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.

   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.

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

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

Consider Important Dates of Fasts and Festivals do not clash with the event you are planning. Part 2 of the Equality Act, which came into force on 30 April 2007, deals with the prohibition of discrimination on grounds of religion or belief when providing goods, facilities and services, education, using or disposing of premises and exercising public functions. The government has produced guidance on this legislation. ACAS produced guidance for employees and employers on religion and belief in the workplace (Pdf)

With regard to any particular festival, the guiding principle is how broadly the different segments of that religion accept the festival. The festivals noted in Multi Faith Calendar are annual events that people celebrate once during the course of a solar or lunar year. Other cycles of time are also important: the new or full moon, a season, a week day (for example, the Jewish Shabbat or the Friday prayers in a mosque), or a daily cycle (such as the Eucharist for traditional Christian communities). While these cycles are less obvious, they are as important to the faithful as annual festivals.