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Learning Disabilities: The Annual Health Check

There are around 1.4 million people with Learning Disabilities (LD) in the UK. 

An average practice of 8,000 patients could expect to have about 50 - 100 patients with LDs. 

The definition of a learning disability: 

A significantly reduced ability to understand new or complex information to learn new skills (significantly impaired intelligence) AND a reduced ability to cope independently (impaired social/adaptive functioning) AND which started before adulthood (onset before aged 18) with a lasting effect on development. 

NHSE advice about an annual health check for people with learning disabilities can be found here.

It is well recognised that people with LD have poorer outcomes.  Health inequality remains a leading concern with people with LD dying on average 15-20 years sooner than the general population and experiencing poorer health.  The mean age of death of people with profound or multiple LD is 40 years old.  Unfortunately, often this is not due to complex co-morbidities but due to preventable, treatable conditions.  A concern recently identified in the LeDeR 2018 review is the identification of “diagnostic over-shadowing” or misreading symptoms of illness as being due to person having learning disability rather than a treatable medical condition (see here).

Primary care is well situated to help improve these figures by supporting patients more proactively.  This document sets out how to arrange the annual health check and how your surgery might implement it in a straightforward way, along with useful resources for professionals, patients and carers.  It is important to mention that you need to consider the mental capacity of patients with Learning Disability as this will vary on an individual basis.  For more information on mental capacity visit our webpage: https://www.wessexlmcs.com/mentalcapacity

The Learning Disability Annual Health Check

The Annual Health Check (AHC) is a holistic view of our patients and a recognised, evidenced method of improving the health of individuals with LD.  The national Directed Enhanced Service (DES) for Learning Disabilities Health Check Scheme was designed to encourage practices to identify all patients aged 14 and over with LD, to maintain a LD “health check” register and offer them an AHC, with includes producing a health action plan. 

Benefits of the AHC for practices:

Benefits of the AHC for patients:

The AHC interaction is also an opportunity to build relationships and foundations of continuity of care which is considered mutually beneficial.

The scheme is a voluntary reward programme for primary medical services.  In 2016-17 only 53% of people on a learning disability register had a health check nationally.  NHS England are aiming for 75% uptake of patients on the register by 2020 and we support this effort ( and hope for higher) as it’s not too difficult to set up. 

This document offers a step by step guide of what to consider when setting up your process.

 

Learning Disability Annual Health Checks – What are the steps?

1. Identify

Consider identifying a team of consistent practice staff who are responsible for LD AHCs.  This could include a member of the reception team, a practice nurse and a GP who are the practice LD Leads.  It is useful for this core team to establish regular meetings to review progress/uptake etc.

Ensure your Learning Disabilities register is up to date on an annual basis, recognising that not all LDs are correctly coded.  To help check this there is a useful RCGP table on page 2 with conditions that are associated with LD and their codes.  Anyone over the age of 14 with a LD can be offered an AHC.

Try to identify how your patient likes to be communicated with and what is appropriate for their LD, e.g. easy read letters, phone call, pictures or do they want/need their carer to lead on booking appointments?  Where applicable and with the consent of the patient involving carers and support workers can be really helpful.

2. Plan & Invite

Consider how to invite your LD patients, this will require flexibility and even an individualised approach.  If possible, base your invitation on their own communication preferences and be mindful of the language you choose; clear simple communication is key to avoid misunderstanding.

An invite could be in letter form or by telephone. 

Feedback from patients is often that they may not even understand why they have been invited so consider including information about the reasons they have been invited to attend when you contact them. 

If you send a text/letter requesting the patient makes an appointment consider providing a dedicated staff member who has appropriate language, attitude and communication skills to support and enable patients with Learning Disabilities to make their appointment.

3. Schedule

Location and timing of the AHC are important considerations. 

To encourage uptake, you may also wish to consider:

Special considerations include where is the most suitable location to carry out the AHC, e.g. for some patients being seen in their residences may be most appropriate if a surgery appointment may be impractical.

