Adults with learning difficulties represent a significant proportion of the population, and as most have greater than average physical and mental health needs, providing care that meets their unique needs in a primary care setting can prove challenging for GPs.
Adults with learning difficulties represent a significant proportion of the population, and as most have greater than average physical and mental health needs, providing care that meets their unique needs in a primary care setting can prove challenging for GPs.
People with learning difficulties generally suffer poorer health and increased mortality compared to the wider population. Navigating the health system can be an uphill struggle, for reasons both clinical and societal. Beyond the increased risks associated with the specific causes of learning disability, they are frequently more vulnerable to the effects of health inequalities, the social determinants of health such as poverty and unemployment, and have difficulty communicating their needs.
To meet this challenge, GPs depend on developing an in-depth knowledge of the patient and their carers, something which can be best achieved by seeing them when they are well and unwell. The value of annual health checks then, is obvious.
Annual health checks for adult patients with learning difficulties have been offered to patients since 2006 in Wales, and 2009 in England. In addition to helping build the necessary relationship and understanding of the patients' needs, the Public Health Learning Disabilities Observatory‘s Systemic review in 2010 covering health checks in over 5000 adults with a learning disability demonstrates that introducing health checks nearly always leads to the detection of unmet, and usually treatable clinical needs.
This is particularly relevant considering the fact that people with learning difficulties generally suffer poorer health and increased mortality for a number of factors, including lack of equal access to healthcare, increased exposure to social determinates of health such as unemployment and poverty, and the increased risks associated with the specific causes of learning disabilities.
However, despite this clinical benefits for the patient, and despite the fact that incentive is offered in the shape of directed enhanced service (DES), the number of checks being provided is not as high as it could be, and there is considerable variation from region to region. Data published this year shows that the number of annual health checks being provided went up by only 8% between 2009-10 and 2010-11, from 41% of eligible patients, to 48%.
The reasons suggested by an Oxfordshire investigations suggested that, in addition to the complexity of identifying patients, and low response rates, GPs were unconvinced of the value of the checks, believing that it was a waste of time without accompanying lifestyle change. In addition, the investigation suggested that DES does not cover the extra costs, and that the GPs concerned did not feel confident in providing treatment for people with learning difficulties.
Of course it is not all bad news; some areas have achieved more than 90% coverage. Many practitioners have been through the training and done a good job identifying and assessing their own patients with intellectual disabilities. Having done this, they may have been surprised by the number of formerly hidden conditions which have emerged, and often, how simply these may be addressed at relatively little cost with actual overall saving to care services.
The RCGP has made its commitment to closing the health inequalities gap clear, and the College is working to ensure GPs are armed with the tools to provide the best possible care for their patients with learning difficulties. Crucially, caring for people with learning disabilities is now part of the RCGP Curriculum.
This has also been identified as a clinical priority for the College, hence my appointment as RCGP Clinical Champion, and we are about to launch a Mental Capacity toolkit to help GPs and primary care staff assess capacity and how to conduct a best interests for patients who are temporarily or no longer able to a make a decision
Providing health checks for patients with learning difficulties is cost effective and clinically sound; the real challenge is to ensure that the enthusiasm and commitment is consistent across the UK, and that GPs use their unique relationship with their patients to provide the best possible care to their patients.
Dr Matt Hoghton a GP in Bristol and RCGP clinical champion for learning disabilities.
