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Providing reasonable adjustments: case studies

This section contains a range of case studies to illustrate the recommendations in our guidance.

Managing the impact of perceived special treatment

Dr A was a trainee in psychiatry with a chronic condition that meant they could only use a computer screen for brief periods.

Appropriate accommodations with regard to laptop use, remote working and admin support were organised and Dr A was happy with their job plan. However, members of the MDT raised concerns that Dr A was getting ‘special treatment’.

With Dr A’s consent, the management team, which included Dr A’s supervisor, met the whole team to explain their circumstances. It was agreed that the whole team should have access to filters on their computer screens, and that anyone else struggling with workload due to their personal circumstances should raise it as soon as possible with their respective line managers. The team felt reassured and were able to work well with Dr A for the remainder of their time in the post.

This case highlights: the importance of inclusion. Offering reasonable adjustments to the whole team can support all members of the team to optimise their functioning and minimise resentment about ‘special treatment

Prioritising practical support over discussion of principles

Dr B had Long COVID for over three years, with long-term physical and cognitive issues and deterioration over that period.

Accommodations included working four days instead of five and no on-calls due to the extent of cognitive fatigue beyond 5pm.

One day midweek was worked from home to reduce the effect of travel, and an FFP3 mask was worn in all clinical areas to reduce further acute Covid risk.

There remained a need for complete rest on the three non-working days in order to manage the four that Dr B was working, but with a longer-term view of increasing work as able.

The occupational health opinion was that Dr B is “likely to be classed as having a disability under the Equality Act 2010 and therefore the need to consider reasonable adjustments is likely to apply”.

They pointed out ACAS guidance that employers should focus on the reasonable adjustments they can make rather than trying to work out if an employee’s condition is a disability and further occupational health review is at least yearly.

This case demonstrates: the positive action-based approach that is expected from employers and colleagues, getting reasonable adjustments in place promptly rather than delaying and debating disability.

Using reasonable adjustments for physical disability

Dr C is a consultant psychiatrist and advocate for speciality and specialist (SAS) doctors for the NHS organisation where they work.

They have childhood post-polio paralysis and have had multiple surgeries throughout their life.

They walk with two crutches all the time, with limited mobility. They were assessed and supported to access reasonable adjustments in a timely manner in this role.

Reasonable adjustments they have been provided with include a designated parking space outside the unit, staff helping to manage heavy doors and handling equipment like a laptop, having a risk assessment in place to manage challenging patients on the unit and the emergency escape.

They are also able to work remotely and manage their own schedule.

This case highlights: that physical disability should not be a barrier in achieving career goals to work at full capacity with reasonable adjustments. It is vital that the right support is sought and that colleagues and leaders within the organisation understand the potential, limitation and needs of staff with disabilities.

Evolving support to enable gradual return to work

Dr D had a diagnosis of Long COVID for over two years.

Their organisation offered an extended graded return over a year with no loss of pay, and a locum consultant was employed to cover some duties until full-time work was achieved to optimise the chances of a successful return.

Dr D’s office was moved into the building where patients were seen in order to reduce physical exertion and prevent post-exertional malaise, with provisional support for a parking permit to enable closer parking once out working with the Crisis Team again.

An FFP3 mask was recommended at all times in the inpatient unit, even if there were no Covid positive patients.

Remote working was recommended in the event of a Covid outbreak on the ward. If, after a year, Dr D had not been able to perform full-time duties, then the organisation had planned to look at adjustments to their contract and pay.  Dr D felt well supported.

This case highlights: good practice regarding graded return in a relatively new condition where a prolonged recovery process is common, with practical, personalised reasonable adjustments and promoting wellbeing, retention and resilience.

The importance of Mental Health Occupational Health for recurring and relapsing conditions

Dr E is a successful consultant psychiatrist in leadership roles, who has a recurrent depressive disorder.

On the first episode within this job, they had access to a consultant psychiatrist in Occupational Health (OH) who supported six weeks of sick leave.

After this, the Human Resources (HR) department advised the line manager to insist on an immediate full-time return to work.

The OH psychiatrist was able to advise HR and the line manager about the employer’s obligations under the Disability Discrimination Act to provide reasonable adjustments around graded return to work.

The OH psychiatrist also provided frequent CBT-type support in order to help manage return-to-work anxiety. Several years later, another episode with associated anxiety was triggered by caring duties.

Supported by the same OH psychiatrist, reasonable adjustments were made to allow full-time work from home for three months until anxiety related to caring duties reduced. On this occasion, Dr E’s line manager and Clinical Director were extremely supportive and accommodating.

