose role is to:
Help shape the future of the healthcare system from an equality, diversity and inclusion perspective; focussing upon improving access, experience, and health outcomes for all patients, service users, carers and the NHS workforce. To achieve this, the EDC undertakes a strategic approach and through agreement initiates programmes to support and enhance quality performance across the healthcare system.51
It is unclear if, until now, the EDC has specifically dealt with LGBT issues or if it has considered the LGBT Action Plan, as its website has not been updated since 2017. However, NHS England has told us that the National LGBT Health Advisor will be invited to sit on the EDC.52 This is a positive step, but only if the role of the Advisor is truly embedded in NHS England so that this role can be an effective part of the EDC.
35.In practice, most of the innovation in creating LGBT-inclusive services seems to come from individuals working on the ground, or from individual commissioners of services, rather than at a strategic level. There is a lack of clear strategic thought about providing LGBT-inclusive services in health organisations, whether these are care homes, local authorities or the NHS. We heard from witnesses that much of the policy and research work is being done by relatively junior members of staff who have no authority to create systemic change.53 At the tops of these organisations are individuals, who, while well-intentioned, do not have the expertise to ensure that LGBT needs are embedded into all strategic thinking, whether due to an overly broad portfolio or simply through being overstretched. Dr Justin Varney of Birmingham City Council told us:
Much of the work that has been done in health, whether in Public Health England, NHS England or the Department of Health and Social Care, has been through committed individuals with personal passion, often at personal cost, in order to deliver what they fundamentally believe is important to shifting the lives of LGBT people.54
36.This has led to a lack of strategic, organisation-wide drive that often results in initiatives getting stuck or not being effective. Harri Weeks of the National LGB&T Partnership told us:
There is a lack of investment and commitment behind these pieces of work. They happen, again, once and then there is little thought given to how to disseminate them or how to keep driving forward, keeping them updated, because often these pieces of work only really come about because of the passion and interest of one particular person who then may move on to a different role, and who was often doing it above and beyond their usual work.55
37.Mx Weeks also explained the role of the National LGB&T Partnership in liaising between various parts of the NHS, many of whom are not working in a joined-up fashion. As members of the Health and Wellbeing Alliance, the role of the Partnership is to bring together examples of good practice and share them across the NHS.56 Dr Varney spoke about good practice not being widely enough replicated across multiple health services, each of which is working independently:
What I would say [ … ] is that there are lots of gemstones, but there is not a coherent necklace in place. That is the gap for us; it is about how we take fantastic examples of good practice in individual hospitals, GP practices, partnerships with the voluntary and community sector, the NHS and local government, and go, “Here, this is how this connects from this part of the country to this part of the country and does it in a way that is not enforcing one-size-fits-all”.57
38.While we welcome the fact that there are pockets of good practice, as Dr Varney also pointed out, it is not single projects or small-scale activities that are going to make the difference to the everyday experiences of the majority of LGBT people across health and social care settings.58 If there is no clear commitment from the very top of health and social care organisations, it is difficult to see how good practice can be spread effectively or how a consistently good service can be provided to LGBT people.
The NHS Long Term Plan
39.Much of the Government’s overarching strategy for healthcare in England is contained in the recent NHS Long Term Plan, published in January 2019.59 The Long Term Plan sets out the vision that the Government has for the NHS for the next decade. Part of the Long Term Plan focuses on the need to reduce health inequalities. The Plan states that:
For reasons both of fairness and of overall outcomes improvement, the NHS Long Term Plan therefore takes a more concerted and systematic approach to reducing health inequalities and addressing unwarranted variation in care.60
Although the NHS Long Term Plan addresses the need to reduce inequalities generally, LGBT people are not one of the specific groups for whom the Plan specifically urges action to improve health outcomes and there are no references to LGBT service users as a targeted group beyond a single mention in the context of mental health provision in schools.61This is surprising given the health inequalities for LGBT people already outlined in this report.
