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Draft Briefing Document on Sir Jonathan Michael 'Healthcare for
All' Report
1.
Aim of the LCRPCT Response to the Report
To ensure that the care pathway for children and adults with learning disabilities is
clear, transparent and understood by all of those involved
Championed by: Chief Executive
Oversight of Action plan: Director of Market Development
The Independent Inquiry, led by Sir Jonathan Michael ‘sought to identify the action
needed to ensure adults and children with learning disabilities receive appropriate
treatment in acute and primary healthcare in England’. The outcome of the report,
which was published in July 2008, found that there was evidence of good practice,
but also ‘appalling examples of discrimination, abuse and neglect across the range
of health services’.
LCR PCT will need as a matter of urgency to ensure that it is able to respond
positively to the ten recommendations that are made within the report and this is
totally in line with the vision of LCRPCT to “Lead Leicestershire and Rutland to
become the healthiest place in the UK.” The action plan, once agreed, will be
reviewed and monitored by the Equality and Human Rights Group Disability
Compliance Group and through the Local LD Partnership Boards and
Commissioning Board.
This is a draft report, very much work in progress and we are seeking comments and
inputs into it from stakeholders over the next two months. However, there are some
actions contained within this report that as a PCT we need to do throughout this
period we are seeking people’s views. The draft action plan has been reviewed by
the Executive team and will feed into our commissioning intentions and into our
strategic plan.
Sir Johnathan Michael ‘Healthcare for All’ Report
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2.
What the Michael Report Found
The Inquiry found convincing evidence that people with learning disabilities have
higher levels of unmet need and receive less effective treatment, despite the fact that
the Disability Discrimination Act and Mental Capacity Act set out a clear legal
framework for the delivery of equal treatment. The report makes it clear that:
“…People with learning disabilities are not visible or identifiable to health services,
and hence the quality of their care is impossible to assess.”
The research also found evidence that:

People with learning disabilities find it much harder than other people to
access assessment and treatment for general health problems that have
nothing directly to do with their disability.

There is insufficient attention given to making reasonable adjustments to
support the delivery of equal treatment, as required by the Disability
Discrimination Act. Adjustments are not always made to allow for
communication problems, difficulty in understanding (cognitive impairment), or
the anxieties and preferences of individuals concerning their treatment.

Parents and carers of adults and children with learning disabilities often find
their opinions and assessments ignored by healthcare professionals, even
though they often have the best information about, and understanding of, the
people they support. They struggle to be accepted as effective partners in
care by those involved in providing general healthcare; their complaints are
not heard; they are expected to do too much of the care that should be
provided by the health system and are often required to provide care beyond
their personal resources.

Health service staff, particularly those working in general healthcare, have
very limited knowledge about learning disability. They are unfamiliar with the
legislative framework, and commonly fail to understand that a right to equal
treatment does not mean treatment should be the same. The health needs,
communication problems, and cognitive impairment characteristic of learning
disability in particular are poorly understood. Staff are not familiar with what
help they should provide or from whom to get expert advice.

Partnership working and communication (between different agencies
providing care, between services for different age groups, and across NHS
primary, secondary and tertiary boundaries) is poor in relation to services for
adults with learning disabilities. This problem is not restricted to services used
by people with learning disabilities but particularly affects those who may not
be able to communicate for themselves, or whose treatment needs careful
planning and coordination because they have complex needs.
Sir Johnathan Michael ‘Healthcare for All’ Report
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The report uses the definition of ‘learning disability’ adopted by the Department of
Health since 2001 and means:
A significant 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.
3.
Actions Already taken
The Michael’s Report signals a direction of travel that LCC and LCRPCT had already
embarked upon and the PCT has already commissioned an enhanced service for
people with learning disabilities. Leicestershire and Rutland already has in place an
interim commissioning strategy for learning disability services 2006 – 2009. This
provides an overall strategic direction for learning disability services commissioned
by social services and the 4 County PCTs, now the LRCPCT. This strategy is based
upon the vision and principles of valuing people and underpins its approach to
commissioning activity with the principles agreed by the PCTs and the Local
Authority. The aim of the partnership between health and social services is to
ensure the strategic direction is towards integration of health and social care
services for learning disabilities. It is anticipated that this partnership working will
result in improved access to mainstream services for people with learning
disabilities.







