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Keywords:

  • health checks;
  • health needs;
  • intellectual disabilities;
  • review

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References

Background  Health checks for people with intellectual disabilities (ID) have been recommended as one component of health policy responses to the poorer health of people with ID. This review summarises evidence on the impact of health checks on the health and well-being of people with ID.

Methods  Electronic literature searches and email contacts were used to identify literature relevant to the impact of health checks for people with ID.

Results  A total of 38 publications were identified. These involved checking the health of over 5000 people with ID from a range of countries including a full range of people with ID. Health checks consistently led to detection of unmet health needs and targeted actions to address health needs.

Conclusions  Health checks are effective in identifying previously unrecognised health needs, including life-threatening conditions. Future research should consider strategies for optimising the cost-effectiveness or efficiency of health checks.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References

People with intellectual disabilities (ID) have poorer health than their non-disabled peers, differences in health status that are, to a significant extent, avoidable (Sutherland et al. 2002; US Department Health & Human Services 2002; Kerr 2004; NHS Health Scotland 2004; Graham 2005; Ouellette-Kuntz 2005; Van Schrojenstein Lantman-de Valk 2005; Krahn et al. 2006; Nocon 2006; Van Schrojenstein Lantman-de Valk & Walsh 2008; Emerson et al. 2009; Emerson & Baines 2010; O'Hara et al. 2010). It has been argued that the poorer health of people with ID is partly because of barriers associated with identifying ill health and ensuring timely access to healthcare services (Disability Rights Commission 2006; Mencap 2007; Michael 2008).

The implementation of health checks has been recommended internationally as one component of health policy responses to the poorer health of people with ID. In New Zealand, it was recommended that primary healthcare providers should have health assessment tools for people with ID as part of recommendations to urgently address systemic neglect of the health of adults with ID (National Advisory Committee on Health and Disability 2003). Within both the UK and Australia, there have been policy initiatives to promote health checks for people with ID. In 2007, the Australian Government introduced a new Medicare rebate for people with an ID who have an annual health check, at an estimated cost of $11 million over 4 years (Pyne 2007). The Comprehensive Health Assessment Program has been licensed and used widely across Australia to deliver these health assessments in what is described as unusually rapid translation of evidence into practice (Lennox et al. 2010).

In the UK, the Disability Rights Commission in 2006 recommended the introduction of annual health checks for people with ID in England and Wales as a ‘reasonable adjustment’ in primary healthcare services (Disability Rights Commission 2006). ‘Reasonable adjustments’ refers to the legal duty of public sector services to make their services as accessible and effective as they would be for people without disabilities (Hatton et al. 2011). Annual health checks for every adult on a local authority register were introduced as a Directed Enhanced Service (DES) in primary care services in Wales in 2006, since when there has been a year on year improvement in uptake with the proportions of people with ID who received a health check in July 2006, August 2007 and September 2008 being 31%, 34% and 41% (Perry et al. 2010). In 2008, the National Health Service and the British Medical Association announced plans for a DES to deliver annual health checks in England. Since that time, significant progress has been made in increasing access to annual health checks across primary care trusts and strategic health authorities in England, although in 2009/2010 only 41% of people who were eligible for a health check received one (Emerson & Glover 2010). The Scottish Government is also proposing the development of a framework for regular health assessments for people with learning disabilities across Scotland (Scottish Government 2008).

The underlying rationale for the use of health checks is that: (1) primary care services tend to be reactive, responding to problems raised by patients (Martin et al. 1997b); (2) people with ID may be unaware of the medical implications of symptoms they experience, have difficulty communicating their symptoms or may be less likely to report them to medical staff (Beange et al. 1995; Purcell et al. 1999; Kerr et al. 2003; McKenzie & Powell 2004; Martin et al. 2004b); (3) carers may not always attribute the manifestations of clinical symptoms to physical or mental illness (Wilson & Haire 1990); (4) as a result, health checks provide a way to detect, treat and prevent new health conditions in this population (Wilson & Haire 1990; Barr et al. 1999; Cassidy et al. 2002; Disability Rights Commission 2006; Backer & Jervis 2007; Michael 2008; Jones et al. 2009). It has also been argued that health checks can help provide baseline information against which changes in health status can be monitored, a particular issue given the frequency of changes in paid carers supporting people with ID and the difficulties that people with ID may have in detecting and reporting longer-term changes in health status (Martin 2003; Jones et al. 2009).

