Sexual orientation A practical guide for the NHS

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Sexual orientation A practical guide for the NHS
Sexual orientation
A practical guide for the NHS
Sexual orientation A practical guide for the NHS
DH InformatIon reaDer box

Policy                                Estates
HR/Workforce                          Commissioning
Management                            IM & T
Planning/                             Finance
Clinical                              Social Care/Partnership Working

Document Purpose      Best Practice Guidance
Gate reference        9755
title                 Sexual orientation: A practical guide for the NHS
author                Department of Health/EHRG
Publication date      February 2009
target audience       PCT CEs, NHS Trust CEs, SHA CEs, Foundation
                      Trust CEs, Directors of PH, Directors of Nursing,
                      NHS Trust Board Chairs, Special HA CEs,
                      Directors of HR, GPs
Circulation list

Description           This document gives practical advice to
                      enable NHS organisations to address their
                      responsibilities relating to sexual orientation
                      and employment or healthcare delivery
Cross reference       N/A
Superseded Docs       N/A
action required       N/A
timing                N/A
Contact details       Equality and Human Rights Group
                      Department of Health
                      Skipton House
                      80 London Road
                      London SE1 6LH
                      020 7972 5097
for recipient’s Use
Sexual orientation:
                                                                        A practical guide for the NHS

Foreword                                                                                     2

Executive summary                                                                            3

Section One: Context                                                                         4
Part One – Legal requirements and policy implications                                        5
Part Two – How the legal requirements are the same as other equality strands,
           and how they differ                                                              14

Section Two: Process – How to work with staff and patients                                  18
Part One – Understanding the needs of lesbian, gay and bisexual staff                       19
Part Two – Assessing and implementing policies, practices and procedures for staff          24
Part Three – Involving lesbian, gay and bisexual staff                                      29
Part Four – Understanding the needs of lesbian, gay and bisexual patients                   31
Part Five – Assessing and implementing policies, practices and procedures for patients      44
Part Six – Involving lesbian, gay and bisexual people                                       47

Section Three: Resources                                                                    50
Worksheet 1: Action planning framework for lesbian, gay and bisexual staff                  51
Worksheet 2: Action planning framework for lesbian, gay and bisexual patients               56
Worksheet 3: Delivering inclusive services to gay men and men who have sex with men         62
Worksheet 4: Delivering inclusive services to lesbians and women who have sex with women    64
Worksheet 5: Delivering inclusive services to people who are bisexual                       66
Worksheet 6: Getting everyone on board – frequently asked questions                         67
Worksheet 7: Encouraging disclosure from service users and patients                         69
Worksheet 8: Setting up a lesbian, gay and bisexual staff network                           70
Worksheet 9: Monitoring staff                                                               71
Worksheet 10: Working with lesbian, gay and bisexual staff – a ten point action plan        73
Worksheet 11: What help is available                                                        75

Contacts                                                                                    82

                                                                                           Contents 1

                                                     As an employer and a provider of healthcare
                                                     services, the NHS should not only comply
                                                     with the law but should also aspire to be an
                                                     exemplar of good practice and seek to ensure
                                                     that its services and employment practices
                                                     respond to the needs of the whole of our
                                                     society. This means that it is essential that we
                                                     strive to take account of everyone’s needs, in
                                                     the design and delivery of all our services
                                                     – including people from the lesbian, gay and
                                                     bisexual community. It is also essential that
    This guide is part of a suite of guidance        we strengthen our role as an inclusive
    which seeks to equip NHS staff at all levels     employer by removing barriers that might
    – whether as employers or employees, or as       prevent us from attracting, recruiting,
    service providers, commissioners or planners     developing and retaining people with the
    – to understand the needs of all people.         best skills and aptitude to make their careers
                                                     in the NHS.
    There is increasing evidence of the health
    inequalities experienced by patients and         This guidance should create new work
    service users as a result of their sexual        programmes and activities that will enable
    orientation and how this can be addressed        NHS organisations to be more inclusive
    through better access and targeted               workplaces, reduce health inequalities
    intervention. Increasing protection under the    experienced by lesbian, gay and bisexual
    law highlights the rights of lesbian, gay and    people and help us achieve the priorities set
    bisexual people to receive equal treatment in    out in the NHS Operating Framework 2008/9.
    the same way as everyone else.

    Other existing public sector equality duties,
    ongoing reform towards personalised services
    and World Class Commissioning present a
    real opportunity for NHS organisations to
    reconsider the design of services to take full
                                                     Surinder Sharma
    account of the equalities agenda. By
                                                     National Director for Equality and Human
    developing expertise and implementing the
                                                     Rights, Department of Health
    lessons learnt, we can embed equality at the
    heart of all functions and structures and
    contribute to a better understanding of our
    staff and more informed, personalised
    patient care.

Sexual orientation:
                                                                          A practical guide for the NHS

Executive summary

This guidance document, produced by the           However, in developing an SES, it is
Department of Health (DH), gives practical        important to understand that there are
advice to NHS organisations to help them          significant differences between the legal
comply with recent equality legislation,          requirements for the different equality
understand the role of sexual orientation in      strands that must be understood in order
the context of healthcare, and integrate this     that they are complied with. This guidance is
knowledge into single equality schemes (SES).     designed to assist NHS organisations to
Other guides in this series cover disability,     implement and comply with the requirements
gender, religion or belief, and trans people.     of legislation on sexual orientation enacted
Age Concern are producing a companion             recently, and also provides general practical
guide to age equality. The Race for Health        guidance around the issues that fall out of
programme provides extensive guidance and         that for the NHS.
support for the NHS on issues of race.
                                                  The guidance will provide a workbook and a
Many NHS organisations will already be            one‑stop shop for information about the
working towards developing an SES. A single       legislation and its impact. It will take readers
equality approach helps to bring together         through the steps necessary for equality
parallel strands of key systems, for example      impact assessment and planning for the
equality impact assessment, data collection       integration of issues of sexual orientation
etc, needed to respond to the specific duties     during the development of overall equality
of the different equality laws. This helps to     schemes. Many of the processes, such as
utilise expertise and scarce resources more       equality impact assessment and consultation,
effectively. It also contributes to a better      are similar to those described for the other
understanding of staff and workforce issues       equality strands, but the guidance will
and encourages a personalised approach to         highlight any areas that need special
patient care, treating patients as individuals.   attention for sexual orientation and will also
A combined approach will help to minimise         provide a handy reference for cohesive and
the number of requests for information and        collaborative working.
ensure that key personnel, for example public
health analysts, service managers,
administrative and frontline staff, are
encouraged to work together to ensure a
co‑ordinated approach to achieving
equality of outcomes.

