What are reasonable adjustments, and why do they matter?
Reasonable adjustments are changes to the way a service works so that a disabled person can get the same quality of care as everyone else. They are not favours or extras. Under the Equality Act 2010, service providers, including every NHS and independent healthcare service, have a legal duty to make them.
People with a learning disability and autistic people experience serious health inequalities in the UK. The national Learning from Lives and Deaths (LeDeR) programme has repeatedly found that some deaths of people with a learning disability were from causes that good-quality care could have treated or prevented. Recurring themes include delays in recognising illness, communication problems, adjustments not being made and misunderstanding of the Mental Capacity Act.
Since 2022, the Health and Care Act has required CQC-registered providers to make sure staff receive learning disability and autism training suited to their role. A statutory code of practice in force from September 2025 explains how to meet this, and the Oliver McGowan Mandatory Training on Learning Disability and Autism is the government's recommended training.
Learning disability and autism: what's the difference?
| Learning disability | Autism | |
|---|---|---|
| What it is | Reduced intellectual ability and difficulty with everyday activities, starting before adulthood and lifelong | A lifelong neurodevelopmental difference in communication, social interaction and how the world is experienced |
| Range | Mild, moderate, severe or profound | Very varied. Many autistic people have no learning disability; some do |
| Common needs | Simple information, extra time, pictures, support from people who know them | Predictability, warning before changes or touch, reduced sensory load |
| Not the same as | A learning difficulty such as dyslexia | A learning disability |
Ask people how they like to be described. Many autistic people prefer "autistic person", while many people with a learning disability prefer "person with a learning disability". Many autistic adults are diagnosed late or never formally diagnosed, so respond to the needs in front of you rather than waiting for a label.
What are examples of reasonable adjustments in healthcare?
| Type | Examples |
|---|---|
| Time | Double appointments; first or last slot of the day; extra time to process questions |
| Environment | Quiet side room; dimmed lights; waiting in the car or outside until called |
| Communication | Easy read information; pictures or objects; Makaton; using the person's communication passport |
| People | A family carer or support worker present; the same clinician each time; learning disability liaison nurse involvement |
| Procedures | Showing equipment first; a familiarisation visit; numbing cream before blood tests; combining procedures under one anaesthetic |
| Information and systems | Needs flagged on the record; letters in an accessible format or a phone call instead; no automatic discharge after a missed appointment |
Nathan, 41, has a severe learning disability and becomes very distressed in clinical settings. He needs dental treatment under general anaesthetic and is also overdue blood tests and a hearing check. His learning disability liaison nurse arranges for the blood tests and ear examination to be done while he is anaesthetised for dentistry, with his consent decision handled under the Mental Capacity Act. His support worker brings him to a side room, he goes first on the list, and his favourite music plays as he goes to sleep. One visit replaces three that he would have found very hard.
What is diagnostic overshadowing, and how do you avoid it?
Diagnostic overshadowing is when symptoms or a change in behaviour are put down to someone's learning disability, autism or mental health condition instead of being investigated as possible physical illness. It is a major cause of delayed diagnosis.
- A man who starts hitting his face is described as challenging, when he has a dental abscess.
- An autistic young woman who stops eating and withdraws is said to be in a meltdown, when she has a bowel obstruction.
- A person who is unusually quiet and sleepy is assumed to be like that normally, and nobody asks the people who know her.
- Establish the baseline: Ask the person, family and carers, and read the hospital passport: how do they usually communicate, move, eat, sleep and show pain?
- Find out what has changed: Ask when the change started and how it differs from usual.
- Think physical first: Consider pain, infection, constipation, dental problems, sepsis, seizures and medicine side effects before attributing change to the person's condition.
- Use the right tools: Distress tools such as DisDAT (Disability Distress Assessment Tool) help when someone cannot easily describe pain. Use them with carers' knowledge.
- Listen and record: When a carer says "this isn't like her", treat it as clinical information and write it down.
Hospital passports, the Accessible Information Standard and the digital flag
A hospital passport is a document the person or their family completes. It describes how they communicate, how they show pain, what upsets them, what helps, their medicines and key health information. Ask for it, read it before you start, and use it.
The Accessible Information Standard applies to NHS care and publicly funded adult social care. Organisations must identify, record, flag, share and meet the communication needs of people with a disability, impairment or sensory loss. The 2025 update added a requirement to review those needs and keep records up to date.
In England, the Reasonable Adjustment Digital Flag is a national record showing that a person needs reasonable adjustments, with optional details of their impairments and key adjustments. It lets staff see these needs wherever the person is treated. NHS England set 30 September 2026 as the deadline for NHS and publicly funded health and social care providers to fully implement it. Find out how to view and update it in your organisation's systems.
- Do not send a standard letter to someone whose record says they need easy read or a phone call.
- A missed appointment from an inaccessible letter should not be treated as a simple 'did not attend'.
- Share needs when you refer, so the next service is ready.
How should you communicate with a person with a learning disability or an autistic person?
- Speak to the person, not their carer, even if they do not use words.
- Introduce yourself and say what you are going to do.
- Use short sentences, plain words and one idea at a time. Avoid idioms and sarcasm, which may be taken literally.
- Give time to process. Do not rush to rephrase or fill a silence.
- Use pictures, easy read leaflets, objects or the actual equipment.
- Check understanding by asking the person to show or tell you, not "Do you understand?"
- Be predictable: say what will happen next and how long it will take. Warn before touch.
- Reduce noise, bright light and unnecessary touch. Avoiding eye contact does not mean someone is not listening.
Healthcare assistant, to the support worker: "Can she have her blood pressure done? Hold her arm still for me." The cuff goes on without explanation, it tightens suddenly, and Grace pulls away and cries.