It has also been argued that health checks may be cost-effective as the detection of new or underlying medical conditions may reduce the consumption of resources in other areas of health care (Ryan & Sunada 1997), such as services for challenging behaviour and mental health problems (Gunsett et al. 1989; Ryan & Sunada 1997) and reduce the need for future and potentially more expensive treatment.

In the context of recent policy responses to the poorer health of people with ID outlined above, a review of evidence on the impact of health checks is timely. This paper summarises the results of a systematic review of published scientific evidence concerning the impact of health checks on the health and well-being of people with ID.

Methodology

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References

Searches of electronic literature databases (Medline, Cinahl, Web of Science and PsycINFO) were conducted in June 2010 to identify relevant peer reviewed articles published from 1989 onwards in the English language. In each database, terms for ID were combined with search terms relating to health checks (e.g. health screening; health monitoring). In addition, a request for information on research relevant to the review was sent to the membership of the International Association for the Scientific Study of Intellectual Disabilities Health Special Interest Research Group in June 2010. This enabled the identification of research literature not identified in the electronic searches, e.g. relevant articles which were ‘in press’.

All articles identified by searches were assessed for their relevance to the review objectives firstly by reading abstracts. If abstracts were unavailable, or did not provide enough details to assess the relevance of the article, the full text of the article was obtained and relevance assessed from this. Studies were included if they: were published in English between 1989 and 2010; presented information on the effectiveness of health checks for people with ID based on quantitative research or qualitative research; were peer reviewed.1 Studies were excluded if they: were not published in English; did not focus on the effectiveness of health checks for people with ID, e.g. studies mapping coverage of health checks for people with ID; were not peer reviewed.

All relevant studies were included in the review regardless of methodological quality, although studies were categorised by research design in order to illustrate the overall number of studies identified in relation to established hierarchies of evidence (GRADE Working Group 2004).

Data extraction & synthesis

Data were extracted from the full text of articles identified as meeting the inclusion criteria. Textual descriptions were produced for each study which included bibliographic details, the country within which the study took place, details of the health check employed, details of who conducted the health check, sample size and characteristics, study design and data sources, outcome measures, main results and issues raised in the discussion. This information was also tabulated.

Two researchers independently reviewed the textual descriptions of the studies in order to identify themes emerging from the literature for inclusion in the review results. Following pooling of identified themes, final themes for inclusion in the review were agreed and studies providing evidence in relation to these themes identified from the textual descriptions. It is generally not possible to compare results between studies directly because of variation in the implementation of health checks and variation in how outcomes were recorded. As such, no meta-analysis was conducted.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References

A total of 38 publications were identified for inclusion in the review. Key features of these studies and themes emerging from them are summarised here.

Geographical spread

Geographically, the majority of the publications identified were based on studies conducted in the UK, including 13 from England (Wilson & Haire 1990; Wells et al. 1997; Martin et al. 1997a,b, 2004a,b; Bollard 1999; Hunt et al. 2001, 2006; Cassidy et al. 2002; Martin 2003; Backer & Jervis 2007; Chauhan et al. 2010), five from Wales (Jones & Kerr 1997; Baxter et al. 2006; Felce et al. 2008a,b; Perry et al. 2010), four from Scotland (McKenzie & Powell 2004; Cooper et al. 2006; Jones et al. 2009; Romeo et al. 2009) and two from Northern Ireland (Barr et al. 1999; McConkey et al. 2002). Additional publications were identified based on studies conducted in the following countries: six from Australia (Beange et al. 1995; Lennox et al. 2001, 2006, 2007, 2008, 2010), five from the USA (Gunsett et al. 1989; Carlsen & Galluzzi 1994; Ryan & Sunada 1997; Aronow & Hahn 2005; Hahn & Aronow 2005), one from New Zealand (Webb & Rogers 1999) and one from Ireland (Marsh & Drummond 2008). One paper was based on a pooled analysis of the results of two randomised controlled trial (RCT) studies from Australia and one non-randomised matched control group study from Scotland (Lennox et al. 2011).

