Editorials

Annual health checks for people with intellectual disabilities

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7589 (Published 15 November 2012) Cite this as: BMJ 2012;345:e7589
  1. Matt Hoghton, general practitioner1,
  2. Graham Martin, retired general practitioner2,
  3. Umesh Chauhan, general practitioner3
  1. 1Clevedon Riverside Group, Clevedon BS21 6DG, UK
  2. 2RCGP Health Inequalities Standing Group, Cragside, Wolvey, UK
  3. 3Walshaw House, Nelson, UK
  1. matt.hoghton{at}bristol.ac.uk

Potentially an important step towards reducing health inequalities

The recent convictions in the United Kingdom of 11 staff members from Winterbourne View Hospital of the criminal charges of abuse of adults with intellectual disabilities highlights the continued institutional weaknesses in caring for this vulnerable group.1 However, most people with intellectual disabilities reside in the community, supported by primary care services. Substantial effort has been made in recent years to improve the care of these people through a change in legislation and financial incentives to general practitioners.

In 2006 the Disability Rights Commission recommended the introduction of annual health checks for people with intellectual disabilities in England as a way to reduce the health inequalities experienced by this group.2 Since 2008 general practitioners in England have been incentivised to perform a structured annual health check for adults with intellectual disability through an optional payment process (enhanced service).

The Learning Disabilities Public Health Observatory was set up in 2010 in response to a recommendation of the report of the Independent Inquiry into Access to Healthcare for People with Intellectual Disabilities.3 The observatory has published a series of key reports on various aspects of healthcare for people with intellectual disabilities, including surveillance of the number of annual health checks being performed in primary care and local health profiles to help plan local social and healthcare services.4

Life expectancy is increasing in people with mild intellectual disabilities, as it is in the general population. However, mortality from preventable causes is three times higher among people with moderate to severe intellectual disabilities than it is in the general population.5 People with intellectual disabilities also have considerable multimorbidity and have 2.5 times as many long term clinical conditions (excluding intellectual disability itself).6

Rates of admission for some conditions that are sensitive to ambulatory care (such as epilepsy, reflux, and constipation) are higher in people with intellectual disabilities. In addition, a substantially higher proportion of admissions to hospital occur as emergencies in this group compared with the general population (50% v 31.1%).7 Recognising and managing ambulatory care sensitive conditions that are specific to people with intellectual disabilities in primary care should lead to fewer unnecessary hospital admissions.8

An Australian randomised controlled trial of people with intellectual disabilities reported that the detection of new disease was 1.6-fold higher in the regular health check group than in the no systematic health check group.9 In addition, a recent systematic review concluded that the introduction of health checks typically led to the detection of unmet, unrecognised, and potentially treatable conditions, including serious and life threatening diseases such as cancer, heart disease, and dementia.10 Ensuring that all people with intellectual disability receive an annual health check is one way of dealing with the additional unmet health needs of this population.

Although the number of health checks has steadily increased since their introduction, only 53% of people with intellectual disability received a health check in England in the last financial year.4 Health checks are associated with substantial coding activity for incentivised health screening, health promotion, and disease finding related to the quality outcomes framework, but this is less so for processes specific for intellectual disability (visual and hearing assessment, for example), with considerable variation in recording.11 However, there is marked inequality in uptake of health checks, with great variation between primary care trusts (the lowest 10% delivering less than 25%, and the upper 10% completing health checks on more than 69% of their eligible patients).4

It is not yet clear whether health checks lead to improved outcomes, such as fewer hospital admissions related to emergencies. In addition, although the NHS Outcomes Framework 2012-13 is committed to capturing excess mortality in people with intellectual disabilities,12 the lack of substantial data linkage across healthcare settings makes this technically difficult.

The true impact of health checks can be assessed only through continued data gathering and improved surveillance across healthcare settings, and continued funding of the Public Health Observatory for Intellectual Disabilities is essential. However, gaps remain, such as identifying and dealing with the needs of people with intellectual disabilities and their carers; making reasonable adjustments in cancer screening programmes; identifying the needs of ethnic minority populations; and improving the care of children and young people, particularly through transition across healthcare settings.

Currently the programme of annual health checks is renewed on a yearly basis in England, but firm long term commitment to annual health checks and their evaluation is needed, with benchmarking of results at the practice level. Otherwise, we may continue to witness the cascade of disparities and a widening of the health inequality gap between those with intellectual disability and the general population.

Notes

Cite this as: BMJ 2012;345:e7589

Footnotes

  • MH is a Royal College of General Practitioners (RCGP) clinical champion in intellectual disabilities. UC is chair of learning disability research specialist interest group of the Society of Academic Primary Care. All authors are members of the RCGP Intellectual disability professional network.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References