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How disability-friendly is your practice?

Alison Tyson
Senior Policy Manager
NHS Estates

The appearance of healthcare buildings is more important than you might at first think. The building is the first thing the patient sees at a time when they are likely to be worried about their condition and possibly in pain. A well-designed, pleasant and accessible environment provides much welcome reassurance and inspires confidence in the quality of the care that they will receive.
Patients expect GP premises to be accessible, but frequently the buildings themselves are designed and constructed around the needs of people who are fit and healthy, who are able to cope with stairs or heavy doors, and who have no difficulty in hearing conversations or reading signs.(1)
Unfortunately, not everyone is fit and healthy. Older buildings may, without modification, overlook the needs of disabled people, for whom accessibility is so very important. There are over 8.5m disabled people in the UK - approx 15% of the population - and this figure is set to grow as the population ages.(2) The more familiar disabilities affect vision, hearing, speech or mobility and are defined within the Disability Discrimination Act (DDA) 1995 as "a physical or mental impairment which has a substantial and long-term effect on a person's ability to carry out normal day-to-day activities".(3,4) The draft Disability Bill proposed in the Queen's Speech in 2003 extends this definition to include progressive and neurological conditions such as cancer, multiple sclerosis and HIV.(5)
It might be reasonable to assume that the NHS might be ahead of other public services in making environments accessible to the disabled, given that a greater proportion of disabled people are likely to need to access hospitals or health centres than to any other public sector building. However, a recent survey (2003) for the Disability Rights Commission (DRC) found that one in five respondents reported having had difficulty accessing a hospital building or clinic in the course of a visit or appointment.(6) The factors likely to create the most difficulty are steps at the entrance to a building and heavy doors that are difficult to operate when you have limited mobility.
From October 2004, the DDA will require service providers to make "reasonable adjustments" to physical features of their premises and to the delivery of services to overcome barriers to access. These include:

  • Removing the physical feature.
  • Altering the feature so that the limiting effect is removed.
  • Providing a reasonable means of avoiding the physical feature.

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If you are in a building built before the needs of the disabled became a consideration, then you might find yourself struggling to accommodate the needs of a group who are "differently able". If you are lucky enough to be in one of primary care's newer buildings, then your practice is probably already equipped with ramps, hearing loops and low-level reception desks. But is this enough to meet the spirit of the DDA?
Disabled people are not a homogenous group with a single set of needs. Everyone is different, with a different set of needs. Current guidance and legislation has led to special provision being made for disabled people, rather than their needs being integrated with the needs of other users. The installation of specific "access" features has been seen as a necessary evil. This is not inclusive, nor does it create an inclusive environment. An inclusive environment does not attempt to meet every single individual need, but is an environment that can be used equally by everyone, irrespective of age or disability.

What does this mean for GP premises?
The building should be easy to use - no one should have to use undue effort, such as climbing steps or using a ramp when level access would be easier. Signs need to be clear, unambiguous and easily legible - black text or symbols on a gold or orange background are highly contrasting and are most easily discerned by people with visual impairment.(7)
Not only should the environment be safe, but it needs to overtly generate a sense of safety and confidence in its users. Overusing reflective or monochrome surfaces, for example, can be as disabling to people with visual impairment as steps are to wheelchair users. If monotonous colour schemes are disabling for the visually impaired, so too are busy or asymmetric patterns on carpets and flooring, which have been found to cause disorientation and even minor falls.(8) Highly polished flooring that looks slippery may cause those with mobility problems to feel uneasy and insecure.
While much can be done with the overall design of the healthcare environment, more can be achieved by combining it with careful design of the delivery of the service itself. Principles of inclusion need to be carried through into the management of the building or service.
To illustrate this, consider how patients move from the waiting room through to the consulting room. In your practice, the GP might collect the patient from the waiting room, or your receptionist might escort the patient to the consulting room. These are quite obviously strategies that are "disability-friendly". Alternatively, you might summon patients via an intercom, illuminated information board or next-number system that you commonly find in supermarkets. These strategies are less "friendly" to the visually or hearing impaired and may be suitable only when used in conjunction with another strategy.