Study design

Of the 38 publications identified, three were based on RCTs (Jones & Kerr 1997; Lennox et al. 2007, 2010). One study had a non-randomised matched control group (Cooper et al. 2006). One was based on a pooled analysis which included three of the aforementioned studies (Lennox et al. 2011). One additional study used randomised groups varying in relation to the interval between repeated health checks (Felce et al. 2008a). The majority of studies were based on clinical interventions where a sample of people with ID received a single episode of a health check and information was presented on the outcome(s) of the health check. The health checks used in studies varied with respect to: the content of the health check (e.g. whether or not mental health was included); who conducted the health check [e.g. general practitioner (GP), community nurse]; where it was conducted (e.g. GP surgery, own home); whether health checks were repeated; involvement of carers in the process; and how health checks were followed up in terms of addressing identified health needs. A number of studies used questionnaires or interviews to look at the views of service users, carers, GPs or practice nurses with regard to health checks (Martin et al. 1997b; Barr et al. 1999; Bollard 1999; Cassidy et al. 2002; McConkey et al. 2002; Lennox 2008) and one was based on a cross-sectional survey of community ID nursing services in Scotland (McKenzie & Powell 2004). One study used focus groups to look at the views of service users regarding health checks (Perry et al. 2010).

Sample size and characteristics

The sample sizes for those receiving health checks varied from a single case study (Marsh & Drummond 2008) to 1311 people with ID supported by an agency in New Zealand (Webb & Rogers 1999). The pooled analysis (Lennox et al. 2011) includes a total of 795 participants of whom 407 received health checks and 388 received usual care. In total, over 5000 people with ID received health checks in the course of the studies included in this review, with an average sample size of approximately 180. The samples covered a full range of ages, from children (in studies where samples include both adults and children) up to the age of 86. The samples also covered the full range of severity of ID and living situations, including family homes, tenancies, supported accommodation, and large residential facilities.

Outcomes of health checks

The most common outcome measure was whether health checks identified previously undetected health needs. Where the proportion of those who had previously undetected health conditions identified is given (Wilson & Haire 1990; Ryan & Sunada 1997; Martin et al. 1997a; Cassidy et al. 2002; Baxter et al. 2006; Jones et al. 2009) proportions range from 51% (Baxter et al. 2006) to 94% (Cassidy et al. 2002).

Other studies report the number of previously undetected or unmanaged health needs identified per participant with figures indicating that multiple health conditions were detected (Carlsen & Galluzzi 1994; Beange et al. 1995; Hahn & Aronow 2005; Cooper et al. 2006; Lennox et al. 2008) ranging from 2.2 additional diagnoses (Carlsen & Galluzzi 1994) to 5.2 health problems requiring intervention (Hahn & Aronow 2005). Three studies have also compared the number of health needs detected in those receiving health checks with control groups (Cooper et al. 2006; Lennox et al. 2007, 2010). A pooled analysis of these three studies, involving a total of 795 participants, gives odds ratios for the detection of new diseases in those receiving health checks compared with control groups (Lennox et al. 2011). New diseases identified included thyroid disease [odds ratio (OR) 1.1; 95% confidence interval (CI) 0.5–2.7; 3% of those in the health check groups], psychiatric disorder (OR 1.8; 95% CI 0.8–4.0; 4%), heart disease (OR 1.9; 95% CI 0.6–6.5; 2%), reflux disease (OR 1.9; 95% CI 0.7–4.8; 3%), hypertension (OR 2.4; 95% CI 0.6–9.5; 2%), constipation (OR 1.6; 95% CI 0.7–3.9; 3%) and ‘other diseases’ (OR 3.1; 95% CI 1.6–6.1; 10%).

