Medical education organisations in the UK have two overriding expectations in regards to disability.
- Following equality legislation - the Equality Act 2010 in England, Scotland and Wales, and the Disability Discrimination Act 1995 and the Special Educational Needs and Disabilities Order 2005 in Northern Ireland.
- Meeting our standards and requirements for medical education and training in the UK - in Promoting excellence (2015).
In undergraduate medical education, the governing body of the university has overall responsibility for complying with equality legislation. In postgraduate training, the postgraduate deaneries and HEE local teams have overall responsibility.
What do medical education organisations have to do to comply with equality legislation?
The duties from existing equality legislation are:
- Organisations have to avoid unlawful discrimination against disabled learners (for the purposes of this guidance, more generally also against other protected characteristics). This includes specific types of discrimination, which are explained in more detail in the appendix of this guide: direct discrimination, indirect discrimination, discrimination arising from a disability, harassment and victimisation.
- Organisations have a duty to make reasonable adjustments, in order to avoid putting disabled learners at a substantial disadvantage.
The duty to make reasonable adjustments
The duty requires organisations to take positive steps to make sure disabled learners can fully participate in the education and other benefits, facilities and services provided for them.
This means organisations must take reasonable steps when a learner is at a substantial disadvantage because of:
- The way the organisation does things.
- For example, additional provisions or allowances for disabled learners if the standard delivery of the course puts them at a disadvantage. This could include permitted periods of absence to attend medical appointments, breaks in teaching sessions, additional regular 1:1 tutorial support or provision of study skills support.
- A physical feature. This could include removing the physical feature, altering it or providing a reasonable means of avoiding it.
- For example, if locations are not accessible for learners, then these can be altered through installing ramps, automatic doors, accessible lifts and lift buttons, accessible external paths and landscaping.
- Not providing an auxiliary aid.
- For example, equipment to help learners follow teaching activities or facilitate clinical practice, such as laptops or handheld devices to take notes or a note-taker to attend lectures, spell checkers, screen readers, an amplified stethoscope, supportive furniture or cushion or lumbar support and adjustable height chairs.
Key things to know about reasonable adjustments
Organisations must expect the needs of disabled learners. It is the organisation's responsibility to consider support on a case by case basis and decide what adjustments would be 'reasonable' for each individual. It is good practice to keep an audit trail of their decision making.
A request for an adjustment can be declined if it is not deemed 'reasonable', but it is unlawful not to consider reasonable adjustments at all. If the reasonable adjustments provided have not been effective, the organisation might want to consider alternatives. It is good practice to create an inclusive learning environment with adjustments that could help everyone.
1. What does reasonable mean?
There is no set definition of what 'reasonable' means.
What is 'reasonable' can only be decided on a case-by-case basis, and will always depend on the individual person and their circumstances.
The Equality and Human Rights Commission advises that whether an adjustment is reasonable depends upon all the circumstances including:
- if and how effective the change will be in overcoming the disadvantage the disabled person would otherwise experience
- how practicable the changes are
- the cost of making the changes
- the organisation's size and resources
- the availability of financial support.
The Commission has published guidance setting out factors for organisations to consider in assessing whether an adjustment is reasonable. It suggests the following.
- You can treat disabled people better or 'more favourably' than non-disabled people and sometimes this may be part of the solution.
- The adjustment must be effective in helping to remove or reduce any disadvantage the disabled student is facing. If it doesn't have any impact then there is no point.
- It may take several different adjustments to deal with that disadvantage but each change must contribute towards this.
- You can consider whether an adjustment is practical. The easier an adjustment is, the more likely it is to be reasonable. However, just because something is difficult doesn't mean it can't also be reasonable.
- If an adjustment costs little or nothing and is not disruptive, it would be reasonable unless some other factor (such as impracticality or lack of effectiveness) made it unreasonable.
- What is reasonable in one situation may be different from what is reasonable in another situation.
- If advice or support is available then this is more likely to make the adjustment reasonable.
- If you think that making a particular adjustment would increase the risks to the health and safety of anybody then you can consider this when making a decision about whether that particular adjustment or solution is reasonable. But your decision must be based on a proper, documented assessment of the potential risks, rather than any assumptions.
If the decision of an organisation is challenged, the issue is whether or not the adjustment is 'reasonable' is ultimately a question for the courts to determine. The Equality and Human Rights Commission says that: 'The test of what is reasonable is ultimately an objective test and not simply a matter of what you may personally think is reasonable'.
2. How can an organisation expect the needs of disabled learners?
Every organisation should plan ahead and expect the needs of disabled learners and the adjustments that might be made for them. This is regardless of whether they know that a particular person is disabled or whether they currently support any disabled students or doctors.
But it does not mean organisations have to expect the needs of every prospective student or incoming doctor in training. They must think about and take reasonable and proportionate steps to overcome any barriers, for example:
- Adapt the physical environment to help disabled learners
- Give auxiliary aids to learners
- Speak with employers and local education providers to make sure the physical environment would help disabled students and doctors in training, and auxiliary aids can be made available.
- Examine internal policies to see if anything could put disabled people at a disadvantage.
- Consider the impact of changes to the way the organisation does things impact on disabled learners, for example the impact of changes to the course format or curriculum content.
- An example from the Equality and Human Rights Commission is that it may be appropriate for the university to install a hearing loop in lecture theatres to anticipate the needs of students with hearing impairments, but they would not be expected to have a British Sign Language (BSL) interpreter on the payroll.
