Editorials

Disability discrimination

The UK's act requires health services to remove barriers to access and participation

Discrimination on grounds of race and gender is increasingly acknowledged in medicine, ^{1 2} but equal attention has not been given to disability discrimination. Will this change now that the General Medical Council is being taken to a tribunal by a prospective medical student who is disabled?³ Ironically, education is exempt from the section (part III) of the United Kingdom's Disability Dicrimination Act on provision of goods and services that has recently become enforceable. But the act must be taken seriously by the NHS and other organisations that provide services to the public.

The prospective student had been offered a place at medical school, but modifications were needed so she could complete the course. The GMC stated that it "could not in law agree an alternative curriculum which covers a lesser order of knowledge and skill," but an employment tribunal said this position showed a lack of appreciation of the possible modifications that could be made.⁴ The tribunal also ruled that the GMC was a trade organisation and therefore not exempt from the act.⁴ The GMC has appealed against the ruling in order to establish this point of law.⁵

Although transport and education are exempt from part III of the Disability Discrimination Act 1995,⁶ health services are not. To comply with legislation, providers such as the NHS must make "reasonable adjustments" to ensure that disabled people can use their services. ^{6 7} Thus they must "provide an auxiliary aid or service"for example, information in large print; "change a policy, practice or procedure"ensure that receptionists approach deaf patients directly when it's their turn to see the doctor; or "find an alternative method to make services available"provide a domicilary service to wheelchair users if the surgery has stepped access. By 2004 providers must have "removed, altered or provided reasonable means of avoiding physical features that make it impossible or difficult for disabled people to use a service."⁶

There are two broad perspectives on disabilitythe medical and the social models. Crudely, the medical model holds that individuals' impairments are the problem, while the social model locates disability in society rather than in individuals. ^{8 9} Though the Disability Discrimination Act defines disability primarily in line with the medical model, its concept of making "reasonable adjustments" does in practice shift the focus towards dismantling the disabling barriers in society.

Disabled people in Liverpool have provided examples of the sorts of barriers that exclude them from mainstream life.¹⁰ For example, on transport, "They think we have a little outing now and again or go to the hospital. They don't think we lead a full social life or even want to attempt to do so." On reliance on the use of print, "I don't see why I should have to have other people read my bills or letters." Deaf women have described difficulties in using health services, such as communication problems in opticians' and dentists' surgeries and in x ray departments, where rooms are dark, eyes are covered, or the staff are behind screens.¹¹

Addressing disability from the civil rights and social model perspectives is consistent with the public health approach of achieving improved health through organised efforts of society. Many disabled people are systematically excluded from aspects of life known to promote good health, such as education, employment, leisure, and exercise. But the disabling effects of society are not usually included in public health debates. A paper on the health implications of transport policies, for example, does not address the barriers disabled people face.¹² Travelling (to work, to the shops, for social events) is essential for full social inclusion. Walking and cycling are not options for everyone, and public transport is currently not fully accessible. This must be addressed when promoting healthy transport, or travel will become harder for disabled people, increasing their social exclusion.

Locating disability in society makes it easier to implement the Disability Discrimination Act because this approach avoids asking the wrong questions. Applying the medical model results in people being asked about their impairments. They respond by stating the name of their medical condition, but this says nothing about their barriers to access. Applying the social model results in questions about barriers, be these stairs, voice only telephones, or print.

Making services accessible means challenging the concept of what is normal and changing how services are provided. If organisations are to implement change successfully disabled people must contribute to its implementation⁷: they know best the barriers they face and can offer practical solutions. ^{10 11} But barriers to full participation must first be addressed. This means taking into account, for example, that some people use wheelchairs, some use visual languages, and some gain information from audiotape.

At a practical level, all health staff should know their responsibilities under the Disability Discrimination Act and understand the social model. Again, disabled people often identify inappropriate staff attitudes and behaviours as the biggest barrier to using health services.⁷ Can they be confident that they will be afforded equal access to health services if they are not also confident that the medical profession will not discriminate against them becoming doctors?

Joyce M Carter, consultant in public health medicine. 

Liverpool Health Authority, Liverpool L3 6AL (joyce.carter{at}liverpool-ha.nhs.uk)

Natalie Markham, project manager (employment, education, and training). 

Liverpool City Council, Liverpool L3 2AW

1.	McKenzie K. Something borrowed from the blues? BMJ 1999; 318: 616-617[Free Full Text].
2.	Showalter E. Improving the position of women in medicine. BMJ 1999; 318: 71-72[Free Full Text].
3.	Disability Rights Commission. Adjustments to student's medical course not approved by professional organisation. DRC/0/177. on www.drc-gb.org/drc/InformationAndLegislation/page372.asp [accessed 16 May 2001]
4.	London North Employment Tribunal. Case 2203652/2000. Cox Heidi and General Medical Council. London: London Central Employment Tribunal, 2000. (22203652/2000)
5.	General Medical Council. Press statement: 5 March. London: GMC, 2001.
6.	Department for Education And Employment. Disability Discrimination Act 1995. Code of practice. Rights of access. Goods, facilities, services and premises. London: Stationery Office, 1999.
7.	NHS Executive. Implementing Section 21 of the Disability Discrimination Act 1995 across the NHS. Leeds: NHS Executive, 1999 (HSC 1999/156).
8.	Oliver M. Theories of disability in health practice and research. BMJ 1998; 17: 446-449. [The correct citation is BMJ 1998; 317:1446-1449]
9.	Royal College of Physicians. Disabled people using hospitals: a charter and guidelines. London: RCP, 1998.
10.	Liverpool Independent/Integrated Living Project. Report to the joint care planning subgroup for disabled people. Manchester: Greater Manchester Coalition of Disabled People, 1999.
11.	Lomas M. Access to health servicesfalling on deaf ears? Manchester: Association of Greater Manchester Authorities, 1998.
12.	Dora C. A different route to health: implications of transport policies. BMJ 1999; 318: 1686-1689[Free Full Text].