In addition, a number of studies indicate that health checks did identify previously undiagnosed conditions as evidenced by the need for further assessments and referrals following health checks (Wells et al. 1997; Barr et al. 1999; Backer & Jervis 2007). Only one study found that the intervention employed made no significant difference to the identification of health needs (Jones & Kerr 1997). In this case, the intervention was the insertion of a prompt card into medical notes which was designed to promote opportunistic health screening by GPs rather than health screening per se.

Some of the most frequently identified conditions were what might be considered as ‘less serious’ health conditions. For example, in one study 50% of participants were found to have wax totally obscuring one or both eardrums (Wilson & Haire 1990), and a high prevalence of ear wax has also been noted in other studies (Martin et al. 1997a; Hahn & Aronow 2005; Baxter et al. 2006). The impact of what may seem a minor condition is illustrated by the fact that in one study nearly half of those with ear wax subsequently failed a hearing test (Wilson & Haire 1990). Indeed, sensory loss was commonly identified during health checks, e.g. a cluster randomised trial of the Comprehensive Health Assessment Program involving 543 adults with ID found 22 new cases of sensory loss in the intervention group compared with one in the control group (Lennox et al. 2007). One case study of a health check identified hearing deficit as a possible cause of withdrawal and lack of interest in surroundings (Marsh & Drummond 2008). Other commonly identified conditions include: skin conditions (Barr et al. 1999; Lennox et al. 2001, 2006; McConkey et al. 2002), dental problems (Barr et al. 1999; Lennox et al. 2008), constipation (Hahn & Aronow 2005; Lennox et al. 2011), anaemia (Carlsen & Galluzzi 1994; Hunt et al. 2001) and foot problems (Barr et al. 1999; McConkey et al. 2002).

Studies have also identified previously undiagnosed conditions that include serious and life-threatening conditions including: heart disease (Wilson & Haire 1990), hypertension (Wilson & Haire 1990; McConkey et al. 2002; Hahn & Aronow 2005; Baxter et al. 2006), testicular cancer (Wilson & Haire 1990), dementia (Carlsen & Galluzzi 1994; Cassidy et al. 2002; Baxter et al. 2006; Jones et al. 2009), breast cancer (Baxter et al. 2006), diabetes (Hahn & Aronow 2005; Baxter et al. 2006; Lennox et al. 2007), hypothyroidism (Carlsen & Galluzzi 1994; Ryan & Sunada 1997; Barr et al. 1999; Baxter et al. 2006), mental health problems (Cassidy et al. 2002; Jones et al. 2009), cataracts (Ryan & Sunada 1997; Lennox et al. 2001; McConkey et al. 2002), epilepsy (Ryan & Sunada 1997; Lennox et al. 2007), arthritis (Hahn & Aronow 2005), compound fracture in leg and toxic levels of anticonvulsants (Gunsett et al. 1989), skin cancer (Carlsen & Galluzzi 1994), and chronic pain, multiple sclerosis, colon cancer, pancreatic cancer, rectovaginal cancer and lung cancer (Ryan & Sunada 1997).

Health actions resulting from health checks

Studies consistently provide evidence of health checks leading to targeted actions to address identified health needs (Bollard 1999; Webb & Rogers 1999; Hunt et al. 2001, 2006; McConkey et al. 2002; Martin et al. 2004a,b; Baxter et al. 2006; Lennox et al. 2006, 2007, 2008, 2010, 2011; Hahn & Aronow 2005). In the UK, an audit of actions resulting from health checks for 190 participants, of whom 93 had new health needs identified, indicated that management had been initiated for 90% of identified needs by the time of the audit and treatment concluded for 61% of needs (Baxter et al. 2006). However, while a study in Wales found a significant increase in health promotion actions post health check, there was no significant change in rates of contact with primary or specialist care (Felce et al. 2008b).

