There are some instances where patients are discriminatory that should be dealt with differently.

These can be categorised under three headings:

1. When a patient’s behaviours are linked to an underlying condition or pathology e.g. mental health illness, dementia.
2. When the behaviour is from a legal guardian of the patient e.g., parent of a child or person who has power of attorney for a patient.
3. When the characteristic of the healthcare worker will affect the physical and mental wellbeing of a patient e.g. requesting a specific gender for a personal or sensitive care, or psychological treatment.

Behaviours linked to an underlying condition or pathology

Sometimes, abusive behaviour can be a facet of a patient’s distress and inability to cope. Unexpectedly aggressive or disinhibited behaviour can be the result of a patient’s medical condition.

What are the exceptions?

• Patients who are abusive should not be denied urgent treatment or immediately necessary care, where this can be provided safely.
• Where such behaviour does not arise as a result of underlying pathology, and treatment is not urgently required, we support a doctor’s right to delay or refuse immediate treatment.

When a patient displays discriminatory or abusive behaviours due to an underlying pathology, it could be assumed that they have limited control over those behaviours. However, the impact of their behaviours is still relevant. For example, a healthcare worker who works on a ward where there are many patients with dementia may face racial abuse daily – no matter if the patient’s illness is causing or escalating their behaviours, the doctors on the receiving end of abuse will be affected by the abuse, and it must be managed.

What should I do?

Where a patient has an underlying pathology that leads to the discriminatory behaviours, there are three actions to take:

1. The patient should still be challenged about their behaviour, potentially when they are in a period of awareness – if that is not possible the behaviours should be documented.
2. The healthcare worker who was on the receiving end of the abuse should have their wellbeing checked and given support to discuss their experiences and how they would like it to be dealt with. It is essential that the negative impact on the healthcare workers is acknowledged and options for how to deal with the patient discussed.
3. Discuss all options. Moving or discharging the patient should be discussed as a viable option. It is important that the healthcare worker on the receiving end of the abuse is not moved without first discussing if this would have a negative impact on them, as this could be perceived as a punishment on the person who is the victim of the abuse.

Behaviours from a legal guardian of the patient

There are situations where the discriminatory preferences don’t arise from the patient being treated. For example, this may occur if the patient is a child, and their parents or guardians are making the request, or if the patient is an adult and the request is coming from those legally responsible for their health decisions.

The healthcare professional subject to unlawful discriminatory behaviour should be involved in discussions about what action would honour their dignity, which could be consistent either with still seeing or with not seeing the patient, depending on their preference.

In all these situations, protection of the healthcare professional should be a key concern, balanced with the needs of the patient to have appropriate and timely care.

What should I do?

In these situations, the requestor should be spoken to directly and have all the options as to the consequences of their behaviour discussed with them.

Options could include the following (and potentially more than one at once):

• Immediately confront the individual who has displayed discriminatory behaviours and tell them that their behaviour is unacceptable in this public healthcare environment. Be specific and give examples of their language/behaviours that were discriminatory or inappropriate.
• Request that the legal guardian acknowledges their behaviour, apologises and agrees not to exhibit the behaviour again.
• Tell them that the behaviour will be recorded on the patient’s record.
• Obtain agreement that the legal guardian is to be asked to leave the environment.
• If the legal guardian is abusive, but their presence is necessary for the wellbeing of the child/dependant adult, deliver care with security support.
• Remove the legal guardian from the environment (with security or police involvement).
• Engage child protection and vulnerable adult procedures if the safety of the child/dependant adult is at risk, e.g., if the care for the patient is being restricted there may be a need to involve social services.
• Involve the police and security to ensure safety of healthcare professionals.
• As a last resort, discharge the patient from care - dependent on the presence of abuse, the way the request is expressed, and the health needs of the child/dependant adult.

Impact on the physical and mental wellbeing of a patient

There may be examples where there is evidence that there are disproportionately poor healthcare outcomes for a group and that service provision at a local level is trying to rectify those outcomes. In these instances, the consideration of the ethnicity, gender, etc., of a healthcare worker could be an organisational response to patient need based on evidence, not patient preference alone (which could be based on discrimination).

There are some instances when a patient may need their healthcare worker to have a particular characteristic for valid reasons, where that personal characteristic is necessary to deliver reasonable care. This is accommodated for within the Equality Act 2010 that defines this an ‘occupational requirement’, which for example allows exclusively women to be employed as counsellors in a women’s refuge.

What is deemed ‘valid’ is broad and context-specific; examples could be for personal care or to support an agreed treatment plan where the characteristic of the patient as it relates to the protected characteristics of the healthcare workers has been identified as linked to the illness being treated. These valid reasons must be distinguished from a patient who wants to choose a healthcare worker’s protected characteristic purely based on unlawful discriminatory reasons, with no clinical benefit.

Psychological impact may be another reason when having a healthcare professional of certain characteristics may be better for patient care e.g., someone who has knowledge or experience of the ethnic, cultural or religious background of a patient as it relates to their personal experiences that may be relevant to their healthcare.

An example would be the practice of ‘race conscious medicine’ to counteract racial health inequalities and improve ‘cultural safety’ . For example, having an ethnic minority psychiatrist where a patient’s trauma is identified as being a result or experiences of racism, or similarly a woman psychiatrist for a woman who has been the victim of sexual violence from a man.

These situations should be dealt with on a case-by-case basis, weighing up the benefits to patient care – while also planning how decisions like this should be managed to ensure that all parties understand why such accommodations have been made.

Gender and personal care

When operating a service that deals with personal care, processes should be in place to accommodate requests that are valid. Intimate examinations and personal care may mean that some patients want a healthcare professional of the same gender.

In paragraph 8 of the GMC guidance on Intimate examinations and chaperones, it states ‘When you carry out an intimate examination, you should offer the patient the option of having an impartial observer (a chaperone) present wherever possible. This applies whether or not you are the same gender as the patient.’

Whether or not a patient can request the healthcare worker to be born in a specific sex is not covered by the guidance, although it is likely to be a very small number of incidents where this issue may occur.
When a person has affirmed their gender to be different than the sex they were assigned at birth, they are protected from discrimination. The sex they were assigned at birth becomes irrelevant to their current working and day-to-day lives. A patient does not have a right to know if a healthcare worker has a gender different to the sex they were assigned at birth. In some instances, a healthcare professional may not physically present in a way that could be assumed to be any gender.

As outlined above, in some instances, for the psychological safety of a patient, there may be occasions where accommodations can be made about the presenting gender of a professional who treats a patient – this would be on a case-by-case basis. For example, if a patient had been the victim of sexual abuse by a person of a particular gender, they may ask for a professional to examine them who physically presents in a different gender. If the patient then refused treatment from a particular healthcare worker who came to examine them, this should be dealt with sensitively, and communicated to the worker how it would be managed with their agreement. In reality, the potential situations where issues like this would arise, although limited, are varied in how they would manifest.

It is important to recognise that trans people are a very diverse, heterogenous group and individuals may have transitioned at different life stages and may not physically present as trans, gender fluid or in binary gender norms that are evident to a patient.