Flexible use of available resources
A seamless service for people with learning disabilities
A single service with a single vision and culture
A single set of policies governing, for example, access and eligibility to service
Improved access, co-ordination of services and equity of response
Provision of a person-centred service that is holistic in addressing both health
and social care needs
A good skills and knowledge base within an effectively planned workforce
The LCRPCT and the Leicestershire County Council and Rutland County Council
have already agreed to take a Joint Strategic Approach to;







Joint Strategy
Joint Commissioning plan
Pooled Budget arrangements LCC, Rutland and County PCT– Local
Authorities are lead commissioners
Joint Performance framework
Commissioning Board
Learning Disability Partnership Board (the Leicestershire LDPB is not a
joint board with Rutland).
Leicestershire Together – partner organisations in Leicestershire, including
PCT, LPT and District and Borough Councils - works to the Sustainable
Community Strategy 2008
Sir Johnathan Michael ‘Healthcare for All’ Report
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While estimates vary on the prevalence of learning disabilities in the UK the DH
estimate that about 1.5 million people (2.5% population) have a learning disability.
The prevalence of learning disability in the general population is expected to grow
overall by 10% by 2020.
4.
Leicestershire Learning Disability Register
Leicestershire has a Learning Disability Register which is a joint venture between the
University of Leicester and Leicestershire and Rutland Health Care NHS Trust, with
support from Social Services. The Register was established in 1987 to provide an
evidence-base for improving the health and quality of life of all people with learning
disabilities and their carers. We currently hold information on approximately 3,400
adults with learning disabilities living in the city of Leicester, Leicestershire and
Rutland.
The ultimate aim of the Register is the promotion and maintenance of health of
people with learning disabilities and their carers. This is addressed by improving our
understanding of the conditions involved and their impact on life and maximising the
benefits of treatment and supporting services. The overall functions/aims of the
Register are:





5.
Planning and evaluation of services
Public health and clinical research
General support and information
Health action planning
Operational planning and administration
Recent Research by Leicestershire and Rutland PCT
Research in 20071 showed that the prevalence rate in Leicestershire and Rutland
PCT by June 2007 was 3.5 per 1000 with a possible variation between 3.3 and 3.7
per 1000 (95% confidence intervals).
The prevalence in Leicestershire and Rutland PCT decreased with age from 6.0 per
1000 (95%CI 5.5-6.5) among those aged 19-29 years old to 0.5 per 1000 (95% CI
0.2-0.7) among those 80+. The same trend was observed among both men and
women. This decreasing rate possibly reflects the early mortality among people with
learning disabilities, but also some forms of migration. For example, when they
become adults they could move from the County into the City where perhaps there
are more alternatives to accommodate them to live independently.
Prevalence rates were significantly lower in the least deprived areas in the PCT, but
there was no difference between the most and the middle deprived areas. There
were no significant differences by ethnic group in this PCT.
1
Reyes-Beaman Sandra Learning disabilities in Leicester City and
Sir Johnathan Michael ‘Healthcare for All’ Report
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Leicestershire County and Rutland PCTs, 2007
Approximately 50 per cent of people with learning disabilities have profound or
severe disability, 21 per cent has moderate, 23 per cent has mild and four per cent
has borderline disability. Although they more or less have the same distribution, the
proportion of people with severe or profound disabilities was significantly higher in
Leicester City PCT (50 per cent vs. 54%). In this PCT the proportion of borderline
and mild was higher in the most deprived areas, while proportions of those moderate
and profound were higher among those living in least deprived areas (p<0.001).
Severe and profound cases were significantly more frequent among non-white
people in both PCTs (48 per cent among white people vs. 82 per cent among nonwhite people in Leicestershire and Rutland PCT and 47.7 per cent vs. 69.5 per cent
respectively in Leicester City PCT) (p<0.0001).
It is important to note that in 2007, the number of people registered as having a
learning disability in GP practices in the PCT was compared with the number of
people registered in the Learning Disabilities Register (LDR) and it was found an
under-register of cases in GP practices that needed to be solved. Therefore, it
seems that the LDR is still a more reliable source of information.
Severity of the Disability by PCT
PCT
Severity of the Disability Leicestershire and Leicester City
Rutland
Borderline
4.9
2.9
Mild
23.6
22.6
Moderate
21.7
20.5
Profound
25.6
26.1
Total
4.0
23.1
21.1
25.8
The Michael Inquiry makes ten recommendations for change and while the Trust will
need cognisance of all of the recommendations, a number of the recommendations,
especially 6, 8 and 5 place responsibility on the Department of Health to action or
direct.
Sir Johnathan Michael ‘Healthcare for All’ Report
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RECOMMENDATIONS
Recommendation 1

