Adjustments and proportionality

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Reasonable Adjustments for Doctors: Cost, Proportionality, and Governance

Purpose

This document sets out a clear, evidence-based framework for assessing the cost and reasonableness of adjustments for doctors, particularly within NHS medical training but applicable across all stages of employment. It explains why cost-based refusals are frequently misconceived, why proportionality must be assessed at the correct organisational level, and why most adjustment requests represent a fraction of the foreseeable cost of not making them.

The aim is practical: to support fair, lawful decision-making; to prevent avoidable workforce loss; and to provide a shared analytical framework for clinicians, HR, and senior leaders.

Key Principles for Doctors

This document is not intended to turn doctors into lawyers. It is intended to clarify a small number of core principles that underpin reasonable adjustments under the Equality Act, and which are often misunderstood in practice.

1. Reasonableness is contextual, not absoluteThe Equality Act does not impose a fixed cost limit on reasonable adjustments. Cost must be assessed in context, including by reference to the foreseeable consequences of not making the adjustment.
2. The correct comparison is adjustment versus failureAn adjustment should not be assessed against a zero baseline, but against the foreseeable cost of unmanaged sickness absence, delayed progression, or workforce loss.
3. Most adjustments cost a fraction of what they preventIn practice, most reasonable adjustments represent a small proportion of the cost associated with training failure, prolonged absence, or attrition.
4. Competence must be assessed with adjustments in placeIt is neither lawful nor logical to assess capability on an unadjusted basis where reasonable adjustments are required.
5. Cost-based refusals require senior oversightDecisions that rely on proportionality or resource allocation cannot properly be made at junior or local level. They require visibility of employer-wide resources and system-level risk.
6. Training and permanent posts differ in form, not substanceWhether a doctor is in training or a substantive role, the cost of not making adjustments is borne either by the NHS as a system or by the employing Trust directly.
7. Harm to the doctor is part of the legal analysisThe Equality Act recognises injury to health, dignity, and career as relevant harms. Liability for such harm is uncapped and must be considered alongside organisational cost.

These principles are not aspirational. They reflect how the Equality Act is intended to operate when applied correctly.

1. The Core Error: Treating Cost in Isolation

A recurrent problem in adjustment decisions is the use of absolute cost as a veto. Adjustments are often assessed against local budgets or rota pressures rather than against the foreseeable consequences of refusal.

This is a category error. The Equality Act requires a balancing exercise, not a price tag. The correct question is not:

“How much does this adjustment cost?”

but:

“Is this cost proportionate when compared with the foreseeable cost of not making the adjustment?”

Where that comparison is made honestly, many refusals collapse.

2. The Correct Comparator: Adjustment vs Failure

For doctors, the foreseeable consequences of refusing or delaying adjustments include:

·        prolonged sickness absence (often at full pay),

·        locum cover and rota disruption,

·        delayed progression or training extensions,

·        formal capability or performance processes,

·        attrition from training or exit from the NHS workforce.

Even using deliberately conservative assumptions, these outcomes represent very substantial financial and workforce costs. Against that backdrop, most reasonable adjustments cost only a fraction of the foreseeable cost of not making them.

This comparison is implicit in the Equality Act’s reasonableness test and is not an additional or novel requirement.

Important: An employer must consider foreseeable serious consequences when assessing proportionality, even where those consequences are not immediate or are judged to be unlikely if viewed in isolation.

3. Avoiding Arbitrary Cost Thresholds

Experience shows that citing illustrative figures (for example, “most adjustments cost £X”) creates implicit ceilings that are then misused. Cost must therefore be assessed relatively and contextually, not by reference to arbitrary amounts.

The appropriate framing is:

Adjustment costs should be assessed by reference to the losses they are intended to prevent.

This avoids anchoring bias and reflects the statutory test correctly.

4. Adjusted Working Patterns and Workload

Reduced workload or adjusted hours are often rejected as “too expensive”. This is a misunderstanding.

·        Planned adjustments are predictable and bounded.

·        Unmanaged sickness absence is unpredictable, prolonged, and frequently more expensive.

·        A structured four‑day working pattern, even with cover, is often less costly than repeated absence, locums, or training failure.

Where an adjustment plausibly reduces foreseeable risk, refusal on cost grounds alone is difficult to defend.

5. Effectiveness and Practicability Once Cost Is Accepted

Once it is accepted that an adjustment is financially proportionate, other common objections often fall away:

·        Effectiveness: An adjustment need only be capable of reducing disadvantage; it does not need to guarantee success.

·        Practicability: If an adjustment can be funded and organised, it is not impracticable. Inconvenience is not impracticability.

