15 Mar, 12 | by BMJ
I sat down with a manager who has an in depth knowledge and experience of commissioning services for people with learning disabilities, as I wanted to understand why we seemed to be doing poorly on delivering health checks. It seems so simple. Practices should offer an annual health check to people with learning disabilities. There is a financial incentive—a National Directed Enhanced Service (DES) for GPs. The objective of the health check is to address the fact that people with learning disabilities are more likely to have undetected or poorly managed health needs, contributing to earlier mortality. Reaching out in a proactive way to support and care for the vulnerable is something that I am sure the vast majority of professionals would agree is right and proper. Yet our measure of achieving an annual health check suggests it isn’t happening.
Yet, sometimes looking at a problem in depth reveals hidden barriers and complexities that give cause for thought.
The guidance suggests that practices should use local authority information to collate their registers. The register will depend on the criteria used to create it. It is often based on an individual’s eligibility to receive social care support. Many local authorities are changing their eligibility criteria. In addition there are some GPs looking after people with learning disabilities whose care is funded by a different local authority. The assumption is that these people will be known to the local authority where they are resident. I always remember a nurse once telling me that the word assume is an acronym for can make an “ass of you and me.” The experience locally is that just using local authority data will mean many people with learning disabilities will fall through the net.
Cross referencing the local authority register and interrogation of local GP registers revealed a discrepancy—the first had about 1800 people with learning disabilities, whereas the GP records suggested about 2600 people. This latter figure is the one we have decided to use as our denominator. It is anticipated that the local authority register will reduce as eligibility criteria are tightened further. We could have played the system and used the local authority register as the denominator. This was firmly rejected. It could mean people who need pro-active healthcare get neglected. We have introduced support for GP practices with primary care liaison nurses to help practices to properly identify people who would most benefit from the health checks and to construct more robust registers. Another problem is that assessing practices’ achievement is measured once a year by the QOF process. All my experience suggests that if you want to make real change happen you need to agree what your ambition is and track and benchmark progress as frequently as possible.
Delivering the ambition of reaching out to some of the most vulnerable and needy in our communities is not easy. It is not being done well across the country and commissioners need to continue to endeavour to improve the incentives and processes that will support professionals to do the right thing. However, at the end of the day it may be worth adapting Ghandi’s aphorism that “A nation’s greatness is measured by how it treats its weakest members.” Perhaps we could say that “A profession’s greatness is measured by how it looks after the most vulnerable in its care” and ask whether as a profession we are aspiring for greatness or not?
Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.