Those with responsibility for the provision and regulation of undergraduate and
postgraduate clinical training, must ensure that curricula include mandatory
training in learning disabilities. It should be competence-based and involve
people with learning disabilities and their carers in providing training.
Recommendation 2

All healthcare organisations, including the Department of Health should ensure
that they collect the data and information necessary to allow people with learning
disability to be indentified by the health service and their pathways of care
tracked.
Recommendation 3

Family and other carers should be involved as a matter of course as partners in
the provision of treatment and care, unless good reason is given, and Trust
Boards should ensure that reasonable adjustments are made to enable them to
do this effectively. This will include the provision of information, but may also
involve practical support and service co-ordination.
Recommendation 4

Primary care trusts should identify and assess the needs of people with learning
disabilities and their carers as part of the Joint Strategic Needs Assessment.
They should consult with the Local Strategic Partnership, their Learning Disability
Partnership Boards and relevant voluntary user-led learning disability
organisations and use the information to inform the development of Local Area
Agreements.
Recommendation 5

To raise awareness in the health service of the risk of premature avoidance
death, and to promote sustainable good practice in local assessment,
management and evaluation of services, the Department of Health should
establish a learning disabilities Public Health Observatory. This should be
supplemented by a time-limited Confidential Inquiry into premature deaths in
people with learning disabilities to provide evidence for clinical and professional
staff of the extent of the problem and guidance on prevention.
Sir Johnathan Michael ‘Healthcare for All’ Report
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Recommendation 6

The Department of Health should immediately amend Core Standards for Better
Health, to include an explicit reference to the requirement to make ‘reasonable
adjustments’ to the provision and delivery of services for vulnerable groups, in
accordance with the disability equality legislation. The framework that is planned
to replace these core standards in 2010 should also include a specific reference
to this requirement.
Recommendation 7

Inspectors and regulators of health service should develop and extend their
monitoring of the standard of general health services provided for people with
learning disabilities, in both the hospital sector and in the community where
primary care providers are located. The aim is to support appropriate,
reasonable adjustments to general health services for adults and children with
learning disabilities and their families and to ensure compliance with and
enforcement of all aspects of the Disability Discrimination Act. Healthcare
regulators and inspectors (and the Care Quality Commission, once established)
should strengthen their work in partnership with each other and with the
Commission for Equality and Human Rights, the National Patient Safety Agency
and Office for Disability Issues.
Recommendation 8

The Department of Health should direct primary care trusts (PCTs) to secure
general health services that make ‘reasonable adjustments’ for people with
learning disabilities through a Directed Enhanced Service. In particular, the
Department should direct PCTs to commission enhanced primary care services
which include regular health checks provided by GP practices and improve data,
communication and cross-boundary partnership working. This should include
liaison staff who work with primary care services to improve the overall quality of
health care for people with learning disabilities across the spectrum of care.
Recommendation 9

Section 242 of the National Health Service Act 2006 requires NHS bodies to
involve and consult patients and the public in the planning and development of
services, and in decisions affecting the operation of services. All Trust Boards
should ensure that the views and interests of people with learning disabilities and
their carers are included.
Recommendation 10

