56.As discussed in Chapter 2 there are barriers that currently prevent health and social care services from becoming LGBT-inclusive. These include staff not understanding that LGBT people can have significantly different health and social care needs, structures that are built on a model of service users being heterosexual and cisgender; and cultures that state everyone should be treated ‘the same’ without considering different needs. Creating LGBT-inclusive services requires proactive steps and strategic thought from providers, rather than waiting for practice to evolve in the hope that it becomes inclusive. Our evidence points to a much good intention and good will among some health and social care providers. This can translate into pockets of good practice and we have heard of health and social care organisations that are taking innovative steps to make their service LGBT-inclusive. But the evidence we received demonstrated this is the exception and not the rule and that there is a pressing need for the development of LGBT-inclusive services to be explicitly part of training and local strategy.
57.We have received examples of good practice guides and materials that can be used to help health and social care services to make their practice LGBT-inclusive. For instance, we heard from Dr Justin Varney of Birmingham City Council that, during his time at Public Health England, PHE produced a variety of public health leaflets and guides, dating back more than 10 years, that helped professionals and the public to understand the needs of LGBT service-users. However, we found little evidence of these materials being used widely or even that practitioners knew about them. When we asked Clare Perkins of Public Health England about this, she told us of various mechanisms that PHE use to disseminate their materials, from publishing them on the gov.uk website to sending out weekly emails to stakeholders. She also highlighted the importance of working with community organisations when producing and disseminating good practice:
One of the key things we are moving to, which is critical [ … ] is that it is absolutely essential for these publications to be co-produced. If we involve our partners, stakeholders and community groups really early on in the process, there is much more ownership and help in disseminating that and working with us to make sure we have an impact.
58.Publishing materials in isolation, with no guarantee that they will be taken up or even seen is a waste of time and resource. Public Health England need to step up their efforts in raising awareness of materials and disseminating them. Given that PHE is keen to work with stakeholders, the National LGB&T Partnership, a group made up of 10 LGBT organisations, is an ideal partner for this work.
59.Public Health England should work with the National LGB&T Partnership to prepare a five-year plan of LGBT-specific campaigns. The plan should include measurable performance indicators on disparities such as smoking and alcohol abuse and should be reviewed annually.
60.Another aspect of inclusive practice involves ensuring that materials for general health and social care use inclusive language and imaging. Sophie Meagher of LGBT Foundation gave us an example of a cervical screening campaign that was inclusive. . told us about a recent campaign that she felt did this well.
61.We also heard of the value of inclusive messaging in relation to social care, where individuals often have a lot more choice of provider. Jim Glennon of Opening Doors London, a charity for older LGBT people, said that he would personally look for signs of inclusion if he were choosing a care home:
People do not realise that, if we saw some marker and had confidence that this place, rather than that place, was doing the right things, with whatever, a sticker or a statement, we would choose to spend our money over there rather than over there. There is a business argument to be made.
62.The issue of having clear LGBT-inclusive policies was also raised as being an important marker of safety for some. Although not all LGBT people will look for these sorts of signs of “safety” in health and social care services, the absence of such explicit policies is noted by some and may deter them from using a service for fear of discrimination.
63.There are also initiatives for individual staff members, such as rainbow lanyards, in some NHS settings which are intended to indicate that the person wearing it is an “ally”. Stakeholders such as the Cicely Saunders Institute for Palliative Care point to such measures as clear markers of inclusion. Macmillan Cancer Support was positive about this, saying:
Our research, ‘More than a Diagnosis’ was clear that some LGBT people felt substantially less anxious about discrimination when they could see signs in a hospital of a commitment to equality and–indeed–actively looked for them.
We were, however, concerned by the possibility that rainbow lanyards, or other markers of allyship could lead to unintended consequences. It is possible that, if a service-provider instigated such a scheme without training or appropriate practical support, individuals with no real understanding of LGBT issues might be signifying themselves as allies or that there would be organisational pressure on staff to take part while, at the same time, those individuals are unaware, unsympathetic or even hostile towards LGBT people. The TUC agreed, saying:
We also have concerns, as highlighted by union members, that many organisations providing such cues have not provided the prerequisite training to enable their staff to meet the needs of LGBT service users. So high quality training must accompany such approaches.
