5Staff training and regulation
69.Every witness that we heard from in this inquiry emphasised the need for frontline staff to better understand the lives and needs of LGBT people under their care. Whether in mental health, cancer care or social care, the need for a “person-centred” approach was highlighted again and again. However, as outlined in the previous chapters, health and social care professionals do not always understand the needs that LGBT people have, and often do not consider these needs to be relevant to their care.91 While outright discrimination may be relatively rare, a single poor experience can undermine confidence in an LGBT person’s future interactions with other health and social care services. Niazy Hazeldine of METRO Charity told us, in relation to young people:
If you have experienced any of those kinds of things, or even if you have a doubt that you might experience those kinds of things, it is going to be very hard for you to access that service with trust. That makes it very difficult to create a feeling of trust where people can access services.92
70.Witnesses told us that there were numerous reasons why healthcare professionals may not provide an inclusive service in practice. These include a lack of training leaving them to feel ill-equipped to deal with LGBT-specific issues, not feeling confident of the questions to ask an LGBT patient or simply working under the misapprehension that treating patients equally means treating them all the same.93 Training for health and social care professionals, registration with professional bodies and ongoing inspection all need to be addressed in order to support better provision for LGBT service-users.
Training of health and social care professionals
71.Whether or not a health or social care professional receives formal occupational training largely depends on their role and whether or not there are mandatory requirements placed on them by professional bodies or inspectorates. This can be extremely prescriptive or light touch. For instance, while doctors and nurses coming from abroad need to pass a series of tests in order to register to practice as individuals,94 social care workers do not need to register.95 Instead, social care workers’ training is delivered by employers so that they can demonstrate that they are working effectively enough to pass inspections. We explored different parts of the training framework at different points in the inquiry, but the consistency with which witnesses raised training issues lead us to conclude that this is an area that needs comprehensive consideration.
Pre-qualification training
72.The bodies that are responsible for training and professional development of regulated health professions varies depending on the occupation. In many cases, a health professional will start their training at a university or college for pre-qualification training, where they will learn the basics of their field. The content of this training is mostly decided by the learning institution, although the parameters are set by bodies such as the General Medical Council (GMC) or Nursing and Midwifery Council (NMC). In this inquiry, we heard mostly about the training provided to doctors and nurses, so these are the examples we have used, although our conclusions are applicable across other disciplines.
73.The NMC told us that its involvement in curricula is light-touch but that it does regulate them, saying:
The NMC does not set detailed curricula for pre-registration programmes. Instead we set the proficiencies that all newly qualified nurses and midwives in the UK and nursing associates in England must be able to demonstrate to enter onto our register [ … ] We approve and monitor the pre-registration programmes designed by approved education providers across the UK against compliance with our standards.96
The NMC within its guidelines, is clear that must staff on their register must:
Provide and promote non-discriminatory, person centred and sensitive care at all times, reflecting on people’s values and beliefs, diverse backgrounds, cultural characteristics, language requirements, needs and preferences, taking account of any need for adjustments.97
However, it also states that “ It will be up to individual education providers to decide the content of their course based on our standards, and other sources”.98
74.We have found that there seems to be a gap between what the registration bodies require from learning institutions and what these institutions are actually providing. Witnesses have told us that inclusion of LGBT health and social care needs in curricula vary greatly across institutions. Wendy Irwin of the Royal College of Nursing told us that:
The feedback that we continually get from students is that the practice within various universities is variable. A number of nursing students have spoken to me about feeling not quite prepared for dealing with the reality of meeting patients who are complete, complex, living and breathing human beings.99
75.A related problem is that, when LGBT issues are touched upon, it tends to be within a much broader context of “inclusive healthcare” or “person-centred care” rather than dealing specifically with inequalities experienced by LGBT communities. Dr Duncan Shrewsbury told us that:
Curricula largely articulate LGBT health-related issues at quite a high level, in terms of how they orientate towards whole person care—a “no health without inclusive health” view.100
He added that, when training on LGBT issues does exist, it tends to be within the context of particular medical issues, rather than being seen as a part of the equalities framework:
You tend to find that they still feature in particular areas such as sexual and reproductive health, but increasingly also in other areas such as mental health.101
The GMC states that “equality, diversity and inclusion (ED&I) runs as a thread throughout our outcomes for education for medical students and doctors too”. However, it states that the “outcome” that newly qualified doctors must be able to demonstrate in ED&I is “clearly, sensitively and effectively with patients, their relatives, carers or other advocates, and colleagues from medical and other professions”.102 While this is relevant to working with LGBT patients, this “outcome” feels insufficient to deal with the barriers that LGBT people are facing in health and social care.