All Trust Boards should demonstrate in routine public reports that they have
effective systems in place to deliver effective, ‘reasonably adjusted’ health
services for those people who happen to have a learning disability. This
‘adjustment’ should include arrangements to provide advocacy for all those who
need it, and arrangements to secure effective representation of PALS from all
client groups including people with learning disabilities.
Sir Johnathan Michael ‘Healthcare for All’ Report
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LCRPCT DRAFT ACTION PLAN
Action Required
More
effective
essential
LCR PCT Response
leadership
Date
Responsibility
is -Inform PCT staff of the report, the proposed September,2008 Catherine
implementation work and seek comments
Griffiths
-Publish
draft action plan
and put on L &D September,2008 SL
/Surinder
Commissioning Board agenda for comment
Perberdy
-We will conduct an equality impact assessment of November, 2008 Umar Zamman
the plan
September,
Laura Summers
-We will consult with carers and people with learning 2008 on
difficulties regarding the content of the action plan
September,
We will seek from our key providers a formal 2008 and
statement asking them about the actions they intend on-going
to take in response to the report ie UHL, LPT,
Provider Arm.
October,2008
-We will seek clarification from the
Prison
establishments in the locality about how they are
going to respond to the Michaels Report.
2009/10
-Review contracts to ensure they are amended to
reflect the requirement to make ‘reasonable
adjustments’ to services to ensure they are accessible
to people with learning disabilities. We will meet the
requirements within the MCAs and reference provider
to the DRC publication which illustrates how
Sir Johnathan Michael ‘Healthcare for All’ Report
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Commissioning
team
Steve Lowden
Commissioning
team
reasonable adjustments could be made.
TBC
Link to service specifications within contract
schedules.
Service
specification
amendments
required in:
- Provider
- East Midlands Ambulance Service
- Mental health contracts
December, 2008
-Run workshop with third sector providers, LCC,
Mental health Trust and GPs to review draft action
plan, amend and input
Every
four
-Publish ‘refined’ action plan and provide Board with months
an update every four months.
March, 2010
Commissioning
team
Steve Lowden/
Laura Summers
Deputy Director
Marketing
Development
With LCC
With Leicestershire County Council, Leicestershire
partnership
Trust
and
SHA
provide
new
accommodation for 57 of the 78 campus residents
with learning difficulties- subject to successful financial
bid
Recommendation 1
Those with responsibility for the
provision
and
regulation
of
undergraduate and postgraduate
clinical training, must ensure that
curricula include mandatory training
in learning disabilities. It should be
competence-based and
involve
people with learning disabilities and
their carers in providing training.
LCRPCT will explore the training needs of provider TBC
services, primary care services and other contracted
providers to raise their awareness of delivering the
Michaels Report. recommendations.
Commissioning
team
We will explore the option to commission an advocacy December, 2008 Laura Summers
group to be trained and then cascade the LD
awareness training to PCT and provider staff as well
as pre registration doctors?
Sir Johnathan Michael ‘Healthcare for All’ Report
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Recommendation 2
All
healthcare
organisations,
including the Department of Health
should ensure that they collect the
data and information necessary to
allow people with learning disability
to be indentified by the health
service and their pathways of care
tracked
We will review and align data and coding sources on
learning disability and carers; and further review the
data set that the PCT needs to meet its commitments.
December, 2008 Simon Freeman
LCRPCT will monitor the take up of the Annual Health
check for learning disabilities by GPs
Annually
Laura Summers
We will set up a ‘rolling programme’ for training GPs
to deliver the Annual Health check
October 2008-
Laura Summers
LCRPCT will review the Learning Disability Register
with the Local Authority
Annually
Steve Lowden/
Simon Freeman
Collect quarterly performance monitoring data for the
SHA on learning disability: number of clients on NHS
campus provision; registered number of LD patients;
PCT population(GP based);number of LD patients as
% of PCT population; number of registered LD
patients that have had a health check in the last 12
months; number of primary care LD healthcare
