Equalities in Health

What is social class?

Social Class can be defined by:

• economic factors (wealth, income, occupation)
• political factors (status, power)
• cultural factors (lifestyle, education, values, beliefs).

Despite arguments that the class system has changed over the past 50 years it is still the case that important differences in shared beliefs and values relate more obviously to class than any other social category.

Social class leads to inequalities of resources, whether that is income, education, housing or health.

People’s experience of class and poverty can lead to their views not being heard, being left out when decisions are being made, isolation and humiliation.

A recent poll showed that poor people in particular think that class, not ability, greatly affects the way they are seen.

In the last 25 years the number of people in the top two social classes has doubled in Glasgow. However while the city’s middle class has grown and prospered, other parts have seen little improvement. Many people are dependent on sickness or unemployment benefits or low paid work. This has led to growing inequality.

Social class discrimination can affect many areas of people lives; access to education, housing, social mobility and job opportunities and pay. Numerous studies have been carried out into the effect being working class might have on an individual’s working life. In 2017, the Social Mobility Commission found there was a class pay gap where professionals from working class backgrounds earn an average of £6,800 less than professionals from higher classes.

There is currently no specific protection within the Equality Act 2010 on the grounds of class; although the Fairer Scotland Duty does offer some protection.  

There is a strong link between social class and groups with other protected characteristics, as they are often denied access to power, wealth, status, resources and opportunities.

For example:

• Employment among all black/minority ethnic groups in Glasgow is 10% lower than for white Glaswegians
• 68% of disabled people have an income of less than £10,000
• Women are more likely to be poor than men due to lower paid jobs, part-time jobs and the fact that 90% of lone parents are women
• In Scotland today the pay gap between women and men can translate to a loss of over £330,000 in a woman’s working life – just because she is a woman.

Social class is not a protected characteristic in the Equality Act 2010 however it has close links to poor health and other forms of inequality. 

The Fairer Scotland Duty came into force on 1 April 2018. It places a legal responsibility on named public bodies in Scotland to actively consider how they can reduce inequalities caused by socio-economic disadvantage when making strategic decisions.

Scottish Government guidance (2021) Fairer Scotland Duty: guidance for public bodies provides a comprehensive explanation of the Duty together with useful tools to assess decision making processes.

Social class leads inequalities of resources, whether that is income, education, housing or health. This has led to widely varying but predictable life chances and health outcomes across Greater Glasgow and Clyde.

The link between social class and health was identified almost 40 years ago. In 1980, there was found to be a clear inequality in life expectancy between men in social class 1 (managers and professionals) and social class 5 (unskilled workers).

The reasons for the link between social class and health includes things such as health risks in low paid, unsafe jobs and stress caused by having low status and lack of power.

Upward and downward social mobility can improve or decrease people’s life chances. Certain events such as such as leaving home, becoming a parent, losing your job or bereavement can make us vulnerable to falling into a low income or low status in society.

Social class inequality has an impact on the whole of society. Research shows that more equal societies have better health rather than richer societies where there is a bigger gap between rich and poor.

NHS Greater Glasgow and Clyde is carrying out a range of work to tackle inequality as a result of income inequality, poverty and social issues.

These include:

• Monitoring the impact of the recession and welfare reform on health
• Increasing referrals to employability and money advice services
• The Healthier, Wealthier Children project which is exploring ways of tackling child poverty at local level 
• Measuring the health gap so that we know that specific programmes of work are making the gap better or worse

In ‘Turning the Tide through Prevention’, the Public Health Strategy 2018-2022, we can see that the determinants of health are well documented and many of them lie outside the direct influence of the NHS, such as relieving poverty, improving housing or education. A crucial element of this strategy is therefore the effectiveness of our influence on these factors through community planning partnerships and the way we work with Scottish and UK governments and the people who use our services.

Local health and social care partnerships mean that staff work together to give people support with health and social issues to reduce health inequality.

More information at:

Addressing Income Inequality, Poverty & Social Issues

Tina’s Story

Tina lives with her husband and two children. Two years ago she suffered a serious brain haemorrhage. The consequences of her illness, which was completely unexpected, were devastating.

In order to care for Tina and the children her husband had to leave his job. But when he tried to claim benefits he was told that he wasn’t entitled and would have to wait 10-16 weeks before they would be given any money at all. They said he had made himself voluntarily unemployed. This advice was wrong.

For four months the family had no income at all except for a small amount of Child Benefit and Tax Credit. They didn’t receive Housing Benefit, although entitled to it, and their rent wasn’t being paid. They sunk deeper and deeper into debt.

The family were struggling to survive on less than £50 a week. Through social services they were put in touch with the Family Support Unit (FSU) who helped with food parcels and Home Start, who were able to offer some support.

Tina’s situation has improved now. Her husband is back in work and they still receive support from Home Start, but the debt is still a major concern and the family still has some way to go before it’s back on track.

Courtesy of Joseph Rowntree Foundation www.jrf.org.uk

• Glasgow Centre for Population Health

‘Lesbian’, ‘gay’, ‘bisexual’ and ‘heterosexual’ are better described as ‘sexual orientation towards people’, rather than ‘sexual attraction to’. This reflects the fact that people build committed, stable relationships and it is not purely a focus on sexual activity.

Everyone has a sexual orientation. Sexual orientation is a combination of emotional, romantic, sexual or affectionate attraction to another person.

