Treating patients with dignity and respect is essential to ensuring a good health service. This should incorporate all patients and not be conditional to race, ethnicity, gender identity, religion, disability or sexual orientation. Everyone has the right for their healthcare needs to be considered and, where possible, met. However, too often this parity of care is not a reality.
Discrimination in care
Numerous reports highlight how people in the lesbian, gay, bisexual and transgender (LGBT) community have faced discrimination or a lack of support when accessing health and social care services (Hunt and Dick, 2008; Hunt and Fish, 2008; Guasp and Taylor, 2012; Somerville, 2015). Discrimination can lead to sub-optimal care, through poor communication and adherence to treatment, and undermine the mental wellbeing of patients (Allmark et al, 2010).
An update to the Equality Act 2010 included a public sector equality duty to eliminate discrimination, advance equality of opportunity, and foster good relations between different people when carrying out their activities (HM Government, 2011). Despite this, a quarter of patient-facing healthcare staff have heard colleagues make negative remarks about LGB people or use discriminatory language (Somerville, 2015). One in five have heard similar negative remarks about transgender people. Further, 1 in 20 patient-facing staff have witnessed colleagues discriminate against or provide a patient or service user with poorer treatment because they are LGB (Somerville, 2015).
The extent to which this discrimination prevails is highlighted by the statistic that 1 in 14 lesbian and gay people expect to be treated worse than heterosexuals when accessing health care for a routine procedure or an emergency procedure—and 8% have the same expectations about general practice (Hunt and Dick, 2008). One survey found that 1 in 7 transgender people felt they had been treated adversely by health professionals because of their transgender status (Allmark et al, 2010).
This discrimination is felt equally by those providing health care, with a quarter of LGB health and social care staff saying they have personally experienced bullying or poorer treatment from colleagues owing to their sexual orientation (Somerville, 2015). This has led to many feeling the need to hide their sexual orientation at work.
What needs to change?
Further education is required around the specific considerations and needs of patients who identify as LGBT to fill major gaps in the knowledge and training of staff. Currently, 10% of healthcare workers say they are not confident in their ability to understand and meet the needs of LGB patients and service users (Somerville, 2015).
The National Ambulance LGBT Network, set up in 2015, is working to tackle discrimination and health inequality among LGBT patients through the development of support packages, a resource base and a dedicated website (Gunn and Renshaw, 2018). The NHS England Lesbian Gay Bisexual and Trans (LGBT+) staff network was also set up in 2015, with the aim of creating an inclusive and diverse working environment that encourages respect and equality for all. Acting as an LGBT+ champion, it raises awareness of LGBT+ staff issues and actively influences NHS policies and strategies affecting LGBT+ patients. These staff networks should be supported to contribute to the workforce and service delivery outcomes of their organisation. If help is needed to do this, adequate support should be provided.
Healthcare needs
It must be recognised that sexual orientation can impact health needs. Almost six in ten health and social care workers do not feel sexual orientation is relevant to health needs (Somerville, 2015), yet studies have shown 15% of lesbian and bisexual women over the age of 25 have never had a cervical screening test, compared with 7% of women in general (Hunt and Fish, 2008). Additionally, less than half of lesbian and bisexual women have ever been screened for sexually transmitted infections (Hunt and Fish, 2008). It has been reported that the risk of an anxiety disorder or depression among LGB people is at least 1.5 times higher than heterosexuals (Equality and Human Rights Commission (EHRC), 2010). These figures highlight a number of specific considerations that need to be factored in when looking after these patient populations.
Feelings of being misunderstood by the health service are regularly reported by patients from the LGBT community. For example, many gender dysphoria patients have expressed frustration that their GP does not support their desire for gender reassignment (EHRC, 2010). Most GPs do not have the expertise to provide adequate holistic treatment for these patients. This means that the role they are providing is neither safe, nor effective. At the very least, more prescribing and monitoring support is needed for GPs—but ideally, care should be provided by GPs with a special interest in gender identity, and who have undergone sufficient training.
Workplace culture
Workplace cultures must become truly inclusive. Currently, not every ambulance service is a member of Stonewall's Diversity Champions Programme, where organisations commit to ensuring LGBT staff are accepted without exception in the workplace. Additionally, the North East Ambulance Service NHS Foundation Trust is the only ambulance service listed in the Workplace Equality Index's Top 100 Employers (Stonewall, 2018). London Ambulance Service NHS Trust and South East Coast Ambulance Service NHS Foundation Trust previously featured. Although many employers compete for a place in this list, ambulance services should also strive for inclusion.
Training
Health organisations, including ambulance services, need to ensure that training on equality and diversity is properly implemented. Not only should this cover bullying and harassment, but also the use of language and practices that are inclusive of the LGBT community. There should be a zero-tolerance policy on bullying and abuse related to sexual orientation and gender identity. It is not right that many staff feel obliged to mask their identity for fear of intolerance from colleagues. This training should be updated on a regular basis so that staff remain mindful of appropriate and unacceptable practices in the workplace.
Conclusions
The nature of the work undertaken by ambulance staff means that they deal with the public on a daily basis. It also means they provide care to all members of society. Treating patients fairly and meeting their individualised needs is an essential commitment for every ambulance service. This equality should be extended to the workplace, so staff can feel supported regardless of their sexual orientation, and not face bullying or discrimination. Though education and awareness of LGBT issues is slowly improving, there is still a long way to go if true equality and diversity is to be achieved.