The targeted actions identified partly reflect the conditions outlined in the foregoing section on the identification of previously undiagnosed health needs, with actions including, e.g. ear wax removal (Bollard 1999; Hunt et al. 2001; Martin et al. 2004b), podiatry (Hunt et al. 2006), dental review (Lennox et al. 2008), treatment for anaemia (Hunt et al. 2001) and referral for skin conditions (McConkey et al. 2002). Where health checks have been undertaken outside of general practice settings, these have led to referrals to a GP (Hunt et al. 2001, 2006; McConkey et al. 2002) with as many as 32 out of 35 participants being referred to a GP (Hunt et al. 2001). Other common actions included: immunisations (Hunt et al. 2001; Lennox et al. 2006, 2007, 2008, 2010), screening for breast, testicular or cervical cancer (Martin et al. 2004a,b; Hunt et al. 2006; Lennox et al. 2007), blood tests (Hunt et al. 2001, 2006; McConkey et al. 2002; Martin et al. 2004b; Lennox et al. 2008) and general health promotion such as healthy eating advice (Hunt et al. 2006). In addition to these what might be considered routine actions, a number of life saving actions have been noted including: provision of a pacemaker, surgery for previously undetected melanoma, and mastectomy for previously undetected breast cancer (Webb & Rogers 1999); and surgery and radiotherapy for seminoma (Wilson & Haire 1990).

Finally, a pooled analysis of data involving a total of 795 people with ID presents information on clinical activities following health checks (Lennox et al. 2011). The intervention group received far more sensory testing and provision of health promotion or disease prevention activities, with large and statistically significant increases in vision testing (OR 4.2; 95% CI 2.3–7.4), hearing testing (OR 10.8; 95% CI 3.4–34.3), hearing loss identified (OR 12.6; 95% CI 2.2–71.0), hepatitis B immunisation (OR 8.5; 95% CI 3.5–20.8) and tetanus/diphtheria immunisation (OR 3.8; 95% CI 2.0–7.5).

Health gains resulting from health checks

Very few studies have evaluated the extent to which providing health checks for people with ID leads to health benefits either in the short or long term. Reported health benefits resulting from health checks include: weight loss for those overweight or obese (Martin et al. 1997a; Wells et al. 1997; Bollard 1999; Hunt et al. 2001); reduction of seizure severity following change of medication, stabilisation of mood following medication review by consultant psychiatrist, improvement in comfort and hearing following ear wax removal, less tired following iron injections, reduction in urinary tract infections and improved mobility (Bollard 1999); effective treatment of constipation, ear wax, infections, anaemia, hypothyroidism and diabetes (Hunt et al. 2001); remission of psychiatric symptoms following treatment of primary medical condition (Ryan & Sunada 1997); improvement in challenging behaviour following treatment of medical conditions (Gunsett et al. 1989); and statistically significant improvements at follow up of an in-home preventative healthcare programme for health strengths, health risks, life satisfaction score, number of falls and self-reported pain (Aronow & Hahn 2005). Finally, a non-randomised matched control group study of health assessment by a primary healthcare nurse with total sample of 100 found that after 1 year there were significantly more met health needs for the intervention group than for the control group (mean 3.56 vs. 2.26, P < 0.001; Cooper et al. 2006).

Outcomes of repeated health checks

The small number of studies that have looked at the outcomes of repeated health checks suggest that health conditions continue to be identified in repeat health checks (Cassidy et al. 2002; Martin 2003; Felce et al. 2008a), including serious conditions such as breast lumps, diabetes and high blood pressure (Felce et al. 2008a). One study found that repeated home visits were an important feature of the intervention employed with additional problems being identified during repeat visits (Hahn & Aronow 2005). It has been argued that annual health checks may be justifiable in view of the numbers of health needs identified in repeat checks (Cassidy et al. 2002) and the lack of relationship between the interval between health checks (mean group intervals 28, 44 and 14 months) and the number of new health needs identified (Felce et al. 2008a).

Perceptions of health checks

Overall, studies suggest that health checks are acceptable to the majority of people with ID and family carers who support them (Martin et al. 1997b; Barr et al. 1999; Cassidy et al. 2002; Lennox et al. 2008; Perry et al. 2010). In a focus group study, Perry et al. (2010) found that those who lived with support tended to have health checks explained to them by a support person. The most abled who lived relatively independently were often the least ‘prepared’ for the health check. Studies suggest that involvement in health checks may lead to an improved awareness by GPs of the health needs of people with ID following health checks (Bollard 1999; Lennox et al. 2001) and more favourable attitudes to undertaking health checks (McConkey et al. 2002).

