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NHS

National Health Services - This guide is part of a suite of guidance that seeks to equip NHS staff at all levels – whether as employers, employees, service planners, commissioners or providers – to understand the needs of all people. Research suggests that attention to the religious and cultural needs of patients and service users can contribute to their well being and, for instance, reduce their length of stay in hospital. Religion and belief are therefore important considerations for all patients and staff. This guide, whilst summarising our legal obligations in this regard, also sets out how equality issues in religion or belief relate to the principles that underpin our health objectives.

Legal requirements - Over recent years in the UK, levels of awareness of different religions and beliefs have grown – and, in the main, equitable treatment of individuals and inter-faith relations have improved. But, in spite of this, discrimination on the grounds of religion or belief, religious intolerance and prejudice still exist in certain areas.

The European Council Directive of 2000 establishing a general framework for equal treatment in employment and occupation came into force in the UK in December 2003 through the Employment Equality (Religion or Belief) Regulations. These regulations make it unlawful to discriminate against people on the grounds of their religion or belief. The regulations apply to vocational training and all aspects of employment including recruitment, terms and conditions, promotions, transfers, dismissals and training.

The role of religion or belief in healthcare - We live in a society with an ever widening and diverse mix of religions and beliefs, which NHS organisations need to take into account when developing both services to the public and employment policies. Even within established religions there are various branches and regional and sectional variants with different traditions of interpretation, rituals and practices, moral guidelines and laws. There are also levels of personal compliance ranging from nominal to strict observance. Additionally, many people hold strong views about not having personal religious belief.

Further, research has highlighted differences in the health and wellbeing of different religious communities – a finding that provides an opportunity to target services. The British Muslim community, for example, has the poorest reported health, followed by the Sikh population. For both groups, as well as for Hindus, females are more likely to report ill health, whereas for Christians and Jews there is only minimal gender difference. It should be borne in mind that this is not necessarily a case of cause and effect, but more likely is compounded with other factors such as housing and economic and social status.

Implications

   Policy implications - Religious and cultural views on the beginning of life can influence attitudes towards reproductive medicine, abortion, contraception and neonatal care. Views on dying, death and the afterlife can influence attitudes towards pain relief for terminally ill people, means of determining the moment of death, brain death, organ donations and care for the corpse.

Palliative care is the prevention of and relief from suffering by means of early identification and treatment of pain and other problems (physical, psychosocial and spiritual). It aims to enhance the quality of life for terminally ill patients as well as for their relatives or family. It seeks to integrate both physical and spiritual aspects, and leaves room for religious communities’ interpretations of the relationship of body/mind/soul/spirit. (A more detailed explanation is in ‘Palliative care’ in Section Three.)

The inclusion of relatives / family is particularly relevant in religious communities, where high emphasis is often placed on familial bonds and responsibilities. With due attention to confidentiality and the patient’s wishes, where the family and relatives are included in care, it is vital that staff involved are aware on some level of the patient’s religious attitudes towards disease, suffering, dying, death, religious practices and rites, as well as their views on familial responsibilities and traditions, in order to ensure sensitivity and respect when administering care to the patient. Staff should also be aware that an individual’s level of compliance with their religious belief may well vary according to their perception of their illness, and that relatives and/or next of kin may have differing views on religion, practice and observance.

Religious and other beliefs can also impact on the types of treatment and drugs used: for instance, the prohibition of eating pork in Judaism and Islam means that porcine-or alcohol-based drugs might be forbidden in these communities. Similarly, the use of bovine-based drugs or cattle-derived cartilage transplants would have belief implications for Hindu communities and for some vegans and vegetarians.

Religious attitudes towards different forms of healthcare, such as in-vitro fertilisation (IVF), organ donation and palliative care, can often be the result of a lack of understanding amongst client and patient groups about the processes and the benefits to be derived from them. Raising awareness in communities and sensitively explaining some of these processes could lead to greater flexibility in attitudes towards some medical procedures. However, there is a need to be very aware of religious stereotyping and to be mindful that there can be individual differences within groups.

The Improving Working Lives Standard in the NHS makes it clear that every member of NHS staff is entitled to work in an organisation which can demonstrate its commitment to more flexible working conditions and gives staff more control over their own time. This is especially relevant to taking religion or belief into account.

Other issues include an awareness of different religions or beliefs when arranging meetings – for instance, not meeting in a place where alcohol is served, or not holding Friday-afternoon events or Saturday awaydays, which persons from certain religious communities may not be able to attend. In the same way, dietary considerations should be taken into account when arranging catering, and attendees should always be asked for their requirements or preferences.