Other considerations such as reasonable adjustments may be necessary.  This is the legal requirement under the Disability Discrimination Act (2005) and the Equality Act (2010) to ensure organisations are making services accessible for people with a disability. 
This may include:

Usual practice is to schedule one hour for the AHC.  Some practices schedule 30 minutes with a GP and 30 minutes with a practice nurse, others provide a nurse led service with GP focusing on the medication review.  The exact template of the LD AHC is up to the practice to decide but be mindful that a flexible approach may be required as some patients with LD will not tolerate multiple professionals and longer appointments whereas others will. 

However you schedule your AHCs it is important an AHC slot is offered and it is not fitted into a routine GP/nurse appointment.  It is therefore prudent to ensure that all reception staff are aware that your practice offers LD AHCs so can book patients the appropriate slot when patients phone to book appointments.

4. Prepare & confirm

Asking the patient to complete a health questionnaire prior to attending helps identify concerns the patient, can reduce anxiety and improve the effectiveness of the consultation.  This allows time to prepare for the appointment and helps clinicians lead patient centred consultations.  It is recommended you either send this out with your confirmation of the appointment or with the invite, it is up to your practice to decide.

Some patients may need a blood test a week before their AHC. 

Ensure your clinicians identify the appropriate patients who require bloods and alert administration staff in time so that they can arrange these additional appointments, similar to other annual reviews, e.g. diabetes.  This is not appropriate for all and remember you need to take a “best interest” decision for those who may not have the capacity to consent to a blood test.  Routine tests may include FBC, U&Es, LFTs, TFTs, Glucose, Cholesterol, HbA1c and if indicated Lithium levels, anti-epileptic drug levels, Calcium and Vitamin D (especially if on anti-epileptic drugs), consider FSH if prolonged amenorrhea and CRP/PSA if indicated.

Again, remember that you may need to provide easy to read information on blood tests and be clear about how the invitation to have bloods is made.

Once you have booked the appointment please consider how you remind the patient of the appointment, e.g. could a member of your LD team contact them the day before? 

5. Complete

The AHC is a longer appointment with a clinician which includes asking history, taking measurements and examination.  There is now a national health check template, for the information on how to activate your clinical system’s software template click here.  The findings can be easily populated in the clinic room.  There is also a useful paper-based template which can be used if the AHC is being held remote to the practice (e.g. in residential or care setting) or you can print a blank template to act as an aide memoire – Welsh Health Check for Adults with a Learning Disability

It is worth taking time to familiarise yourself with the patient’s background and any recent results before they attend.  Ensure you use appropriate, clear communication styles appropriate to the patient’s level of understanding.  It is useful to start with what the patients have provided as to what their current top concerns in any documentation they bring with them.

There are NHS England national electronic templates to help complete the assessment which highlight useful prompts to help understand the process:  https://www.england.nhs.uk/wp-content/uploads/2017/05/nat-elec-health-check-ld-clinical-template.pdf

The RCGP toolkit is seen as a comprehensive walk through the process (https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/health-check-toolkit.aspx).


If appropriate, the AHC is another opportunity to have discussions and help fill in other documents that may be helpful for patients and their carers.  It may be an opportunity to initiate discussions about future planning or to fill in advance care wishes so that a patient's wishes are known in the event of an emergency.

An example of this is www.futureplanning.org.uk/nextstep

At the end of the AHC the Health Action Plan will pre-populate, providing a personalised care plan to print out and share with the patient and/or their carer.  If the patient’s specific learning disability impacts on their ability to read and /or understand the information ensure that it is provided in the best format to maximise their understanding and involvement.  The health action plan should contain key action points discuss and agreed during the AHC.

Additionally, be sure to explain any additional referral processes clearly in a manner appropriate to the patient’s level of understanding.      

In recent years in Hampshire there have been preventable deaths of adults with a learning disability. All died from choking and all were known to have dysphagia so we have developed a webpage to highlight this.

For further resources for clinicians, LD patients and carers see our page here.

Thanks goes to Southern Health's LD team for help compiling this resource.

Monitoring & payment

There is a one payment count for this enhanced service.  Practices are required to manually input data into CQRS on a quarterly basis.  The data input will be in relation to payment count only with zeros being entered in the interim for the management information counts.