                                                                                     Executive summary 3
Section One: Context

Sexual orientation:
                                                                          A practical guide for the NHS

Part One – Legal                                  was decriminalised, people stopped using
                                                  these words.

requirements and                                  Some men may be in opposite‑sex
                                                  relationships but engage in sexual activity
policy implications                               with people of the same sex. Healthcare
                                                  providers should not assume that men in this
This part begins by setting out some              situation are gay, but should instead discuss
definitions. It then summarises the legislation   behaviour. Healthcare providers should also
which gives rights to equal treatment             consider the impact that any disclosure may
regardless of sexual orientation, and provides    have on partners and therefore take steps to
practical illustrations of how the legal          be discreet. Men in these circumstances may
framework impacts on health and social care       not respond to preventive healthcare
providers and commissioners.                      messages in the same way as openly gay
                                                  men. This has long‑term implications relating
                                                  to sexually transmitted infections and other
What is ‘sexual orientation’?                     communicable diseases.

Sexual orientation refers to the general          Homophobia is defined as hostility or
attraction a person feels towards one sex or      prejudice based on a person’s status (actual
another (or both). Most people are familiar       or perceived) as a lesbian woman or a gay
with the terms ‘heterosexual’ or ‘straight’,      man, or someone who is attracted to
where people are attracted to the opposite        someone of the same sex even if they do not
sex. Other people are attracted to people         call themselves LGB. It can lead to
who are the same sex as them (lesbian or          discrimination, bullying, harassment and, at
gay) or people of both sexes (bisexual).          its worst, violent hate crime against LGB
                                                  people or those who are thought to be LGB.
Women who have a sexual orientation
towards other women are often referred to         There are two issues to note, which will be
as lesbian, while men who have a sexual           referred to again elsewhere in this guidance.
orientation towards other men are referred to     First, most lesbians, gay men and bisexuals
as gay (although gay can also be used as a        would consider that their sexual orientation is
generic term for both lesbian and gay             only one aspect of who they are. In addition,
sexuality). Those people who have a sexual        they will have a gender, an ethnic and
orientation towards both their own and the        cultural identity, possibly a disability, a
opposite sex are usually referred to as           religious or non‑religious belief, and of
bisexual. These three groups make up what         course they will have an age – in other
is sometimes referred to as the LGB – lesbian,    words, they will have ‘multiple identities’.
gay and bisexual – community.                     Each of these other aspects may have an
                                                  impact on how they are seen by people from
Generally speaking, the worlds homosexual         different groups, whether at work or when
and homosexuality are outdated. These             using the health service. It can also affect the
words used to describe the ‘medical illness’      services that they need and the way these
of being gay and therefore when being gay         need to be provided. This guide will discuss in
                                                  later sections what consideration needs to be

                                                                                               Context 5
given to issues of multiple identities, which      laws which seek to achieve greater equality
    will support any trust’s work towards a single     on the grounds of sexual orientation. It is for
    equality scheme.                                   these reasons that the NHS has
                                                       commissioned separate guidance on trans
    The second issue to note at this stage is that     employment and healthcare (Trans: A
    sometimes reference is made to LGBT                practical guide for the NHS). However, trans
    equality, where the ‘T’ stands for trans           people, like everyone else, have a sexual
    people. There are a small but significant          orientation, and might be heterosexual,
    number of people born each year whose              lesbian, gay or bisexual.
    gender identity does not match the
    appearance and/or anatomy with which they          Towards LGB equality
    were born. A trans person is a person who
    adopts the opposite gender to the one              Recently, a number of legal measures have
    assigned at birth. It is a term which embraces     required people to be treated equally
    different expressions of gender identity –         regardless of sexual orientation.
    including transvestite, transsexual and the
    different points a trans person goes through
    when they undergo a medical procedure to
                                                       • In 2001, the age of consent was equalised
                                                         at 16 for all
    acquire their new gender identity. The
    process is known as ‘gender reassignment’.
    The term also includes people living in their
                                                       • In 2003, the Employment Equality (Sexual
                                                         Orientation) Regulations made it unlawful
    new gender.                                          to discriminate against a person in
                                                         employment and training on the grounds
    Sometimes, issues of sexual orientation and          of sexual orientation
    gender identity have been aligned as if they
    were very similar. It is true that individuals
    from both groups have been treated unfairly
                                                       • Since November 2004, the Civil
                                                         Partnership Act has given same‑sex
    in the past because of a lack of                     partners clear legal rights, similar to
    understanding about their identities, and            those previously only available to married
    similar prejudices may apply to both. At one         couples
    time, both groups may have been thought of
    as challenging established sexual behaviour,
    and were treated similarly because of this.
                                                       • Since April 2007, the Equality Act (Sexual
                                                         Orientation Regulations) 2007 has
                                                         prohibited discrimination on grounds
    LGB and trans people have undoubtedly                of sexual orientation in the provision of
    benefited from sometimes campaigning                 goods, facilities and services.
    together for greater equality. However, sexual
    orientation and gender identity are different
    issues. They raise different questions of how
                                                       Equality at work
    to promote equality and eliminate
                                                       The Employment Equality (Sexual Orientation)
    discrimination. Different legal frameworks
                                                       Regulations 2003 make it unlawful to
    apply to LGB people and to trans people;
                                                       discriminate in employment or training on
    trans people have generally been included in
                                                       grounds of sexual orientation. The
    sex discrimination legislation, or have specific
                                                       Regulations apply to all aspects of
    laws relating to them under the Gender
                                                       employment and training, including
    Equality Duty, which are separate from the
                                                       recruitment, promotion, terms and conditions

Sexual orientation:
                                                                                                          A practical guide for the NHS