Workplace

   Religious observance in the workplace - Most religions or beliefs have special spiritual observance or holy days when some staff may wish to request time off in order to attend the associated ceremonies or festivals. A practical step for NHS organisations to take is to display a multi-faith event calendar and year planner so that, where appropriate, preparation and cover can be organised in advance. Employees should make requests for such leave well in advance, to allow managers to support their requests where it is reasonable and practical to do so. Where several requests are made for leave on the same day, managers should hold discussions with staff to seek mutually acceptable compromises and solutions. Employers may want to be proactive in reminding managers and those responsible for rotas of upcoming significant dates that may impact on staffing and/or attendance of patients.

It should be noted that the dates of some religious festivals are not known until quite close to the day, because the dates depend on lunar phases and change from year to year. Again, discussion and flexibility on both sides can hopefully lead to a satisfactory outcome. At the same time, consideration should be given to those who do not hold any specific religion or belief, so that they are not unduly disadvantaged by any arrangements made. Managers may wish to keep a record of who has been granted leave in these cases, and how decisions have been reached.

Many religions also require time during the day for prayer or meditation. It is good practice to provide a room for this purpose, designated for use by all members of staff for the specific purpose of prayer or quiet contemplation. Consideration should also be given to providing separate storage for the different ceremonial objects.

Flexibility around time allowed for prayer and ablutions can be best achieved by discussion with the person concerned, as individual needs can vary. Being flexible with the times of normal break periods can often lead to acceptable solutions. It is important to remember that most individuals have had a great deal of experience at fitting such needs around the ordinary call of work and study. It is essential that all such arrangements conform to the organisational policy and are seen as transparent and fair to all employees.

Some religions prohibit working on certain days – for instance, from Friday sunset until Saturday sunset in Judaism, and on Sundays in some Christian religious groups – although there are often exceptions made for those involved in caring for others. Shift patterns and any necessity for weekend working should be discussed from the first day of training or employment so that suitable compromises can be reached. Flexible working hours can often accommodate such requirements. Where it is impossible to do so for reasons of staffing or other business necessities, it is important to show that every effort has been made to find suitable solutions, particularly where the employee has previously indicated working preferences because of religious belief.

Many religions or beliefs have specific dietary requirements. For this reason, those bringing food into work may need to store and heat it separately from other food. For instance, some Jewish people cannot store meat products alongside dairy products, and Muslims will not wish their food to be in contact with pork or with anything that may have been in contact with pork. Those who are vegetarian for reasons of religion or belief may not wish their food to be stored near meat. These are all very real issues for those concerned, and employers should be ready to discuss and reach acceptable solutions.

In some religions, it is a requirement to fast for a certain period of time. Consideration should be given to ways of supporting staff during these periods, but employers should also be careful to ensure that excessive extra duties are not placed on other staff which could cause conflict or claims of discrimination.

Cultural dress codes based on religion or belief should be considered sympathetically unless there are justifiable reasons, such as health and safety issues, for not permitting certain items of clothing. As mentioned previously, issues on wearing traditional religious clothing whilst working in any healthcare setting should be taken into account at the very first stages of training so that students are aware of any health and safety issues, and so that suitable arrangements can be put into place.

NHS organisations that have policies regarding the wearing of jewellery or other symbolic items should factor in due consideration for items that are traditional within some religions or beliefs, unless the rules are for health and safety or other justifiable reasons. Some items of jewellery can be highly symbolic in certain religions and cultures, so any rules against the wearing of these must be justifiable so as not to constitute indirect discrimination.

In some religions, a long period of mourning is required when a person dies – for instance, in Hinduism the period of mourning is 13 days, and in Judaism there are seven days of mourning or ‘Shiva’. In Hinduism a male relative is sometimes required to carry the ashes to the Ganges. In Islam some widows observe an extended mourning period of four months and 10 days; during this period the widow is not permitted to move from her home. Where the policy for leave on the death of a close relative is three days, extra time given for religious reasons could be seen as discriminatory to non-religious and other staff. Each case should therefore be dealt with on an individual basis, and consideration may be given to using annual or other leave to cover the period of leave required.

The tradition in some religions is to wear white or in some cases black clothing during the period of mourning, and it should be remembered that during the mourning period close relatives of the deceased, and especially widows, may not be permitted to attend social functions.

Fasting

Diet, modesty and other matters - Patients should always be asked to state their dietary needs; nutrition is an essential element in the treatment and recovery of patients, and patients could refuse food if it does not meet the requirements of their religion or belief. This is especially relevant in older patients, who may not indicate their needs unless they are asked, or in those who fear they are likely to die and are therefore even more observant in their religious practice at the time. There is a risk that the refusal of food may be attributed to a loss of appetite, leading to poor nutrition if the real reason for refusing food is not established. An example of this could be offering a chicken sandwich with butter to a Jewish person, whose religion forbids the mixing of meat and dairy or milk-based products.

