Inequalities in health status

The achievement of good health is an appropriate goal for all, including people with learning disabilities. This brings particular challenges, as individuals with learning disabilities are a heterogeneous population with varying needs, who receive a similarly complex array of health care provision. Furthermore, the impact of societal and environmental factors on health status is arguably greater in this group. The imperative to remove the great disparity between the health of learning-disabled people and that of the general population is strong, because improved health is likely to improve quality of life, both of individuals and their families. In this article I make the premise that the general health of learning-disabled people can be improved by addressing those areas in which disparities in health and in health care provision are evident. These include:

1. • a difference in health because of:

   1. • increased mortality

   2. • increased morbidity

   3. • increase in negative determinants of health such as poverty;

2. a difference in health care because of:

   1. • unequal access to services

   2. • inequality of services.

To focus on how health improvements can be made, I consider here the following five areas: the disparity in health; health needs; barriers to health care; health provision in primary care; addressing the disparity.

The disparity in health

If an appropriate aim for any improvement in health for this population is to reach at least the same level of health and access to health care as that enjoyed by the general population, then it is necessary to address the issues of disparity in health. In the past, the concept of health disparity has mainly been applied to minority ethnic or other special groups (such as those facing social deprivation) to show inequality in health status and health access between such groups and the general population. More recently, interest has focused on the disparity for people with learning disabilities (Surgeon General, 2002).

The concept is important and can add a focus to the planning of services. It does, however, present some difficulties, particularly when trying to allow for the impact of the aetiology of the individual's disability on any apparent disparity. An example of this would be the reduced life expectancy seen in profound learning disability. To address this problem, comparison within groups who share the same disability may be needed. This is not to say that some aspects of mortality in the different groups are not preventable. For example, continued advances in accident prevention and in the treatment of swallowing abnormalities and epilepsy may well reduce disparity in some groups. Table 1 highlights key disparity issues.

Table 1 Health disparity in people with learning disabilities

Area of disparity	Example in learning disability
Increased mortality	Lower life expectancy
Increased morbidity	High levels of epilepsy, sensory impairment and behavioural disorder
Increase in negative determinants of health	High levels of obesity and underweight; low employment; fewer social connections and meaningful relationships
Access to services	Low rates of uptake of health promotion
Quality of services	High prescription rate of antipsychotic medication with no evidence of psychosis; high rates of unrecognised disease identified on health screening

Health needs

Box 1 summarises the main findings of the 1995 Welsh Health Survey (Reference Van Allen, Fung and JurenkaWelsh Office, 1996), a large questionnaire-based survey that provides a baseline for the community health status of individuals with learning disabilities.

People with learning disabilities have both general and special health needs. General health needs include the treatment of acute and chronic illness, health promotion and appropriate hospital or other referral. These should be met within a primary health care setting. Specialist health needs can be divided into common morbidities that occur at a greater frequency and patterns of health need associated with specific medical conditions.

These conditions are not unique to people with learning disabilities, but their high prevalence in this population means that they are an important part of any assessment. A reasonable consensus can be made that sensory deficit, epilepsy, and behavioural and psychological disturbance in particular are more common in learning-disabled people.

Barriers to health care

A potential cause of the disparity between the health of people with learning disabilities and that of the general population is the concept of barriers to care. Several such barriers have been suggested (Table 2), and it is likely that all of these, often interacting, play a role in disparity. Certainly, the clinician will need to recognise the potential existence of these barriers and minimise them where possible.

Table 2 Barriers to health care

Domain	Effect
Mobility	Difficulty accessing health services
Sensory impairment	Reduced communication and comprehension of health processes
Behaviour problems	Difficulty in examination and investigation of disease
Communication	Reduced comprehension of health processes; difficulty in presenting disease owing to reduced communicative skills; poor communicative skills of health professionals
Knowledge, attitudes and accessibility of specialist services	Poor professional knowledge; attitudinal barriers to accessing care

Does primary care meet the health needs of learning-disabled people?

The three key papers in this area give consistent findings (Reference HowellsHowells, 1986; Reference Beange and BaumanBeange & Bauman, 1990, Reference Beange, Bauman and Fraser1991; Reference Whitefield, Lagan and RussellWilson & Haire, 1990). These studies (from Wales, Australia and England respectively) suggest that examination of any community-based population of people with learning disabilities receiving primary care will consistently uncover three serious problems:

1. • untreated, yet treatable, medical conditions

2. • untreated specific health issues related to the individual's disability

3. • a lack of uptake of generic health promotion such as blood-pressure screening.

The lack of control data in these initial studies reduces their impact, as it is difficult to reflect on which aspects were specifically disability-related: the surveys might well have reflected generic difficulties in the delivery of primary health care.

Subsequent studies (Reference Lagan, Russell and WhitefieldLagan et al, 1993; Reference Beange, McElduff and BakerBeange et al, 1995; Whitefield et al, 1996) used controlled comparison data. This has allowed for comparative information on health status, health promotion activity and service contact.