(including pay) and dismissals (including                               also covers discrimination on the grounds of
selection for redundancy). In essence, the                              perceived sexual orientation, whether the
Regulations mean that it is unlawful to                                 perception is correct or not. In this case,
discriminate at work against people who are                             applicants will not need to establish that they
lesbian or gay, heterosexual, or bisexual. They                         are gay to bring a complaint. If someone has
cover not only how people ‘are’, but how                                assumed them to be gay and discriminated
they are seen by others. This means that if                             against them as a consequence, that is enough.
someone thinks a person is gay (even if they                            The wording also covers discrimination by
are not), and discriminates against them, that                          association, so discriminating against
person is protected by employment law. It is                            someone because of the sexual orientation
up to employers to regulate the conduct of                              of their friends is not allowed.
their employees towards one another while
on duty, whether at work or out of the office                           Indirect discrimination is where an
on behalf of work, provided that the way                                organisation has employment rules, selection
they do this is reasonable and even‑handed.                             criteria, policies and other practices in place
                                                                        which put people of a particular sexual
Organisations may be held responsible for                               orientation, including the person who
the actions of their staff as well as their staff                       complains, at a particular disadvantage when
being individually responsible. If a person                             compared with others. Indirect discrimination
believes they have been discriminated against                           can be unlawful whether it is intentional or
at work on the grounds of sexual orientation,                           not. However, in contrast to direct
they can bring a claim for financial                                    discrimination, indirect discrimination is not
compensation for loss of earnings and injury                            unlawful if it can be shown to be justified as
to feelings and, in some cases, reinstatement                           a proportionate means of achieving a real
to their former job, at an Employment                                   business need.
                                                                        Harassment is defined as unwanted conduct
The Regulations define four types of                                    which takes place with the purpose or effect
discrimination: direct, indirect, harassment                            of violating the dignity of a person and of
and victimisation.                                                      creating an intimidating, hostile, degrading
                                                                        or humiliating environment. The test for
Direct discrimination is where one person is                            whether a person’s conduct will be seen to
treated less favourably than another person is                          have these effects is whether “having regard
treated, has been treated, or would be                                  to all the circumstances, including in
treated in a comparable situation, on grounds                           particular the perception of [the
of sexual orientation. For example, it is                               complainant], it should reasonably be
unlawful to decide not to employ someone,                               considered as having that effect.” Unwitting
to dismiss them, refuse to promote them,                                harassment is included. The fact that many
deny them training, give them adverse terms                             lesbians, gay men and bisexual people still
and conditions, or deny them benefits                                   conceal their sexual orientation,1 often for
available to others of a different sexual                               fear of prejudice, renders them particularly
orientation because they are or are thought                             vulnerable to unwitting harassment. People
to be lesbian, gay or bisexual. ‘Thought to                             can often make anti‑gay remarks on the
be’ is included because direct discrimination                           mistaken assumption that everyone present is

1   Data derived from Stonewall Diversity Champion member staff satisfaction surveys indicate that half of LGB people are not out in the

                                                                                                                                       Context 7
heterosexual, but it is clear that lack of
    intention to offend is no defence. If the            HERTFORDSHIRE PARTNERSHIP NHS
    conduct has the purpose or effect of violating       FOUNDATION TRUST
    a person’s dignity, or creating an intimidating
    environment, and it is reasonable for the            Hertfordshire Partnership NHS Trust has
    complainant to take offence, then it is              reviewed all its policies, practices and
    harassment. Ignorance is no excuse.                  procedures in line with their equality
                                                         impact assessment processes. The Trust
    Victimisation is defined as treating someone         has ensured that all policies reflect
    less favourably because they have made a             recent legislative changes to protect
    complaint or intend to make a complaint              lesbian and gay people, including
    about discrimination or harassment, or have          providing bereavement leave, adoption
    given evidence or intend to give evidence            leave or maternity/paternity leave for
    relating to a complaint about discrimination         staff who are married, in civil
    or harassment.                                       partnerships or with unmarried partners
                                                         of the same or opposite sex.
    Civil partnerships: The Regulations were
    amended when civil partnerships were       ‑us/
    established in 2004. Employers must treat            trust‑papers/human_resources_policy_
    staff who are in a civil partnership equally to      and_procedures
    those who are married, in a wide range of
    areas. Employers should therefore ensure that
                                                       There are two main exemptions where
    any benefits provided to married people
                                                       discrimination on grounds of sexual
    extend to those in a civil partnership. The
                                                       orientation may be permitted, both involving
    Regulations allow for certain benefits, such
                                                       occupational requirements. These are:
    as survivor benefits in pension schemes, to be
    conferred on civil partners and spouses to the
    exclusion of others without such a status. The     • where sexual orientation is “a genuine and
                                                         determining occupational requirement”,
    effect is that an individual who is neither in a
    civil partnership nor a marriage, whether gay
    or heterosexual, cannot claim that such a
    practice amounts to unlawful discrimination        • in the case of “employment for purposes
                                                         of an organised religion”.
    under the Regulations. However, the
    Regulations make it unlawful for an employer
                                                       In general, where either exemption applies, it
    to provide employment‑related benefits to
                                                       permits discrimination in refusing to appoint,
    unmarried opposite‑sex partners but deny
                                                       promote or transfer people of a particular
    them to same‑sex partners not in a civil
                                                       sexual orientation to a particular position, or
                                                       in dismissing them from that position
                                                       because of their sexual orientation. However,
                                                       if people are already employed (whether the
                                                       employer realises their sexual orientation or
                                                       not) then unless and until they are dismissed,
                                                       the exemptions do not allow them to be
                                                       employed on less favourable terms than
                                                       others: for example, paid less, harassed or

Sexual orientation:
                                                                            A practical guide for the NHS

In relation to the first exception, an employer    Legal recognition for same‑sex
is allowed to discriminate if “having regard to
the nature of the employment or the context
in which it is carried out... being of a
                                                   The Civil Partnership Act 2004 means that
particular sexual orientation is a genuine and
                                                   same‑sex couples can now register a civil
determining occupational requirement”.
                                                   partnership to gain legal recognition of their
It must also be “proportionate” to apply that
                                                   relationship, entitling them to similar rights
requirement. This is similar to provisions in
                                                   and responsibilities to those of a married
sex discrimination law which allow employers
                                                   couple in a wide range of legal matters.
to advertise for a worker of a specific sex, for
                                                   As well as providing important rights, civil
example a female housing worker to work
                                                   partnership also allows people to
with homeless women, although it remains
                                                   demonstrate their commitment to each other.
to be seen in what circumstances an
employer can say that sexual orientation,
                                                   Civil partners are treated equally to married
whether lesbian, gay, bisexual or straight, is
                                                   couples across a wide range of areas. These
an essential ingredient of doing a particular
job. It is possible that NHS organisations
could argue that staff who work in sexual
health clinics for men who have sex with men       • tax, including inheritance tax
would have to be gay men, or an LGB drop‑
in centre have gay volunteers, but this has yet    • most state and occupational pension
to be tested.