76.Understanding the real needs of LGBT people is necessary in order for health and social care professionals to truly deliver person-centred care. Those responsible for the education and training of health and social care professionals should treat training on LGBT needs with the same integral importance as other basic training. This must happen early in training and not be seen as a “specialism” to be delivered post-qualification.
77.The GMC and NMC should review their guidance for medical schools with a view to ensuring that LGBT content exists in every medical school curriculum. This content should be spread across modules rather than being restricted to modules on, for instance, sexual health.
Post-qualification training and continuing professional development
78.Training after initial qualification is equally inconsistent. Training in certain disciplines can be set by Royal Colleges, such as the Royal College of Nursing, although not exclusively. However, these bodies have more control than over curriculum design than registration bodies do over initial training. Royal Colleges and other bodies set curricula for a wide range of specialisms, from cardiology to social work. Some institutions are developing specific equality and LGBT health modules, however, these training programmes are mostly optional and are delivered at an advanced stage of health or care professional’s working life.103 This approach runs the risk of not reaching the professionals who need the training the most. As Wendy Irwin of the Royal College of Nursing told us:
What we do know about post-registration CPD for nurses is that it can be quite hit and miss. Often people do not understand how complex people’s identities are. [ … ] What we do not often see is very clear, mandatory, high quality CPD that enables nurses to do the job that they want to do, which is a great one for all patients.104
79.For GPs, who provide the most frequent frontline service for patients, Dr Shrewsbury told us that decisions on training tended to be set by CCGs, meaning that the provision is even more uneven:
There is no formal structured and delivered training programme that is rolled out for all people in their post-qualification training. It is very much set and determined by local needs that are identified and matched to local resources. It can be quite variable and it can be quite hit and miss, to a certain extent.105
Dr Shrewsbury nevertheless emphasised the role of Royal Colleges in the training landscape, saying that the Royal College of GPs had e-learning available to GPs who wanted to use it.106 The GMC also told us about the post-graduate curricula content that it is responsible for, but was unable to provide an accurate picture of which content covered LGBT needs.107
80.We would urge the GMC to look again at its curricula to truly assess whether the mandatory training for these specialties includes LGBT content and, if they are found lacking, to revise them.
81.Witnesses were critical of e-learning in equalities , with Dr Shrewsbury telling us that:
You have to do your [equality and diversity] modules every year. It is all done online. It is not a particularly engaging means of teaching somebody about something that is really complicated, dynamic and ever-changing—a lot of these things have not been updated for a couple of years.108
82.Even when training is delivered in person, our witnesses told us that the content left much to be desired. Sophie Meagher of the LGBT Foundation gave an example of where stereotypes were being used instead of an holistic approach:
We know that first-year students had one case study of a LGBT person—it was a gay man who caught HIV and his life spiralled and everything went terribly for him—and that was the only time in that whole year that they learned about LGBT people.109
83.Training can be the first exposure that students have to LGBT health needs. All registration bodies should ensure that case studies featuring LGBT people are included in courses in a way that does not play into stereotypes. Registration bodies should develop these case studies in cooperation with local LGBT organisations.
Registration of individual professionals in health or social care
84.The registration requirements for health and social care vary from none at all for care workers to over a decade of training for consultant doctors. We were particularly concerned about the lack of any registration or qualification requirement in England to work as a care worker or to offer mental health services.
