9.4 Patient Advocacy & Reasonable Adjustments

Patient Advocacy & Reasonable Adjustments

Advocacy and equal access are fundamental human rights imperatives embedded within professional nursing practice. The NMC Code (2018) charges registered nurses with a professional duty to act as advocates, prioritizing patient needs, protecting vulnerable individuals from harm, and upholding their human rights under the Human Rights Act 1998 and Equality Act 2010. This section outlines statutory advocacy frameworks, reasonable adjustments, and strategies to empower patient autonomy.

+-----------------------------------------------------------------------------------+
|                        STATUTORY ADVOCACY FRAMEWORKS                              |
+-----------------------------------+-----------------------------------------------+
| IMCA (Mental Capacity Act 2005)   |  - Mandatory for unbefriended patients lacking|
|                                   |    capacity facing major treatment / housing  |
+-----------------------------------+-----------------------------------------------+
| IMHA (Mental Health Act 1983/2007)|  - Statutory right for patients formally      |
|                                   |    detained under Mental Health Act sections  |
+-----------------------------------+-----------------------------------------------+
| Care Act Advocate (Care Act 2014) |  - Supports individuals lacking capacity or   |
|                                   |    substantial difficulty in care assessments |
+-----------------------------------+-----------------------------------------------+

The Equality Act 2010 & Reasonable Adjustments

The Equality Act 2010 creates a statutory duty for healthcare organizations to make "reasonable adjustments" for people with disabilities. Disability is defined broadly as a physical or mental impairment that has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities.

Anticipatory Duty & Types of Adjustments

Healthcare providers have an anticipatory duty—meaning NHS services must plan ahead and put adjustments in place before a disabled patient presents for care, rather than reacting after barriers cause distress or harm.

1. Environmental Adjustments: Wheelchair-accessible ramp access, wide doorways, height-adjustable examination couches, accessible toilet facilities, and sensory-soothing quiet rooms.
2. Organizational & Process Adjustments: Offering flexible appointment times (e.g., first appointment of the morning to minimize waiting time), extended double-slot appointment durations, allowing carers/supporters to remain present during clinical procedures, and home visits.
3. Communication Adjustments: Providing information in Easy Read format, visual picture cards (PECS), Makaton, large print, or arranging BSL interpreters.

Learning Disability Hospital Passports (Health Passports)

A Hospital Passport is a personalized document owned by a person with a learning disability or autism spectrum condition. It communicates vital information to healthcare staff during hospital admissions.

---

Statutory & Independent Advocacy Roles

An advocate is an independent professional who works with an individual to help them understand their rights, express their views, make informed decisions, and ensure their voice is heard in care planning. Advocates are independent of the NHS trust and social services.

Independent Mental Capacity Advocate (IMCA)

Established under the Mental Capacity Act 2005, instruction of an IMCA is a statutory legal requirement under specific conditions:

• Eligibility Criteria: The patient is aged 16 or over, lacks capacity to make a specific major decision, and has no family or friends ('unbefriended') whom the decision-maker considers appropriate to consult.
• Statutory Triggers:
  1. Serious Medical Treatment: Decisions involving proposing, withholding, or withdrawing treatment where there is fine balance of benefit/risk or major life-altering consequences (e.g., chemotherapy, major surgery, amputation, organ donation, stopping life-sustaining treatment).
  2. Long-Term Accommodation Change: Moves into hospital accommodation for more than 28 days, or care home accommodation for more than 8 weeks.
• Role of the IMCA: Represents the person's past and present wishes, challenges decision-makers if necessary, and submits a formal report that must be considered before final decision-making.

Independent Mental Health Advocate (IMHA)

Established under the Mental Health Act 1983 (amended 2007):

• Eligibility Criteria: Automatically available to patients who are formally detained under the MHA (e.g., Section 2, Section 3), subject to Guardianship, or under a Community Treatment Order (CTO). (Voluntary / informal patients are generally excluded unless facing electroconvulsive therapy / ECT).
• Role of the IMHA: Helps detained patients understand their legal status, detention sections, tribunal appeal rights, rights under the MHA Code of Practice, medical treatment rules, and represents them at Mental Health Review Tribunals.

Independent Care Act Advocates & Voluntary Advocates

• Care Act Advocates: Mandated under the Care Act 2014 for individuals undergoing social care assessments, support planning, or safeguarding inquiries who have 'substantial difficulty' being involved and have no appropriate informal carer to support them.
• Peer / Voluntary Advocates: Non-statutory advocates who support individuals facing general health service challenges or NHS complaints processes.

Empowering Autonomy & The Nurse as Patient Advocate

Registered nurses hold a continuous responsibility to advocate for patient autonomy, human rights, and dignified care within multidisciplinary teams.

Nurse Advocacy in Practice

• Challenging Paternalism: Questioning clinical interventions or decisions that override a competent patient's expressed wishes or fail to apply the least restrictive option.
• Supported Decision-Making: Providing accessible information, visual aids, and extra time to enable patients to make their own choices, moving away from substitute decision-making whenever possible.
• Human Rights Alignment: Upholding rights under the Human Rights Act 1998, particularly Article 8 (Right to respect for private and family life) and Article 3 (Prohibition of inhuman or degrading treatment) during physical care, restraint, or isolation procedures.
• Safeguarding Advocacy: Acting as the patient's voice when escalating safeguarding concerns, whistleblowing on unsafe practice, or asserting patient preferences during best-interests case conferences.