1. Annual Health Checks 2014/15 Heather Burns, Sheffield Health and Social Care Foundation Trust Helen Grant, Community Nurse Professional Lead (Sheffield Health and Social Care Foundation Trust) Dr. Amy Lampard, Designated Safeguarding Lead and GP

2. Valuing People, the 2001 White Paper on the health and social care of people with learning disabilities, included the following definition of learning disabilities: ‘Learning disability includes the presence of: a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development. This definition is broadly consistent with that used in the current version of the World Health Organization’s International Classification of Disease (ICD-10).’ What is a Learning Disability ?

3. Prevalence of Learning Disability Nationally it is estimated 2-3% of the population have a learning disability. Estimates suggest: 210,000 people with severe & profound learning disabilities 1.2 million people with mild/moderate learning disabilities Per GP practice of 2000 patients – average of 40 people with learning disabilities

4. Disability Rights Commission “Equal Treatment: Closing the Gap” found people with learning disability died ten years younger than other people of preventable health conditions Mencap report “Death by Indifference” looked into the treatment and deaths of 6 people with learning disability in hospital and found widespread serious concerns Sir Jonathan Michael’s subsequently published his independent investigation “Healthcare for All” into the deaths of the above individuals, and made 10 recommendations to the NHS on improving services to learning disabled people, including the introduction of Annual Health Checks by GPs Health Ombudsman “Six Lives” (an independent inquiry) and response to Sir Michael’s report “Six Lives” asking health and social care organisations to look at local services for people with learning disability Evidence of health inequality - keeps growing

5. Improving Health and Lives: Learning Disabilities Public Health Observatory (PHO) Department of Health are funding a 3 year project to provide information on the health and wellbeing of people with learning disabilities; the causes of their deaths and to identify quality improvements that will ensure better outcomes for their health and lives. (NHS Sheffield are one of 6 partner CCGs that were chosen to contribute to this PHO work.) Winterbourne View –investigation into criminal abuse of people in private hospital care CIPOLD (2013) Confidential Inquiry into the Premature deaths of People with LD Evidence of health inequality - keeps growing

6. Professor Eric Emerson et al. identified five key determinants of health inequalities: The 5 key determinants of health inequalities faced by people with learning disability Increased risk of health problems associated with specific genetic and biological causes of learning disabilities. Communication difficulties and reduced health literacy. Personal health risks and behaviours such as poor diet and lack of exercise. Deficiencies relating to access to healthcare provision. Greater risk of exposure to social determinants of poorer health e.g. poverty, poor housing, unemployment, and social isolation.

7. Be discharged quickly Die early Die from breathing problems Have heart problems Be overweight, and eat badly Have certain cancers Have epilepsy Have Autism Be mentally ill Health Issues: people with LD are more likely to: Be given psychotropic drugs Have a physical disability Be deaf or blind Have dementia Have communication problems Have thyroid dysfunction Have dental problems Use medical hospital services

8. Have a health check Be screened for cancer Use surgical hospital services Have sight tested Have hearing tested Receive pain relief Get health promotion advice Be included in consultations/ patient forums Health Issues: people with LD are less likely to:

9. Top ten causes of death: people with any condition associated with learning disabilities compared with people without a LD How people with learning disabilities die: Gyles Glover and Muhammad Ayub: Improving Health and Lives (Learning disability observatory) June 2010

10. Is made up of the following organisations:- Nepho North East Public health Observatory NDTi National Development Team for Inclusion CeDR Centre for Disability Research Provide information and statistics on effects of the health checks by region. Other health information relating to people with a learning disability is also available on the website www.nepho.org.uk Improving Health and Lives Learning Disabilities Observatory http://www.improvinghealthandlives.org.uk/ http://www.improvinghealthandlives.org.uk/

11. It checks key health indicators of young people and adults aged 14 and over with moderate to severe learning disability. Nationally the annual health check has been found to detect up to 8 unmet health needs Strengthens the relationship between the practice and the patient with LD and their family or paid carer Enables prevention and early intervention by signposting to relevant health services Improves the management of health conditions and reduce emergency admissions. Helps to put individuals and their families more in control of their health improvement. VITAL step to reduce the 20 year life expectancy gap faced by this population What does the DES aim to achieve?