85.In the care sector, care workers who work for agencies or in care homes are indirectly inspected by the CQC and are expected to be able to demonstrate inclusive behaviours.110 This covers scenarios where social care workers will have received their training and education in other countries. In all cases, it is the responsibility of the employer to ensure that, if inspected, staff can demonstrate understanding of the UK’s equality law framework and practice.
86.In mental health and counselling services, while professionals may choose to register with trade organisations such as the British Association for Counselling and Psychotherapy (BACP), or the Health and Care Professions Council (HCPC) this is not mandatory. This means that, in effect, such workers may, at best, be ignorant of equality law and, at worse, be causing harm to their patients with practices such as conversion therapy. Dr Joanna Semlyen of the University of East Anglia told us that:
We have people offering lay interventions without any qualification. People can set themselves up, or people can describe what they are doing in a faith setting as mental health support.111
87.If someone works outside of a formal organisational structure, for example as a personal assistant (PA) to a disabled person, they would not be subject to CQC inspection and any discrimination may go unchecked. As Dr Ju Gosling of Regard told us of their research with users of self-directed care, they found that:
More than half of those surveyed said that they never or only sometimes disclosed their sexual orientation or gender identity to their PAs, and less than a third said they were very comfortable with talking about their support needs in relation to being LGBTQI+. More than a third said they had experienced discrimination or received poor treatment from their PAs because of sexual orientation or gender identity. This went all the way to somebody being sexually assaulted, having told the PA that they were gay.112
88.In the regulated professions (e.g. doctors and nurses), on the other hand, there are rigorous registration processes for, for instance, doctors who have qualified outside of the UK (which accounts for over a third of doctors currently practicing). Both the Nursing and Midwifery Council and General Medical Council outlined the processes they have in place to ensure that medical professionals are trained up to UK standards, which include being tested on the Equality Act 2010.113
89.The Government should consult on ways in which effective knowledge and understanding of unacceptable discriminatory practices and the Equality Act could be ensured amongst the widest range of health and social care providers. This should include staff feeling empowered to take action when they are aware of LGBT discrimination. All NHS and social care providers should ensure these expectations are embedded into their interactions with new patients or residents and provide staff with the relevant training so they feel confident in challenging discriminatory behaviour. The CQC might consider how to strengthen the monitoring of these issues as part of their existing inspection regime.
Identifying and dealing with poor practice
90.While many of the barriers for LGBT people accessing health and social care seem to stem from misunderstanding and ignorance, we did hear of specific incidences of outright discrimination and poor practice. Some instances of discrimination may seem minor to outsiders, but can and do cause considerable distress to the individual concerned. These low-level acts were described as “micro-aggressions” by witnesses,114 events that, over time, wear down an LGBT person and cause them to lose confidence in the institutions that are meant to provide their care. The Encompass Network, an LGBT charity, gave an example of this in their evidence:
Ignorance and awkwardness took the form of inappropriate terminology, describing heterosexual sex as “proper” sex, or inappropriate comments such as “nurse said she could never be a lesbian because she had seen so many disgusting vaginas”.115
91.In cases of direct discrimination, it is very difficult for LGBT people to know how to complain and whether their complaint will be taken seriously. In common with other groups, LGBT people may be at their most vulnerable when accessing health or social care, but they are also less likely to have family support during these times, thus increasing their vulnerability.116 One participant in our outreach session observed that
We are expected as patients to complain but don’t always have strength or time [ … ] lots of this is left to charities.117
92.Beyond this, it seems that some healthcare providers are ignoring the problem, for fear of negative exposure. For example, one trans man in our outreach session spoke about trying to access mental health services and A&E. He said that some NHS staff use transphobic and homophobic slurs, which he was able to hear on the ward. This made him feel unsafe as an LGBT person. He said that this was especially acute in one hospital:
I am talking about stuff like nurses talking about killing gay people … the hospital was terrified to have this talked about, [to have it known] that it was happening in our city.118
93.Stonewall’s 2015 report Unhealthy Attitudes made a similar finding, stating that a quarter of patient-facing staff had heard negative remarks being made about LGB people in five years preceding the survey.119 The report also found that one in six (16 per cent) of health staff would not feel confident challenging such language.
