Reasonable Adjustment Strategies
A reasonable adjustment is a change that has been made to a service so that people with learning disabilities can use them like anyone else. Under the Equalities Act (2010) public sector organisations have to make changes in their approach or provision to ensure that services are accessible to disabled people, or those with other difficulties such as autism, as well as everybody else.
The Confidential Inquiry into the Deaths of People with Learning Disability (CIPOLD) found that almost a sixth (16%) of people with learning disabilities were described as having a significant fear of contact with medical professionals such that it might affect healthcare interventions. This included a fear of needles and it was recommended that such anxiety should be addressed by desensitisation work.
The strategies below aim to provide guidance for professionals with ways to make changes to enable patients with learning disabilities to have blood tests completed to maintain health and wellbeing. More than one strategy can be used at any one time to enable success.
Please note: these strategies may need to be repeated several times until the person is comfortable and fully prepared for the procedure. Before a referral to the Community Learning Disability Teams will be accepted, evidence that these strategies have been attempted and were unsuccessful will be requested and reviewed.
Communication and consent
- Use easy read or pictorial information to support understanding of the reason for and process of taking blood - this information can be given and reiterated over time prior to the appointment. Here is an example of an easy read document for blood tests. For further easy read information and templates visit the GOV UK website.
- Has the person given informed consent to the procedure under the Mental Capacity Act (2005) framework?
- If the patient is unable to provide informed consent and has been assessed to lack mental capacity in regards to blood tests, has a best interest discussion, and a best interest decision been made and documented (including family, carers and other appropriate individuals)?
- Use simple, clear words to explain what is going to happen and why
- Clearly explain in simple terms each part of the procedure as it is being done, unless it is agreed beforehand that this will cause distress
- Stop the process if the person withdraws consent either verbally or by their behaviour
- Provide reassurance using a calm quiet approach
- Keep conversation to a minimum if the person is becoming anxious
- Talk about a subject of interest as a distraction – this information could be gained at time of invite to the appointment
System
- Offer longer appointment times to ensure the person has time to process information and does not feel rushed
- Offer a preferred time of day (i.e when it is quiet, before or after school)
- Ensure a full discussion and care plan has been agreed with the patient and carers which may include motivators or rewards that will be brought to the appointment and where the procedure will take place
Environment
- Consider whether a home visit is appropriate if a patient cannot come into surgery for any reason (such as illness, inability to tolerate environment)
- Offer an opportunity for the patient to visit the practice or treatment room before the procedure – the person may need a few visits to become familiar and comfortable with the environment where the procedure will take place, alternatively, photos and videos could be used for this purpose
- Use the same room each time the procedure needs to be repeated to ensure consistency and familiarisation
- Reduce the number of people present – for example, one carer and one practitioner in the room
- Have sensory or distraction items available
- Offer a quiet area to wait, either in the surgery, outside, or the car if preferred
Equipment
- Consider supplying ‘pretend’ equipment before the appointment so the person can get used to it – carers can support with familiarisation and ‘play’ with this to reduce anxiety
- Consider providing pictures of key equipment (needle, syringe) if real equipment is not available
- Can a less invasive procedure be carried out to get the desired result? (such as a finger-prick test rather than venepuncture)
Staff and carers
- Allow the person to have a carer or friend with them if they wish to
- Provide an opportunity for the person to meet who will be doing the blood test (either in person or picture)
- Have consistent staff available who can get to know the person and build trust – the same person should repeat the procedure at future appointments if possible
- Have staff available who understand the needs of people with learning disabilities and are confident in supporting them
- Have preferred gender staff available if possible
- Consider whether removal of uniform would be possible – some patients are anxious around staff in uniform
Procedure preparation
- Agree procedure with carers including motivations or rewards (stickers, favoured snack)
- Use diversion if appropriate (music, iPads)
- Consider whether carers could undertake any part of the procedure under supervision (such as completing a finger-prick test). The person may allow this as their carers will be in close proximity at other times
- Offer ‘practice’ sessions prior to the appointment – such as visit one to sit in the chair with their sleeve rolled up, visit two to practice putting the tourniquet on. These may need to be repeated several times
- Consider the prescribing of Emla cream to help support the blood test. Practice putting cream on both arms so the person becomes familiar with the feeling of this being applied – this can be practiced at home prior to the appointment
- Consider the use of ‘cue cards’ to use throughout the procedure to reduce verbal communication if this is making the person anxious
- Practice putting on plasters and cotton wool – again, this could be practiced at home or in the surgery
- Sedative medication could be considered but only as a last resort and when all other practicable steps outlined above have been unsuccessful
- Use of arm holds or any other form of physical restraint is not to be used at any point
Supporting Documents
Blood tests for people with learning disabilities: making reasonable adjustments – guidance.
Health Facilitation Service: Supporting people who have a learning disability to give a blood sample.