12. Moving in the right direction… 2011/12 1108 2012/131078 (out of a larger cohort) 2013/14 1196 (out of a larger cohort) More GP practices signed up and more checks were completed in 13/14! More people became eligible for a health check so the increase is a step in the right direction… This year (14/15), the DES includes younger people (14+) so the number eligible will increase further. Uptake of Annual Health Checks

13. Invitations Use the accessible letters provided by CCG for the invitation Support and encourage individuals living alone to attend by practice manager/ nurse calling them Reminder texts/phonecalls Reasonable adjustments e.g. offer home visit for people with known complex needs/elderly parents/appointments at quieter times in surgery/ done over 2 short rather than 1 long appointment etc. No response to invitation letter? Let helen.grant4@shsc.nhs.uk and lucy.ashall@nhs.net know whether this is a person living on their own, with a family carer or in paid support. Tell us who the support provider is and we will take this up as a contract compliance issue through CHC or LAhelen.grant4@shsc.nhs.uklucy.ashall@nhs.net DNAs Let Lucy and Helen know with the information as detailed above Carers arrive but with little information Let Lucy and Helen know the details as above What practices can do to improve take up

14. Difficulties in access for people with autism / challenging behaviour / complex physical needs Ask carer what will help Look at ways in which appointment time / waiting area / venue can be adjusted Ask for support to the practice from the SHSC Community Learning Disability Team: helen.grant4@shsc.nhs.uk; anita.winter@shsc.nhs.uk; heather.burns@shsc.nhs.net.This has been agreed with CCGhelen.grant4@shsc.nhs.uk anita.winter@shsc.nhs.ukheather.burns@shsc.nhs.net North GP Locality has worked on access to primary care with an organisation called Inclusion North to explore improving access to primary care and to look at the DES uptake We have identified some people with very complex needs in ages 18- 25 for Helena team clinicians to help with the annual health check this year too We have developed two QIS schemes around LD/SMI and dementia What we can all do to encourage health checks

15. How to participate? Practices choosing to participate in the DES can access the list of patients thought to be eligible on their practice list, by looking at the practice reporting system Any patient additions or deletions should be verified with Helen Grant helen.grant4@nhs.net before final eligible totals are submittedhelen.grant4@nhs.net Patients undergoing an annual health check can be marked as such on practice system. This can be carried out using the Cardiff Health Check as a guide. Health action plans and health passports are extra documents that you could use to improve the quality of your patients’ care and experience

16. The Cardiff Health Check This is a seven section document Uses Yes/No tick box format Asks a series of questions in relation to the health of the individual More effective when delivered using a ‘health action plan’ Health Promotion Chronic Illness and Systems Enquiry Epilepsy Behaviour Physical Examination Syndrome Specific Medication An updated version of this is available on the RCGP and SignpostSheffield website

17. Cardiff Health Check for People with a Learning Disability Date Name Marital status Ethnic origin Principal carer Age Sex Address ______________________________________________________________________________________ Weight (kg/stone)………………..……… Height (meters /feet) …………………… Blood Pressure ………………………… Urine Analysis …………………………. Smoke (per day) …………………………. Alcohol (units per week) ………………. Body Mass Index Cholesterol/ (weight in kg / height in m2) ………………… Serum lipids ……………………….… _____________________________________________________________________ Immunization - People with learning disability should have the same regimes as others and the same contra indications apply. (please circle) Tetanus in last ten years?Yes No If no has tetanus been given?Yes No Has influenza vaccine been given?YesNo Is Hepatitis B status known? YesNo Result? ………………………………………………………………………...…… ________________________________________________________________________ Cervical screen – people with a learning disability have same indications for cervical cytology as others. Is a smear indicated?YesNo If yes when was last smear?..…/……/……When is next due? ……/……/…… What was the result? ………………………………………………………………… ________________________________________________________________________ Mammography – this should be arranged as per local practice.

18. Health Action Plans Simply a plan which identifies WITH the person. Can be populated using info from pre- check questionnaire and the health check itself. Includes… The health need The action to be taken Who will help the person do it The date when the plan will be reviewed

19. Basic personal information Health/medication details Likes and dislikes Communication page Could be given to patients as part of annual health check to improve the coordination of their care www.signpostsheffield.org.uk Hospital passport

20. Mental Capacity Act 2005 “Provides a statutory framework to empower and protect vulnerable people who may not be able to make their own decisions. It makes clear who takes decisions in which situations and how they should go about this. It enables people to plan ahead for a time when they may lose capacity.” Implemented 1 April 2007 For more information go to the GP CCG intranet. http://www.sheffieldccg.nhs.uk

21. 1.Presumption of capacity, unless proved otherwise. 2.Right to be supported to make decision, before concluded they can not make own decision. 3.Right to make “eccentric or unwise” decisions. 4.Best interests – any act done for a person without capacity must be “in their best interests”. 5.Least restrictive intervention. 5 Key Principles

22. The burden of proof is on any person who asserts that the other person lacks capacity. They will have to show, on the balance of probabilities, that the individual lacks capacity to make the decision in question. The two stage test 1. Impairment of, or disturbance in functioning of, person’s mind or brain? If so, 2. is the impairment sufficient that they lack capacity to make the decision. Defining mental capacity Ability to make decisions or take actions affecting daily life

