AIS applies to patients, service users, carers and parents (collectively known as the patient from here on in) who have communication and/or information support needs related to a disability, impairment or sensory loss, this includes but is not limited to: people who are blind, deaf, have a learning disability, aphasia, autism and/or a mental health condition which affects their ability to communicate.
This policy applies to staff who have direct contact with patients within One Health Group (OHG) Once OHG is aware of a communication or information support we will respond in a format that is relevant to the needs of that person, for example, if a person requests communication in braille, by telephone or audio disc we communicate in these formats rather than sending a printed letter.
Depending on the needs of the individual, other formats may include for example, Easy Read, Large Print, British Sign Language. The AIS is a mandatory national standard which applies to all providers across the NHS and adult social care system. Failure to provide information to our Commissioners is a breach of contract. The Care Quality Commission and Monitor will review this information as part of the ‘well-led’ domain in inspection programmes.
The NHS Constitution establishes the principles and values of the NHS, to this end the AIS is aligned with the Constitution. The Equality Act 2010 places a legal duty on all service providers to take steps or make “reasonable adjustments” in order to avoid putting a disabled person at a substantial disadvantage when compared to a person who is not disabled.
This policy communicates OHGs’ commitment to AIS, whereby, patients are communicated with and informed in a format that is relevant to their needs ensuring each person is in a better position to
• make decisions about their health, wellbeing, care and treatment
• self-manage condition
• access services appropriately and independently
• make choices about treatments and procedures.
This respects confidentially in delivering healthcare, communicating directly with the individual in a format that is personal to them at the same time maintaining their dignity and independence. Making reasonable adjustments advances the equality of opportunity for people to engage in society, who may otherwise be disadvantaged or excluded and furthers OHG’s commitment to the Public Sector Equality Duty of the Equality Act 2010.
Accessible Information Standard 8 - there are exclusions and exceptions from the Standard, for example (not exhaustive):
• Annual Reports, Corporate Documents not directly related to patient care
• DVD’s, CD’s and presentations
• Information supplied by other organisations
OHG expects that staff will familiarise themselves with this Policy, the AIS and ensure they apply it to patients, who have communication and/or information support needs related to a disability, impairment or sensory loss and will know how to access Interpreting and Translation Services. It is the responsibility of individuals to communicate with the patient, provide information in a format that is required by the individual and ensure the accuracy of content.
All staff have a responsibility to ensure that they are communicating with patients and colleagues in a way which is effective and understood by all parties. If legal requirements are ignored, both OHG and the individual employee(s) concerned may be liable to legal proceedings. It is the responsibility of staff who have patient contact to:
Ask: identify/find out if an individual has any communication/information needs relating to a disability, impairment or sensory loss
Record: record those needs in a clear and standardised way in electronic and/or paper- based record/administrative systems/documents. The OHG primary recording system is Compucare
Alert/flag/highlight: ensure that recorded needs are ‘highly visible’ whenever the individual’s record is accessed.
Share: include information about individual’s information/communication needs as part of existing data sharing processes.
Act: take steps to ensure that the individual receives information which they can access/understand and receive communication support if they need it.
All staff have an individual responsibility to:
• Inform their manager in circumstances where any part of the 5 requirements cannot be met.
• Promote the AIS when undertaking their duties for example to explain what is available as alternative formats of communication and/or information.
• Must ensure that any requests received are handled fairly, consistently and efficiently and that individuals are not disadvantaged by any delay in receiving information in an accessible format. Turnaround times should not exceed 20 days.
• Additional time is allowed for consultation, care or treatment where the patient has an accessible communication need in particular if an interpreter is involved e.g. British Sign Language.
• Make sure the incident reporting system is used, where appropriate.
• Ensure they are aware of interpreting and translation services and how to access them
Managers have a responsibility to ensure they understand this Policy and implement it within their areas of responsibility and for ensuring that employees adhere to the terms of this Policy. This will require Managers to:
• lead by example, promoting AIS by their behaviours and actions
• promote this Policy and ensure that all staff are aware of it and clear on their responsibilities
• ensure that patients have access to communication and/or information that is relevant to their needs and healthcare needs
• ensure that complaints relating to AIS are responded to under OHG’s Complaints Procedure in a fair and consistent manner
• apply OHG’s Incident Reporting System (Sentinel) where appropriate
• understand current legislation and the implications of not carrying out the policy
Chief Executive supported by the Senior Management Team and OHG Board has the responsibility for ensuring that this Policy is implemented and acted on.
Progress reports will be presented by the Quality Assurance Committee to inform the Trust Board on the implementation and compliance of this policy.
OHG will work the Healthwatch, Acute Trust, CCG’s, County Council and Voluntary organisations e.g. Deaf Direct, Speak Easy Now, Sight Concern and others in the application of this policy and the interests of the people who this Policy is meant to benefit.
This policy is to be communicated to all staff, with particular emphasis on staff who are likely to have initial contact with the patient and identify if a person has a communication and/or an information support need. Continual communication through the OHG media (newsletters, posters, electronic and social media – intra/internet and so on.) will be used to promote this policy.