Reference Beange, McElduff and BakerBeange et al(1995) in Australia found significant greater levels of obesity, vision and hearing impairment, hypersomnia, endocrine disease, skin disease and psychiatric disorders in adults with learning disabilities. Additionally, non-Down's syndrome women had increased hypertension and showed a lack of sufficient exercise. The control population used were ‘population norms’ from the National Heart Foundation survey of the general population. Whitefield et al(1996) compared a random sample of learning-disabled people taken from the patient register of a primary health care team in an English city with age- and gender-matched controls from the same register. The study found a significant increase in the use of antipsychotic and anticonvulsant medication and an increase in consultations for neurological and skin conditions in the people with learning disabilities. The control population was significantly more likely to receive regular blood-pressure monitoring.

These studies indicate a lack of uptake of health promotion in people with learning disabilities. This is unlikely to be due to lower levels of contact with primary health care teams. Research in the UK, USA and Australia suggests that people with learning disabilities visit their general practitioners at least as regularly as do the general population (Reference Jacobson, Janicki and AckermanJacobson et al, 1989; Reference Beange, McElduff and BakerBeange et al, 1995; Reference Kerr, Richards and GloverKerr et al, 1996a ; Reference Van Allen, Fung and JurenkaWelsh Office, 1996). Furthermore, they have been shown to use specialist services and to be hospitalised more frequently than the general population (Reference Beange, McElduff and BakerBeange et al, 1995; Reference Kerr, Thapar and DunstanKerr et al, 1996b ).

Addressing the disparity

To decrease the disparity between the health of people with learning disabilities and that of the general population, two separate key areas need to be discussed: first, primary care and second, specialist psychiatric care.

Specialist psychiatric care

Specialist psychiatric care in the context of a multidisciplinary team primarily provides specific psychiatric assessment and treatment. Its broader function as an organiser of and conduit to general health care services is, though less well defined, equally important. In both of these areas, key clinical competencies are required, particularly when medical and psychiatric needs combine, as for example in issues relating to the treatment of epilepsy in people with learning disabilities. Table 3 identifies these functions and necessary competencies. Of particular importance in learning disability is the presentation of physical disease through psychiatric symptoms. This is commonly seen when pain presents as agitation. The chronic pain and anorexia associated with reflux oesophagitis and gastric ulcer disease mimic depressive symptoms. There should be particular diagnostic caution with learning-disabled patients whose ‘depression’ is associated with sleep disturbance and agitation.

Table 3 Functions of psychiatric practice in delivering health care to people with learning disabilities

Function	Health improvement	Clinical competencies
Psychiatric illness
Treatment and assessment of all psychiatric illness	Reduced morbidity in individuals and carers	Knowledge of presentation of mental illness in those with communication deficits
		Assessment of behaviour disorder
Treatment and assessment of challenging behaviour		Knowledge of pharmacological, behavioural and psychotherapeutic treatment
Interface between epilepsy and psychiatric illness
Diagnostic assessment	Reduced seizure-related morbidity and mortality	Knowledge of seizure types and their presentation as behaviour disorder or mental illness
Treatment of epilepsy	Reduce inaccurate diagnosis	Knowledge of epilepsy treatment
Treatment of mental illness coexistent with epilepsy	Identified and treated comorbid mental illness	Knowledge of diagnostic standards for epilepsy
		Knowledge of behavioural assessment
Health care organisation
Recognition of psychiatric symptoms as presentation of physical morbidity	Reduction in inappropriate psychiatric diagnosis and treatment	Knowledge of patterns of unrecognised physical ill health in people with a learning disability
Appropriate referral to health care specialty through general practitioner	Decrease in physical ill health	Knowledge of appropriate referral pathways

Conclusions

Considerable evidence points to a disparity between the health of people with learning disabilities and that of the general population. Psychiatric practice can be central to ameliorating this situation. Psychiatric interventions for common mental illnesses and complex behavioural problems in learning disability can have a direct impact on health status. Perhaps the most important function of psychiatric practitioners in this area is to act as catalysts and drivers of general health improvement by facilitating patients’ access to the appropriate pathways to care.

Multiple choice questions

1. 1 As regards people with learning disabilities:

   1. a they have a 50% prevalence of epilepsy

   2. b have rates of psychiatric illness of at least 30%

   3. c 80% have poor vision

   4. d more than 50% are clinically overweight

   5. e 40% have a healthy diet.

2. 2 Reduced life expectancy in people with learning disabilities has been shown to be associated with:

   1. a psychiatric illness

   2. b mobility problems

   3. c feeding difficulties

   4. d epilepsy

   5. e behaviour abnormality.

3. 3 The following have been identified as barriers to receiving health care:

   1. a behaviour abnormality

   2. b gender

   3. c mobility

   4. d the treating psychiatrist's knowledge

   5. e communication.

4. 4 Problems identified in the primary care of people with learning disabilities include:

   1. a untreated medical conditions

   2. b greatly reduced access to appointments

   3. c lack of uptake of health promotion

   4. d patients often being removed from general practitioners’ lists

   5. e specialist health issues not being addressed.

5. 5 Actions identified to improve health care in Valuing People include:

   1. a annual health checks in primary care

   2. b health facilitators

   3. c more community learning disability nurses

   4. d all patients are to be registered with a general practitioner

   5. e Health Action Plans for each patient.