In other words, it’s about who you are attracted to, fall in love with and want to live your life with.

For the purposes of this sexual orientation web page, we have looked at lesbian, gay, bi-sexual and heterosexual issues only, as the term transgender does not relate to sexual orientation but rather the gendered identity of an individual. For more information on transgender issues go to our page

• ‘What is Gender Reassignment?‘.
• Stonewall’s glossary of terms

Routine Data Collection

NHSGGC wants to get better at understanding both its workforce and the people who use our services. We know that sexual orientation affects health. However, at the moment we do not routinely collect information on sexual orientation from the people who use our services. Without this, it is difficult to deliver services that meet everyone’s needs. We are therefore going to introduce the collection of routine information relating to sexual orientation and will support this with a Sexual Orientation E-Learning module for all staff.

Staff Training

Staff training on ‘Getting it Right for LGBT People’ is being run throughout NHSGGC in partnership with LGBT Youth. This practical learning session offers the opportunity to find out more about sexual orientation and gender identity and why it’s so important for health professionals to respond confidently to LGBT people’s specific needs and build trust in service delivery.

LGBTQ+ Staff Forum

The NHSGGC LGBTQ+ Staff Forum is a group of staff members made up of those that identify as lesbian, gay, bisexual, transgender, queer inclusive (LGBTQ+) and our allies. The group aims to create a safe and welcoming space for staff members within our LGBTQ+ community though our social activities, programme of events, formal and informal meetings.

For more information about the group and how to join, visit our web page.

Stand Against LGBT+ Discrimination

LGBT+ discrimination can take many forms.  Click here to read about our campaign to promote a zero tolerance approach to homophobia, biphobia and transphobia and support the LGBT+ community.

Discrimination on the grounds of sexual orientation can take several forms – from blatant abusive behaviour (1 in 3 gay men and 1 in 4 lesbians have experienced violent attacks) to more subtle forms that may go unnoticed by many.

Discrimination on the basis of sexual orientation is a crime under current Scottish Law.

Some examples of discrimination include:

1. Refusing to employ someone because of their sexual orientation. A case recently heard how a gay man was ‘advised’ not to follow a career in paediatrics – based on the belief that gay men are a risk to vulnerable groups. This is at odds with all evidence, which clearly shows that sexual orientation does not influence the likelihood of carrying out sexual abuse or a sexual assault.
2. Refusing accommodation. A recent survey showed that 70% of people living in rural areas of Scotland supported the right to refuse holiday accommodation on the grounds of sexual orientation.

Following is a short film by the Equality & Human Rights Commission titled ‘What is sexual orientation discrimination?’.

Any sexual orientation other than heterosexual often receives negative responses from parts of our society and this can be made worse when combined with other equality issues.

Disabled lesbians and gay men face the same challenges experienced by many disabled people who live in poverty or on very low income. In addition, lack of money means that many disabled lesbians, gay men and bisexuals are excluded from the LGB social scene, often based in pubs and clubs, which can result in increased isolation. Even if money were not an issue, many venues would be inaccessible to some disabled people.

There may be tensions between sexual orientation and other protected characteristics. For instance, someone who identifies as being LGB but also belongs to a particular faith group may experience negative attitudes from other members of that faith group. It may be that some members of a faith group act in a way that might discriminate against LGB people. Recent high profile media coverage has centred on people with faith beliefs refusing to provide goods and services to LGB people in terms of holiday/leisure accommodation.

Examples of how sexual orientation can affect health include:

1. Research looking at mental health suggests gay men and lesbians report more psychological distress than heterosexuals. This can often be associated with a lifelong exposure to bullying and abuse. Surveys have shown extremely high percentages of young lesbian, gay and bisexual (LGB) people reporting verbal and physical abuse. It has also been found that young LGB people are up to six times more likely to attempt suicide that heterosexual youth.
2. Drug use amongst gay men has been found to be significantly higher than for heterosexual men. Research suggests that drug use is in part due to low self-esteem, and also due to the attitudes of society towards this group.
3. Lesbians have specific health issues relating to fertility, pregnancy, sexual health and mental health. However, there is evidence that lesbians are afraid to tell their GP of their sexual orientation in case they experience discrimination.
4. Figures show that gay men and men who have sex with men are generally at higher risk of contracting HIV/AIDS than heterosexual people. In 2006, 38% of all new cases of HIV/AIDS were found within this population group. Gay men and men who have sex with men are also at higher risk of contracting Ghonorrea, with 81% of all new cases diagnosed in 2006 found within this group.

A young lesbian woman was taken into hospital suffering from Leukemia. The treatment was lengthy and painful, both physically and mentally.

While in hospital, the young woman suffered homophobic bullying from another patient to the point where she felt it was difficult to have her partner visit her on the ward.

The nurses noticed how upset she was and that her partner was no longer visiting, so asked what was wrong. The young woman explained the situation and was immediately supported by staff, including the consultant in charge of her care, who challenged the other patient’s behaviour. They made it very clear that NHS services should be free of all types of discriminatory behaviour – including homophobia.