The other exemption allows employers who           • income related benefits, tax credits and
                                                      child support
are part of an ‘organised religion’ to apply a
requirement relating to sexual orientation
“so as to comply with the doctrines of the         • employment benefits.
religion”, or “to avoid conflicting with the       The essential point for employers and those
strongly held religious convictions of a           who deliver services is simple: treat staff and
significant number of the religion’s               patients or service users who are civil partners
followers”. This exemption requires a very         in exactly the same manner as you treat staff
high standard to apply and is very narrow in       or patients who are married. In relation to
its scope, so, for example, a religious            the health and social care sector, civil partners
organisation providing a service such as social    are the legal next of kin to any service user.
care could not discriminate on grounds of          Failure to treat a civil partner as next of kin is
sexual orientation when recruiting care staff.     likely to be discriminatory. This guidance will
                                                   help NHS organisations to apply this principle
The other parts of this guidance are designed
                                                   as an employer and in the services they deliver.
to help you to make sure that you are
treating your employees fairly and in
accordance with these Regulations, whatever
their sexual orientation.

                                                                                                 Context 9
orientation, whether the perception is, in
         “The department would not hold a                                     reality, correct or not. The General Medical
         collection for me (as with weddings),                                Council (GMC) suggests that failure to
         individually sign the congratulations                                examine or respond to a patient properly, for
         card or put a congratulations message                                example, not offering a smear test to a
         on the white board. Certain people                                   lesbian, or refusing to accept someone as a
         would blank me if I spoke about my                                   patient because of their sexual orientation,
         honeymoon… I was told I was a nice                                   could be considered direct discrimination.2
         person but they did not agree with
         what I was doing… Those who did                                      Indirect discrimination occurs where a
         congratulate me said it in private…                                  provision, criterion or practice which is
         the two line managers that support                                   applied equally, puts a person of a particular
         my lifestyle did not openly support me,                              sexual orientation at a disadvantage as
         that is, they said nothing.”                                         compared to some or all persons who are not
         Nancy (Community specialist podiatrist)                              of that orientation and which cannot be
         South East, Being the gay one,                                       reasonably justified by reference to matters
         Stonewall (2007)                                                     other than that person’s sexual orientation.
                                                                              Indirect discrimination is more complex than,
                                                                              and often not as obvious as, direct
     Equal access to goods, facilities                                        discrimination.
     and services
                                                                              Just as the 2003 Employment Regulations
     The Equality Act (Sexual Orientation                                     ensure that gay, bisexual and straight
     Regulations) 2007 makes it unlawful to                                   employees are treated equally, these laws
     discriminate on grounds of sexual orientation                            extend that protection to service users.
     in the provision of goods, facilities and                                Similar laws already protect service users from
     services and the exercise of public functions.                           discrimination on grounds of their race,
     They cover both the private and public                                   gender and disability, and laws that came
     sectors, including healthcare, and a wide                                into force at the same time as the Sexual
     range of other areas. The Regulations make                               Orientation Regulations protect customers
     two key kinds of discrimination unlawful:                                and service users from discrimination on the
     direct discrimination and indirect                                       grounds of religion or belief or lack of
     discrimination. Victimisation is also covered –                          religion or belief.
     so it is unlawful to treat someone less
     favourably because they have complained or                               The Regulations give protection against
     have brought proceedings or intend to do so.                             discrimination to everyone, whether they are
                                                                              lesbians, gay men, heterosexuals or bisexuals.
     As with employment law, direct                                           The laws apply if discrimination occurs on
     discrimination takes place when a person, on                             grounds of the sexual orientation of the
     grounds of sexual orientation (or perceived                              person being less favourably treated or on
     sexual orientation), treats another person less                          the grounds of the sexual orientation of any
     favourably than he treats or would treat                                 other person.
     others. Direct discrimination also covers
     discrimination on grounds of perceived sexual

     2   Protecting patients: your rights as lesbian, gay and bisexual people, General Medical Council and Stonewall leaflet (2007)

Sexual orientation:
                                                                         A practical guide for the NHS

There are a small number of exemptions to
discrimination under the Regulations. Certain       CHARING CROSS HOSPITAL –
restrictions imposed by religious organisations     THE ORANGE CLINIC
are excepted where this is necessary to
comply with the doctrine of the organisation,       The West London Centre for Sexual
or to avoid conflicting with the strongly held      Health (Chelsea and Westminster
religious convictions of a significant number       Hospital NHS Foundation Trust)
of a religion’s followers. This will protect        recognised that lesbian and bisexual
practices that arise from basic doctrines of        women were less likely to take up
faith, such as religious celebrations, but not      opportunities for sexual health
where a religious organisation is operating on      screening and cervical screening
a commercial basis or providing services to         because general healthcare providers
the community on behalf of and under                sometimes do not understand lesbian
contract with a public authority. At that           health needs. The Centre therefore set
point, the rights of lesbian, gay and bisexual      up the weekly Orange Clinic which
people not to be discriminated against in           provides a unique health service to
accessing those services come to the fore. So       women who have sex with women.
again, a healthcare provider established by a       Located in the West London Centre for
religious organisation is unlikely to lawfully      Sexual Health, the clinic is promoted
be able to refuse to make its services              through magazines and internet spaces
available to gay, lesbian or bisexual people.       aimed at lesbians and bisexual women.
Having decided to serve the public, the             The Clinic offers services that include
organisation cannot choose which sections of        screening for sexually transmitted
the public they will and will not serve.            infections, hepatitis B vaccinations,
                                                    cervical smear taking and sexual health
The Regulations also include an exception           education and promotion. The clinic
which allows education, training and welfare        also provides safer sex advice, free
services to be provided in such a way as to         condoms, dental dams and gloves.
meet the special needs of persons on the
basis of their sexual orientation. One example‑sexual‑health/
where this could apply is the addressing of         west‑london‑centre‑sexual‑health.html
the low take‑up of mainstream sexual health
services among lesbians, gay men or bisexual
                                                  There is special provision in the Regulations
                                                  for persons operating a blood service, such as
                                                  the National Blood Service (NBS). Such
                                                  services are allowed to reasonably exclude
                                                  donations by persons where this is based on
                                                  an assessment of risk to the public based on
                                                  clinical, epidemiological and other data
                                                  obtained from a reliable source. This
                                                  exception could cover the refusal of
                                                  donations from gay men, where this meets
                                                  the legislative criteria such as being tied to
                                                  close and regular monitoring of blood
                                                  samples from people donating blood in the
                                                  UK. The current policy of the NBS is that they

