Why does closing the inequality gap in LGBTQ+ NHS staff experience remain so hard?

Each year, I write a blog for International Day Against Homophobia, Biphobia, Intersexphobia and Transphobia in which I reflect on the latest NHS Staff Survey results. The results tell us that despite the NHS employing more LGBTQ+ people than many other employers in the UK, LGBTQ+ staff report that they are still having a worse experience. 

Despite us and others pointing this out for several years, the LGBTQ+ equality gap remains stubbornly wide in every NHS People Promise indicator. On a national basis, there appears to have been very little progress in recent years.

"When LGBTQ+ NHS staff are subject to more discrimination, violence, bullying and harassment than the wider workforce, and feel less supported and welcome at work, they are held back from fully thriving and giving of their best for patients."

Why does this matter? About one in twenty NHS staff are LGBTQ+. And when they are subject to more discrimination, violence, bullying and harassment than the wider workforce, and feel less supported and welcome at work, they are held back from fully thriving and giving of their best for patients. They’re not able to develop and progress at a pace commensurate with their potential. And they’re more likely to leave the NHS. 

The survey tells us that 15 per cent of staff who did not identify as LGBTQ+ were intending to leave the NHS; this rose to 21 per cent for lesbian and gay staff, and 23 per cent for transgender staff. With the urgent need for better efficiency and productivity within the NHS, accepting this potential loss of talent is not just unethical; it is bad business.

How to close the LGBTQ+ equality gap

But despite awareness, the equality gap isn’t closing. Why not? Part of the reason probably reflects the wider environment that has seen high levels of prejudice and discrimination affecting LGBTQ+ people (ILGA-Europe ratings). For example, during a period when transgender people featured significantly in political rhetoric, transgender staff in the NHS experienced double the likelihood of discrimination from the public (18 per cent compared with 9% for those who are not transgender) and were more than twice as likely to experience discrimination from colleagues (19 per cent compared with 8 per cent and worsening from last year). Another reason is that with so many competing priorities, some managers may not get around to specifically addressing the LGBTQ+ staff equality gap.

"With the urgent need for better efficiency and productivity within the NHS, accepting this potential loss of talent is not just unethical; it is bad business."

So, what would it take for managers to start closing the equality gap and to improve the experience of LGBTQ+ staff in the NHS? The NHS Confederation’s Health and Care LGBTQ+ Inclusion Framework identifies some key opportunities which have been co-created and tested within the NHS, and my book Breaking the Rainbow Ceiling looks at the wider research around LGBTQ+ people at work. Bringing them together identifies many opportunities; here are some examples.

Use the data

The NHS Staff Survey results website is freely accessible, but leaders do not always take full advantage of its analysis capabilities. It is fast and fairly easy to analyse the NHS Staff Survey for your organisation to identify any differences in experience your LGBTQ+ staff might be having. You can also look at the intersectional data with other diverse characteristics. Doing that analysis is a great first step to see where there might be challenging areas in your patch.

Having acquired that knowledge, exploring it with curiosity can deliver valuable insight (while bearing in mind that any survey provides an incomplete picture). To understand what the data really means for your teams, you may consider running focus groups or staff group discussions based on the results. 

"Developing your own knowledge base will help dispel inadvertent prejudice and assumptions and empower anyone to have more meaningful conversations with your teams."

To prepare well for these discussions, there is ample information available about what factors may positively or negatively affect LGBTQ+ people at work (including the diversity of experience and challenges even within that abbreviation). 

Developing your own knowledge base will help dispel inadvertent prejudice and assumptions and empower anyone to have more meaningful conversations with your teams. These discussions may help you identify what lies beneath the numbers, and what practical changes could lead to a substantial improvement in staff experience.

But remember: our NHS Confederation’s Health and Care LGBTQ+ Leaders Network survey last year found that a lot of our LGBTQ+ health and care staff may hesitate to be open about their experiences. Only 14 per cent of respondents to our survey felt their organisation responded swiftly and appropriately when they previously raised concerns about a negative experience related to them being LGBTQ+. 