23. Testing whether someone is unable to make a specific decision (4 questions of functional test). 1.Understand the information relevant to the decision (understand the consequences of options) 2.Retain that information 3.Weigh up that information as part of a decision-making process, OR 4.Communicate the decision A ‘No’ on any = lack of capacity. Assessing lack of capacity: two stage test 1. Impairment of, or disturbance in functioning of, person’s mind or brain? If so, 2. is the impairment sufficient that they lack capacity to make the decision? STAGE ONESTAGE TWO

24. Everything done for person who lacks capacity must be in their “best interests” Section 4 sets out a checklist of steps and factors to be considered (see next slide) Consideration must be given to whether there are other options that may be less restrictive of the person’s rights. The decision maker must reasonably believe that any action intended to restrain a person who lacks capacity is necessary to prevent harm to the person and a proportionate response to the likelihood of seriousness of harm. Forms and guidance: http://www.intranet.sheffieldccg.nhs.uk/mental- capacity-act.htmhttp://www.intranet.sheffieldccg.nhs.uk/mental- capacity-act.htm Best interests

25. The Oxford Dictionary defines “restraint” as “to check or hold in; to keep in check or under control; keep down” What is restraint? Physical restraint Mechanical restraint Chemical restraint Restricting individuals’ choices Withholding information And more……… Easy English guide

26. How do you support people with a learning disability to complain? Are your leaflets accessible? Have you identified someone who can help? Is your feedback communicated in a way that that the person can understand ?

27. Community Learning Disability Teams (CLDT) 33 Love Street, Sheffield, S3 8NW 0114 226 2900 Intensive Support Service (ISS) 32 Firshill Rise, Sheffield, South Yorkshire, S4 7BW S4 7BW 0114 226 1559 ISS@BSupport@shsc.nhs.uk Respite Care Services The Sheffield Case Register Case Register, Sheffield Health and Social Care NHS Trust, Fulwood House, Old Fulwood Road, Sheffield, S10 3TH Phone: 0114 271 6940 Email: Case.register@shsc.nhs.ukCase.register@shsc.nhs.uk Working Together

28. Think about any safeguarding concerns you might have whilst completing the health check Embed learning from case studies Consider creating a practice policy for Safeguarding adults, including domestic abuse GPs need to be effective “eyes and ears” Spot patterns and join the pieces - improve documentation that is recorded - consider how to increase visibility of previous concerns. There are templates for capacity decisions and best interest meetings on the intranet - http://www.intranet.sheffieldccg.nhs.uk/mental-capacity- act.htmhttp://www.intranet.sheffieldccg.nhs.uk/mental-capacity- act.htm Safeguarding adults is everybody’s responsibility Think about all vulnerable people in the household Opportunities to Safeguard whilst completing the health check

29. Safeguarding Adults intranet home page http://nww.sheffield.nhs.uk/standards/adults.php http://nww.sheffield.nhs.uk/standards/adults.php Case advice, for example whether to raise an alert or not, can be obtained from the Sheffield Safeguarding Adults Office. Tel. 0114 2736870 or email: safeguardingadults@sheffield.gov.uk Out of hours advice can be obtained from the Adult access team on 0114 2734908. safeguardingadults@sheffield.gov.uk Alert form http://www.jtpm.co.uk/nhstest9/index.php/referrals/item/179-safeguarding- alert Referrals are made to the Adult access team on 0114 2734908http://www.jtpm.co.uk/nhstest9/index.php/referrals/item/179-safeguarding- alert Training for all professionals https://www.sheffield.gov.uk/caresupport/adult/adult- abuse/professionals/training.html Details of e-learning on the intranet home page,https://www.sheffield.gov.uk/caresupport/adult/adult- abuse/professionals/training.html Mental Capacity Act useful documents http://nww.sheffield.nhs.uk/standards/mca.phphttp://nww.sheffield.nhs.uk/standards/mca.php Ronda Ninkovic is MCA Lead for NHS Sheffield and can be contacted at ronda.ninkovic@nhs.net ronda.ninkovic@nhs.net Safeguarding Resources

30. www.signpostsheffield.org.uk http://www.gmc-uk.org/learningdisabilities http://www.bris.ac.uk/cipold/fullfinalreport.pdf Deprivation of Liberty Safeguards Code of Practice - http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_085476 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_085476 Continued

31. Steve.thomas5@nhs.net – CCG Mental Health Commissioning Team clinical leadSteve.thomas5@nhs.net Helen.grant4@nhs.net – SHSC Community Nurse Professional leadHelen.grant4@nhs.net Deprivation of Liberty Safeguards hotline – 0114 205 3783 (Mon-Fri 9.30-4.00) Alternatives to Restraint – Dr Zara Clarke – 0114 271 6939 or Anita Winter 0114 271 6741 Useful contacts