                                                                                            Context 11
do not accept blood donations from men                                    Resolving issues
     who have sex with men (or from women
     who have sex with men who have had sex                                    Some people consider that their religion or
     with men in the past).3                                                   belief prohibits same‑sex relationships, and
                                                                               employers and service deliverers can be
     Harassment in the provision of goods,                                     concerned about whether it is possible to be
     facilities and services is not specifically                               fair to everyone in a situation where the two
     covered by the Regulations, but in many                                   issues may appear to be in conflict.
     cases, harassment – usually defined as
     unwanted conduct that has the purpose or                                  It is true that some religions or beliefs
     effect of violating a person’s dignity or                                 prohibit same‑sex relationships. However,
     creating an intimidating, hostile, degrading                              while one person’s religious convictions
     or humiliating environment for them – on the                              should be respected, a lesbian, gay or
     grounds of sexual orientation could amount                                bisexual person has an equal right to respect
     to less favourable treatment on the grounds                               and should not be discriminated against. It is
     of sexual orientation. The patient or service                             in fact unlawful to do so under the 2007
     user could therefore have a claim under                                   Regulations. All staff involved in healthcare
     the Regulations.                                                          provision should take steps to inform
                                                                               themselves (and educators and managers
     Where a person believes they have been                                    should ensure that this happens) of the
     discriminated against in the provision of                                 requirement that patients or service users be
     goods, facilities and services, they can bring                            treated fairly regardless of sexual orientation,
     a claim in the County Court for financial                                 and of what this means, for example, not
     damages, and/or for a declaration or                                      making assumptions about what services are
     injunction, to make the service provider do                               or are not appropriate, and not refusing to
     something or stop doing something.                                        provide treatment except in circumstances
     Generally, service users who have                                         covered by the Regulations.
     experienced discrimination from NHS
     organisations are encouraged to follow the                                The GMC sets out the principles of good
     complaints procedures of that organisation,                               practice in its core guidance to doctors, Good
     and only go to County Court if the matter                                 Medical Practice.5 It tells doctors:
     has not been resolved. It is hoped that the
     goods, facilities and services regulations                                        “You must not unfairly discriminate
     will lead to an improvement in the delivery                                       against [patients] by allowing your
     of services, rather than an increase in                                           personal views…about sexual
     litigious cases.4                                                                 orientation… to affect adversely your
                                                                                       professional relationship with them or
                                                                                       the treatment you provide or arrange.”

     3   In addition, exemptions or transitional arrangements which are less relevant here apply to:
         • insurance companies who can use actuarial data about sexual orientation in order to assess premiums, although this was due to be
             reviewed during 2008;
         • religious adoption agencies who had until the end of 2008 to adapt their practices in order to comply with the new legislation;
         • charities who can focus on a particular group if they were established to benefit specific people on the basis of sexual orientation;
         • private members’ clubs where sexual orientation is specifically linked to the club’s purpose (if it is not, the club must treat everyone
             equally and allow equal access).
     4   Your rights as an LGB patient
     5   General Medical Council Good Medical Practice (2006) www.gmc‑

Sexual orientation:
                                                                      A practical guide for the NHS

     “…You must not express to your
     patients your personal beliefs, including   The BRITISH MEDICAL ASSOCIATION
     political, religious or moral beliefs, in   (BMA)
     ways that exploit their vulnerability or
     that are likely to cause them distress.”    In June 2005, the BMA developed
                                                 guidelines on sexual orientation. These
This guidance applies to doctors’ personal       guidelines explore equality and diversity
beliefs about sexual orientation; it sets a      strategies for doctors in the workplace,
good standard for all staff involved in          and provide information about service
providing healthcare.                            delivery. The development of these
                                                 guidelines demonstrates a commitment
It may be that the situation can be resolved     by the BMA to create a practice that is
without offence to either party by speaking      safe and non‑discriminatory. This
to the person who is refusing to carry out       guidance is intended to provide doctors,
duties and reminding them of NHS equality        managers, human resource managers
policies which apply to everyone, and of the     and other healthcare related staff with
fact that discrimination on grounds of sexual    essential information for preventing
orientation is also unlawful. It would also be   discrimination based on sexual
sound practice to speak to local trade union     orientation.
representatives and/or religious staff
networks on these issues and agree a joint       The guidelines provide some practical
policy on how to proceed in such situations,     steps to help create an inclusive
to ensure consistency in dealing with them       workplace and service for LGB people.
before they arise. Homophobic behaviour          Some of the initiatives that are
should not be tolerated under any                recommended in the guidelines include
circumstances.                                   creating awareness of the current
                                                 legislative protection for gay people
Worksheet 6 sets out ways of managing            within the medical profession, providing
resistance to sexual orientation equality from   confidential counselling services for gay
other staff, whether or not this is related to   colleagues and regularly reviewing the
religious or other beliefs.                      medical curricula to reflect equality and
                                                 diversity for LGB people.


                                                                                          Context 13
Part Two –                                       apply for or take up a job or access training
                                                      and that it is reasonable to expect the
                                                      employer to make, in terms of cost and
     How the legal                                    difficulty, having regard, for example, to its
                                                      size and budget. A failure to make a
     requirements are                                 reasonable adjustment is in itself
     the same as other                                A second important difference between the

     equality strands,                                different areas of equality is that protection
                                                      from age discrimination in employment is

