Through many years of research it is now well understood that individuals in the community with Learning Disabilities are more likely to experience a range of chronic health conditions. These include thyroid problems, constipation and diabetes. We also know that these conditions can be effectively prevented and managed within the community therefore increasing longevity, improving quality of life and reducing care costs.
As a response to this research, the UK National Health Service has introduced annual health checks for people with learning disabilities to be carried out by their local general practitioners. Early literature suggests that the introduction of these health checks has resulted in the detection of unmet needs and potentially treatable health conditions in this population
Public Health England have been documenting the uptake of these annual health checks by individuals with learning disabilities since they were introduced in 2008. They have found that in just four years there had been a fourfold increase in the numbers of check undertaken in England. However, these data did highlight that still just under half of individuals with learning disabilities are receiving these health checks and there is high levels of regional variation.
Health checks were introduced in Northern Ireland later than other parts of the UK with 2011/12 being the first year to have a complete data set across the province.
One of the features of Northern Ireland’s implementation of annual health checks is the introduction of health facilitators. These are trained learning disability nurses whose role it is to liaise with GPs to help identify patients with learning disabilities in the practice, encourage attendance to the health checks and follow up any further actions.
The authors examined the uptake of annual health checks across Northern Ireland from 2011-2014 with the aim to assess how such uptake could be optimised and whether the role of health facilitators impacted on uptake.
The Health and Social care board in Northern Ireland provided the authors with the data on the claims made by GP practices for reimbursement for the health checks undertaken for three financial years: 2001/12, 2012/13 and 2013/14. They were also supplied with the number of individuals with learning disabilities known to each GP practice; however, there was no indication as to the reliability of this figure.
All the data were anonymised and did not contain any personal details of the people attending the health checks. Whilst this meant that the authors did not require ethical approval, it also did not give any information on the demographics of the people attending or not attending the annual health checks which might provide some insight into potential sources of inequity. To remedy this, the authors also conducted an analysis on the anonymised data held by health facilitators. These data were only available for one trust and contained the information on all patients with learning disabilities known by that trust.
The data show that over the past three years the number of practices signed up to perform annual health checks has risen from 77% to 92%. There are, however, some variations between the percentages of practices in each trust undertaking these health checks.
The highest uptake is in the Northern Trust compared to the lowest uptake which is Belfast Trust. It is of note that the Northern Trust has had three full time health facilitators over the period, whereas Belfast began with just one part time health facilitator post. This post was made full time in the third year of the data and there appears to be a marked increase in the uptake of annual health checks by the Belfast Trust.
The results also indicate that the number of health checks performed by trusts in Northern Ireland has risen each year from 4478 in 2011/12 to 5376 in 2013/14.
The proportion of individuals with learning disabilities known to GP surgeries receiving health checks ranged from 56% to 70% across the trusts, although this is the lowest level of variation across the three years. Comparably, these figures in England range from 37% to 64%.
The authors did notice that the proportion of individuals receiving health checks has fallen in the last year of data. The authors suggest that this may be due to the increased number of individuals identified as eligible for health checks in practices as well as to clinical judgement on behalf of the GP as to whether there was need for particular patients to be called in annually if there were no concerns from the previous check.
However, the scheme is designed to ensure that individuals with a learning disability are seen annually therefore clinical judgement may not be an appropriate reason for the fall in numbers.
Analysis of the demographic information of patient records held by the health facilitators shows that there was no significant difference between the males and females in terms of uptake of health checks.
Likewise, there were no significant differences with regards to level of learning disability. However, the authors found that individuals who lived in nursing, residential or support living were more likely than those who lived with family or independently to have had health checks.
Also, they found that those patients who had health checks tended to live in more affluent areas (as determined by postcode).
When compared with the figures from England and Wales, the results suggest that a greater number of patients with learning disabilities have been registered by practices offering annual health checks.
This evidence also supports the view that health facilitators can be used to optimise the uptake of health checks in Northern Ireland, as there has been a demonstrable increase in the number of health checks performed in areas after the appointment of a full time health facilitator.
These professionals may have been able to support practices and patients to access and deliver health checks. However, despite the best efforts of the health facilitators, demographic data still suggest that there are particular groups of patients with learning disabilities that may be missing out on the annual health checks. These include those living independently or with family, and those from more deprived areas.
Whilst this study shows that across Northern Ireland there have been impressive uptake figures in the three years covered in this study, the data also show that still less than 50% of people with learning disability are receiving health checks every year.
The authors suggest that this may in part be down to clinical judgment from the GPs as to whether annual checks are needed if there are no concerns from previous checks. It may also be important to think about the motivation of the patients themselves to return to have checks each year, especially if they feel themselves to be healthy or if they do not fully understand the importance of these checks. This may be an area to focus the work of the health facilitators.
Strengths and Limitations
The study highlights the need for centralised data across Northern Ireland, as the lack of this meant that some conclusions had to be drawn from one particular trust and then generalised across the rest of Northern Ireland. This is unhelpful and does not allow the authors to accurately represent the variability in each trust in terms of population, demographics and geography, and how this may impact on the uptake figures across the whole country.
It is also the case that there are many potential problems with the identification of individuals with a learning disability in General Practice, such as individuals who are borderline learning disabled and so may be missed and individuals with specific genetic conditions who may not be explicitly labelled as learning disabled. The authors do not comment on such concerns and there is relatively little information to ensure the reader of the reliability of the data.
However, overall this study picks up some important points about how the introduction of health checks across Northern Ireland has been received by the medical and learning disabled communities. It has given a good clue to the utility of health facilitators in optimising the uptake of these health checks across the country and this would be a useful start for future work. It may also help to identify if such a position could be useful across other parts of the UK to improve the uptake of health checks.
One area where this study could be expanded would be to include qualitative data, such as a thematic analysis of the views of health staff and service users with regards to health checks. This would give a valuable insight into how the health checks work day-to-day on the ground and what is important in terms of health needs to GPs, health facilitators and learning disabled patients.
McConkey, R., Taggart, L., & Kane, M. (2015). Optimizing the uptake of health checks for people with intellectual disabilities. Journal of Intellectual Disabilities, 19(3), 205-214 [abstract]
Buszewicz, M., Welch, C., Horsfall, L. et al. (2014). Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study. Lancet Psychiatry, 1, 522-530
Lennox, N. G., Diggens, J. N., & Ugoni, A. M. (1997). The general practice of care of people with intellectual disability: barriers and solutions. Journal of Intellectual Disability Research, 41(5), 380-390
Phillips, A., Morrison, J., & Davis, R. W. (2004). General practitioners’’ educational needs in intellectual disability health. Journal of Intellectual Disability Research, 48(2), 142-149
Public Health England. (2013). The Uptake of Health Checks for Adults with Learning Disabilities 2008/9 to 2012/13. London: Public Health England