Publications

• National LGBT+ Health Needs Assessment 2022 – short films explaining the process and outcomes – Full summary of findings   Wish list
• Don’t look back?
• Fair For All – The Wider Challenge – Good LGBT Practice in the NHS
• Gay and Bisexual Men’s Health Survey Scotland
• Getting Equalities Monitoring Right
• Halt Hate Crime
• Hate Crime – What You Need To Know
• Hate Crime Poster
• Hidden Lives
• Inclusive Language in the NHS
• LGBT In Scotland – Health Report
• Life in Scotland for LGBT Young People
• Not Just A Friend
• Protecting Patients – Your rights as LGB people
• Social context of LGBT people’s drinking in Scotland
• Tackling Homophobia
• The Needs and Experiences of LGBT People in Glasgow
• Your Services, Your Say

Websites

• LGBT Helpline Scotland
• Stonewall – information pages
• LGBT Health
• Healthy Gay 
• LGBT Youth Scotland
• The Sandyford Initiative

Discrimination with a focus on religious belief and religious difference is not a new phenomenon. For many years the West of Scotland has been characterised by sectarianism which continues today. Religious discrimination, and suspicion of religions, has come to the fore again due to a rise in Islamophobia – particularly after September 11th and the July 7 bombings in London.

In the past there was no specific protection against discrimination for most religious groups. There was, however, protection for people from Sikh and Jewish communities who were protected under the Race Relations Amendment Act as an ethnic group. Religion is often woven in with race and culture to form personal or group identity. Black/Minority ethnic communities, who can be on the outskirts of society, have often used religion to express and to sustain their identity.

There is now greater protection from religious discrimination through the Equality Act 2010. Religion & belief is a protected characteristic and everyone who is protected under law from discrimination, harassment or victimisation is afforded the same level of protection.

For some people, their religion is important to their health yet often the cultural and practical dimensions of religion are not assessed and taken account of when individuals attend for health care. This can be considered as a form of discrimination, can cause distress and as a result can have a negative impact on the effectiveness of diagnosis and treatment. In the same way that other examples of equality categories often remain invisible to health care organisations and therefore in the way that services are planned, there is lack of data on patients for whom religion is significant to their wellbeing. In addition, strong views on any particular form of religion can lead to prejudice and discrimination against other beliefs – often referred to as sectarianism. This too can have an impact on the physical and psychological wellbeing of individuals.There can also be assumptions that everyone has a faith of some description despite of a large percentage of people who consider themselves to be atheist. Any assumptions about faith can lead to experience of discrimination.

Following is a short film by the Equality & Human Rights Commission titled ‘What is religion and belief discrimination?’.

There may be examples of poor health resulting from the disharmony between some followers of religion and other equality groups. For example, people within the LGBT communities who practice or follow a religion may face additional health issues such as mental health problems or feel isolated, perhaps due to discrimination within their faith community.

A person’s value system, sense of purpose and inner strength, whether resulting from religious or other sources, has been linked to how they respond to illness and treatment. Our approach in NHSGGC focuses on ‘spiritual care’ and ‘spiritual needs’ as outlined in the Spiritual Care Policy. This recognises that all people, whether religious or not, have spiritual needs that may or may not include aspects of formal religion or belief. People will gain comfort and strength to face illness from being allowed to practice their religion while in hospital.

Appropriate recognition of religious practices and preferences, and consideration of the patient’s spiritual needs, are particularly important in the care of the dying and in dealing with the deceased and their family after death. This also has a relevance to the care offered in our Maternity Units at a time of peri-natal or neo-natal death. Consideration of spiritual needs equally applies to people who have a non-religious stance.

Religion and Belief within a health care environment can also impact on

• Gender and choice of staff;
• Disclosure of sensitive information;
• Attitudes towards illness and health practices;

Religious views may also affect the way in which health promotion messages are received and acted upon. Some religious practices, such as not drinking alcohol or vegetarianism, may have positive links to health. Others may affect whether or not certain medications can be taken due to animal/alcohol by-products.

NHSGGC has a multi-levelled response in tackling inequalities associated within religion and belief.

• The organisation actively pursues the capture of religion / belief from its staff at recruitment stage as well during the course of employment (SWISS) to ensure that it doesn’t discriminate against one group of staff.
• We have developed a Spiritual Care Policy outlining the nature of spiritual care, the provision of spiritual care facilities in our hospitals, training and education, the role of all staff in delivering spiritual care and the importance of consultation with faith and belief groups.
• Healthcare Chaplaincy, as an NHS service, has a key role in responding to the spiritual and religious needs of staff, patients and visitors. Healthcare Chaplains function on a ‘generic basis’ whereby their service is for all people, regardless of faith or belief. They are a point of contact to draw in care and support from particular faith and belief groups.
• The organisation provides training to staff at induction level and during the course of employment on equality and diversity which includes religious/ belief issues. Training on subjects such as Loss and Bereavement include reference to the needs of those from faith communities.
• Our Equality Impact Assessment can identify whether services are actively addressing issues associated with religion and belief and put in place necessary actions.
• The Catering Service provides Halal, Kosher and vegetarian meals upon request. Work is being undertaken to meet the needs of other religious groups.

Baldeep’s Story

Baldeep is a baptised Sikh and follows the practice of wearing the 5 ‘Ks’ – this includes wearing the Kirpan. The Kirpan is a very small sword. As is the custom, Baldeep wears hers under her clothing in a cloth sheath. For her, and for all baptised Sikhs, it is a symbol of the commitment she has made to follow the Sikh way of life and carries a deep spiritual significance. She will never remove it unless absolutely necessary.