facilitators as a % of GP practices; number of
secondary care LD patient advocates; number of
acute beds in hosted trusts; number of secondary
care advocates per 1000 beds.
In our contract with Leicester Partnership Trust we
Sir Johnathan Michael ‘Healthcare for All’ Report
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Every
months
three Steve Lowden
expect compliance with Health Care Commission
Good Practice for in-patient care for people with
learning difficulties.
September,2008 Steve Lowden
We will monitor the East Midlands Darzi review and
the actions around care pathways for epilepsy,
Every
three Commissioning
diabetes, respiratory disease and CHD and review our months
with team
LD practices accordingly.
action plan
Recommendation 3
Family and other carers should be
involved as a matter of course as We will receive updates from the lead agencies on
partners in the provision of treatment the implementation of this recommendation through
and care, unless good reason is the normal monitoring route
given, and Trust Boards should
ensure that reasonable adjustments
are made to enable them to do this
effectively.
This will include the
provision of information, but may
also involve practical support and
service co-ordination.
Sir Johnathan Michael ‘Healthcare for All’ Report
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TBC
Recommendation 4
LCRPCT ALREADY HAS IN PLACE AN INTERIM
COMMISSIONING STRATEGY FOR LEARNING
Primary care trusts should identify DISABILITY SERVICES 2006 – 2009.
and assess the needs of people with
learning disabilities and their carers The LCRPCT and the Leicestershire County Council
as part of the Joint Strategic Needs and Rutland County Council have already agreed to
Assessment. They should consult take a Joint Strategic Approach to:
with the Local Strategic Partnership,
their Learning Disability Partnership  Pooled Budget arrangements LCC, Rutland and
Boards and relevant voluntary userCounty PCT– Local Authorities are lead
led learning disability organisations
commissioners
and use the information to inform the  Joint Strategy
development
of
Local
Area  Joint Commissioning plan
Agreements.
 Joint Performance framework
 Commissioning Board
 Learning Disability Partnership Board
 Leicestershire Together – partner organisations in
Leicestershire, including PCT, LPT and District
and Borough Councils - works to the Sustainable
Community Strategy 2008
 Increased the numbers of people in settled
accommodation
Through
Commissioning
Board six times
a year
Recommendation 5
To raise awareness in the health
service of the risk of premature
avoidance death, and to promote
sustainable good practice in local
assessment,
management
and
evaluation
of
services,
the
LCRPCT will actively communicate this initiative September 2008 Steve Lowden
through its regular newsletters and briefings with staff onwards
LCRPCT will review and amend the action plan in
response to action Government takes to this TBC
recommendation
Sir Johnathan Michael ‘Healthcare for All’ Report
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Steve Lowden
Department of Health should
establish a learning disabilities LCRPCT will contribute to requests for data from DH
Public Health Observatory.
This
should be supplemented by a timelimited Confidential Inquiry into
premature deaths in people with
learning disabilities to provide
evidence
for
clinical
and
professional staff of the extent of the
problem
and
guidance
on
prevention.
TBC
Recommendation 7
.
Inspectors and regulators of health
service should develop and extend
their monitoring of the standard of
general health services provided for
people with learning disabilities, in
both the hospital sector and in the
community where primary care
providers are located. The aim is to
support appropriate, reasonable
adjustments to general health
services for adults and children with
learning disabilities and their families
and to ensure compliance with and
enforcement of all aspects of the
Disability
Discrimination
Act.
Healthcare
regulators
and
inspectors (and the Care Quality
LCRPCT will review and amend the action plan in
response to action the Regulators take on this TBC
recommendation.
LCRPCT will set out a clear communication pathway
with Regulators on LD
October,2008
Sarah Cooke
Steve Lowden
Steve Lowden
LCRPCT will work with the Learning Disability Health TBC
facilitator(s) to progress this action plan
Steve Lowden
Primary Care Psychological therapy services contract TBC
will meet the mental health needs of people with
learning difficulties.
Wal Holynski
Sir Johnathan Michael ‘Healthcare for All’ Report
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Commission, once established) The LCRPCT will link with www.easyhealth.org.uk September,
