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Reasonable Adjustment Flag

The Reasonable Adjustment Flag is a national record which indicates that reasonable adjustments are required for an individual and optionally includes details of their significant impairments and key adjustments that should be considered.

The Reasonable Adjustment flag was developed 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.

The capability is now available on the National Care Records Service (NCRS).

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, provides 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, individuals’ carers or individuals 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.

Benefits of the Flag

Improved patient outcomes, improved patient safety and a better patient experience

These improvements can be made because specific, individual needs are acted on in a tailored way:

  • the Flag is immediately visible (to reception staff) when the patient is referred or presents for care, often when no other information is available
  • the Flag will ensure that details of impairments and other key information (such as communication requirements) are shared consistently across the NHS – with patient consent
Reduced stress

It can help to reduce stress both for the patient and those treating them.

More effective and efficient delivery of care

Specialist teams will be able to set the Flag – driving up the number of patients recorded on registers, who are identified for and can benefit from adjustments.

Screening services will adapt services to ensure patients receive screening.

Carers will feel more supported

Carers will feel less stressed if they know adjustments are being made to services.

Improvement in the quality and number of adjustments provided across the NHS

This satisfies legal obligations under the Equality Act 2010 and NHS contracts and as defined in the NHS Long Term Plan


Case study - reasonable adjustments for Jamie

How the Reasonable Adjustment Flag works

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 National Care Records Service (NCRS). Longer term, a Fast Healthcare Interoperability Resources (FHIR) software interface will be available for clinical systems to integrate directly 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.

Additional support

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
  • needle phobia
  • 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 
  • noise intolerance
  • photophobia
  • 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

Along with the details of adjustments to care, the Flag can record if a patient meets the Equality Act definition of disability - the code is:

  • "Impairment with substantial and long-term adverse effect on normal day to day activity (Equality Act 2010)"

It can also 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 impairment types that can be recorded. The Harmonised Impairment Standard enables the consistent, high profile and routine recording of impairment (including the option of ‘prefer not to say’).

Impairment types

Vision - for example blindness or partial sight

Hearing - for example deafness or partial hearing

Mobility - for example walking short distances or climbing stairs

Dexterity - for example lifting and carrying objects, using a keyboard

Learning or understanding or concentrating


Mental health

Stamina or breathing or fatigue

Social or behavioural - for example associated with autism spectrum disorder (ASD) which includes Asperger’s, or attention deficit hyperactivity disorder (ADHD)

Other (please specify)

Prefer not to say

How to create a Flag

This guidance takes you through how to create and view reasonable adjustments on the NHS Spine.

Project history

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:

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
  • ADSS
  • 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
  • LeDer teams 
  • 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) is being developed for integration of clinical and screening systems with the Flag.

The SCRa development was piloted in Gloucestershire and Devon during the back end of 2019 and early 2020.

The Gloucestershire and Devon SCRa pilots

Current activity

Work is being undertaken to start the process leading to first of type direct integration of the Reasonable Adjustment FHIR API with clinical systems. This will complement the current functionality available in NCRS and lay the groundwork for wider adoption of the Flag across the NHS. Current expectation is that this work on integration will be completed by the end of 2023, after which the capability will be made available for wider use in systems across health and care.

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.

Further information

The confidential inquiry into premature deaths of people with learning disabilities (external link, opens in a new tab)

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.

Accessible Information Standard (external link, opens in a new tab)

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.


Last edited: 30 January 2023 12:18 pm