Since 2006 in Wales and 2009 in England, GPs have started to offer annual health checks to adult patients with learning disabilities. People with learning disabilities suffer poorer health and increased mortality due to:
- Increased risk of exposure to social determinates of health, such as poverty and unemployment.
- Increased risk associated with specific causes of learning disabilities (for example, congenital heart disease in patients with Down's syndrome).
- Communication difficulties.
- Lack of equal access to quality healthcare.
Annual health checks have been repeatedly recommended as a response to the poor health of this significant proportion of the population (two per cent). Only four out of 10 adults with learning disabilities in England received a health check in 2009/10 with the bottom 10 per cent of PCTs providing health checks for fewer than 14 per cent of patients with learning disabilities. In contrast, the top 10 per cent of PCTs provided health checks for 67 per cent or more of identified patients with learning disabilities. One study showed that once GPs realise many of the health needs identified by screening were ones that could be coped with in primary care, their attitude to screening changed.1
Frontline GPs recognise the importance of seeing a patient with learning disabilities when they are well and to establish a long-term relationship and in-depth knowledge of them and their carers. The Public Health Observatory in Learning Disabilities (2010) reviewed all relevant scientific studies on the effectiveness of health checks for patients with learning disabilities.2 The introduction of health checks nearly always leads to:
- the detection of unmet, unrecognised and potentially treatable health conditions (including serious and life-threatening conditions such as cancer, heart disease and dementia);
- targeted actions to address these health needs.
The review also concluded that healthcare checks were relatively cheap and affordable compared with standard care.
As well as cost-effective and evidence-based medical care, provision of annual health checks to this group of patients is an effective reasonable adjustment as required by the Disability Discrimination Acts 1995 and 2005, the Equality Act 2010 and is likely to be looked for by the Care Quality Commission when they inspect GP practices from 2012.
Do not overlook common problems, such as a build up of ear wax (Photograph: SPL)
Tips for starting health checks
Start with a core team of an administrator, lead GP and lead practice nurse and meet regularly to review. Your practice is probably already organising annual health checks for patients with mental health problems and dementia for QOF. Discuss your plans with the PCT lead and the community learning disability team to arrange training and checking of your register.
Develop a plan. Visit a practice that is already doing the health checks and see how it does them.
Computer templates can be downloaded (see resources). Start off using a paper version to perform a systematic check and to keep your focus on the patient not the computer.
Allow 30 minutes with the practice nurse and 30 minutes with the GP for each check. Consider arranging blood tests a week before the examination.
Patient and carer's concerns
At the beginning of each check ask the patient and their carer if they have any concerns or worries and check at the end if you have addressed them.
Make sure you take an accurate history. If the patient's key carer has not been able to accompany them, ask for the patient's permission to telephone them to ask about the history.
Focus your assessment on:
- Feeding, bowel and bladder function
- Behavioural disturbance
- Vision and hearing
Whilst vision is usually checked by the patient's optician, you can assess hearing using the whisper test by standing at arm's length behind the patient (to prevent lip reading). You occlude the opposite auditory canal and rub the tragus in a circular motion. You whisper a combination of numbers and letters (example 4-K-2). If the patient responds incorrectly, then you repeat using a different number-letter combination.
If on repeated testing, the patient can answer three out of a possible six number-letter combinations correctly, the patient passes. If they cannot answer three out of six or more, the patient needs referral to audiology. Repeat the sequence in the opposite ear using different number and letter combinations.
Adapt your clinical skills. Experience of other health checks and screening, particularly in dementia, is invaluable. Consider if are there are any syndrome-specific checks needed.
Investigate and refer
Do not overlook common problems, such as ear wax, drug interactions and side-effects, reflux oesophagitis, dental problems and Helicobacter pylori. Do not delay investigations.
Healthcheck action plan
At the end of the check give the patient a simple list of issues you and the practice nurse have identified, action and keep in the notes.
- My health needs
- What needs to done?
- Who will help me?
- When will this need to be reviewed?
Keep the PCT informed of whom you have checked.
- Dr Hoghton is a GP partner in Somerset and RCGP Clinical Champion for Learning Disabilities
- Download computer templates from 'Management of health for people with learning disabilities'. www.pcc.nhs.uk/management-of-health-for-people-with-learning-disa
- Hoghton M and the RCGP Learning Disabilities Group. A Step by Step Guide for GP Practices: Annual Health Checks for People with a Learning Disability. www.rcgp.org.uk/pdf CIRC_Summary Of Process for Annual Health Checks in General Practice.pdf
- GP resource pack from the Sheffield Joint Learning Disabilities Service www.signpostsheffield.org.uk/healthy-safe/healthy/gpcorner/gp-pack
- Oxleas NHS Foundation. Steps for primary care staff to complete LD checks www.oxleas.nhs.uk/gps-referrers/learning-disability-services/health-check-resources/
1. McConkey R, Moore G, Marshall D. Changes in the attitudes of GPs to the health screening of patients with learning disabilities. J Intellect Disabil 2002; 6(4): 373-84.
2. Public Health Observatory in Learning disabilities.Health Checks for People with Learning Disabilities: A Systematic Review of Evidence. 2010 www.improvinghealthandlives.org.uk/projects/annualhealthchecks