     and how they
                                                      qualified; employers are allowed to justify
                                                      conduct that is, on the face of it, overtly or
                                                      directly discriminatory. Neither of these
     differ                                           approaches applies to sexual orientation:
                                                      there is no wider concept of reasonable
     This part considers how sexual orientation       adjustments or failure to make them. In
     equality sits within a single equality scheme    addition, direct discrimination on the grounds
     (SES), and how existing equality work by NHS     of sexual orientation cannot be justified. This
     bodies can be extended or adapted to cover       makes the test for direct sexual orientation
     sexual orientation.                              discrimination relatively straightforward: has
                                                      a person been treated less favourably than
                                                      someone of a different sexual orientation? In
     Similarities and differences                     the case of indirect discrimination, you have
                                                      to ask: was a policy or practice applied which
     Broadly, the requirement not to discriminate
                                                      had a disproportionate impact on people of a
     on the grounds of sexual orientation in
                                                      particular sexual orientation? If so, could this
     employment and training gives the same
                                                      be justified?
     protection as that provided in employment
     for gender including trans status, race or
                                                      The protection from discrimination on the
     ethnicity, disability, religion or belief, and
                                                      grounds of sexual orientation in providing
     age. Concepts of direct and indirect
                                                      goods, facilities and services is again very
     discrimination, harassment, victimisation and
                                                      similar to that applying to gender including
     discrimination by association are similar
                                                      trans status, race or ethnicity, disability and
     – though not identical – across all the
                                                      religion or belief. There is no protection at
     different equality areas. Some differences
                                                      present from age discrimination in relation to
     exist: for example, there may be specific
                                                      delivery of services or provision of goods/
     exemptions in each area.
                                                      facilities. Service providers are, like employers,
                                                      required to make reasonable adjustments for
     In addition, disability discrimination law is
                                                      disabled service users, but not for other
     based on the concept not just of less
     favourable treatment but also of requiring
     employers to make ‘reasonable adjustments’
                                                      Perhaps the most significant difference
     for disabled applicants, employees and
                                                      between sexual orientation and the grounds
     trainees. A reasonable adjustment is an
                                                      of race and ethnicity, gender, and disability is
     adaptation that enables a disabled person to

Sexual orientation:
                                                                           A practical guide for the NHS

that there is not, as yet, public or positive
duty relating to sexual orientation. However, it     QUEEN MARY’S SIDCUP NHS TRUST
is expected that organisations will integrate
actions to address issues on sexual orientation      The Queen Mary’s Sidcup NHS Trust has
into their SESs and action plan. An SES              developed a single equality scheme
enables NHS organisations to demonstrate             (SES). This scheme includes similar and
that they have taken the necessary steps to          equal protection for race, gender,
prevent discrimination on the grounds of             disability, religion or belief, age and
sexual orientation, both in employment and           sexual orientation. In order to roll out
service delivery, by including sexual                the SES, the Trust has ensured that the
orientation in their monitoring practices and        induction programme for doctors
equality impact assessments (EqIAs), together        considers all equality strands, including
with the other equality strands of race,             sexual orientation. The Trust has also
disability, gender, religion or belief and age.      included action points in its Equality
The drawing up of a specific sexual                  Action Plan and intends to develop
orientation equality scheme, however, with           mentoring opportunities for lesbian and
requirements for consultation or involvement         gay staff. The mentoring programme is
of employees and service users from particular       an extension of existing mentoring
communities, is not a legal duty.                    schemes that exist for women and for
                                                     black and minority ethnic staff.
This guidance is designed to give you
practical ideas and examples. What it aims to        The Trust has also revised the content of
help you achieve is a consistently positive          its ‘Healthy Diversity fact file’ to include
approach to equality for LGB staff, patients         information about sexual orientation
and service users, focused on actions and            and caring for LGBT patients.
outcomes appropriate to your core business
determined in consultation with LGB staff  
and stakeholders, allowing you to check              Equality%20and%20Diversity.aspx
through monitoring that you are succeeding,
but not overburdening you with bureaucracy.
It is hoped that this will contribute to a         Building on existing work:
productive workplace where staff are able to       opportunities and challenges
be themselves, alongside services that reflect
the needs of a diverse community. Preventing       Monitoring: Owing to existing equality
discrimination is more cost effective and          schemes for race, disability and gender,
more inclusive than simply responding to           organisations should already be collecting data
incidents of discrimination as and when they       on the ethnicity of their employees, as well as
arise, and can help take account of the            data relating to gender (including trans staff)
multiple factors of identity mentioned earlier.    and disability. Ideally, you will want to do the
                                                   same for sexual orientation in consultation with
                                                   health service unions and LGB staff
                                                   associations. Monitoring staff enables
                                                   employers to examine the make‑up of their
                                                   staff. It highlights differences between groups,
                                                   such as minority groups or staff from particular
                                                   teams or grades, in terms of productivity,

                                                                                                Context 15
satisfaction and progression. It can also help an                    Employee and service user involvement
     organisation identify, tackle and prevent                            and consultation: Because of existing
     discrimination against LGB staff, which can                          equality schemes, NHS organisations should
     undermine productivity and cohesion.                                 already be involving and consulting their local
                                                                          communities on delivery of services, so some
     The same is true of patients and service users:                      mechanisms, such as patient forums, may
     NHS organisations may not necessarily want                           already be in place. It is possible these can be
     to monitor service users on the grounds of                           used to consult on sexual orientation issues,
     sexual orientation, but there are key steps                          although again this needs to be handled with
     that can be taken to encourage disclosure                            sensitivity and to ensure confidentiality is
     where this is relevant. This helps healthcare                        maintained. It is unlikely to be productive if
     workers to deliver more effective and                                forums have not yet fully engaged local LGB
     informed care. Being able to track different                         people and organisations. An alternative
     service use and user satisfaction by, for                            approach may be to work with established
     example, both sexual orientation and                                 LGB organisations in the local area, as a
     ethnicity or by sexual orientation and age,                          starting point.
     can help you to better understand the needs
     of these groups and how they may differ                              Staff opinions can be sought via network
     from the mainstream, therefore tailoring                             groups where they already exist, or via trade
     services more appropriately and ensuring fair                        unions and confidential staff surveys. In the
     treatment.                                                           absence of (or in addition to) these it might
                                                                          be useful to set up a staff network.
     Past discrimination may lead individuals to be
     reluctant to say that they are lesbian, gay or                       In order to get a truly representative range of
     bisexual: for example, if there has been                             opinions, NHS organisations should consider
     gossip at work, or a poorer service after                            breaking down the consultation process
     disclosure or failure to respect confidentiality                     where possible in order to gather the views of
     by a service provider. Research shows that                           lesbians, gay men and bisexuals from different
     approximately half of lesbian and gay staff                          ethnic groups, of different ages, who are
     conceal their sexual orientation from their                          disabled, or who hold different religious or
     employers and co‑workers.6                                           non‑religious beliefs. Further ideas on setting
                                                                          up staff networks and how to involve and
     This makes it more difficult to collect data                         consult staff and service users can be found
     and monitor the effectiveness of policies                            later on in the guide and in Worksheet 8.
     relating to sexual orientation. Lack of
     information should therefore not be taken to                         Assessing policies: It is considered sound
     mean that there are no or very few LGB                               business and clinical planning practice to
     people in your workplace or using your                               conduct equality impact assessments on
     services. Suggestions on how to build                                employment and service delivery policies and
     confidence, increase disclosure and monitor                          practices which cover sexual orientation. It is
     staff are covered in Worksheets 7 and 9 in                           helpful if all staff are confident they will be
     this guide.                                                          treated fairly and that the impact of policies
                                                                          upon them has been considered. This sends a
                                                                          positive message to staff that their employers