64.We agree with stakeholders who say that clear signs of LGBT-inclusion are to be welcomed. Markers of individual inclusivity are important, but this cannot be a replacement for service-wide commitment, which should also be clearly visible to all service users in an organisation’s aims and strategy and communicated visibly through posters and other visible markers. It is vital that staff who want to be identified as allies are properly trained to take on this role. All NHS and social care providers should ensure that all staff understand their legal responsibility to deliver a service that is inclusive of LGBT people but that, until this is rolled out in the NHS and in social care provision, only staff that have had training should be allowed to identify themselves in this way.
65.The role of LGBT-specific services is subject to ongoing discussion, both within the LGBT communities and in health and social care policy. The importance of community organisations that provide support for different parts of the LGBT communities is well-documented and accepted by the Government as a vital part of health and wellbeing. Macmillan Cancer Support wrote that:
Macmillan’s 2018 study–More than a Diagnosis–undertaken with De Montford University - showed the benefits that tailored LGBT support groups can bring. Their work showed clearly that LGBT support groups had proven popular and successful where they existed, and that there was demand for a greater range of LGBT support resources.
66.However, there was some disagreement among people we heard from about whether health and social care services that were exclusive to LGBT people were desirable. Some of these services, such as CliniQ (a wellbeing clinic for trans people) and MindOut (a mental health service for LGBT people), have been very successful and seem to be filling a gap in provision. When asked if these sorts of models should be more widespread, views varied. For social care, the School of Health Sciences at the University of Brighton said that:
One study showed that the preference of some older LGBT people was living independently in their own home, followed by shared accommodation with other LGBT people.
Similarly, the University of Bristol, undertaking research with older LGB people found that:
Half of the older LGB adults participating our study indicated their preference to live in LGB-specific care and nursing homes if needing these services in the future. These were imagined environments in which heterosexual norms and assumptions would not feature in the delivery of care and participants could anticipate feeling safe and valued as LGB adults. This was more common among older lesbians who had established women-only networks for mutual support.
67.Jim Glennon of Opening Doors London, however, took a slightly different view. He felt that, when LGBT people asked for services that were just for them, it might stem from fear of discrimination in mainstream services. He said:
I have had this conversation several times, and I have heard different views from our group. Some say, “Yes, that would tick all my boxes; that would be perfect”. It is often to do with fear, fear about treatment. That seems to be an issue that I am picking up. I have also spoken to people [ … ] who have said, “The last thing I want to do is have my retirement completely surrounded with LGBT people”.
Dr Michael Brady, the National LGBT Health Advisor, felt that mainstream services should be catering to the needs of LGBT people rather than relying on specialist services to deal with the problems created by non-inclusive services:
Services in the broadest possible sense should be LGBT-inclusive and acceptable, full stop. Whatever kind of service you go to, it should be accessible and inclusive for you. That is the first thing. I do not see a case for LGBT cardiology services or LGBT physio services necessarily. All services need to have this on their agenda.
However, Dr Brady also recognised that, as stop-gap measures, LGBT-specific services were valuable:
For some areas, you could make a case for specific services that bridge from one place to the next. If it is going to take five years or even longer to make things truly inclusive, I do not want LGBT individuals to keep suffering for those five years until things get better.
68.We agree with Dr Brady that, while LGBT-specific services play a vital role in the health and social care landscape at the moment, these services often exist because mainstream services are not yet fully inclusive. These services should continue to be sustained and supported for as long as they are needed. In the meantime, the priority should be for mainstream services to become inclusive to the needs of the LGBT communities.
73 Dr Justin Varney ()
78 Dr Michael Toze (), The National LGB&T Partnership (), University of Bristol ()
79 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation ()
80 Macmillan Cancer Support ()
81 Trades Union Congress ()
82 Government Equalities Office, (July 2018), p 6
83 Macmillan Cancer Support ()
84 CliniQ CIC ()
85 , accessed 24 September 2019
86 School of Health Sciences, University of Brighton ()
87 University of Bristol ()
Published: 22 October 2019