Classification: Official
Publication reference: PRN01502

To:

• integrated care boards:
  • chief executive officers
  • chief nursing officers
  • medical directors
  • chief people officers
• NHS trusts and foundation trusts:
  • chief executive officers
  • chief nursing officers
  • medical directors
  • chief people officers
• GP practices
• dental practices
• pharmacy contractors
• general ophthalmic service contractors

cc:

• regional directors

Dear colleagues,

NHS response to 2024 riots

Last week we held a meeting with integrated care board (ICB) and trust chief executives and deputies to discuss the NHS’s response to the civil unrest and groundswell of hate we have seen across the country – including online – over the last fortnight in particular.

These racist and Islamophobic riots have been shocking and have had a deep impact on many of our staff and patients. We are conscious that these traumatic events have come swiftly after other racist incidents in our society affecting our staff, such as continuing acts of antisemitism, all of which are deeply concerning.

Thank you for the very clear determination and commitment that we heard in that meeting to look after all our colleagues and patients. We know this extends well beyond the chief executives and others who joined us last week, which is why we are sharing this letter with a wider group.

We know also that while the events of the last week have brought a particularly acute focus on the racism that some colleagues and members of our communities still face, these are longstanding issues that require long term commitment. While much of it is not within our influence, what happens within the NHS is.

A key takeaway from the meeting was that colleagues would appreciate a ‘do once’ approach to bringing together, and in some cases interpreting, relevant resources, guidance and policies: relating to supporting our staff, and to addressing racist or other discriminatory behaviour, whether from patients or colleagues.

Since then, we have held two calls with all chief people officers to establish further what would be helpful. We have continued to hear updates from the frontline.

Our starting principle is that discrimination is unacceptable, and the NHS should have zero tolerance of racism towards our patients or colleagues.

As we pointed out in the NHS equality, diversity and inclusion (EDI) improvement plan last year, this is not just a question of values; but of staff feeling safe to come to work, wanting to remain in the NHS, and being able to contribute to the best of their ability; and of patients having the confidence that they will be looked after appropriately if they need our care. As such, it is fundamental to our core business.

This letter is the first main step in responding to your ask on last week’s call. The annex below provides guidance and information and clarifies key points of concern.

We are conscious it is not the full picture. Some elements of it will be more applicable to some organisations than others. Other elements need further work to finalise, which we are doing with national partners.

Our intent in writing now is to share what we can quickly, but we are committed to continuing to work with you and staff representatives to address additional questions and considerations.

Finally, the information below is by necessity written for you as leaders of your respective organisations, responsible for developing and implementing policies; you will know best what works in terms of how you communicate this to your staff, patients and the different communities you serve.

However, as you will appreciate, it is important that this communication does take place, with an emphasis on empowering individual staff and patients to take action where they encounter racist behaviour, and giving confidence that their organisation will back them when they do. London Ambulance Service gave us a good example of this earlier this week.

Thank you, again, for everything you are doing to support both staff and patients.

Yours sincerely,

Dr Navina Evans, Chief Workforce, Training and Education Officer

Professor Sir Stephen Powis, National Medical Director

Steve Russell, Chief Delivery Officer

Duncan Burton, Chief Nursing Officer, England

Annex: Listening to and supporting affected staff

1. Ensuring staff can access the support they need

NHS employers will already have well-established policies in place to support staff who are concerned about their safety at work. The general principles relevant to the events of the last fortnight are that:

• staff know how concerns can be raised, and use of these processes is monitored to ensure they are fit for purpose
• line managers have adequate advice and training so that they can directly support colleagues where possible, and signpost to other forms of support where needed.
• (where staff raise concerns about their personal safety) mechanisms exist to undertake a local risk assessment and put appropriate mitigating actions in place, such as consideration of temporary remote working arrangements and/or safety measures for lone workers

Employers may wish to increase promotion of their local health and wellbeing support for staff. Details of nationally-commissioned routes of support, including the 24/7 text helpline ‘SHOUT’ and NHS Practitioner Health, can be found at NHS England – Support available for our NHS People.

It is important to recognise that while some staff may need support because they have been directly affected by attacks to themselves or friends of family, others may face less-direct impacts, including those living or needing to travel through affected or at risk areas. These impacts should be addressed as proactively as possible through line management conversations.

2. Involve staff networks in organisational response

Staff networks within an organisation are often a valuable source of peer support for colleagues.

Senior leaders – both executive and non-executive – may find it helpful to specifically engage with staff networks or other groups (for example, in primary care, this may be the whole team) to understand how colleagues feel about the current unrest and ensure their involvement in key decisions.

All staff have a responsibility to report where they see acts of discrimination, whether it affects them directly or not.

We know that many staff are strong allies on issues of discrimination, and they should be called upon to support.

Dealing with instances of racism and discrimination

3. Refusal to treat

In general terms, it is lawful for providers of NHS services to refuse to provide treatment where a patient’s behaviour constitutes discrimination or harassment towards staff; but this must be reasonable, and the approach tailored to specific cases.