Healthcare assistant, to Grace: "Hello Grace, I'm Tom. I'd like to check your blood pressure." He shows her the cuff and lets her touch it. "It goes on your arm and gets tight, like a big squeeze, then it lets go. It takes one minute." He checks her passport, which says she likes to count, and they count together. Grace stays calm and the reading is done.
Healthcare settings can overwhelm autistic people with noise, lights, waiting and uncertainty. Sensory overload can lead to a shutdown or meltdown, which is not deliberate behaviour. Offer a quiet space, explain any change in plan, and allow coping strategies such as headphones or fidget items. Many autistic adults speak fluently and seem to cope but find appointments exhausting, so ask what would help.
How do capacity, consent and families fit in?
The Mental Capacity Act 2005 applies to people aged 16 and over in England and Wales. A person must be assumed to have capacity unless it is shown they lack it, and having a learning disability or being autistic does not mean someone lacks capacity. A person must not be treated as unable to decide until all practicable steps to help them have failed. Reasonable adjustments to communication are those steps.
- Support the decision with accessible information, the right time and place, and people who help the person communicate.
- Assess capacity for the specific decision at the specific time.
- If the person lacks capacity, make a best interests decision, considering their wishes, feelings and values and consulting family, carers and any attorney or deputy.
- Instruct an Independent Mental Capacity Advocate for serious medical treatment when there is nobody appropriate to consult other than paid staff.
- Record the assessment, the decision and who you consulted.
Families and carers often know the person best and are essential partners. Listen to them. At the same time, an adult with capacity has the right to make their own decisions and to confidentiality.
Putting reasonable adjustments into everyday practice
Most adjustments cost little: a few extra minutes, a quieter room, a phone call, a question to a carer. What makes them happen reliably is asking every time, recording what you learn, and sharing it. If something went wrong in a person's care, reflect honestly on communication, overshadowing and adjustments, and if a complaint or investigation follows, take advice from your union or defence organisation.
Our course Learning Disability and Autism: Communication and Reasonable Adjustments covers the law, diagnostic overshadowing, accessible communication, capacity and families, with case studies and reflective prompts. It builds on, but does not replace, the Oliver McGowan Mandatory Training required by your employer.
Frequently asked questions
What are examples of reasonable adjustments for a person with a learning disability?
Common examples include longer or first appointments, a quiet waiting space, easy read letters and leaflets, involving a carer or support worker, seeing the same clinician, showing equipment before using it, numbing cream before blood tests, and combining procedures under one anaesthetic. Ask the person and their carers what helps.
Are reasonable adjustments a legal requirement in the NHS?
Yes. The Equality Act 2010 requires service providers, including NHS and independent healthcare services, to make reasonable adjustments so disabled people are not put at a substantial disadvantage. The duty is anticipatory, so services must plan ahead rather than wait to be asked.
What is diagnostic overshadowing?
Diagnostic overshadowing is when symptoms or behaviour changes are wrongly put down to a person's learning disability, autism or mental health condition instead of being investigated as possible physical illness. It can delay diagnosis of serious problems such as pain, infection or bowel obstruction.
What is a hospital passport?
A hospital passport is a document, usually completed by the person or their family, describing how they communicate, how they show pain, what helps, what upsets them, their medicines and key health information. Staff should ask for it and read it before starting care.
What is the Reasonable Adjustment Digital Flag?
It is a national record in England showing that a person needs reasonable adjustments, with optional details of impairments and key adjustments, so staff can see them wherever the person is treated. NHS England set 30 September 2026 for providers to fully implement it. Check how to access it locally.
Can a parent consent for an adult with a learning disability?
Not automatically. An adult is presumed to have capacity. If they lack capacity for a specific decision, a family member can only decide if they hold a relevant lasting power of attorney for health and welfare or are a court-appointed deputy. Otherwise the clinician makes a best interests decision after consulting family.
Is autism a learning disability?
No. Autism is a lifelong neurodevelopmental difference affecting communication, social interaction and sensory experience. A learning disability involves reduced intellectual ability and difficulty with everyday activities. Some autistic people also have a learning disability, but many do not.
Related courses
Learning Disability and Autism: Communication and Reasonable Adjustments
This course helps you communicate well with people with a learning disability and autistic people, make reasonable adjustments, and avoid diagnostic…
Breaking Bad News Training (SPIKES)
This course teaches a structured, compassionate approach to breaking bad news using the six-step SPIKES framework. Each step is explained with worked…
Difficult Conversations with Patients and Families
This course gives you practical, published approaches for conversations that involve anger, disagreement, complaints or expectations that cannot be…
Sources and further reading
- Equality Act 2010. legislation.gov.uk.
- Mental Capacity Act 2005 Code of Practice. Office of the Public Guardian.
- Accessible Information Standard (DAPB1605). NHS England.
- The reasonable adjustment digital flag action checklist. NHS England.
- The Oliver McGowan code of practice on statutory learning disability and autism training. Department of Health and Social Care.
- Learning from Lives and Deaths (LeDeR) annual reports. NHS England.
- Autism spectrum disorder in adults: diagnosis and management (CG142). National Institute for Health and Care Excellence.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
More guides
The SPIKES Protocol for Breaking Bad News, With Example Conversations
The SPIKES protocol for breaking bad news explained step by step, with example conversations, useful phrases, common mistakes and what to do afterwards.
How to Handle Difficult Conversations With Patients and Families
How to handle difficult conversations with patients and families: calming anger, the NURSE approach, apologising, complaints, disagreement and safe boundaries.
SBAR Handover: Examples and Template for Nurses and Doctors
SBAR handover explained with a simple template and worked examples for nurses, doctors, physiotherapists, paramedics and community staff, plus read-back tips.