Who should care for people with learning disabilities?

EDITOR - In his personal view, Sellar[1] advocates the development
of a general practitioner for the intellectually handicapped, and
envisages a vocational training programme which might include psychiatry,
developmental paediatrics, general medicine, neurology, cardiology,
behavioural science,and rehabilitative medicine,also ENT,ophthalmology and
genetics. Surely exposure to the above specialities is part of
undergraduate, and vocational training for general practice.

The training
of doctors in medical and social issues related to patients with learning
disabilities in the community should indeed be a priority[2], but the
question is, which doctors? Psychiatrists or general practitioners? If
general practitioners should they be specialist GPs or the GP with whom
the patient is actually registered? As a general practitioners, we are
grateful for the advice of consultant psychiatrists in learning
disabilities, particularly regarding anticonvulsants, anti psychotic and
other CNS drugs but they see only 25-30%of the patients with moderate,
severe and profound learning disabilities, whereas over 85% of these
patients see their GP in any year. On average, each GP in UK has 6-7 such
patients. General practitioners have a pivotal role in liasing with and
accessing specialist care on behalf of their patients. In a large practice
one partner might develop expertise for managing their patients with
learning disabilities, but at present general practitioners regard
themselves as responsible for the medical care of their patients with
learning disabilities[3]. Primary care groups/large organisations for the
care of people with learning disabilities might wish to identify and
employ a GP/physician specialist. Although training is advocated for
general practitioners,[4] demand for and supply at undergraduate and post
graduate levels remains sparse. General practitioners often feel they do
not have the necessary skills to manage people with learning disabilities
and that they need to refer patients to their psychiatrist colleagues.

However, some people with learning disabilities presenting with
behavioural problems may turn out to have to have fairly common medical
conditions with 'low tec' solutions such as ear wax, urinary tract
infections, dyspepsia and constipation. People with learning disabilities
are often multidisabled so multiple interventions are appropriate; they
need carers to advocate on their behalf because they often have
communication problems. As well as some training, what general
practitioners actually need is extra time and therefore additional
reimbursement[5] if they are going to provide a better service for their
patients with intellectual impairment.

Graham Martin, chair, RCGP learning disabilities working group.

Red Roofs Surgery, Nuneaton, Warks. CV11 5TW

1. SellarW, Who should care for people with learning disabilities?
BMJ 2000; 1297

2. AsprayTJ,FrancisRM,TyrerPJ,QuilliamSJ. Patients with learning
disabilities in the community have special medical needs that should be
planned for.BMJ Editorial 1999; 318:476-477

3. KerrM,DunstanF,ThaparA.Attitudes of general practitioners to
caring for people with learning disability. BJGen Pract 1996;46:92-94

4. SinghP Prescription for Change: A Mencap report on the role of
GPs and carers in the provision of primary care for people with learning
disabilities. Mencap,1997;47

5. HowellsG. Situations vacant:doctors required to provide care for
people with learning disability. BJ Gen Prac Editorial 1996;59