Taking forward complaints
94.Complaints about the standard of care provided by health and social care professionals need to be taken through the relevant NHS or care processes, ultimately ending with one of the two ombudsmen that are responsible,120 if the matter remains unresolved. But these processes take a long time and often individuals do not have the knowledge or confidence to take them forward.121 This may especially be the case with LGBT communities as making a complaint would involving “outing” themselves multiple times to different agencies. When we asked about this, Helen Jones of MindOut, an LGBT mental health charity told us that her solution would be increased support to make complaints:
We need more advocacy services. Independent advocacy is really vital for people to be able to complain. We run a lot of advocacy services in Brighton and Hove, and even where people do not want to take the issue forward themselves—for all sorts of reasons they may not—we can take issues forward as collective concerns. That can be really useful.122
95.We agree that advocacy services can be a way to increase access for LGBT people who have concerns about their care. We also feel that more and clearer information is required to help LGBT people to take a complaint forward. The Government should help fund more capacity in national health advocacy services as part of the LGBT Action Plan. The GMC and NMC should, in addition to this, produce information specifically for LGBT patients that clearly explain what level of service they can expect from their doctor, nurse or midwife and how to complain if they encounter discrimination.
Inspection
96.One of the ways of more efficiently identifying and dealing with non-inclusive practice is through the existing inspection regimes, the majority of which falls to the Care Quality Commission (CQC). The LGBT Action Plan specifically includes the CQC within its commitments, saying that:
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. The Care Quality Commission will develop guidance for care quality inspectors on the healthcare pathway for people who are transitioning their gender, and embed LGBT equality issues into the methodology used by inspectors.123
97.Debbie Ivanova of CQC told us that much of this framework is already in place through the CQC’s “key lines of inquiry”:
Within our key lines of inquiry, we have very specific prompts and questions about equality. Under our questions on “safe”, we will make sure that people are not discriminated against. If people felt they were discriminated against because of their faith, religion or sexual orientation, we would follow that through and make sure they had access to complaints and were able to do that.124
Ms Ivanova told us that there is work still to be done with health and social care providers to move them away from a view that “person-centred” means that everyone is treated the same and to a better understanding of the individual needs of LGBT people.125
98.While the steps that the CQC have been taking to ensure that inspections are looking for evidence of LGBT-inclusive practice, inspection cannot always be the solution as it cannot uncover every incident of poor practice.
99.The CQC should conduct a thematic review of social care services for LGBT people which should include examples of best practice and guidance to social care providers around how to create LGBT-inclusive care services.
100.CQC and NHS England should work together to produce a guide to making complaints along with an online form that can be used to ensure that complaints are received by the appropriate body to address them.
91 Stonewall, Unhealthy Attitudes (2015), p 15
92 Q95
93 Q109, Q129
95 Health and Care Professions Council, ‘Regulating further professions’, accessed 24 September 2019
97 Nursing and Midwifery Council, Future nurse: Standards of proficiency for registered nurses (March 2018), p 6
99 Q26
100 Q24
101 Q24
103 Qq25–26
104 Q10
105 Q24
106 Q24
108 Q24
109 Q28
110 Care Quality Commission, ‘Regulation 10: Dignity and Respect’, accessed 24 September 2019
111 Q79
112 Q117
114 Q2, Q33
116 Q112
117 See Appendix
118 See Appendix
119 Stonewall, Unhealthy Attitudes (2015), p 6
120 The Parliamentary and Health Service Ombudsman or Local Government and Social Care Ombudsman
122 Q81
123 Government Equalities Office, LGBT Action Plan (July 2018), p 10
124 Q109
125 Q109
Published: 22 October 2019