40.Part of the Long Term Plan involves restructuring local health providers into new and existing Integrated Care Systems (ICS). Each ICS:
… will agree system-wide objectives with the relevant NHS England/NHS Improvement regional director and be accountable for their performance against these objectives. This will be a combination of national and local priorities for care quality and health outcomes, reductions in inequalities, implementation of integrated care models and improvements in financial and operational performance.62
41.One of the requirements that the Long Term Plan introduces is that all ICSs set out how they are planning to reduce health inequalities within “System Plans” that will run until 2023/24. The Long Term Plan states that ICSs will need to identify health inequalities in their area and set out “evidence-based interventions” that would reduce these inequalities. ICSs would then be able to set these out in their System Plan, which would then be used to make the case for additional funding.63 Support to identity these “evidence-based interventions” these are being developed by NHS England. While these interventions are welcome and will hopefully be able to deal with unequal outcomes that are considered to be part of public health, they are likely to be of limited help in eliminating structural discrimination affecting LGBT people within the NHS itself if the data identifying that group remains voluntary to collect and Systems Plans do not address problems in social care provision.
42.It is vital that all local health and social care organisations actively consider the needs of their LGBT communities, as required by the public sector equality duty. This should be mandated directly from the Department of Health and Social Care and from NHS England as a part of commissioning requirements and as a requisite for receiving funding.
43.All commissioning outcome frameworks should include an explicit requirement to demonstrate how a service provider will meet equalities obligations and best practice and show that it has consulted on and considered the needs of LGBT service-users. This should include both NHS contracts and local authority contracts for social care provision.
44.We also recognise that some NHS and social care providers will not have considered LGBT issues as part of their commissioning requirements before. We have seen plenty of good practice among individual CCGs but this practice needs to be promoted throughout the NHS and social care. DHSC and NHS England should work together to create an LGBT inclusion commissioning toolkit that health commissioners can use to spread best practice in commissioning LGBT-inclusive services.
45.NHS England should review all new bids for funding from CCGs and Integrated Care Systems to ensure that not only are they having due regard for the need to eliminate discrimination but also that the needs of the LGBT populations of their areas have been specifically taken into account. Any bids that are found to be lacking should be passed on to the Equality and Human Rights Commission for enforcement action.
Integrating the LGBT Action Plan into NHS Strategy
46.The NHS Long Term Plan contains the core policy for health care provision generally. It does not specifically set out requirements for improving LGBT health inequalities in the way that the LGBT Action Plan does (see below). The NHS Long Term Plan speaks in very general terms about public health problems, rarely going into detail on specific populations, even in the sections that are dedicated to eliminating inequalities. The assumption that the Government seems to be making is that interventions that benefit the population in general will equally benefit all parts of the population. The Secretary of State spoke to us about the goals of the NHS Long-Term Plan, including using the example of smoking cessation. He stated that:
First, by monitoring the gap, we know the level of inequality. Secondly, we have a whole series of measures aimed to tackle smoking across the board, including interventions at what are called teachable moments. If you go into hospital—and this is true across the whole population—we will be intervening to give people smoking cessation support.64
47.While we applaud the intention, such generalised measures overlook the specific barriers that LGBT people are facing, described in more detail in Chapter 2. For example, evidence from organisations such as Action on Smoking and Health (ASH) suggest that, while smoking rates are dropping, rates remain significantly higher in LGBT populations. It is impossible to tell, due to lack of consistent data collection, whether measures intended to improve the health outcomes of the entire population would have a similar impact on LGBT communities. We do not consider such interventions to be specific enough to tackle the unique inequalities that LGBT people are experiencing. The Government, in the LGBT Action Plan, acknowledges that these problems need bespoke solutions, so it is disappointing that most of the measurement of success seems to be tied to the long-term plan and is therefore too general to be able to pinpoint whether LGBT service-users are benefiting.