Barriers to implementing effective health checks

The only study to specifically ask about barriers to implementing health checks was a cross-sectional postal survey of community learning disability nursing services in Scotland (McKenzie & Powell 2004). One potential barrier to the implementation of health checks is the reluctance of GPs to undertake health checks (Kerr 1996; McConkey et al. 2002; Perry et al. 2010). Measures such as enhanced training for specific practices have resulted in an increase in health checks (Perry et al. 2010).

A further potential barrier is low uptake of health screening with, e.g. 29% of those scheduled to have health checks not having them (Felce et al. 2008a) and only 33% of offered health checks being translated into actual health checks (Perry et al. 2010). A telephone call by a community nurse to confirm attendance and answer queries has been found to increase uptake (Jones et al. 2009). During health checks, some people with ID may be reluctant to participate in invasive tests (Martin et al. 1997b; Wells et al. 1997).

Once health checks have been conducted, there may be barriers that prevent the identification of health needs being translated into action to address these needs. In a study in Northern Ireland, health screens were conducted by a specialist health screening service and outcomes forwarded to the person's own GP with a referral letter if necessary (McConkey et al. 2002). However, as many as half of GPs took no further action on the referrals, with 49% not recalling having received a referral letter for the patient. The authors suggest that the most central reason for involving GPs more closely with health screening is that they are in a position to ensure that problems detected are attended to.

The cost of health checks

To date, there has been only one study which includes a comprehensive assessment of the cost of health checks (Romeo et al. 2009). Service use patterns and costs for 50 adult participants with ID who received the C21st Health Check were compared with 50 individually matched control participants who received standard care only. The health check was carried out by a primary healthcare nurse who discussed the results with a specially employed GP before sending a summary report to the participant's own GP. The nurse directly actioned referrals to professionals within the local ID service, and other referrals were recommended to the GP to action. The total cost of the health check intervention was £4080 (covering equipment and professional time), averaging £82 per person. It was concluded that the healthcare check was relatively cheap and was not associated with higher health costs for service usage.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References

The evidence in this review consistently suggests that health checks are effective in identifying a wide range of previously unidentified conditions. Only one study, which was designed to promote opportunistic health screening by GPs rather than a study of health checks per se, found that the intervention made no significant difference to this outcome (Jones & Kerr 1997). Conditions detected included serious and life-threatening conditions such as cancer, heart disease and dementia. More commonly, health checks have identified a substantial proportion of participants with what might be regarded as more minor health conditions, such as impacted ear wax and sensory impairments. However, it has been argued that such conditions: (1) are often easily treated; (2) may be more significant for people with ID than for the general population because of their impact on already limited social, communicative and practical abilities; (3) may limit independence and/or social participation in ways that lead to additional costs to the public purse; and (4) may lead to more serious health problems in future (Baxter et al. 2006). It is also likely that less serious problems impact negatively on the quality of life of people with ID.

The evidence also suggests that health checks consistently lead to targeted actions to address health needs. However, few studies have investigated the extent to which the provision of health checks leads to short-, medium- or long-term changes in health status. It has been suggested that in the majority of studies, measured outcomes (e.g. identification of ill health, recommendations for specific health actions) can be viewed as ‘intermediate steps’ towards better health (Lennox et al. 2011). There is a clear need for larger and longer-term studies to establish whether there are indeed clinically significant reductions in morbidity and premature mortality (Lennox et al. 2007). While lack of evidence on this issue is of concern, it needs to be kept in mind that the aim of health checks is to assist in the identification of treatable morbidity. Such identification opens up the possibility of people with ID experiencing the level of health gain available to the general population from whatever health procedure is instigated. Failures of health systems to appropriately respond to identified treatable morbidity cannot ethically or legally be used to justify failing to make ‘reasonable adjustments’ to the detection of potentially treatable ill health.