Unfortunately, one day Baldeep felt very unwell and had to go the nearest Accident and Emergency Department. Whilst she removed clothing to be examined the nurse asked what it was that she was wearing. The nurse became alarmed that Baldeep was carrying what looked like a knife and refused Baldeep any further assistance until the Kirpan was removed. Baldeep explained that the Kirpan was a sacred item in her faith and she could not remove it; was it absolutely necessary to remove it in order to be examined? The nurse said that on health and safety grounds no patient should be carrying a weapon. Baldeep argued that if treatment was denied to her because she was wearing this sacred symbol, it was tantamount to religious discrimination.

The nurse seemed unsure about this and consulted her ward manager. The ward manager came to meet Baldeep and enquired more about her faith and the Kirpan. It was clear that treatment could not be denied as Baldeep was observing the requirements of her faith in the wearing of the Kirpan. This had to be respected. It was agreed that she could be examined whilst wearing it but if an x-ray or any other sort of scan was required it would have to be removed. Baldeep understood this and before going to the x-ray her Kirpan was removed, along with the Kara (the steel wristband) and held by the nurse during the procedure. Baldeep then replaced it accompanied by the saying of a prayer.

Comment and Background Information:

The wearing of the Kirpan is permitted by UK law as it is an intrinsic part of the Sikh faith and Sikh religious observance. It is generally not visible. Legislation makes it clear that a service cannot be denied to anyone on grounds of the religion or belief and the ward manager above was correct to see this. The discussion that took place leading to an agreed solution was also appropriate and correct.

Further information about the Sikh religion can be found in the resources identified in section 6 – Support and Resources.

Publications

• A Multi-Faith Resource for Healthcare Staff
• Advice to British Hajjis
• Faith and Belief Communities Manual
• Information and Guidance on Visiting Hospitals for Faith and Belief Community Representatives
• Ramadan Health Guide
• Seen and Not Heard – Voices of Young British Muslims
• Spiritual Care Policy
• Values in Harmony

Websites

• Al-Khair
• Almeezan
• Central Mosque
• Glasgow Gurdwara
• Glasgow Unitarians
• Hindu Mandir Glasgow
• Methodist Church in Scotland
• Nil By Mouth
• Orthodox Church
• Salvation Army
• Scottish Baptist
• Scottish Lutherans
• United Reformed Church

Within Greater Glasgow & Clyde there are approx. 5700 adults with learning disabilities. A learning disability is a significant, lifelong, condition that starts before adulthood. It affects a person’s development and means they need help to:

• Understand information
• Learn skills
• Cope independently

Learning difficulties, such as dyslexia, ADHD, dyspraxia and speech & language difficulties are not defined as a learning disability due to the specific nature of their developmental delay.

People with learning disabilities represent a diverse group. Historically, people with learning disabilities lived in hospitals. Then, in 2000, policies were introduced which advocated that people with learning disabilities should be supported to live in their local communities and have equal access to employment opportunities & health services. Despite this shift towards independent community living, people with learning disabilities are one of the most disadvantaged groups within Scotland.

90% of people with a learning disability have described an experience of bullying or harassment, with 32% experiencing this daily.

65% of people with a learning disability would like a job. In 2010/2011, 6.6% of people with a learning disability were in paid employment, the majority of whom worked less than 16 hours a week. This is significantly less than in the working age population (77.3 %) and the disabled population (47.4 %), NHSGGC is one of the partners involved in running an award winning learning disability employability programme called Project Search.

People with learning disabilities die younger than the general population – on average 13 (for females) or 20 (for males) years younger, with many of these deaths being from preventable causes.

People with a learning disability will also possess other protected characteristics and their experience of inequality will be made worse as a result.

Protected characteristics – characteristics that are protected by law, such as Disability – are listed on our home page and include sex, age and race.

Gender-based Violence & Women with Learning Disabilities

Research tells us that disabled women and girls are more susceptible to gender-based violence than non-disabled women and girls. Women with a learning disability are at greater risk of sexual abuse and are more likely to experience violence from perpetrators that are not partners, most notably other service users and men with learning disabilities.

Dependency on care, attitudes of staff and carers, poverty and isolation can make women more vulnerable or make it more difficult for them to disclose abuse. Poor availability of services such as day care centres also make it difficult for women to find help and support. As a result, the abuse often goes undetected and unreported.

To tackle gender based violence and support women with learning disabilities, services need to remove barriers to disclosure and provide better access to information and health and support services. Within NHSGGC, a programme of work is underway to raise awareness about the experience of gender-based violence amongst people with learning disabilities and to build staff confidence and competence in knowing how to identify and respond to this.

Learning Disability & Human Rights

When the behaviour of people with learning disabilities challenges carers and services, complex and competing human rights issues may emerge.

A Human Rights impact assessment was carried out in Netherton Learning Disabilities Unit. This initiative looked at human rights in relation to everyday practices in the Unit.

This work, which included workshops and interviews with staff and patients, highlighted a number of issues around the patients’ rights. For example, some residential units allowed free access to kitchen areas whereas others were much more restrictive. By using human rights guidelines along the PANEL principles set put below, they were able to explore the differences between practices in a patient-centred way.