Access audits
So how do you know if your practice is "disability-friendly"? The first step for any practice nurse is to thoroughly evaluate the practice through an access audit. NHS Estates' guidance access audits for primary healthcare facilities provides clear standards of access to and within premises.(9) These should cover:

  • Approach.
  • Entrances.
  • Receptions and waiting rooms.
  • Corridors.
  • Lifts.
  • Stairs.
  • Ramps.
  • Bathrooms and toilets.
  • Signs and information.
  • Means of escape.
  • Spaces for patients and for staff.

The document, following the patient journey, offers a simple practical approach to auditing and is particularly relevant if you are considering refurbishing your practice. It is essential that you involve disabled people in the access audit. You cannot respond to a patient's needs until you first understand what those needs are. 
Many improvements are easy to implement by simple changes in working practice; others might require minor physical alterations. Think about the "shop window" of your practice - the reception desk. A physical alteration might involve lowering one section of the desk so that it is accessible to wheelchair users or screening the reception area so that it no longer opens directly onto a waiting room. A change in practice might involve taking patients with hearing impairment through to a more private area away from the main reception desk.(10)

Patient communication
Having evaluated the physical environment, the second stage in the audit process is to assess how you communicate with your patients, considering both information that is sent to patients and the means by which that information is delivered.(11) All information should be in a format that is appropriate to patient needs. For patients with sensory impairment, this may mean using large fonts or braille in printed information, providing information on a tape or training practice staff to use sign language. Communicating in the right way is as important as the information itself.
Knowing the right way to communicate needs awareness. Research has consistently shown that many disabled people feel that staff within the NHS are not fully aware of how best to communicate with them. The Employers' Forum on Disability publishes a series of disability communication guides designed to guide people through disability etiquette. To support staff more directly, the Department of Health issued Welcoming Patients with Disabilities - a distance learning programme designed to cover the dos and dont's of communicating with disabled people. Disability awareness training should be incorporated into mainstream training programmes and feature as a regular part of staff induction.

Conclusion
This article has been written very much with the patient in mind as the principal user. However, new emphasis being placed by the government on valuing diversity means developing positive strategies to bring disabled people more firmly into the NHS workforce. As one-third of our day is spent at work, the environment and staff workspaces must be sufficiently flexible to meet the needs of disabled staff - both at present and in the future. Major programmes, such as Positively Diverse and New Deal for Disabled People, are underway to help ensure that the NHS workforce reflects the diversity of the communities it serves. As the country's largest employer, the NHS is well placed to both contribute to, and gain from, these programmes.

References

  1. NHS Estates. Disability access. London: The Stationery Office; 1997.
  2. Disability Rights Commission. Inclusive Design - Inclusive Built Environment. 2003.
  3. NHS Estates. Disability ­discrimination - people with ­disabilities. Quarterly Briefing. 1999/2000;9:18-9.
  4. Disability Discrimination Act. London: The Stationery Office; 1995.
  5. Department for Work & Pensions, Draft Disability Discrimination Bill. London: The Stationery Office; 2003.
  6. Disability Rights Commission. Inclusive Design - creating inclusive environments. 2002.
  7. Royal National Institute for the Blind. Challenging Blindness: Information Pack. London: RNIB; 1995.
  8. NHS Estates. Lighting and colour design for hospital environments. NHS Estates; 2004.
  9. NHS Estates. Access audits for primary healthcare facilities. London: The Stationery Office; 1997.
  10. NHS Estates. Primary and social care premises: planning and design guidance. Available at: www.primarycare.nhsestates.gov.uk
  11. Department of Health. Implementing Section 21 of the DDA 1995 in the NHS. London: DH; 1999.

Resources
Centre for Accessible Environments
W:www.cae.org.uk
Department of Health
W:www.dh.gov.uk
Disability Rights Commission
W:www.drc.org.uk
Disability Matters
W:www.disabilitymatters.com
Disability Net
W:www.disabilitynet.co.uk
Disability Now
W:www.disabilitynow.org.uk
Disability on the Agenda
W:www.disability.gov.uk
The Employers' Forum on Disability
W:www.employers-forum.co.uk
New Deal
W:www.newdeal.gov.uk
NHS Estates
W:www.nhsestates.gov.uk
W:www.primarycare.nhsestates.gov.uk
Royal Association for Disability and Rehabilitation
W:www.radar.org.uk
Royal National Institute for the Blind
W:www.rnib.org.uk
Royal National Institute for the Deaf
W:www.rnid.org.uk