- An example for postgraduate training organisations is to liaise with the local education providers where they place doctors to make sure locations are accessible. However, postgraduate training organisations would not be expected to have a piece of equipment required for an individual doctor's specific circumstances, before they are aware of this doctor's needs.
3. Which learners does this duty apply to?
Medical schools owe this duty to applicants, existing students, and, in limited circumstances, to disabled former students. This relates to making reasonable adjustments in respect of qualifications awarded by a further or higher education institution. For example, if a former student needs a certificate in a different format as a result of a disability.
Postgraduate training organisations owe this duty to all applicants and doctors in training under their organisation, and, in limited circumstances, to former doctors in training.
4. How long does the duty apply for?
The duty is ongoing. If an adjustment has been made and it is not effective in overcoming the disadvantage, then the education body may need to think again – they cannot just assume that, having made one adjustment, their duty is completed.
5. Can the organisation not make reasonable adjustments for disabled learners?
An organisation must always show it has considered adjustments. But it can decide not to make an adjustment if it is not 'reasonable' (see Panel 6 in 'How can medical schools apply their duties?'). If after consideration, an organisation decides not to provide an adjustment on the grounds it is not reasonable, they should consider whether there are any alternative reasonable adjustments that might meet the person's needs.
6. Does the organisation need to consider each learner individually?
Yes. Reasonable adjustments must be considered on a case by case basis, taking into account the individual's circumstances and the specific barriers. This is because the impact of a disability or condition will be unique to each individual. Even if two people have the same disability, it might affect them differently, so each may need a different set of adjustments.
7. Are there adjustments that will frequently be considered reasonable?
Yes. There will be some adjustments that will be seen as reasonable for a number of students in the context of education and training. For example, extra time for someone with dyslexia when taking an examination after considering each case individually. But there is no prescriptive list. It is good practice for organisations to create an inclusive learning environment that could help all their students and doctors, which may include:
- printing documents on coloured paper
- providing plans, summaries, notes, and handouts in advance of lectures and other teaching activities in electronic format
- providing subtitled or transcribed video material
- reserved areas in all teaching and learning locations, including the library
- ensuring availability of coaching and mentoring.
Panel 5: Can the GMC provide a list of adjustments that are reasonable in medicine?
The GMC cannot specify what adjustments are reasonable in medicine. We do not have the authority to do this as an organisation.
Because of all the factors taken into account when deciding what is reasonable, it is not possible to give general instructions on whether an adjustment is or is not reasonable in a medical setting. The medical school or employer (in collaboration with postgraduate training organisations) must exercise their judgment to assess and balance these factors. It will not necessarily be easy, but it may be made easier by consulting the individual about their need.
An adjustment will not be reasonable if:
- It is not effective in removing or reducing any disadvantage
- If the adjustment alters or reduces the competency required of the learner at the specific stage of training
- If the adjustment poses an unacceptable risk to the safety of the learner or others. This has to be based on an objective assessment of the risk.
What is considered reasonable depends on the individual and their particular circumstances, so the same adjustment could be considered reasonable under one set of circumstances, but not reasonable under another. For example:
- A doctor in training requests an adaptation to the physical environment so they can work in a trust. The cost of the adaptation could be prohibitive to one organisation, while it could be proportionally lower for another organisation. The first organisation could say the adjustment is not reasonable due to cost, while the second could say it is reasonable (if in line with the other factors considered).
- Two medical students with diagnosed learning disabilities request additional time to complete an assessment. In one student case, this is supported by an expert report recommending additional time as an effective adjustment for the student. In another student case, additional time is not recommended for their particular form of learning disability. The medical school could say the adjustment is reasonable in the first case (if in line with the other factors considered), but not in the first case, if additional time would not be effective in helping the student.
These examples are illustrative. Often situations are more complex than the illustrative examples, so decisions always need to be made an individual basis.
Panel 6: Am I disadvantaging or discriminating against others by supporting disabled learners?
The Equality Act 2010 says it is not direct discrimination against a non-disabled person to treat a disabled person more favourably.
The law allows an organisation to treat a disabled person more favourably if it removes a barrier or disadvantage that the person is experiencing. For example, guaranteeing a placement or training post in a particular location because it is the one closest to the disabled learner's home or where they receive care.
A disabled learner may be at a disadvantage compared to their non-disabled peers before reasonable adjustments are made for them. The reasonable adjustments should aim to remove that disadvantage and bring the disabled person to an 'equal standing' with their peers. It does not give them an unfair advantage over others.
Some illustrative examples are below. Often situations are more complex than the illustrative examples, so decisions always need to be made an individual basis.
- A student with diabetes is at a disadvantage in a usual exam environment, they may not be able to complete the exam without taking their medication or eating to regulate their sugar levels. By putting a reasonable adjustment in place to allow this student to take breaks from the exam to eat, to rest or to take medication, the medical school can allow them to perform at an equal level with other students who do not have diabetes.
- A doctor with chronic depression needs to attend regular medical appointments with their treating specialist. These cannot always be fitted around their rota. Therefore, the doctor is at a disadvantage compared to their peers, as they might suffer from the effects of their depression, which may interfere with their training and progression. By putting a reasonable adjustment in place to allow time off for attending clinical appointments, or adjusting their rota to attend certain shifts, the employer with the postgraduate training organisation can allow the doctor to overcome that barrier.