The Hijab and Bare Below the Elbows (HBBE) project was developed by a group of healthcare professionals with an interest in tacking workplace inequalities and discrimination. We felt there was a requirement to support female Muslims in the healthcare sector, as there was growing anecdotal accounts of dress code challenges within the workplace. In response, in April 2016, a questionnaire was developed to explore experiences of the NHS bare below the elbow (BBE) policy and experiences of wearing the hijab in theatres. The questionnaire was handed out to female attendees of a British Islamic Medical Association (BIMA) conference (Muslim Women Excelling in Islam and Medicine). The findings, published by the BMJ Open (1), revealed that more than half of Muslim women surveyed experienced problems with wearing a headscarf in theatre (51.5%), with some feeling embarrassed (23.4%), anxious (37.1%) and even bullied (36.5%). These experiences were shown to have a negative impact on their career choice. Consequently, women who were surveyed reported “avoided going to theatres” and deciding to give up their surgical dreams to follow careers in General Practice where they could wear “Islamic clothes with no concern”.
It is widely acknowledged that Muslims (both men and woman) must adhere to modest dress. For women this includes covering her body including the head and arms (2) [Quran 23:31]. However, in 2007 the NHS pursued a Bare Below the Elbows (BBE) policy, which has led many Muslim women to question whether adhering to the policy would compromise their religious beliefs. NHS guidelines necessitate BBE when in direct contact with patients however, there have been anecdotal accounts suggesting Muslim women in the workplace are being reprimanded for covering their arms during non-patient facing activates i.e. when at computer desks.
The HBBE working group and the Muslim Council of Britain (MCB) have continued raised these issues with the Department of Health (DoH). The previous DoH guidance on this issue does make reference to equalities legislation on BBE policy relating to faith (3) . However, a national audit conducted by BIMA found that only 9 out of 33 Trusts had managed implemented this guidance in their workplace policies (1). The audit also found that only 1 of 33 Trusts provided guidance for head coverings in theatres. Another problem Muslim women face is the use of hijabs in theatres. As there is no clear guidance in policies regarding hijabs in theatres there is huge discrepancy, not only between trusts but also amongst theatres within the same hospital. At a time where there is growing evidence explaining the disadvantage that Muslim women in the British labour market (4) and widening pay gaps from ethnic minority backgrounds (5), it is important, now more than ever, that inadvertent inequalities are exposed to prevent further discrimination.
In 2017, with the help of NHS Trust managers, infectious disease specialists and policy experts, HBBE working group, a toolkit was launched to aid health professionals facing work wear difficulties at work. As well ask acknowledging the rights of other faith groups, the toolkit highlights individuals’ rights when it comes to wearing the hijab and/or practicing BBE at work. It also includes a user-friendly flowchart guiding readers on how to initiate often sensitive conversations with their local trusts as well as how to escalate any incidents that have occurred. The toolkit is available online and can be accessed through the website of the British Islamic Medical Association (BIMA) , here:
The research conducted by the HBBE group and the toolkits has drawn growing interest from BIMA, the MCB and the General Medical Council (GMC). To disseminate the work further, the research has been presented at the Infection prevention Society (IPS) conference. In November 2017, BIMA also presented these findings at a national roundtable initiated by the British Medical Association (BMA) and hosted by NHS Employers. The meeting included the following stakeholders; BMA, General Medical Council (GMC), NHS England, NHS Improvement, Equality and Human Rights Commission, IPS.
There is clearly much more that needs to be done. However, there has been recognition that this work is having an impact. The London Faith and Belief forum for inclusivity and innovation presented BIMA and University College London Hospital (UCLH) an award for their work in this area. Through discussions and careful consideration of changes in their policy, UCLH have aimed to achieve equality in the work environment whilst upholding the best level of patient care possible.
A member of the HBBE team has been working closely with UCLH to help update their dress code policy. The new policy now details the allowance of full-length sleeves when not in direct clinical contact, ¾ length sleeves, and the use of disposable sleeves when in direct patient care. In addition to this, headscarves, kippots and turbans are allowed to be worn in the operating theatres providing they are washed daily at 60 and changed if soiled. Where available, orthopaedic hoods and single-use disposable head coverings are also permitted.
A year and a half later we are in discussions regarding the national policy. The HBBE team have many reports during this time from female medical professional deterred from taking a stand due to threats of escalation to GMC or dismissal. Some junior doctors feel so burdened by the hierarchy set in medicine that they are afraid to voice their concerns whilst others are bullied into nearing resignation.
It is clear that female Muslims employed by the NHS are facing extensive challenges with the BBE policy and wearing the headscarf in theatres; a mark of their faith. It is acknowledged that NHS leadership models centered on ‘compassionate leadership’ seek to encourage wider representation at senior levels as this could improve patient safety and better productivity (6). Questions need to be raised when policies hinder such steps.
The HBBE working group, BIMA and others have worked hard for several years to try to bring about greater awareness of the challenges faced by female Muslims in the NHS and we have reached out to many organisations at the top in an attempt to have more inclusive policies. We now call on each individual to create a change at a grassroot level. We urge you to look at and use the BIMA toolkits and our published findings to push for positive change in your local trusts. “Verily, Allah will not change the condition of people as long as they do not their state themselves.”, Quran 13:11 (2).
- Malik A, Qureshi H, Abdul-Razakq H, et al. ‘I decided not to go into surgery due to dress code’: a cross-sectional study within the UK investigating experiences of female Muslim medical health professionals on bare below the elbows (BBE) policy and wearing headscarves (hijabs) in theatre
BMJ Open 20.3.2019 . Access at :
- Haleem, M. A. S., translator. The Qurʾan: English Translation and Parallel Arabic Text. Oxford UP, 2010.
- DoH. Department of Health. Uniforms and Workwear: An evidence base for developing local policy, 2007. Available at:
- Khattab, N. and Hussein, S., 2018. Can religious affiliation explain the disadvantage of Muslim women in the British labour market?. Work, Employment and Society, 32(6), pp.1011-1028.
- ONS. Office for National Statistics. Ethnicity pay gaps in Great Britain: 2018. 2019.
Access at: https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/earningsandworkinghours/articles/ethnicitypaygapsingreatbritain/2018
- Cummings J. Building and Strengthening Leadership: NHS England, 2014:3–12