should strengthen their work in which contains jargon free information and pictorial 2008
partnership with each other and with health information
the Commission for Equality and
Human Rights, the National Patient
Safety Agency and Office for
Disability Issues.
Sue Cavill
Recommendation 8
The Department of Health should
direct primary care trusts (PCTs) to
secure general health services that
make ‘reasonable adjustments’ for
people with learning disabilities
through a Directed Enhanced
Service.
In
particular,
the
Department should direct PCTs to
commission enhanced primary care
services which include regular
health checks provided by GP
practices
and
improve
data,
communication and cross-boundary
partnership working. This should
include liaison staff who work with
primary care services to improve the
overall quality of health care for
people with learning disabilities
across the spectrum of care.
Confirm with the DH when they will action this September,2008 Catherine
recommendation
Griffiths
Review contracts to ensure they are amended to
reflect the requirement to make ‘reasonable April , 2009
adjustments’ to services to ensure they are accessible
to people with learning disabilities
Data and information systems will be reviewed across September,
the board to enable LCRPCT and providers to identify 2008
people with learning disabilities.
Commissioning
team
Steve Lowden
Joint Strategic Needs Assessment will collate QOF On going
data on learning disabilities
A workshop on the Michaels Report will be run for February,2009
LCRPCT PALS to raise their awareness of the report
and its implications.
Sir Johnathan Michael ‘Healthcare for All’ Report
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Laura Summers
Working with Leicester City Council LCRPCT will
pump prime 3 nursing posts to aid ‘reasonable
adjustments’ and so help drive up outcomes through
contracts
Subject
to Steve
negotiations but Lowden/Surinder
hopefully
Perberdy
November,2008
Adjust the SLA with NHS Trust provider to ensure TBC
access for 18yrs plus and priorities training for primary
care services for responding to meet the general
health needs of young people with learning disabilities
The Trust will meet DH guidelines for the transfer of 1st
December
responsibility for the commissioning of social care for initial response
adults with a learning disability from the NHS to local
government and transfer appropriate funding
Sandra Webster
/Steve
Lowden/Surinder
Perberdy
We will review our own information and ensure that it December, 2008 Sue Cavill
meets DDA requirements such as the PCT complaints
leaflet, OOH service leaflets etc
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Recommendation 9
Section 242 of the National Health
Service Act 2006 requires NHS
bodies to involve and consult
patients and the public in the
planning and development of
services, and in decisions affecting
the operation of services. All Trust
Boards should ensure that the views
and interests of people with learning
disabilities and their carers are
included
The Board will continue to offer support for anyone
with a learning disability that wants to attend a Board
meeting.
In place
The Trust will update its enhanced hearing loop in the
Board room.
December, 2008 Moosa Patel
We will involve pwld and carers in the process of
assessing ‘reasonable adjustments’ following
appropriate training
March 2009
LCRPCT will produce consultation documents that are
fit for purpose for people with learning disabilities ie.
‘Our plans for Community Healthcare for the next 10
As Required
th
years- Tell us what you think’ 16 June to 5 October
2008
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Moosa Patel
Laura Summers/
Moosa Patel
Sue Cavill
Recommendation 10
All Trust Boards should demonstrate
in routine public reports that they
have effective systems in place to
deliver
effective,
‘reasonably
adjusted’ health services for those
people who happen to have a
learning disability. This ‘adjustment’
should include arrangements to
provide advocacy for all those who
need it, and arrangements to secure
effective representation of PALS
from all client groups including
people with learning disabilities.
Through delivering the action plan and receiving
updates of the plan every four months the Trust Updates
to Moosa Patel
Boards will demonstrate that they have effective, Board every four
legal, `reasonably adjusted’ services in place.
months
We will seek out best practice and review our
processes to see how we can engage and involve
pwld/carers in the Trust Board.
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January, 2009
Steve Lowden/
Moosa Patel