Intended for healthcare professionals

Rapid response to:


People with learning disabilities were treated “less favourably than others”

BMJ 2009; 338 doi: (Published 25 March 2009) Cite this as: BMJ 2009;338:b1261

Rapid Response:

If Annual Health Checks for people with learning disabilities can address failings identified in their health care, why are more GPs not doing them?

In 2009, Kosia Kietowicz reported that people with learning
disabilities were treated 'less favourably' than others, due to lack of
leadership and a failure to understand the legal duty to make reasonable
adjustments to ensure equitable access for disabled people. A response to
this, and other failings in NHS care for people with learning disabilities
identified in Sir Jonathan Michael's Report, Healthcare for All (2008),
was the introduction of Annual Health Checks for this group. Health
Checks, covering physical and mental health, and a review of medication
are intended to lead to early detection of serious health issues. GPs are
incentivised to offer these Checks to patients with moderate and severe
learning disabilities on their lists through a Directed Enhanced Service
introduced in 2008.

At the end of July, Improving Health and Lives, the Learning Disabilities
Health Observatory, published national figures showing that the number of
Annual Health Checks for people with learning disabilities had increased
only marginally, from 41% of those eligible in 2009/10 to 49% in 2010/11.

This means that over half of the people who should get these Checks are
not receiving them. And in the bottom 10% of Primary Care Trusts, fewer
than one in four are getting the Check.

The Health Check is an evidence based intervention. A systematic review of
research conducted by the Learning Disabilities Health Observatory
indicates that comprehensive and regular screening has the potential to
detect hitherto undetected health conditions. Proactive screening is
important for this group, because they rely heavily on carers and others
to note ill health and take action to address it; and because they are
frequently subject to 'diagnostic overshadowing', the assumption on the
part of those close to them that any change in behaviour is attributable
to the learning disability, rather than a physical or mental health
problem. Hence a high level of undetected conditions - which can be
discovered through a comprehensive and regular check.

The Annual Health Check is the most significant attempt yet to address
theunacceptably poor health care provided for these patients. The Royal
College of GPs has put its weight behind the Checks, and during 2010
published guidelines, Getting it Right, on how to carry them out.

So why are more GPs not doing them? With financial support from The Health
Foundation, we carried out an investigation in Oxfordshire, where only
just over a quarter of those eligible had such a Check in 2009/10. Local
GPs cited a number of reasons. Probably foremost amongst these was that
GPs believe they already do a good job for their patients with learning
disabilities and are unconvinced, despite the evidence, that the Checks
are valuable. Other reasons cited were that identification of eligible
patients was unnecessarily complicated; that the Check was a waste of time
if carers were unprepared to support people to take exercise, eat well and
adhere to medication; that the payment of ?100 did not cover the extra
costs; and that people did not respond when invited for a Check. On the
whole GPs lack confidence and experience in treating people with learning
disabilities, and this too contributed to the low priority accorded to
providing the Check.

But it does not have to be like that. Some areas have achieved over 90%
coverage. One GP in our Oxfordshire sample had taken a special interest in
learning disabilities and had managed to reach 65 of her 89 eligible
patients - and detected some significant and numerous minor undiagnosed
conditions through doing so. In her view, providing the Checks was of
considerable benefit in familarising people with GPs and what they have to
offer, making it more likely that they will contact her in future if they
have health concerns.

When My Life My Choice asked our members about Annual Health Checks, we
found that few people knew about them, nor did they know what to do if not
offered them. Several said they would be scared if asked to attend their
doctor, clearly care is needed when sending out an invitation to provide
reassurance, as is awareness raising amongst family members and paid

The incentive to GPs to provide Annual Health Checks was renewed for
2011/12. There is still time to use this funding to address the
unacceptably poor physical health experienced by too many people with
learning disabilities. Is it not time GPs really prioritise the Annual
Health Check?

Letter from
My Life My Choice, representing people with learning disabilities in

Jan Walmsley, independent researcher

Matt Hoghton, Learning Disabilities Champion, Royal College of General

Competing interests: No competing interests

28 July 2011
Jan S Walmsley
Independent researcher
My Life My Choice, Oxfordshire, Matt Hoghton, Learning Disabilities Champion, Royal College of General Practitioners
London South Bank University