Enhancing the Pathway for Patients With Additional Needs

As healthcare professionals there is a legal responsibility to provide support and make reasonable adjustments for patients with additional needs, such as autism and learning disabilities. Mind, a health charity, defines reasonable adjustments as ‘changes to prevent your disability putting you at a disadvantage compared with others who are not disabled’, this ensures equal access to services [1]. The Equality Act 2010 created a legal framework that reflects on accessibility to care for children and young people with additional needs [2]. In response, NHS England developed a Reasonable Adjustment Digital Flag on the NHS Spine, this allows health professionals to record and share reasonable adjustments an individual may need [3]. Guidance released in 2019 by Public Health England under ‘Oral Care and People with Learning Disabilities’, stated the importance of being ‘anticipatory’ with reasonable adjustments [4]. The Oliver McGowan mandatory training package was formulated to enable staff to understand autism from the perspective of the patient and how to make adjustments [5]. The patient journey through the paediatric dental department at University College Hospital London (UCLH) begins with a telephone assessment followed by a face-to-face assessment. A detailed patient history taken at the telephone appointment should help identify patients who may need reasonable adjustments and the support required. To evaluate the existing pathway for patients with additional needs and make improvements that enhance the patient experience when attending the paediatric dental department. This was a retrospective service evaluation with the data extracted from the hospital's electronic health record system (EHRS) by the author. Patients attending telephone and face-to-face new patient clinics in November 2023 were reviewed. Patients were identified as having additional needs through the referrals and information gathered at the telephone assessment. Inclusion criteria included all patients with neurodiversity, learning difficulties, developmental delay or complex medical histories. Patient records were reviewed to assess if a digital flag alert was present, if a 60-min appointment was requested and booked, and if reasonable adjustments were identified and recorded. A second service evaluation was completed for patients seen in July 2024 and included a survey of staff on the use of the BSPD Autism Questionnaire, which was introduced as part of the action plan for the first evaluation [6]. The survey had three open questions, which were: likes, dislikes and recommended changes. This was completed by all staff groups involved in the care of patients with additional needs. There were 26 children identified with AN in Evaluation 1 and 30 children in Evaluation 2 (Table 1). There were improvements in all areas evaluated between the first and second evaluations, particularly in patients having the 60-min extended appointment booked when requested (from 22% to 100%). The improvement was less marked in the use of the digital flag, with an increase from 12% to 33%. Opinions were sought from all staff groups on the BSPD Autism Questionnaire; this included: dentists (n = 14), dental therapists (n = 1), dental nurses (n = 4), ward nurses (n = 4), pre-assessment nurses (n = 2), anaesthetists (n = 1) and play specialists (n = 4). There were 30 responses gained. The project delivered improvements to the experiences of children and young people with additional needs attending the Department of Paediatric Dentistry and highlighted the importance of early correct identification of this patient group. Staff experience was enhanced as more information about the patient's needs was available prior to the clinic visit and reasonable adjustments could be made, resulting in a positive dental experience. The administrative and clinical teams worked collaboratively to ensure appointments were booked correctly as it went from 21% to 100%. This came from ensuring the importance of longer appointments was explained to staff and highlighting why appointments at a specific time of day are requested, improving the understanding of the administrative team. Communication between clinical and administrative teams was enhanced by the introduction of a new electronic template for appointment requests. The longer appointment slots mean clinics are running more efficiently with shorter waiting room time for patients, which has led to fewer informal complaints from waiting parents saying their child is becoming agitated. Gathering information about the specific needs of a patient prior to them attending the hospital helps identify communication preferences or sensory triggers that can then be avoided and increase the chance of a positive dental experience. Introduction of the BSPD Autism Questionnaire provided a structured approach to gathering information about patients' additional needs and reasonable adjustments. The second evaluation saw an improvement from 12% to 77%, but staff felt that the questionnaire could be improved as they felt that it was not suitable for every patient with additional needs. This resulted in the creation of the Adapted Autism Questionnaire, which utilised staff feedback to adapt the questionnaire and was met with a very positive response as staff felt that it now captured all patients. Digital flag alerts highlight to staff the barriers a patient may encounter when accessing care, and prompt reasonable adjustments to be made. Patients encounter multiple staff groups along their healthcare journey. The digital flag informs the radiography team that the patient needs to be fast-tracked so as to avoid additional stress, and play specialists can identify patients, which helps them to prepare in supporting them. Also, they remind the administrative team to book longer appointments and try to minimise waiting room times. The increased awareness and use of the flagging system should improve coordination of care and delivery of safe care for patients with additional needs. This project saw the increased use of the digital flags as it went from 12% to 33%; however, 67% of patients still did not have the digital flag placed. The use of the patient flag system on the EHRS needs to be further embedded, with additional teaching and inclusion in the induction program for new staff. The next stage of the project will be to gain feedback on the new questionnaire from all stakeholders, including service users. Thank you to all staff working within the Department of Paediatric Dentistry. The authors declare no conflicts of interest.