Pride In Practice: Supporting LGBTQ+ patients in general practice

Alex Matheson, deputy director of education at the LGBT Foundation, talks to senior reporter Jess Hacker about its Pride In Practice scheme, an outreach programme aimed at reducing health inequalities experienced by LGBTQ+ patients in general practice

What is Pride In Practice?

The point of Pride In Practice is to reduce the barriers to healthcare for LGBTQ+ people, and it does that by supporting practitioners, practice managers or anyone within primary care that works with patients to improve their understanding of what LGBTQ+ patients need. To do that we offer training and guidance alongside an assessment – ranking from bronze to gold – depending on how well they’re meeting these patients’ needs. That might include how they handle changing a patients’ gender marker or if they provide bridging prescriptions for hormone therapy or how they manage call and recall programmes. To help improve on those, we try to help them understand why these create barriers for LGBTQ+ people.

We’re funded by Greater Manchester integrated care board (ICB) to work with all GP practices in its boroughs. We work with PCNs in London and around the country, and that’s predominantly funded out of their health inequalities budgets.

What are these barriers to care and where do they come from?

It’s clear that LGBTQ+ identities have been pathologized, which makes it difficult for people to come forward to health professionals. Historically, there have been times were LGBTQ+ identities have been criminalised and negatively viewed in England and globally. If you look within the NHS itself, homosexuality and being transgender have both been classified as mental illnesses – which is still technically the case for the latter. It was only in the 1970s that the NHS stopped offering aversion therapy: a process of conditioning someone to associate certain behaviours with undesirable outcomes. There are similar conversations today about conversion therapy, with NHS England last year signing a memorandum of understanding condemning it.

Evidence shows that health workers have historically advised lesbian women that they don’t need a cervical smear screening because they don’t have sex with men, which is not true. And eligible trans people might be removed from recall programmes for cervical smears or other public health efforts tied to a person’s recorded sex.

It sounds like these come from a lack of understanding. How would Pride In Practice help a GP surgery manage that?

Helping clinicians understand on a very basic level. It’s often not malicious and just comes from a level of ignorance: a clinician might say they treat every patient the same regardless of their orientation, but that can be important information. Helping them to understand why it matters and offering a supportive environment so they can ask questions is the first step, because medical education in this country doesn’t typically cover LGBTQ+ care in a significant amount of detail.

They often have a lot of questions around trans people and they don’t know where to go: when you look online it can get very heated. What they need to know is factual: if they need to know how to change a trans patient’s NHS number and gender marker we will run them through that.

Bridging prescriptions is a very contentious but misunderstood one, so we help GPs understand the guidance that’s out there for them. Their responsibilities are actually quite clear and the times when it is an important part of their duty as a GP to consider a bridging prescription are outlined in the guidance. [We at the LGBT Foundation] aren’t clinicians so we don’t give medical advice, we review what’s out there. In this case, it often helps to consider how similar this work is to prescribing HRT for menopausal people. In that example it’s about monitoring hormone levels, it’s doing the appropriate checks, looking at titration where needed: it’s a replicable process and it just takes that frame of mind and the time to review the guidance.

Of the services that have worked with Pride In Practice, 87% now monitor sexual orientation and 60% monitor trans status. What is the benefit to practices?

If you’re not counting, they don’t count: you don’t know who is in your patient cohort and you won’t meet their specific needs. There’s a real clinical benefit to monitoring that for LGBTQ+ people. The NHS previously didn’t monitor ethnicity but it’s only through implementing that that we can track illnesses, behaviours and prevalence among people from different ethnic backgrounds, which was lifesaving during Covid. It’s the same for LGBTQ+ people. Through this monitoring we know that they often present to their GP at a later point in their journey of illness than a straight or cisgender person, which raises the possibility of a worse outcome or losing eligibility for personalised treatment. Cervical screening is a great example of that: how can you be sure trans men and lesbians in your care are presenting for smears if you don’t know you care for them. Because of that we know how important it is to tackle early barriers to care to prevent patient harm.

There is an NHS information standard for sexual orientation monitoring which the LGBT Foundation supported through to its implementation, but there is no information standard currently for recording trans status, so it’s been harder to push for that.

This is a big undertaking for practices. How do you encourage them to take part?

In areas like Greater Manchester we’re funded by the ICB to work with all practices, so we’ll reach out and actively speak to them to explain the full benefits if they’ve not taken part. It’s a service that’s being offered to them at no cost, so more often than not the issue is just scheduling a time to begin because it does require as many people from the practice as possible to take part.

Outside of Manchester, in London, practices tend to approach us after hearing about the scheme from practices in their own PCN or those nearby, and we can work with them as an individual practice or across their network.

Is there a benefit to delivering the scheme across a PCN?

The great thing about PCNs is that when they’re working together you’ve got a really wide footprint which means you’re reducing the likelihood of someone on one street having a totally different experience of care than someone two streets over, for reasons as minimal as where a practice’s catchment begins and ends. It’s important to think about the economy of scale – we want practices to sign up and improve their care because it’s the right thing to do, but we are often able to make it more cost effective for PCNs. That definitely helps. So when you have the PCN working together it means each of those practices becomes each other’s support network.