The NHS Constitution, to which all NHS bodies and all providers of NHS care (including primary care providers and sub-contractors) have a statutory duty to have regard, is clear that access to NHS treatment is contingent on patients and the public acting in a respectful way.

This is reinforced by the NHS Standard Contract 7.2.3, which confirms that a provider is not required to provide or continue to provide a service to a patient “…who displays abusive, violent or threatening behaviour unacceptable to the Provider, or behaviour which the Provider determines constitutes discrimination or harassment towards any Staff or other Service User”, with the provider “in each case acting reasonably and taking into account that Service User’s mental health and clinical presentation and any other health conditions which may influence their behaviour”.

Similar but different provisions exist in general practice, dental services, pharmacy and optometry under the relevant regulations.

All healthcare settings should have policies relating to abuse, violence and racism against their staff (including trainees) by patients and or their accompanying relatives, that put processes in place to trigger a refusal of treatment, with appropriate safeguards and that are in keeping with the regulations and rules the service is delivered under.

Implementation of NHS England’s violence prevention and reduction standard is an important part of delivering safe services.

All policies should be in keeping with the guidance issued by professional regulators and bodies.

In particular, NHS trusts and GP practices should note:

• the General Medical Council’s (GMC) guidance, Racism in the workplace – GMC (gmc-uk.org) and ending the professional relationship a patient, which includes important provisions on emergency care, and is aligned with the BMA’s guidance
• the NMC’s professional guidelines and the Royal College of Nursing’s (RCN) guidance on Refusal to treat | Advice guides | Royal College of Nursing (rcn.org.uk)

It should also be noted that some types of behaviour potentially constitute criminal acts. Where this is suspected, and particularly where the safety of colleagues or other members of the public is threatened or compromised, it should be reported to the police immediately, or as soon as practicable afterwards.

While respecting the wishes of individual staff in this regard, we support organisations pursuing criminal charges and convictions in all applicable cases.

Notwithstanding the guidance above, we recognise that developing and applying these policies is not simple. If colleagues require further information or advice, they should contact their professional leads within ICBs and regions. Primary care contractors (general practice, dentistry, optometry and pharmacy) should contact their commissioner.

4. Consistency in approach to social media policies

Many healthcare providers already have established social media policies for staff, covering activity inside and outside of work.

In general it is good practice that social media policies are reviewed and re-communicated to all staff periodically. Where appropriate, it is also good practice that policies make specific links to the requirements of professional regulators, for example the GMC, Nursing and Midwifery Council (NMC), the Health and Care Professions Council (HCPC) and the General Dental Council (GDC).

It is also important that these policies link to broader disciplinary policies and procedures.

Appended to this email is the NHS England social media policy, which may be useful as an example – we are also reviewing this in light of the current situation.

As above, some comments made on social media may contravene the law. Where this is suspected, organisations should report them to the Police for investigation.

5. Consistency in our approach to dealing with staff involved in civil unrest, or other racism-related activities outside of the workplace

NHS Employers has developed specific advice and guidance for NHS HR directors/chief people officers, which addresses conduct outside of working hours, incidences involving the police and the use of social media. This can be accessed online: Legal advice in relation to the summer 2024 riots | NHS Employers

We support a robust and proactive approach to applying local disciplinary policies where staff are allegedly involved in discriminatory behaviour, inside or outside of work.

This may include a risk-based approach to concluding the investigation, hearing the evidence, and appropriate sanction applied, in advance of the police concluding their procedures.

You should note that onward referral to professional regulators may be appropriate. Additionally, there may be cases where there has been no police involvement to date, but where internal investigations suggest criminal acts may have taken place; in these cases, employers should report their concerns to the police.

NHS Employers will be available to support this approach.

Demonstrating ongoing commitment to equality, diversity and inclusion

6. Improving our own progress in addressing key EDI concerns

The concerns of staff about the discrimination they experience working in the NHS are not new; nor do they manifest solely in the ways we have seen over the last fortnight.

We all have a duty to staff, patients and the public to root out discrimination in all forms in the NHS. We can do this by taking forward the 6 high-impact EDI actions set out in the NHS EDI improvement plan, through a plan of tangible actions against which performance can be assessed internally by leaders, in a transparent way.

In doing so, it is important to pay attention to the experience of students/learners, bank workers, international recruited and subcontracted staff, to ensure they are included in our support and their experiences shape our wider work.

7. Working closely in partnership with our trade unions

Trade unions have a long history of advocating for staff, including dealing with and addressing discrimination in our society and workplaces.

Some of the issues that you will be dealing with locally will be relatively new and require new or more proactive approaches.

Many of you will be working closely with your local trade unions, and we would encourage a united approach with our local partnerships forums. Trade union health and safety representatives are an important partner in addressing safety issues including violence and aggression in the workplace.

8. Ongoing joint working and advice

To support leaders, the national NHS England Workforce, Training and Education team will convene all HR directors and chief people officers on a regular basis. The first of those meetings happened last week and was instrumental in shaping the content of this letter.

For individual cases that require support, the relevant regional director of workforce, training and development should be contacted.

NHS Employers will also convene a weekly ‘drop in’ session, with legal support, to support consistency of local application. Details of how to access this support will be sent shortly.