• Participation – People should be involved in decisions that affect their rights.
• Accountability – There should be monitoring of how people’s rights are being affected, as well as remedies when things go wrong.
• Non-Discrimination – Nobody should be treated unfairly because of their age, gender, ethnicity, disability, religion or belief, sexual orientation or gender identity. People who face the biggest barriers to realising their rights should be prioritised when it comes to taking action.
• Empowerment – Everyone should understand their rights, and be fully supported to take part in developing policy and practices which affect their lives.
• Legality – Approaches should be grounded in the legal rights that are set out in domestic and/or international law.

NHSGGC is working to ensure that the organisation is addressing health inequality experienced by people with learning disabilities.

NHSGGC continues its engagement activity with patients and 3rd sector organisations. This includes our co-production work with The Life I Want partnership forum. This work is a valuable way of sharing information between our own organisation, learning disability support services and patients themselves and is one of the main ways in which we receive up to date feedback from patients regarding their experiences of accessing and using our health services.

We are also planning a new programme of staff training designed to provide a better awareness of how we can provide the best support for patients with a learning disability and improve their experiences of using our services. Patients with a learning disability will be involved in developing and delivering this training.

The Keys to Life (2019) is the Scottish Government strategy to promote inclusion and equality in all areas of life for people with learning disability. NHSGGC is committed to delivering these recommendations which promote a vision and shift towards independent living, employment opportunities, equal access to health services, education that meets the needs of every child and a Scotland with zero tolerance for inequalities.

The Learning Disability Liaison Team supports and enables NHSGGC services to adapt their approaches to meet the needs of people with learning disabilities. The Team supports the system to anticipate and respond to the general medical needs of people with learning disabilities. It also works with local learning disability teams and other agencies to ensure a co-ordinated approach in addressing health inequalities for people with learning disabilities.

For information contact: PCLTAdmin.Generic@ggc.scot.nhs.uk

A Strategy for the Future is NHSGGC’s service redesign for all community based learning disability specialist services. The redesign will enable NHSGGC services to deliver responsive and appropriate healthcare and provide specialist support when required. It aims to give people with learning disabilities more equality and control as well as improving health, wellbeing and safety.

The Scottish Learning Disabilities Observatory has been funded by the Scottish Government to help build understanding of the causes of poor health and health inequalities experienced by people with learning disabilities. The aim of the Observatory is to produce high quality evidence to support learning disability policy and practice and to work in partnership with the NHS, local authorities and Scottish government to improve the information gathered on people with learning disabilities.

Project Search is a targeted programme of employment training and support for young people who have a learning disability (18-24). Participants learn job skills which are transferable and marketable when looking for full time paid work. Students are supported to find work with their job coach either on site with the host business or with another employer. NHSGGC is planning for the 3rd year of this programme following 2 successful years resulting in graduates securing employment within NHSGGC.

As part of A Fairer NHSGGC 2020-24 we have a specific outcome looking at improving service delivery and experience of healthcare appointments for patients with a learning disability. This includes a programme of engagement with patients and third sector organisations to ensure service users are involved in this work.

Edwards’s Story

The video below is from a website featuring people with learning disabilities and their carers, written in collaboration with the Rix Centre. It presents the thoughts and feelings of these individuals in their own words, so that doctors and other health professionals can see what people want and how they wish to be involved in their own healthcare.

NHS Greater Glasgow and Clyde gathers stories and experiences of patient with a learning disability through our ongoing engagement activity. Some of these individual patient experiences will be used to inform our staff training programme.

Publications

• Coming Home – A Report on Out-of-Area Placements and Delayed Discharge for People with Learning Disabilities and Complex Needs
• Death by Indifference
• Health Needs Assessment for People with Learning Disability in Greater Glasgow and Clyde
• Keys to Life
• Learning Disability & Autism
• Project Search
• Specialist Adult Learning Disability Services in NHSGGC – A Strategy for the Future
• The Challenges of Estimating Scotland’s Learning Disabled Population
• The Keys To Life – Scotland’s National Learning Disability Strategy
• Towards Transformation 
• SCLD – Learning Disability Statistics for Scotland
• Learning Disabilities – Learning for NHS Staff

Video Resources

More information coming soon…

Websites

• CIPOLD – Confidential Inquiry into Premature Deaths of People With Learning Disabilities
• Easy Health
• ENABLE
• Epilepsy Scotland
• Keys to Life
• Learning Disability Change Programme
• Mencap
• PAMIS
• People First
• Scottish Consortium for Learning Disability
• Scottish Learning Disability Observatory
• Shaw Trust

People with learning disabilities experience some of the poorest health outcomes of any group in Scotland and much of their health needs are unrecognised and unmet. In addition to the same everyday health needs as the general population, people with learning disabilities have a different pattern of health needs

People with learning disabilities –

• have differing causes of death (respiratory illness, cardiovascular disease and gut cancers, as opposed to lung cancer, heart disease and strokes in the general Scottish population)
• have more physical health problems
• are more likely to have mental health problems – 40-50% of the learning disability population compared to 1-10% of general population
• on average, have 5 long term health conditions, compared with 1 or 2 in the general population
• are more likely to have a sensory impairment (approximately 60% will have a visual impairment and 40% will have a hearing impairment)
• are more likely to be underweight or obese than the general population.