48.When it comes to policy to improve healthcare for LGBT people specifically, the flagship policies are contained in the LGBT Action Plan, published in July 2018 by the Government Equalities Office.65 The Action Plan set out 75 commitments to improving the lives of LGBT people in the UK. Of these commitments, there were 12 that related specifically to health and social care, set out in the table below:
Table 1: Government Commitments to health and social care and responsible body
|
We will appoint a National Advisor to lead improvements to LGBT healthcare |
Government Equalities Office |
|
The National Advisor will work to improve healthcare professionals’ awareness of LGBT issues so they can provide better patient care. |
National Advisor |
|
We will improve the way gender identity services work for transgender adults. |
NHS England and Government Equalities Office |
|
We will improve our understanding of the impacts on children and adolescents of changing their gender. |
Government Equalities Office |
|
We will take action to improve mental healthcare for LGBT people. The Department of Health and Social Care and the Government Equalities Office will jointly develop a plan focussed on reducing suicides amongst the LGBT population. |
Department of Health and Social Care, Government Equalities Office and Health Education England |
|
We will enhance fertility services for LGBT people. The Department for Health and Social Care will revise surrogacy legislation so single people (including LGBT individuals) can access legal parenthood after a surrogacy arrangement. |
Department of Health and Social Care |
|
We will ensure LGBT people’s needs are taken into account in health and social care regulation. The Care Quality Commission will continue to improve how it inspects the experience of LGBT people in adult social care and mental health in-patient wards, and we will begin to inspect all gender identity clinics on a risk basis |
Care Quality Commission |
|
We will support improved monitoring of sexual orientation and gender identity in healthcare services to enable better patient care. |
Government Equalities Office, National Advisor and Care Quality Commission |
|
We will work to tackle body image pressures that LGBT young people face. |
Government Equalities Office |
|
We will continue to review the blood donation deferral period for men who have sex with men. |
NHS Blood and Transplant |
|
We are committed to tackling HIV transmission, AIDS and HIVrelated deaths. As part of this, we are currently funding a 3 year trial with 10,000 people to determine how best to deliver ‘PrEP’. NHS England will consider the impact of increasing the PrEP trial further. |
NHS England |
|
We will take action to improve the support for LGBT people with learning disabilities. The Department of Health and Social Care will review, collate and disseminate existing best practice guidance and advice regarding LGBT issues and learning disability; and will also ensure that training requirements for support staff and advocates who work with people with learning disabilities includes advice regarding LGBT people |
Department of Health and Social Care |
Source: National LGBT Action Plan, Government Equalities Office
49.One of the commitments was that the Government Equalities Office would report back on progress on the Action Plan annually, which the Government did in July 2019.66 The Government reported that it had progressed its health work through: the appointment of the National LGBT Health Advisor, Dr Michael Brady; funding of five organisations working to improve LGBT health; completing work on revising adoption legislation; expanding the PrEP trial to include an extra 26,000 places; and beginning a national procurement process to identify organisations best placed to deliver gender identity services in the future.67
50.While these are positive steps, we are concerned that the Government seems to be taking a lot of action without being able to quantify whether it is having any measurable impact on the health outcomes of the LGBT communities. This was highlighted to us by Wendy Irwin of the Royal College of Nursing, who commented:
What are the metrics that matter? It is really easy within the current system to produce lots of statistics, but often I wonder whether those KPIs matter, in terms of the communities they are supposed to serve and the healthcare they are supposed to reflect?68
51.Dr Brady, the National LGBT Health Advisor, agreed that he would only consider the Action Plan to have been successful if outcomes across a range of health and social care measures have improved, saying:
In five years’ time, if my team, our partners and I have done what we have been asked to do, we will have seen a significant difference [ … ] in the health inequalities experienced by LGBT individuals, and also in the experience. We need to give equal focus to the clinical and mental health, physical and mental health, outcomes as to the experience; it is not just, “Are you going to smoke less, have less mental health or less chance of getting a sexually transmitted infection?” It is, “Will your experience of going to the GP or A&E, going for an operation or going to your cancer specialist be the same as those who are from the non-LGBT community?”69
52.When we asked the Government about measuring success of the LGBT Action Plan, the Secretary of State for Health and Social Care cited the publication of the Action Plan itself as a mechanism for accountability, adding:
We are being held to account for delivering against that action plan, and this Select Committee is one example.70
While we are heartened by this vote of confidence, a select committee cannot responsible for the day-to-day accountability of establishing mechanisms for measuring the impact of Government policy. His response also did not deal with how he will know that the Action Plan has been effective in reducing the disparities in health outcomes.