     6   Feedback from Stonewall Diversity Champion members Staff Satisfaction Surveys.

Sexual orientation:
                                                                       A practical guide for the NHS

wish to support a harmonious work
environment.                                       ROYAL COLLEGE OF NURSING

In addition, awareness of the impact of a          The Royal College of Nursing has
particular approach on LGB patients and            designed a programme that enables
potential service users is an important step in    them to assess equality on the grounds
ensuring the effective delivery of personalised    of sexual orientation. Diversity Impact
or individualised services; sexual orientation     Assessments are an integral aspect of
may be an important factor in what services        any project. All members of staff within
an individual needs to be able to access and       the College must demonstrate how
the way they need to access them.                  sexual orientation equality has been
                                                   considered when developing any policy.
Therefore when developing new policies,            This process encourages all members of
sexual orientation should be included in           staff to involve a wide selection of
existing impact assessment procedures used         members when developing policy.
for race, disability, gender and other
characteristics if it is practical to do so.
Further information and suggestions for how        diversity_strategies
to put this into practice are in Section 2, Part
Two (page 24) for staff and Section 2, Part
Five (page 44) for patients.

Action Planning: Objectives, outcomes and
timescales that arise out of equality schemes
should be clearly indicated to make it easier
to track progress. See Worksheets 1 and 2
for Action Planning Frameworks for lesbian,
gay and bisexual staff and patients.
Worksheets 3, 4 and 5 are checklists for
organisational policy and practice and may
also be used as slides for training or other

                                                                                          Context 17
Section Two: Process – How to
     work with staff and patients

Sexual orientation:
                                                                          A practical guide for the NHS

Part One –                                        most advertising campaigns, possibly
                                                  encouraging applications from high‑calibre
                                                  candidates who may not have otherwise
Understanding                                     applied. The entire process is therefore a
                                                  unique opportunity for an organisation to
the needs of                                      send out a message about what it values
                                                  both in its staff and in its wider community.
lesbian, gay and                                  However, recruiters may have stereotyped

bisexual staff                                    notions of what LGB people are good at or
                                                  not so good at, and these can affect
                                                  recruitment and selection decisions. Some may
This part looks at the evidence that exists       believe LGB people will not fit in. Others, and
about the needs of LGB people in the              this is illegal, simply do not want to appoint
workforce, and barriers to inclusion. There       people they know or think are LGB. Excellent
are often significant gaps in managers’           potential applicants may not apply for jobs in
knowledge about the issues that affect LGB        organisations they, rightly or wrongly, believe
staff, so a number of examples are provided.      to be intolerant of LGB people.

                                                    GUY’S AND ST. THOMAS’ NHS
People are a vital resource for high‑               FOUNDATION TRUST
performing organisations. Recruiting and
retaining the best people from the widest           In 2003, Guy’s and St. Thomas’ NHS
possible field is key to building competitive       Foundation ran a recruitment drive
advantage. Staff selection is an obvious area       known as the ‘We Need a Hand’
where unfair discrimination can occur, and          campaign. The campaign, which was
has long been an issue for those concerned          the first of its kind in the NHS, was
with race, gender and disability equality.          intended to attract candidates that
Many organisations should already have a            reflected the diverse population within
policy and set of procedures, plus training, in     the boroughs of Lambeth and
place to support those involved in                  Southwark. This included black and
recruitment and selection. These can be             minority ethnic candidates, disabled
adapted to ensure they address the                  candidates, and lesbian, gay and
challenges LGB people often face in                 bisexual candidates. The recruitment
advancing their careers.                            campaign included adverts in
                                                    newspapers and magazines, radio
However, there is much more to the                  adverts and posters at bus stops and
recruitment and selection process than              underground stations. As a result of the
appointing an individual to a job. With each        campaign more than 300 people
job advertisement, the organisation is              applied for jobs with both hospitals.
potentially communicating with a huge               The recruitment process has proved to
audience. How enquirers, applicants and             be very successful for both hospitals.
candidates are treated can potentially give
rise to a network of discussion about the 
organisation that can extend further than           sectionhome.aspx

                                                                                             Process 19
A key feature of the guidance that
     accompanies the race, gender and disability                                 “In my final placement I decided to
     equality legislation is that selection criteria                             tell my mentor and one or two of the
     should be fair, related to the job, and applied                             staff [that I was gay] and in general
     consistently. However, the criteria are only as                             I was treated well, but I began to
     fair as the managers who apply them.                                        feel uncomfortable with some of the
     Providing training in issues relating to sexual                             comments being made by certain
     orientation as well as in the other equality                                staff members, and it became obvious
     areas for those involved in designing the                                   that they disliked me. Some of the
     selection process, shortlisting, interviewing                               comments were not directed at me,
     and decision‑making is crucial to recruiting                                but said loud enough for me to hear,
     fairly.                                                                     such as ‘homosexuality is all wrong’,
                                                                                 and jokes about ‘feeling queer’ and
     Workplace bullying and                                                      ‘Nowt so queer as folk’ etc. It was also
                                                                                 intimated that I was not trustworthy
     harassment                                                                  with the care of female patients.”
                                                                                 Paulina (Staff nurse) South West,
     Anti‑gay harassment is demotivating and                                     Being the gay one, Stonewall (2007)
     unlawful. It can take the form of being
     ignored or excluded; physical or verbal abuse;
     ‘outed’ as gay; or made the subject of jokes                             It is assumed that harassment on the grounds
     and remarks. Extreme cases involve violence,                             of sexual orientation is under‑reported.
     forced resignation or unfair dismissal.                                  A recent survey indicated that almost one in
     A generally hostile environment can be a                                 five LGB people have been harrassed at
     form of harassment, even where actions                                   work.8 This means that the true scale of the
     and comments are not apparently aimed at                                 problem is unknown. As more and more
     individuals.7                                                            employers tackle the issue, however, evidence
                                                                              is emerging that anti‑gay harassment is all
                                                                              too common. LGB people who are from
                                                                              minority ethnic backgrounds or disabled may
                                                                              have experience of different kinds of
                                                                              harassment, and there is some indication that
                                                                              lesbians face a disproportionate amount of
                                                                              sexual harassment at work.