Poor health can result from social isolation and deprivation. A large majority of people with learning disabilities have endured a lifetime of exclusion resulting from lack of choice and opportunity. People with learning disabilities experience a number of barriers when trying to access appropriate healthcare within the NHS. These include:

Communication – Many people with a learning disability may take longer to express what they want to say and may simply require patience and understanding on behalf of the listener to allow them to do this. Some people with learning disabilities have limited verbal communication skills and difficulties with understanding and processing information which can impact on their ability to understand health information. Health services are reliant on written information for advice, appointments, signs and information and this creates a significant barrier if it is not provided in an easily understood way. NHSGGC’s Clear to All accessible information policy aims to ensure that we provide effective communication for everyone and that information is provided in the format and language required.

Physical access – NHS establishments are required by law to be accessible to those with a disability. However, accessibility and signage is not always clear and navigating health centres and hospitals can be difficult for wheelchairs users or those with poor mobility who also are unable to read.

Attitudes – NHS staff all strive towards person centred care. However, many have not had experience of working with people with learning disabilities or had learning disability awareness training. This can often lead to negative assumptions about a person’s ability, even when it is well intentioned eg, a health care professional may talk to a carer to obtain health information instead of asking the person directly.

Diagnosis overshadowing – This occurs when a behaviour change is attributed to a person’s learning disability when it is in fact due to physical ill health or pain. Unfortunately this is common for people with a learning disability and can lead to delayed treatment and in some cases death.

What is Gender Reassignment?

In most cases we grow up feeling a sense of comfort or acceptance with our gender but this is not true for all people. Around 1 in 11,500 people will find that as they grow up, they feel less comfortable with the gender prescribed to them at birth, and will instead, find greater comfort and connection to another gender. They may then express the need to live in this different and more appropriate gender. In Scotland, those of us experiencing this are referred to as ‘transgender’ or ‘trans’ people. ‘Trans’  is an umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth.

In the Equality Act it is known as gender reassignment*. All transsexual people share the common characteristic of gender reassignment.

To be protected from gender reassignment discrimination, you do not need to have undergone any specific treatment or surgery to change from your birth sex to your preferred gender. This is because changing your physiological or other gender attributes is a personal process rather than a medical one.You can be at any stage in the transition process – from proposing to reassign your gender, to undergoing a process to reassign your gender, or having completed it.

*’Gender reassignment’ is a term of much contention and is one that Stonewall’s Trans Advisory Group feels should be reviewed.

The Equality Act 2010 says that you must not be discriminated against because you are transsexual, when your gender identity is different from the gender assigned to you when you were born. For example:
• a person who was born female decides to spend the rest of his life as a man

In the Equality Act it is known as gender reassignment. All transsexual people share the common characteristic of gender reassignment.

To be protected from gender reassignment discrimination, you do not need to have undergone any specific treatment or surgery to change from your birth sex to your preferred gender. This is because changing your physiological or other gender attributes is a personal process rather than a medical one.You can be at any stage in the transition process – from proposing to reassign your gender, to undergoing a process to reassign your gender, or having completed it.

The Equality Act says that you must not be discriminated against because:
• of your gender reassignment as a transsexual. You may prefer the description transgender person or trans male or female. A wide range of people are included in the terms ‘trans’ or ‘transgender’ but you are not protected as transgender unless you propose to change your gender or have done so. For example, a group of men on a stag do who put on fancy dress as women are turned away from a restaurant. They are not transsexual so not protected from discrimination
• someone thinks you are transsexual, for example because you occasionally cross-dress or are gender variant (this is known as discrimination by perception)
• you are connected to a transsexual person, or someone wrongly thought to be transsexual (this is known as discrimination by association)

Intersex people (the term used to describe a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t fit the typical definitions of female or male) are not explicitly protected from discrimination by the Equality Act, but you must not be discriminated against because of your gender or perceived gender. For example:
• if a woman with an intersex condition is refused entry to a women-only swimming pool because the attendants think her to be a man, this could be sex discrimination or disability discrimination

Following is a short film by the Equality & Human Rights Commission titled ‘What is gender reassignment discrimination?’.

Trans people are entitled to the same level of quality care as everyone else and should expect to receive it based on their gender identity, gender expression or physical body. However, it is important to appreciate the lived experience of many Trans people to ensure the care health services provide is appropriate and sensitive.

Findings from the recent INCLUSION Project research showed significant issues for Trans people include:

• Mental health problems including suicide, self harm, anxiety and depression
• Lack of primary care facilities as many GPs have no or little knowledge of Trans people’s needs
• Lack of access to essential medical treatment for gender identity issues, i.e. electrolysis for Trans women
• Lack of awareness and understanding of care providers so that Trans people are in appropriately treated in single gender out patient and in patient services.
• Inconsistent funding and access to transitioning services throughout Scotland
• Lack of social work service to support children, young people, adults and families with gender identity issues.
• Social exclusion, violence and abuse and the resulting negative impact on health and well-being

Trans people are entitled to the same level of quality care as everyone else and should expect to receive it based on their gender identity, gender expression or physical body. However, it is important to appreciate the lived experience of many Trans people to ensure the care health services provide is appropriate and sensitive.