In terms of who provides health checks, the majority of studies involved mainstream primary healthcare workers. It has been argued that health checks should be conducted by the person's own practice staff as it enables them to get to know the person and their health needs (Perry et al. 2010) and that GPs should be closely involved as they are in a position to ensure that identified problems are addressed (McConkey et al. 2002). There was some evidence of reluctance on the part of GPs to take responsibility for health checks, but attitudes were more positive for GPs who had been involved in a referral than those who had not (McConkey et al. 2002). The authors suggest that this may be due to a realisation that the health needs identified by health checks were common to other patients and ones that they could deal with. Health checks have also been found to increase following enhanced training for specific practices (Perry et al. 2010).

Many of the studies in this review were conducted prior to incentivisation of health checks via the DES scheme. As noted above, progress was made from 2008–2009 to 2009–2010 in England in increasing the number of health checks for adults with ID but still less than half of those eligible received them in 2009–2010, with the percentage of people receiving a health check varying between strategic health authorities and primary care trusts (Emerson & Glover 2010). Potential strategies to increase implementation within local and regional areas include: strategic leadership within organisations and embedding the reduction of health inequalities in strategy documents, the use of data to create a benchmark against which to measure progress and using the Performance and Self-Assessment Framework to reinforce the importance of implementing health checks (Turner & Robinson 2010). Further, as implementation is dependent on the accuracy of GP learning disability registers, these should be updated and validated, and where practices have not signed up to the DES, people with learning disabilities should receive health checks from an alternative provider (Turner & Robinson 2010). Reasonable adjustments, such as easy read information and flexibility in delivering health checks, should be put in place to ensure that health checks are accessible.

As access to health checks is scaled up, research needs to further evaluate the effectiveness and efficiency of health checks as the existing research comprises of many relatively small-scale studies of non-routine practice. Future research could focus on strategies for optimising the cost effectiveness or efficiency of health checks through addressing such issues as: the optimal frequency of health checks; the costs and benefits of health checks; the effectiveness of different strategies for increasing the provision, uptake, acceptability, content and effectiveness of health checks; ensuring equity of access, uptake and outcomes of health checks across sub-groups of people with ID; and identifying and addressing barriers to the implementation of actions resulting from health checks.

Strengths & limitations

The studies reviewed involved checking the health of over 5000 people with ID from a range of countries, including the full range of people with ID in terms of age, gender, severity of ID and living situation. There are, however, some significant limitations apparent in this evidence base. These include: (1) a relatively small number of RCTs or alternative robust designs; and (2) relatively sparse information on such issues as the costs of health checks, the acceptability of health checks to people with ID and their carers, barriers to the uptake of health checks, the optimal timing of health checks, the rate of implementation of targeted actions resulting from health checks, the impact of health checks on future health and well-being and the extent to which any such effects may be moderated by such factors as age, severity of ID, gender, ethnicity and level of socio-economic deprivation (Lennox et al. 1997). Finally, this review has not considered how differences between countries in the structure of healthcare systems and the history of regulation may have impacted on the outcome of the studies reviewed.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References

Given the specific difficulties faced by people with ID (e.g. identifying and communicating symptoms of ill health, negotiating access within complex health systems), targeted health checks should be considered to constitute an effective and important adjustment to the operation of primary healthcare services as one component of health policy responses to the poorer health of people with ID. As noted by one person with ID in the study by Perry et al. (2010), ‘You don't know if something is wrong with you, so health checks are very important’ (p. 19). It is the responsibility of healthcare systems to respond effectively to the identification of treatable morbidity to allow people with learning disabilities to experience the level of health gain available to the general population from whatever health procedure is instigated.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References

This review was funded by the Department of Health as part of the work of Improving Health & Lives: Learning Disabilities Observatory.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgement
  9. References
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Footnotes
  • 1

    One non-peer reviewed article (Perry et al. 2010) has been included in this report because of the important contribution it makes to knowledge on the views of people with intellectual disabilities regarding health checks.