title: The barriers to and enablers of providing reasonably adjusted health services to people with intellectual disabilities in acute hospitals: evidence from a mixed-methods study.
abstract: OBJECTIVE
  To identify the factors that promote and compromise the implementation of reasonably adjusted healthcare services for patients with intellectual disabilities in acute National Health Service (NHS) hospitals.
  
  
  METHODS
  A mixed-methods study involving interviews, questionnaires and participant observation (July 2011-March 2013).
  
  
  METHODS
  Six acute NHS hospital trusts in England.
  
  
  METHODS
  Reasonable adjustments for people with intellectual disabilities were identified through the literature. Data were collected on implementation and staff understanding of these adjustments.
  
  
  RESULTS
  Data collected included staff questionnaires (n=990), staff interviews (n=68), interviews with adults with intellectual disabilities (n=33), questionnaires (n=88) and interviews (n=37) with carers of patients with intellectual disabilities, and expert panel discussions (n=42). Hospital strategies that supported implementation of reasonable adjustments did not reliably translate into consistent provision of such adjustments. Good practice often depended on the knowledge, understanding and flexibility of individual staff and teams, leading to the delivery of reasonable adjustments being haphazard throughout the organisation. Major barriers included: lack of effective systems for identifying and flagging patients with intellectual disabilities, lack of staff understanding of the reasonable adjustments that may be needed, lack of clear lines of responsibility and accountability for implementing reasonable adjustments, and lack of allocation of additional funding and resources. Key enablers were the Intellectual Disability Liaison Nurse and the ward manager.
  
  
  CONCLUSIONS
  The evidence suggests that ward culture, staff attitudes and staff knowledge are crucial in ensuring that hospital services are accessible to vulnerable patients. The authors suggest that flagging the need for specific reasonable adjustments, rather than the vulnerable condition itself, may address some of the barriers. Further research is recommended that describes and quantifies the most frequently needed reasonable adjustments within the hospital pathways of vulnerable patient groups, and the most effective organisational infrastructure required to guarantee their use, together with resource implications.
authors.affiliation: Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK.
authors.forename: Irene
authors.initials: I
authors.lastname: Tuffrey-Wijne
authors.forename: Lucy
authors.initials: L
authors.lastname: Goulding
authors.forename: Nikoletta
authors.initials: N
authors.lastname: Giatras
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Abraham
authors.forename: Steve
authors.initials: S
authors.lastname: Gillard
authors.forename: Sarah
authors.initials: S
authors.lastname: White
authors.forename: Christine
authors.initials: C
authors.lastname: Edwards
authors.forename: Sheila
authors.initials: S
authors.lastname: Hollins
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D017028:Caregivers / Q000523:psychology*; D003625:Data Collection / Q000379:methods; D004739:England / Q000453:epidemiology; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008607:Intellectual Disability / Q000453:epidemiology*; D008297:Male; D010564:Personnel, Hospital / Q000523:psychology*; D063508:Social Discrimination; D013222:State Medicine
references.citation: BMJ. 2013 May 29;346:f3421
references.pmid: 23719643