·        Impact on others: Where cover or redistribution is planned and resourced, generalised fairness concerns cannot justify refusal.

Assertions of ineffectiveness or impracticability must therefore be evidence‑based, not assumed.

6. Professional Competence Must Be Assessed With Adjustments

Competence cannot lawfully be assessed on an unadjusted basis where reasonable adjustments are required. To do so would defeat the purpose of the duty itself.

Doctors in training and substantive posts have:

·        met entry and progression standards,

·        been appointed through competitive processes,

·        demonstrated capability within adjusted environments previously.

If competence is questioned, it must be assessed after appropriate adjustments are in place.

7. Training Posts: NHS‑Wide Cost and Risk

In training posts, cost and risk cannot be confined to a single Trust:

·        training is nationally coordinated,

·        doctors rotate between organisations,

·        employment conditions (including pensions and pay frameworks) are NHS‑wide,

·        attrition harms the NHS as a system.

Local refusal of adjustments therefore represents cost‑shifting, not cost avoidance. Proportionality must be assessed at system level, not solely against local budgets.

8. Substantive Posts: Local Cost Becomes Immediate

In permanent or substantive roles, the logic is even more direct:

·        sickness absence costs are borne immediately by the Trust,

·        locum cover and turnover are expensive and disruptive,

·        loss of experienced staff damages service continuity and morale.

While the locus of cost differs from training posts, the conclusion is the same:

Refusal of reasonable adjustments on cost grounds increases, rather than reduces, expenditure.

9. Case Law Context: Cordell v FCO

In Cordell v Foreign and Commonwealth Office, the Employment Appeal Tribunal rejected an adjustment only because the proposed cost was exceptional and vastly exceeded the claimant’s own salary.

The judgment:

·        confirmed that there is no low‑cost ceiling on reasonable adjustments,

·        emphasised proportionality and context, not absolute affordability,

·        implies that substantially lower—though still significant—costs may fall within the scope of reasonableness.

The scale of expenditure in Cordell was far beyond anything ordinarily requested in medical adjustment cases.

10. Governance: The Appropriate Decision Level

Where refusal relies on judgments about proportionality, affordability, or resource allocation, such decisions cannot properly be made at junior or local level.

A lawful proportionality assessment requires visibility of:

·        employer‑wide resources,

·        workforce strategy,

·        system‑level risk and loss.

Accordingly, cost‑based refusals should be escalated to senior management or board level.

11. Contract Length, Rotation, and Retirement Arguments

Refusal cannot be justified by:

·        fixed‑term contracts,

·        rotational placements,

·        speculative assumptions about future employment or retirement.

The duty applies during the period of employment, and shorter time horizons often make adjustments easier—not harder—to justify, as they are bounded and predictable.

12. Damage to the Claimant and Liability Exposure

While this document focuses primarily on cost, proportionality, and governance, it is also important to recognise that the Equality Act explicitly considers harm to the individual claimant.

Failure to make reasonable adjustments can result in:

·        deterioration in physical or mental health,

·        exacerbation of disability-related symptoms,

·        stress, anxiety, and loss of confidence,

·        prolonged sickness absence,

·        reputational and career damage.

These are not peripheral issues. They form a central part of Equality Act liability. Compensation for discrimination is uncapped and may include:

·        injury to feelings,

·        aggravated damages,

·        financial loss linked to career delay or exit,

·        pension and future earnings impact.

Where refusal or delay of adjustments foreseeably causes harm, the employer’s exposure is not limited to workforce or service costs. Direct liability to the claimant must also be considered as part of proportionality assessment.

This reinforces, rather than replaces, the economic analysis set out above: refusal of proportionate adjustments risks compounding loss by creating parallel liabilities that are avoidable.

13. Time Limits and Practical Safeguards

Internal processes do not stop Employment Tribunal time limits. Doctors experiencing refusal or delay should assume the clock is running and protect their position in parallel with internal discussions.

Conclusion

Across all stages of employment, the analysis converges on a single principle:

Most reasonable adjustments cost only a fraction of the foreseeable cost of not making them.

Cost‑based refusals typically reflect structural decision‑making failures rather than genuine financial constraint. Proper application of the Equality Act requires contextual, proportional assessment at the appropriate level of governance.

Done correctly, reasonable adjustments are not a cost burden but a rational investment in workforce stability, service continuity, and lawful practice.

Disclaimer: These pages are for general information only and does not constitute legal advice. For individual guidance, contact for children SENDIASS, IPSEA, otherwise Advisory, Conciliation and Arbitration Service(ACAS) or the Equality Advisory and Support Service (EASS). See the full Legal and Support Disclaimer for details.