5. Service Delivery
OHG is committed to ensuring that all its services are designed and delivered to meet the needs of the communities. Reasonable adjustments will be made in partnerships with client sites to ensure our services are accessible and equitable to all groups in our community except where there is evidence to objectively justify alternative arrangements. The AIS will be promoted to patients via the internet, consultation with patients and organisations such as; Healthwatch, voluntary organisations, NHS organisations and others.
6. Letters and Documents
The following statement is to be included in all letters, leaflets and documents made available to patients: If you require information in any other format such as large print, braille or require an interpreter please contact the OHG Office on 0114 2505510 or via email on firstname.lastname@example.org.
7. Alternative Formats (accessible information)
Alternative formats means information or communication provided in a different format to that traditionally used e.g. a printed letter or spoken communication in English. Examples include but are not limited to: Braille Audio (tape, compact disk, MP3) Easy Read SMS/TXT E-mail British Sign Language (BSL) Telephone Large Print Lip-reading Using a Hearing Loop Advocate
8. E-mails and SMS/TXT
When asking a patient if they have communication or information support needs, they can ‘opt’ to receive information via e-mails and/or SMS text. Staff are to ask the patient for their e-mail address and/or mobile phone number and confirm the details to ensure they are correct. Patients receiving electronic data, can through software on their devices, enlarge print, change the background and convert the text in to audio speak. This has many positive applications, the most obvious is for people who are blind and makes communication and information more accessible to a population that would otherwise be disadvantaged through ‘traditional’ forms of communication.
OHG Information Security Policy states data sent electronically, i.e. e-mail, must be encrypted where there is patient identifiable information and is not sent on a secure network such as NHS mail. For the purpose of the AIS Policy, e-mails can be sent to patients who request this format based on the individual having a disability, impairment or sensory loss. Staff must send a ‘test’ e-mail and/or SMS text to confirm accuracy and obtain a receipt to verify the account before any further communication is sent. The e-mail is to be headed ‘Test e-mail and disclaimer’ and include the following disclaimer: This e-mail is being sent to ensure that it is a real/active e-mail address, before sending further information that is specific to you. When OHG sends e-mails that have patient identifiable information they are encrypted, this means the e-mail content is protected. To read encrypted e-mails you will need to download software to access the information.
Accessible Information Standard 12 - if you wish to receive e-mails that are NOT protected (encrypted), that is, confidential and the security of information exchanged cannot be guaranteed please confirm this in your return e-mail, this will confirm you are aware of the associated risks e.g. possible hacking, others having access to the data. Please send a return e-mail to confirm receipt of this e-mail and if you wish to have unencrypted e-mail (not protected) otherwise e-mails will be sent encrypted with details of how to access encrypted e-mails. When sending us e-mail please use the minimum amount of personal information needed to identify yourself and/or others (where appropriate service to specify). OHG has no control, or responsibility, over personal information stored by a person’s own Email Service Provider.
Any personal information that is processed by OHG will be done so in accordance with UK data protection legislation. Staff need to advise the patient of associated risks of electronic communication (e.g. possible hacking, others having access to the data) and seek ‘explicit’ consent to proceed (this can be recorded on Compucare). It is worth noting that the risk of an individual email being hacked whilst being transmitted from the sender to the recipient, is quite low. However, person identifiable information should still be minimised whenever possible.
9. Hearing Loops (Accessible Information Standard 13)
A Hearing Loop is a special sound system for people with hearing aids. A hearing aid usually has three positions 'O', 'T' and 'M'. Most of the sites OHG work from have hearing loops – details of the position to use will be available at the site Reception desks.
10. Interpreting/translating services
Interpreting services are available at each site – usually via telephone through providers such as Language Line.
11. Recording Communication and/or Information needs
Communication and/or Information needs will be recorded on ‘Compucare’ which has the facility to alert OHG staff of that person’s communication requirements.
Where there is a breach in complying with this Policy and that breach has implications on the delivery of safe, effective healthcare then the OHG Incident Reporting procedure must be applied via Sentinel. This will then be investigated by the OHG Clinical Governance Team.
Annual reports will be submitted to the Clinical Governance Committee highlighting:
• the number of patients recorded on Compucare (OHG primary patient record system)
• the number where no communication or information needs were required
• where needs were stated and recorded
• the format or adjustment to communication or information to meet the individuals need
• unexpected/unanticipated themes and trends with possible rationale.
The report will also identify any areas where information is not being recorded and where patients are being referred to OHG by external organisations and OHG was not advised of the patient’s communication or information support need. The content of this report will be made available to OHG Board. The purpose of monitoring is to assess how effectively this Policy is being implemented and identify gaps where improvement is needed.
This Policy will be reviewed 12 months from ratification to reflect the changing landscape of the NHS. Thereafter, this policy will be reviewed on a 2 yearly basis or earlier if there are changes to legislation or national/local requirements.
14. Legislation – Policy Compliance
The following documents have been used to inform this policy: -
• Accessible Information Standard Specification (NHS England)
• Accessible Information Standard Implementation guide (NHS England)
• Accessible Information (AIS) Guide
• Equality Act 2010 and the Public Sector Equality Duty
• Health and Social Care Act 2012
• Care Act 2014
• Data Protection Act 2018
• Information Security Policy
• Equality and Diversity Policy
• Interpreting & Translation Policy Accessible Information Standard 15
• OHG Communication Policy