NHS Digital and NHS England have built the flag in the NHS Spine to enable health and care professionals to record, share and view details of reasonable adjustments across the NHS, wherever the person is treated.
Having been successfully piloted, the capability is now in further final development, and will be available for wider use from the end of 2020.
Under the Equality Act 2010, organisations have a legal duty to make changes in their approach or provision to ensure that services are as accessible to people with disabilities as they are for everybody else. These changes are called reasonable adjustments.
Reasonable adjustments can mean alterations to buildings by providing lifts, wide doors, ramps and tactile signage, but may also mean changes to policies, procedures and staff training to ensure that services work equally well for people with physical or sensory disabilities, learning disabilities or long-term conditions such as dementia.
Other adjustments include longer appointments, providing easy read materials or communications via a carer. This legal duty is anticipatory which means a service should know about a person’s need for adjustments when they are referred or present for care. For this to happen, and for optimum care to be delivered, adjustments need to be recorded and shared across the NHS.
All organisations are legally responsible for making reasonable adjustments to their services for relevant individuals. These adjustments may be recorded in some clinical systems but are not always recorded or shared consistently across health and care, or when the patient moves from one care setting to another. The flag complements this existing recording of reasonable adjustments locally and enhances the effectiveness of initiatives such as the national Accessible Information Standard.
The national flag contains key adjustment information promoted from local records to benefit the patient at reception, or on referral where information about adjustments or other special requirements may be incomplete or unknown.
The flag provides an immediate visible alert; providing basic context, is a prompt for key adjustments and can signpost to further information in shared clinical records or from other organisations, other healthcare professionals, the individuals’ carer or the individual themselves.
The flag is designed to provide staff with information on their duties under the Equality Act 2010 and is a means of delivering on them. It offers pick lists of existing adjustments defined by clinical codes – such as communication needs defined using the Accessible Information Standard clinical codes - as well as the opportunity to create highly individualised bespoke adjustments for patients.
The flag is part of the NHS Spine and healthcare professionals and administrative staff can view, create, add or remove information from the flag. This can be done using the Summary Care Record Application (SCRa). Longer term, a FHIR software interface will be available for clinical systems to integrate with the flag.
Access is controlled via NHS smartcards and the appropriate Role Based Access Codes (RBAC), so that only authorised healthcare professionals and administrative staff with the relevant security permissions can access the information in the Reasonable Adjustment Flag. Administrative staff who only access demographics information on the spine can clearly see the presence of the flag but not the information within it.
Health and care organisations create the flag in conjunction with the individual and/or their carer or in line with existing best interest decision processes.
Examples of the categories of adjustments, and the types of adjustments within them, that can be recorded on the flag, are shown below.
Our case study helps illustrate how the adjustments can be used to support care.
Along with the details of adjustments to care, the flag can optionally contain details of the disability or long term condition that is the source of the patient’s impairment(s) in line with the Equality Act 2010.
The list below shows the information that can be recorded and, where relevant, the Equality Act 2010 definition:
This video takes you through how to create and view reasonable adjustments on the NHS Spine.
Our e-Learning resource shows you how to:
Please note: the examples used in the video and e-Learning tool are created using the current version of SCRa.
The capability may look slightly different in the new private beta version of SCRa or clinical systems integrated with the capability in the future, but the approach will be the same.
The original project mandate grew out of Summary Care Record (SCR) programme work. This built on reasonable adjustments identified during the annual health check for patients with learning disability being shared through SCR with Additional Information.
A further request came from NHS England in relation to the findings of the CIPOLD (Confidential Inquiry into Premature Deaths of People with Learning Disabilities) report for a flag to identify when a patient with learning disability presents for care. Co-production and discovery work was undertaken with significant stakeholders including:
In addition, co-production and discovery work was undertaken with clinical system providers including screening services and many individual patients and their carers and families.
In response to findings, NHS England commissioned NHS Digital to create a Reasonable Adjustment Flag on the NHS Spine for the benefit of all relevant patients covered by the definition of impairment under the Equality Act.
This supports the findings of the CIPOLD report and the NHS Long Term Plan requirement that by 2023/24, a ‘digital flag’ in the patient record will ensure staff know a patient has a learning disability or autism.
The first phase of work has seen the capability built into the NHS Spine and available for flag creation, viewing and update through use of the SCR application (SCRa) and SCRa 1-click enabled clinical systems (initially in Servelec Rio).
In addition, a FHIR software Application Programme Interface (API) has been designed for integration of clinical and screening systems with the flag.
Following the successful SCRa pilots, the work has now progressed to the next phase which includes:
The expectation is that technical updates to SCRa and piloting of system integration will be complete towards the end of 2020, when the capability will be made available for wider use across health and care.
For organisations that wish to know more about the future utilisation of the capability and how it complements and extends their existing delivery of reasonable adjustments, please contact: enquiries@nhsdigital.nhs.uk
The NHS Digital Implementation and Business Change team are available to talk to you about how you’re already making reasonable adjustments and how the structured approach to the flag can complement and extend current activity.
For patients and carers who wish to know more about the provision of reasonable adjustments, please visit the Reasonable adjustments for people with a learning disability page on GOV.UK or contact the organisations that are providing your care.
How can I help make sure these adjustments are made? Including what digital flagging means for patients a short film is about how sharing information can help staff in health services know the right way to work with people with a learning disability and/or autism.
Public Health England Guides on how reasonable adjustments should be made to health services and adjustments to help people with learning disabilities to access services.
Social care guidance about making reasonable adjustments for people with learning disabilities.
The inquiry found: 1) The lack of reasonable adjustments … was a contributory factor in a number of deaths. 2) GP referrals commonly did not mention learning disabilities, and hospital ‘flagging’ systems to identify people with learning disabilities who needed reasonable adjustments were limited. 3) There is a need for clear identification of people with learning disabilities on the NHS central registration system and for this information to be made available to care professionals in healthcare record systems. Merely identifying that a person has learning disabilities is not sufficient - this information needs to be supplemented by a statement of the reasonable adjustments required.
Equality and Human Rights Commission guidance on the Equality Act 2010.
You’re disabled under the Equality Act 2010 if you have a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on your ability to do normal daily activities.
All organisations that provide NHS or adult social care must follow the accessible information standard by law. The standard aims to make sure that people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand with support so they can communicate effectively with health and social care services.
Why and how we process your data in the Reasonable Adjustment Flag and your rights.
By 2023/24, a ‘digital flag’ in the patient record will ensure staff know a patient has a learning disability or autism.