                                                                              It is thought that people are frightened to
                                                                              complain because they believe their
                                                                              complaints will not be taken seriously or they
                                                                              will end up taking the blame. An added
                                                                              complication for many LGB staff is that
                                                                              making a complaint would force them to
                                                                              come out as gay or bisexual, possibly leading
                                                                              to further harassment. Since most LGB

     7   Being the gay one: Experiences of lesbian, gay and bisexual people in the health and social care sector, Stonewall (2007)
     8   Serves You Right, Stonewall (2008)

Sexual orientation:
                                                                                                          A practical guide for the NHS

employees are not completely out about their                           Managing performance fairly
sexual orientation at work, they might be
particularly vulnerable to harassment –                                Managing people properly, openly and with
homophobic comments made in the course                                 respect is increasingly being linked with high
of conversation but without the intention of                           performance in businesses. Yet there is
causing direct offence. Such comments are                              evidence that LGB people are not always
often made in the belief that everyone in                              treated fairly at work, for example by being
the immediate audience will be sympathetic                             passed over for promotion, disciplined
to them.                                                               unfairly or even dismissed for no good
                                                                       reason.9 This is now illegal.
Terms and conditions of
                                                                       Organisations have many different ways of
employment                                                             managing performance, from informal chats
                                                                       to systems of appraisal involving
Benefits and working conditions are
                                                                       stakeholders, customers and peers as well as
important motivators for employees. Yet
                                                                       managers. Most NHS organisations will be
some LGB people still do not always enjoy
                                                                       following a formal procedure for objective
terms and conditions of employment equal
                                                                       setting, appraisal and performance
to those of their heterosexual colleagues. For
                                                                       management. However, people sometimes
example, some people with a same‑sex
                                                                       have stereotyped notions of what they feel
partner may not receive the same workplace
                                                                       LGB people are good or not so good at, and
benefits – these include pensions, leave
                                                                       therefore which jobs or assignments are
arrangements, health insurance, travel
                                                                       suitable for them. Both lesbians and gay men
concessions for employees and their partners,
                                                                       are wrongly considered by some, by virtue of
and relocation allowances. Employers are
                                                                       their sexual orientation alone, to be
now obliged to treat gay or lesbian staff who
                                                                       unsuitable to work with children. In addition,
are in a civil partnership in the same way as
                                                                       LGB people can be subject to unspoken
married people. To be sure that you don’t fall
                                                                       assumptions that they cannot be trusted to
foul of the law, it is advisable to offer exactly
                                                                       represent the organisation to the public. LGB
the same terms and conditions to both
                                                                       people report feeling that they are often
heterosexual and gay staff.
                                                                       thought of as not being team players. This
Leave for bereavement or family emergencies                            can arise because they are unable to be
is designed to help employees balance their                            entirely open about their personal or social
work and home commitments so that they                                 lives at work. In addition, managers can fail
can be more effective in the long term.                                to spot homophobia and its effects on LGB
A policy that excludes leave for same‑sex                              people’s performance. They may not notice
partners can cause personal distress and lead                          that they are disregarded by colleagues or
to discrimination claims.                                              badly treated by patients, let alone that there
                                                                       are issues away from work, such as
                                                                       harassment by neighbours or being excluded
                                                                       by their families.

9   Research summaries: Sexual orientation and religion or belief discrimination in the workplace, ACAS (2007)

                                                                                                                            Process 21
Discrimination on the grounds of sexual
     orientation can also happen to heterosexual         CAMDEN AND ISLINGTON MENTAL
     people. For example, if the majority of a team      HEALTH AND SOCIAL CARE TRUST
     are gay, and the heterosexual members of
     the team are in the minority, they might find       In 2006, Camden and Islington Mental
     they are treated differently. This is equally       Health and Social Care Trust supported
     unlawful.                                           lesbian, gay and bisexual staff to set up
                                                         an LGB network. The network group
     Establishing employee networks                      has provided the opportunity for lesbian
                                                         and gay staff to liaise directly, and
     Employee networks – forums for staff                regularly, with the management of the
     who share one or more aspects of their              Trust. As a result issues that affect
     identity – are becoming more popular.               lesbian and gay staff and service users
     Increasingly, they are funded and promoted          are considered when designing policy
     by employers, rather than operating                 and practice within the Trust.
     informally, as employers appreciate the
     benefits they can bring to the whole                Members meet regularly and produce
     organisation. Networks for women and                monthly newsletters. The newsletters
     minority ethnic staff have proved successful        are distributed across the Trust, and
     across the public, private and voluntary            have therefore been used to promote
     sectors, and often provide useful lessons on        lesbian and gay issues to members of
     how best to establish a network for LGB             staff not in the network. As a result,
     employees, as do existing LGB networks in           there has been an increased awareness
     other similar workplaces or organisations.          of issues that might effect improvement
                                                         in the delivery of care to lesbian, gay
     Establishing employee networks can                  and bisexual people.
     demonstrate commitment to diversity in the
     workplace. It tells staff that the organisation‑diversity.htm
     values all its people, and recognises the need
     to bring together staff who may feel isolated
     or vulnerable. Networks can provide a safer
     and more supportive working environment.
                                                       Some of the issues around monitoring have
     In addition they can give the employer a
                                                       been set out earlier. Sexual orientation
     valuable mechanism for consulting LGB
                                                       monitoring will only work if senior staff
     employees about employment practices and
                                                       support the initiative and if a clear business
     customer service, and also ways to engage
                                                       case for collecting the data is communicated
     with LGB clients and potential recruits.
                                                       to staff. Sexual orientation monitoring is not
     However, LGB employees may wish to
                                                       appropriate for an organisation which has
     participate in a network without being outed
                                                       not previously engaged with LGB staff or
     as gay as a result. They need to be confident
                                                       developed initiatives to eradicate
     that joining or contacting a network is safe.
                                                       homophobia from the workplace.
                                                       Consultation with key stakeholders should
     Worksheet 8 provides detailed practical
                                                       take place before monitoring is introduced.
     information on setting up a staff network.
                                                       LGB staff, where known, and an established
                                                       network group can play a vital role in

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