On CQRS there are two inputs for this ES:

  1. ES Indicator LD001 input number: The number of those patients aged 14 years or over in the financial year on the practice’s agreed learning disabilities register who received a completed health check in this quarter.
  2. ES indicator LD001 maximum: The number of patients aged 14 years or over in the financial year on the practices agreed learning disabilities register.

The ES indicator LD001 maximum input will always be manual as the data cannot be supplied by GPES as a local LD register code(s) is not available.  The sum of the ES indicator LD001 input over the year can never exceed the ES indicator LD001 maximum (practices cannot give more health checks than those on the local LD register).  When entering data manually, the LD001 maximum must be entered even when providing a nil return to LD001 input – many practices mistakenly returned a zero value for the register size when providing a nil return for the number of completed health checks.

Read Codes

EMIS

SystmOne

SNOMED

Learning Disability Annual Health Assessment

9HB5

XaL3Q

199751000000100

Learning Disability Annual Health Assessment declined

9HB6

XaQnv

514021000000103

Learning Disability Health Action Plan completed

9HB4

XaJsd

712491005

Learning Disability Health Action Plan reviewed

9HB2

XaJWA

413163007

Learning Disability Health Action Plan declined

9HB0

XaJW9

413132002

Both LD Health Assessment and one Health Action Plan code must be used in order to receive payment

Additional points on clinical coding: (taken from the GMS contract changes & guidance)

https://www.england.nhs.uk/publication/technical-requirements-for-2019-20-gms-contract/

Codes listed below are deemed no longer suitable for use in coding patients with a diagnosis of a learning disability.  Practices may want to  identify any patients with one of the following unsuitable diagnostic codes on their record and opportunistically recode these patients using one of the other available clinical codes.  The Annual Health Check may be a useful opportunity to do this.

Learning disabilities – diagnostic codes

 

SNOMED

Developmental academic disorder

1855002

Mild learning disability

984661000000105

Moderate learning disability

984671000000103

Severe learning disability

508171000000105

Profound learning disability

984681000000101

On learning disability register

416075005

Specific learning disability

889211000000104

Significant learning disability

931001000000105

 

Patients with LD who do not attend scheduled appointments

Top tips for practice for who patients with a learning disability DNA their Annual health Check

  1. Avoid this in the first place by phoning the day before to ensure they are coming.
  2. Check where and who the person lives with.
  3. Contact the person or parent/carer to find out why they did not attend the appointment and whether there is anything that can be done to facilitate next appointment.  It is important to consider reasonable adjustments.
  4. Re-arrange the appointment to suit
  5. Send a letter to confirm the date, time and venue of the appointment in accessible format or email or text
  6. Send accessible Annual Health Check (AHC) information
  7. Phone the person about the appointment a few days before and/or on the day of the appointment to remind them again

If the person DNAs again

  1. Consider if the person has a mental capacity to refuse this or if this has been refused by the support.
  2. If the person has the capacity to refuse an AHC this must be recorded and ideally flagged up so when/if the person attends a routine appointment for other reasons the AHC can be discussed in preparation of next invitation.
  3. If the person age 18 years and above lacks capacity to refuse the AHC, follow the best interest decision making process.
  4. If you do not know whether the person lacks capacity investigate this further.
  5. Consider contacting Adult Services if you have concerns related to the care of the person with a learning disability including the refusal to attend AHC by the parent/carer as this may be a safeguarding issue.
  6. Contact your local Health Facilitator to discuss further.

Annual Health Checks – Checklist/Summary

 

Gather a team of experts within your surgery proficient in the care of patients with LD

 

Ensure your Learning Disability Register is kept current

 

Preparation is key to success – actively include patients (&/their carers)

 

Be flexible and understanding in your approach

 

Consider reasonable adjustments & flag this on the patient’s notes so all staff aware

 

Tailor communication to be appropriate to the individual need/ability

 

Pay attention to language & environment; they are important

 

Consider becoming a Learning Disability Friendly GP Practice

Speak to your local Health Facilitator for details

 

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Updated on Thursday, 16 June 2022 9725 views