Dr E is now functioning well and feels much more loyal to their organisation than ever before as a direct result of this support. Despite having moved a long distance from the employer, Dr E remains in the same organisation.

This case highlights: the importance of having access to a well-informed Occupational Health psychiatrist and supportive line management. Here, the same OH psychiatrist provided intervention for a recurring condition – but this case also highlights the value of a Reasonable Adjustments Passport (see Recommendation 14), which would have been invaluable if the same OH psychiatrist hadn’t been available.

Organisational strategies to support people with neurodevelopmental conditions

Dr F is a successful and well-regarded neurodivergent consultantm clinical and educational supervisor, who had childhood diagnoses of dyslexia, dyspraxia, sensory processing disorder and autism.

Dr F benefited from coaching, which was recommended via Access to Work and delivered some years ago.

This helped with communication and organisational strategies, and having a coach with good understanding of neurodivergence also helped Dr F to gain confidence and advocate for themselves in the workplace.

Reasonable adjustments included having their own office, working from home when viable, a dedicated secretary and autonomy over their own timetable, including scheduling their own breaks between patients.

NB: Specific workplace neurodiversity training for colleagues/the team is usually also part of recommendations, and a neurodivergent doctor should not purely be asked to change their communication style as a one-way effort.

This case highlights that neurodevelopmental conditions should not automatically prevent someone from being an excellent doctor, and that coaching and strategies from someone with good understanding can be as important as the adjustments in the daily workplace.

The need for constant vigilance as circumstances change

Dr G is now a retired consultant psychiatrist with enduring episodic mental ilness after viral encephalitis. Early in their teaching hospital training, they became unwell, resulting in a three month psychiatric hospital admission.

They returned to work and were advised not to disclose their illness. They did, however, disclose their medical status and history to Occupational Health and provided a psychiatrist’s report when they moved jobs or rotated.

Despite no official reasonable adjustments, they felt supported and accepted into their peer group.

However, they relapsed on rotation to a busy District General Hospital, suffering hallucinations and unable to cope, and were readmitted soon after.

Once well enough, they returned to work with partial disclosure and regular follow-up with their consultant.

This helped the transition into higher training, leading to many successful years working as a consultant in a community team with support from a clinical director, mentor and peer group.

Years later, following the retirement of a colleague and lack of funding to replace them, and despite raising concerns, Dr G ended up in a role as a lone consultant with only junior staff for support.

Reasonable adjustments were not applied on this occasion and Dr G retired due to burnout.

This case highlights the challenges around disclosure of diagnosis, importance of appropriate reasonable adjustments being implemented and monitored, and the need for a Reasonable Adjustments Passport to follow staff through job moves. It demonstrates the need for continuous vigilance throughout a career, especially in fluctuating conditions, and the need for access to processes where concerns can be addressed.

When conditions aren't openly disclosed

Like many doctors, Dr H didn't know they were neurodivergent (autistic and ADHD) until over 20 years into their career.

They had masked and sought various self-accommodations over the years, but this resulted in considerable loss of earnings, along with the reduced wellbeing/mental health issues associated with masking and the adverse effects of attitudes towards them.

In their current role, however, despite not disclosing their diagnosis, thoughtful line management has allowed them to negotiate person-centred accommodations, which include:

  • Working part time in order to recover on non-working days from unknowingly masking in a workplace set up not suited to them.
  • No on-call duties – daytime duties could not be sustained if also on the on-call rota. ? In-depth work with complex cases and minimal urgent interruptions – to promote hyper-focus, which is nourishing, replenishing and rewarding, and to reduce transition issues.
  • Autonomy over their timetable – to pace themselves well.
  • Grouping of clinic appointments or home visits together to reduce transitions.
  • Consistently using the same office for predictability.
  • Home working whenever possible to reduce noise, interruptions and improve productivity.

Many of these adjustments were also offered, as a result, to the rest of the team, demonstrating the value of inclusion. Inclusion reduces stigma and marginalisation and improves workforce productivity, wellbeing, resilience and retention.

While it may be easier and clearer for managers and employers to use a reasonable adjustment process and have formal recommendations, Dr H had not formally shared a diagnosis.

It must be remembered that individuals need to feel safe in their working environment to disclose possible or diagnosed neurodivergence.

This case highlights the need, expectation and value of good person-centred support for all staff, whether there has been understanding of a possible diagnosis or not, as well as the value of creating a culture in which it’s truly safe to share and declare conditions.

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