In the NHS Staff Survey, there was a small fall in lesbian and gay staff experiencing bullying and harassment from managers from 12.13 per cent last year to 11.51 per cent in 2024, but the rate is still significant. To access the best insight to improve LGBTQ+ staff experience in the NHS, managers will need to grow that trust. Part of that is being aware of potential unconscious bias and following best employment practices when bullying, harassment or discrimination are reported.

Practical examples of actions that could help

Staff development: In exploring experiences with your LGBTQ+ staff, you might encounter discontent about perceived disparities in promotion opportunities. The research tells us that around the world LGBTQ+ people are less likely than the general population to be promoted when they are ready. There are many complex reasons, including prejudice and discrimination. 

But in my research, I found that LGBTQ+ people (and our managers) are more likely to underestimate our abilities, plus some of us tend to manage our careers a little more independently than the wider workforce; as a result, we are less likely to have mentors and to access networking and development programmes. Of course you’d want to explore this with your teams, but triangulating research evidence with staff experience might offer practical action on talent management.

Visibility counts: There’s an adage that you can’t be what you can’t see. When people see others like themselves succeeding at work, they feel more confident to succeed and thrive. LGBTQ+ people are particularly prone to imposter syndrome and benefit from visible role models. But a recent Pride in Leadership report found that 70 per cent lacked them. This is partly because LGBTQ+ people are less likely to be appointed into more senior roles, and it is one of the most impactful interventions to support others to thrive. This is a key reason we run the Health and Care LGBTQ+ Leaders Network. 

"When people see others like themselves succeeding at work, they feel more confident to succeed and thrive."

But how to achieve that visibility in a safe and appropriate way? Some options that our members have found helpful are senior staff sharing personal stories, for instance at staff-wide meetings, or through blogs or videos; and participation of staff from all levels of seniority in staff groups, including making sure there is an executive sponsor who can support activities and feed back to decision-makers.

Supporting staff to be out when desired: Despite the risks, being out as an LGBTQ+ person at work can be beneficial to the mental wellbeing of staff. It can also improve our engagement, experience and performance at work. But sometimes we hesitate. After all, the latest NHS Staff Survey tells us that 18 per cent of lesbian and gay staff and 20 per cent of transgender staff experience violence compared to around 13 per cent of staff who are not LGBTQ+. 

It showed 67 per cent of transgender staff reported being treated with respect compared to 72 per cent of others. Transgender staff experience higher bullying, harassment and abuse from managers (14 per cent compared with 9 per cent) and colleagues (25 per cent compared with 17 per cent). And 31 per cent of lesbian and gay staff experienced bullying, harassment and abuse from members of the public compared to 24 per cent for heterosexual staff. 

"By consistently emphasising and demonstrating your commitment to NHS values, you can help create an environment where people feel safer to bring more of their authentic selves to work."

If people feel unsafe to be out at work, the board, CEOs, managers and employers can make sure people know that at every level of your organisation, prejudice and discrimination won’t be tolerated. By consistently emphasising and demonstrating your commitment to NHS values, you can help create an environment where people feel safer to bring more of their authentic selves to work.

The need for practical action

Right now, LGBTQ+ staff are less likely than the general workforce to recommend the NHS as a place to work, and the gap is widening. Improvement in their experience so they can thrive at work is essential for the NHS to fulfil its People Promise, remain an employer of choice, and successfully implement the 10-year health plan. 

Do join the NHS Confederation’s Health and Care LGBTQ+ Leaders Network, check out our LGBTQ+ inclusion hub for further ideas and resources and consider your action plan.

Dr Layla McCay is director of policy at the NHS Confederation and executive lead of the Health and Care LGBTQ+ Leaders Network.  You can follow Layla on BlueSky and LinkedIn.

Notes:

• In the NHS Staff Survey staff are not described as transgender. The survey uses two categories: staff whose gender identity is same as at birth and staff whose gender identity is not the same as at birth. In this text, I have used non-transgender/transgender as shorthand but these descriptions may encompass wider identities.
• The data in this blog is illustrative to help describe the trends but please consult the NHS Staff Survey website for the full data.