53.We agree that, while the LGBT Action Plan is integral to achieving the intentions of Government, it cannot exist in a vacuum and not enough is being done to satisfy us that it is being integrated into the existing NHS structures. When we questioned the Secretary of State for Health and Social Care and the Minister for Equalities, we found that each spoke of their own strategies, the Long Term Plan and the LGBT Action Plan respectively, but that there was little read-across. We are concerned that currently the LGBT Action Plan does not require DHSC to take any responsibly for its implementation. This means that the health elements of the Action Plan are not embedded into NHS strategy in a systematic way but are seen as an adjunct to the work of the NHS, to be added on after strategies have already been devised. We feel that the split between the LGBT Action plan, on which GEO has the lead, and the NHS Long Term Plan is extremely unhelpful and seems to imply that responsibility for LGBT-inclusive healthcare lies with GEO rather than within the health and social care institutions. In order to ensure that the LGBT Action Plan is integrated into NHS England strategy, the Chief Executive of NHS England should work with the GEO to produce the next LGBT Action Plan update and should be a signatory to it. The Government Equalities Office and Department of Health and Social Care should formulate and publish a list of key inequalities in LGBT health that the NHS need to be accountable for and include in the LGBT Action Plan and should report back to the Committee annually on progress in eliminating these.
The role of the National LGBT Health Advisor
54.There has been a lot of optimism from stakeholders about the impact of the newly created role of the National LGBT Health Advisor.71 Dr Michael Brady was appointed in March 2019 under funding from the Government Equalities Office. He is working within NHS England and reports to the Director of Experience, Participation and Equalities. When we spoke to Dr Brady, he told us that his role was part-time (20 hours per week) and that his contract was for 12 months only, as the post is subject to the Spending Review. We secured assurances from the Secretary of State for Health and Social Care, despite this, the post would be secure until at least 2022.
55.While this is a positive step, we are concerned about the National Advisor being able to effect long-lasting cultural change across the NHS. For as long as the role remains an advisory one, funded outside of NHS England and reporting to a director rather than being a director-level post, it will continue to feel as though the Health Service considers tackling the health inequalities faced by LGBT people to be an “add-on” rather than intrinsic to the work of the NHS. The Secretary of State told us that, in discussion with the Chief Executive of NHS England, he decided that it would be better for the post to remain advisory, as giving it to a director would risk “focus within that one area, as opposed to having the focus across the board.72 While we agree that it is important for the National Advisor to look across the piece of the NHS, we also believe that Dr Brady does not currently have the authority to make any of the structural changes that are needed for LGBT-inclusion. The continued funding of the role of the National LGBT Health Advisor should be prioritised in the next Spending Review and should be confirmed for, at least, the next three years. The National Advisor should be embedded at a senior level and report directly to the Chief Executive of NHS England.
48 Q109
49 Q25
50 Q47
51 NHS England, ‘NHS Equality and Diversity Council’, accessed 19 September 2019
52 Letter from John Stewart, NHS England, 22 August 2019
53 Q157
54 Q157
55 Q156
56 Q155
57 Q170
58 Q154
59 The Plan does not, for the most part, deal with social care provision as the majority of social care is provided by local authorities rather than the NHS.
60 NHS England, The NHS Long Term Plan (January 2019), p 41
61 NHS England, The NHS Long Term Plan (January 2019), p 41
62 NHS England, The NHS Long Term Plan (January 2019), p 31
63 NHS England, The NHS Long Term Plan (January 2019), p 40
64 Q225
65 Government Equalities Office, LGBT Action Plan (July 2018)
66 Government Equalities Office, LGBT Action Plan: Annual progress report 2018 to 2019, CP 115 , July 2019
67 Government Equalities Office, LGBT Action Plan: Annual progress report 2018 to 2019, CP 115 , July 2019, pp 5–6
68 Q48
69 Q195
70 Q222
71 Dr Justin Varney (HSC0013), Greater London Authority (HSC0064), LGBT Foundation (HSC0035), Mermaids (HSC0068), METRO Charity (The Metro Centre Ltd) (HSC0034), Terrence Higgins Trust (HSC0015), Trades Union Congress (HSC0020)
72 Q243
Published: 22 October 2019