Findings from the recent INCLUSION Project research showed significant issues for Trans people include:

• Mental health problems including suicide, self harm, anxiety and depression
• Lack of primary care facilities as many GPs have no or little knowledge of Trans people’s needs
• Lack of access to essential medical treatment for gender identity issues, i.e. electrolysis for Trans women
• Lack of awareness and understanding of care providers so that Trans people are in appropriately treated in single gender out patient and in patient services.
• Inconsistent funding and access to transitioning services throughout Scotland
• Lack of social work service to support children, young people, adults and families with gender identity issues.
• Social exclusion, violence and abuse and the resulting negative impact on health and well-being

NHS Greater Glasgow and Clyde were the first NHS Board in Scotland to publish a Gender Reassignment Policy which sets out our commitment to ensure equality of access to services that are both appropriate and sensitive. We have the busiest trans services in Scotland at the Sandyford Initiative and provide a number of specialist services that are recognised as being amongst the best in the UK. However, there are still barriers experienced by Trans people using mainstream NHS services. It is essential that frontline NHS staff do all they can to remove the stigma of transitioning and play their part in delivering services of the highest standard to Trans people. To this end, guidance has been issued to support staff in responding to queries from Trans service users.Add info here…

Fran’s Story

Fran transitioned from male to female 10 years ago. She has spent her life experiencing bullying and harassment because of her gender identity and has been the victim of several hate crime incidents.

Fran was experiencing pain in her right thigh and attended an outpatient appointment.  When Fran entered the waiting area she gave her name and confirmed her appointment time.  The receptionist explained there wasn’t an appointment for a Fran Walker but there was one for a Mr Frank Walker.  Fran explained that she should now be referred to as Fran as she had requested all records be updated to reflect her gender reassignment.  The receptionist explained she was unable to do that until the medical records were updated.  Fran was asked to take a seat in the waiting area.  Fran was in discomfort but before taking a seat explained again it was Fran or Ms Walker, not Frank or Mr Walker.

While Fran was waiting for her appointment she heard a member of staff calling for a Mr Frank Walker.  Fran sat where she was, angry, frustrated and embarrassed that she was still being referred to in the wrong gender.  Eventually after a repeat call she stood and walked into the treatment room.  She was still very upset and asked why, despite explaining she wished to be called by her new name, staff insisted on calling her by her previous name.  The member of staff explained the name on her record was Frank Walker, not Fran, and until they heard otherwise, she would continue to be addressed as Frank or Mr Walker.

Fran tried to remain calm and explained that if she was referred to as Frank again she would make a formal complaint.  The member of staff reiterated the position so Fran explained that staff were in breach of legislation protecting trans people. They were deliberately disclosing her previous birth gender and so could be held liable and receive a significant financial penalty under UK law. Fran stated that if it happened again she would take formal action.

The equality Act protects trans people in a number of ways, one of which is to ensure previous birth gender is only disclosed to another party when necessary with appropriate controls in place and then only with the expressed permission of the trans person.

Publications

• Changing for the Better
• Changing Your CHI
• Engaging All Staff in Trans Inclusion
• Gender Reassignment Policy Review 2021
• Getting Equalities Monitoring Right
• Homophobic and Transphobic Hate Crime
• LGBT in Scotland Health Report
• Life in Scotland for LGBT Young People
• Sharing Trans Information
• Transgender Equality

Websites

• Gender Identity Research & Education Society (GIRES)
• LGBT Youth Scotland
• Press for Change
• Sandyford Initiative
• Scottish Trans Alliance

A person has a disability that is covered by the Equality Act 2010 if they have a physical or mental impairment that has a substantial and long-term effect on their ability to carry out normal day-to-day activities.

For example:

• Sensory impairments such as being blind or deaf
• Mobility difficulties and other physical disabilities
• Learning disabilities and people who are autistic (go to our Learning Disabilities page)
• Mental health problems
• Facial disfigurements
• Neurodiversity or autism
• Speech impairments
• Memory problems, such as dementia.
• Long-term conditions, such as epilepsy, dyslexia and cancer.

It is important to note that the definition can cover illnesses and conditions which some people may not immediately think of as a disability, such as asthma, depression, heart disease or diabetes. Also, not all disabilities are immediately apparent and may be described as “hidden disabilities” These could include long term conditions such as epilepsy, Autism, some sensory impairments and mental health conditions.

The social model of disability

This model recognises that an individual is disabled not by their impairment or medical condition, but by a society which fails to meet their needs.

For example, if an individual is unable to read information provided at an open day because they have a visual impairment, the social model sees the organisation as the problem because they have not provided suitable material that can be read by someone who is visually impaired, such as Braille or large print documents.

The lived experience Model of disability

The Lived Experience Model of disability recognises that each individual experience may be different but that there will be commonalities too and it is these commonalities which should inform policy and services etc. Many people see this type of model as a development of the social model.

It is the social and, increasingly, the lived experience models of disability that the Equality & Human Rights Team place at the core of its work in relation to disability

The Equality Act is designed to ensure that large public organisations like NHSGGC promote disability equality and challenge discrimination on the grounds of disability.

Discrimination occurs when a person or organisation treats a disabled person less favourably than they would treat others. This discrimination can affect issues such as education, employment, income and health.

For example:

• Disabled people of working age face considerable disadvantage compared to people without an impairment. On average their incomes are about 20 per cent lower than the incomes of non-disabled individuals and their employment rates are half the size
• International evidence shows that people with learning difficulties or long term mental health problems on average die 5-10 years younger than other people, often from preventable illnesses
• 15% of deaf or hard of hearing people say they avoid going to their GP because of communication problems

Following is a short film by the Equality & Human Rights Commission titled ‘What is Disability discrimination?’.