Consideration should also be given to making clear contractual arrangements with suppliers of food for hospitals, nursing homes and so on to ensure that food for people from different religions or beliefs meets their religious requirements wherever possible and is clearly labelled. Catering suppliers should be advised of the NHS organisation’s policy relating to these requirements, for example for halal, kosher, vegetarian or vegan food. An example of poor practice in this context would be placing meat and vegetarian foods on the same serving platter, or using alcohol in the cooking or preparation of food without clear labelling of such. It may be useful to source catering from suppliers within the religious or cultural groups under consideration, who may have many of these arrangements already in place.

Modesty in dress and a requirement to be treated by a doctor/nurse of the same sex is also important in some religions. NHS staff should consider these requirements in order to preserve the dignity of the patient. However, it is not always possible or feasible to provide same-sex attendance, particularly without adequate notice that this might be an issue, and this should be made clear at the time of making appointments.

Multi-faith event calendar - It should be remembered that many religious festivals are based on the lunar and/or solar calendars, or are on fixed dates which change with the common calendar year. It is good practice for NHS organisations to have, or arrange access to, an up-to-date multi-faith event calendar available for planning purposes.

Do public authorities have a legal duty to work for racial equality?
Yes, most public authorities now have a statutory general duty under the amended Race Relations Act to promote race equality. This means they must do whatever they can to:
• eliminate unlawful racial discrimination;
• promote equal opportunities; and
• encourage good race relations.
Most public authorities also have other specific duties under the Act. These cover the way they provide services and employ people, as well as how they make policy.

Missed appointments. When the outpatients department of an NHS trust examined missed appointments, it found that patients from ethnic minorities were more likely to miss their appointments on certain dates. A closer look at the information showed that many of these missed appointments were on holy days or festivals (for example during Eid, Greek Easter, Divali, or on St Patrick’s Day). To make sure that staff responsible for making appointments knew when those days fell, the outpatients department put a multi-faith and multi-ethnic calendar on its computer system.

Race for Health produces a combined multi-faith calendar and recipe book, Recipes for Success. The calendar combines 12 recipes celebrating food and culture from black and minority ethnic communities with 12 case studies of good practice from the Race for Health primary care trusts, alongside useful facts about race, health and inequality. To obtain a copy, simply email This e-mail address is being protected from spambots. You need JavaScript enabled to view it . Recipes for Success is also now available in a monthly downloadable and printable format. You can link to the calendar from your own organisation’s website or give your staff access to it via your in-house newsletters/email bulletins. http://www.raceforhealth.org/resources/publications/recipes_for_success

Employers

What employers must do - Although employers are not required to provide time and facilities for religious or belief observance in the workplace, they should consider whether their policies, rules and procedures indirectly discriminate against staff of particular religions or beliefs. If they do, they should also consider whether reasonable changes might be made. The following are examples of areas where employers have taken steps to make reasonable changes:
* Break policy
* Flexible scheduling, eg. avoiding important religious festivals when interviewing
* Religious leave
* Responding to dietary needs
* Fasting
* Alcohol
* Prayer rooms
* Time off for prayer
* Uniforms/specific dress codes
* Dress codes and health and safety
* Jewellery
* Undressing / shower facilities
* Social Interaction, eg. acknowledging that some applicants will avoid eye contact for religious reasons and some may not wish to shake hands
* Monitoring of religious beliefs to identify the potential needs of staff
Implications - Possible areas or activities for organisations to consider when considering religion or belief issues in the workplace are:
* Develop staff awareness of belief systems and faith patterns in the UK
* Develop guidance on the equality provisions in the Employment Equality (Religion or Belief) Regulations 2003, including direct and indirect discrimination, victimisation and harassment
* Profile your workforce to identify both risks and opportunities it creates; for example, applications for leave for religious festivals may create flexibility at other times
* Establishing boundaries beyond compliance allows an organisation to consider how far it would go to support employees in practicing their religion or belief; for example staff networks, quiet rooms etc
* Impact assess policies and practices in line with the relevant regulations to ensure they do not disadvantage particular religious groups or beliefs
* Promote a culture of respect through awareness training and how it contributes to the working of the organisation

* Decide if a request is reasonable or practical through engagement with the workforce and wider community (not all requests for adjustments will be met)
* Address practical considerations e.g. food, holidays, dress, prayer etc through learning and development
* Develop a business case on the value of addressing religion or belief e.g. improving efficiency and avoiding claims
* Raise awareness with key stakeholders on how the organisation accommodates and values religious and belief in the workplace

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