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The Reasonable Adjustment Flag is a national record which indicates that reasonable adjustments are required for an individual and optionally include details of their significant impairments and key adjustments that should be considered.
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.
Reasonable adjustments - an overview
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.
How the Reasonable Adjustment Flag can help
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 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.
Categories and types of adjustments
Examples of the categories of adjustments, and the types of adjustments within them, that can be recorded on the Flag, are shown below.
Accessible information - communications support
Details of specific communication methods that are required for interacting with the patient:
does lip read
does use communication device
does use hearing aid
Preferred method of communication: written
Uses alternative communication skill
Uses British Sign Language (BSL)
Accessible information - requires communications professional
Details of specific communication requirements including communication professional and communication devices:
British Sign Language interpreter needed
Hands-on signing interpreter needed
Makaton Sign Language interpreter needed
Accessible information - requires specific contact method
where the patient requires contacts from care organisations to be be provided through specific communication channels or mechanisms:
requires audible alert
requires contact by email
requires contact by letter
requires contact by short message service text message
requires contact by telephone
requires contact by text relay
requires contact via carer
requires tactile alert
requires visual alert
Accessible information - requires specific information format
Where the patient requires information in a specific format:
requires information in contracted (Grade 2) Braille
requires information in Easy read
requires information in Makaton
requires information in Moon alphabet
requires information in uncontracted (Grade 1) Braille
requires information verbally
requires third party to read out written information
requires written information in at least 20 point sans serif font
Additional communications support
Additional communication support beyond that defined in the accessible information standard:
difficulty analysing information
difficulty processing information accurately
difficulty processing information at normal speed
expresses pain atypically
has My Healthcare Passport
needs assistance with communication
requires appointment reminders
requires carer to be present at encounters
uses apps on mobile device to support communication
uses switches for communication
uses Tadoma method for communication
Community language support
Including community language support for patients with impairments and carers who provide communication support for the patient and do not speak English:
Abkhazian language interpreter needed
Over 200 language codes can be used to identify a patient's primary language.
Including additional staff or carer support for the patient:
care to be delivered in consultation with the patients carers
has appointed person with personal welfare lasting power of attorney (Mental Capacity Act 2005)
needs assistance with medication regimen adherence
requires additional staff resource for their mental impairment
requires additional staff resource for their physical impairment
requires additional staff resource for their sensory impairment
requires constant supervision
requires enhanced discharge planning
unsafe to be left alone
Individual care requirements
Including changes to standard clinical activity to meet individual care needs:
dependence on seeing eye dog
has anticipatory care plan
has anxiety related to clinical settings
patient requires minimal waiting time between arrival and being seen
preference for female healthcare professional
preference for male healthcare professional
requires distraction for any procedure
requires extended appointment
requires familiarisation for procedures
requires familiarisation with environment of care
requires first appointment
requires home visits where possible
requires Last Appointment
requires priority appointment
self care deficit for medication management
uses dispensed monitored dosage system
Adjustments to the environment
Changes to the physical environment in which care is provided (including equipment):
eyes sensitive to light
requires low light environment
requires low noise environment
requires single room during inpatient care
requires wheelchair access
Bespoke reasonable adjustments
Personalised adjustments to the individuals care that are not covered by other:
requires reasonable adjustments for health and care access (Equality Act 2010)
Our case study helps illustrate how the adjustments can be used to support care.
Recording of impairments - details of disability or long term condition
Equality Act 2010 definition: Developmental conditions (excluding autism), such as dyslexia or dyspraxia
No specific Equality Act 2010 definition of dementia is available.
No specific Equality Act 2010 definition of learning disability is available.
Mental health condition
Equality Act 2010 definition:
Mental health conditions with symptoms such as:
bipolar affective disorders
obsessive compulsive disorders
post traumatic stress disorder
some self-harming behaviour
mental illnesses, such as depression and schizophrenia
Equality Act 2010 definition: produced by injury to the body, including to the brain
Sensory disability - such as sight, hearing or verbal
Equality Act 2010 definition: sensory impairments, such as those affecting sight or hearing
Equality Act 2010 definition includes:
Impairments with fluctuating or recurring effects
myalgic encephalitis (ME)
chronic fatigue syndrome (CFS)
depression and epilepsy
motor neurone disease
forms of dementia
lupus erythematosus (SLE)
Organ specific impairments
respiratory conditions, such as asthma
cardiovascular diseases, including thrombosis, stroke and heart disease
There is specific guidance in relation to HIV, Cancer or Multiple Sclerosis
Patient would prefer not to say
Some patients may prefer not to share this information and the solution supports this choice.
How to create a Flag
This video takes you through how to create and view reasonable adjustments on the NHS Spine.
Our e-Learning resource shows you how to:
access the SCRa and view the Reasonable Adjustment Flag
create and update a Reasonable Adjustment Flag
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.
Project progress to date
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.
Health and care professionals and supporting staff
This group consisted of:
a broad range of clinicians such as GPs, nurses, psychiatrists, pharmacists, dentists, paramedics, A&E and other emergency staff
clinical specialists in learning disability, autism and other impairments and disability
a wide range of supporting staff including receptionists, practice managers and managers of services
Professional and other related bodies
This group consisted of:
Royal College of Nursing
Royal College of General Practitioners
Royal College of Practitioners
Royal Pharmaceutical Society
Royal College of Emergency Medicine
Royal College Of Psychiatrists
Professional Record Standards Body
British Medical Association
Healthcare Safety Investigation Branch
Care networks and related organisations
This group consisted of::
Primary care liaison networks, other related networks and professional senates
Learning Disability Expert by Experience clinical advisors
Learning Disability Public Health Observatory
Norah Fry Centre, Bristol University – authors of the CIPOLD report
Government and related public sector organisations
This group consisted of:
Department of Health and Social Care - Dementia and Disabilities Unit, Social Care, Ageing and Disability
NHS England Safeguarding team
NHS England Equality and Health Inequalities Unit
NHS England Autism team
The Equality and Human Rights Commission
Patient related organisations
This group consisted of:
Mencap National Autism Society Challenging Behaviour Foundation National Valuing Families Forum Voluntary Organisations Disability Group Age UK – Older Peoples Forum National Digital team for Inclusion (NDTI) - 5 NDTI national events brought together health care professionals, carers and service users - in addition, over 600 online and paper questionnaires were submitted
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.
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: email@example.com
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.
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.
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.
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.