A recent survey of people with disabilities found the following:

• 63% of respondents reported that they were not in work, and 91% of those were not seeking employment – well above national averages.
• Over 30% of respondents stated that they found it difficult or very difficult to manage on their current income.
• In the UK Black people are more likely to be detained under the Mental Health Act
• Women are more likely to become disabled throughout the course of their lives
• More than one third of LGBTQ+ identify as having a disability

Identifying as a disabled person does not mean that a person does not also identify in some other way in relation to, for example, their religion, sexuality or social class. Such intersecting identities need to be considered when promoting disability equality and when ensuring equal access to services across NHSGGC.

In the 2011 census, 22% of NHSGGC’s population declared a disability.

People with disabilities can suffer poorer health for a wide variety of reasons. For example, it may be due to the fact that:

• people can’t get access to services or communicate with service providers
• how we plan our services does not take account of the needs of disabled people e.g. having an adult changing table, quiet space for autistic people
• the health of disabled people is given less priority than that of other patients
• an illness may be wrongly thought to be part of a person’s mental or physical disability
• people with long term disabilities are particularly likely to live in poverty
• some conditions are linked to a higher rate of a particular health problems

NHSGGC promotes the social model of disability, which means that it is up to the organisation and the people in it to ensure that disabled people have the same opportunities to enjoy good health as non-disabled people.

NHSGGC’s The Equality & Human Rights Team works directly with disabled people (patients and staff) and disabled people’s organisations to gain insight and understanding of their lived experience. This insight is then used to inform the work of the team

It is the responsibility of service providers and employers not to discriminate against a person on the grounds of their disability, regardless of how the person may describe themselves. This is important because many people may not regard themselves as ‘disabled’, but they will still have rights under the Equality Act. The law applies to all disabled people who use NHS services. This includes visitors and members of the public, as well as patients and staff

Specific examples of work include:

Sensitising Patient Pathways for Autistic People

Starting with day surgery, the Equality and Human Rights Team are exploring how our patient pathways can be made sensitive to non-neurotypical people and autistic people. Working with staff and the charitable sector we will publish as a learning tool for staff.

Deaf People & Health Services

A range of work currently being undertaken by NHSGGC to promote British Sign Language (BSL) as a language and culture and improve the experience of our Deaf BSL patients. This includes a BSL Online Interpreting Service, a plan to better meet the mental health needs of Deaf and hard of hearing people, staff training in BSL and a BSL Health Champions Group. We are also consulting with our patients regarding NHSGGC’s response to the BSL Act.

Facilities & Estates

The Facilities and Estate Department have a programme of actions to ensure our estate is accessible for disabled people. We work with our disabled patients through the Disability Access Group and our Staff Disability Forum to drive actions for change. For example, a guide for people using mobility scooters to access NHSGGC sites has been produced.

Interpreting Service

Interpreting services address a number of risks for both service users and staff. For example, patients whose first language is British Sign Language or who utilise Deaf Blind communicators must always have interpreters at their out patent appointments and at key times during in-patient stays such as admission, discharge, doctors rounds, significant nurse interventions and to communicate with family members if needed.

Ensuring that everyone has an equal opportunity to engage in the health care process benefits all concerned. In addition, equalities legislation stipulates that the organisation must be pro-active in ensuring that this is the case.

NHSGGC’s in-house interpreting service provides interpreters to our patients on request. BSL user can now also access on line interpreters through our communication support iPads. The iPads also contain a number of support apps including the AVA app which subtitles what staff saying in real time, to help those who have a hearing loss.

Clear to All Accessible Information Policy

Effective information and communication are vital for the provision of high-quality services and care. Many of those who access services have difficulty understanding the information provided. An accessible information policy has been produced to ensure that all information can be made available in the appropriate format to meet the needs of disabled people who may need this e.g. Braille, words and pictures, British Sign Language or audio version.

Details are available on the ‘Clear to All’ Accessible Information Policy web page.

Margaret’s Story

Margaret is deaf. Her first language is British Sign Language.

Margaret fell at home. She couldn’t move and thought she had broken her leg. She couldn’t call for an ambulance as she couldn’t use a hearing phone so she asked her mother to take her to her local Accident & Emergency.

When Margaret got to A&E she told the person checking her in that she was deaf. She explained her mother was also deaf. She said that she would not be able to hear her name being called.

Margaret waited for over an hour and was getting anxious about her appointment, so approached the desk again. She was told she hadn’t been called. She waited again. Eventually after 5 hours and having approached the desk on more than one occasion she was told that she missed her appointment.

Margaret was distressed and frustrated that her needs as a deaf person were not taken into account. She may have had a long wait in A&E if other emergencies had come in but she felt she had waited so long because she was deaf.

NHSGGC’s Communication Support and Language Plan aims to ensure that the communication needs of individual patients are assessed, in order for the right kind of support to be provided.

Publications

• Assistance Dog Policy
• Being Disabled in Britain
• BSL National Plan (2017-2023)
• Disability Perceptions Gap
• Health Needs Assessment – Deafblind and Deaf Communities
• Staff Guidelines for people who are Deaf, have hearing loss or are Deafblind
• NHSGGC Staff Guidelines – Working with people with visual impairment
• Principles of Inclusive Communication

Video

Websites

• Access Panel Network
• Alliance  
• Disability Equality Scotland
• Disability Information Scotland
• Citizens Advice Scotland 
• Glasgow Disability Alliance [GDA] 
• Inclusion Scotland
• Inclusive Communication
• Disability Safety 
• Accessible Travel