learning zone CONTINUING PROFESSIONAL DEVELOPMENT Page 58 Improving communication for people with learning disabilities Page 66 Learning disabilities multiple choice questionnaire Page 67 Read Annette Martyn’s practice profile on type 2 diabetes Page 68 Guidelines on how to write a practice profile Improving communication for people with learning disabilities NS336 Godsell M, Scarborough K (2006) Improving communication for people with learning disabilities. Nursing Standard. 20, 30, 58-65. Date of acceptance: February 6 2006. Summary Patients with learning disabilities have higher healthcare risks than the general population.
Health professionals need to develop skills that enable them to communicate effectively with this patient group. Identifying barriers to communication is the first step to reducing or removing them. Suggested strategies to improve healthcare access for patients with learning disabilities include: developing individualised health action plans, simplifying communication styles and providing accessible facilities and tailored resources. learning activities you should be able to: Understand the impact of communication on interaction between healthcare providers and patients with learning disabilities.
Describe the relationship between communication and the health inequalities experienced by people with learning disabilities. Identify strategies to improve communication between health providers and patients with learning disabilities. Authors Matthew Godsell and Kim Scarborough are senior lecturers, Faculty of Health and Social Care, University of the West of England, Bristol. Email: Matthew. [email protected] ac. uk Introduction Learning disability is not a diagnosis but a term used to describe people with a wide range of strengths and needs.
Eighty per cent of children and 60 per cent of adults with learning disabilities live with their families (Gravestock and Bouras 1997), and many people with learning disabilities exceed the expectations of families and professionals in their capacity to learn new skills and develop their talents (NHS Executive 1999). The term ‘learning disability’ says little about an individual’s strengths and needs but it does incorporate three elements that appear in most definitions (Box 1). Emerson et al (2001) state that the number of people with learning disabilities in the UK has not been determined.
They estimate that in the UK there could be as many as 350,000 people with severe learning disabilities (intelligence quotient (IQ) 50). This means that 2 per cent of patients are likely to have a learning disability (NHS Executive 1999). The ways in which people with learning disabilities are described have changed. Terminology and related facts are listed in Box 2. NURSING STANDARD Keywords Communication; Learning disabilities nursing: attitudes These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.
For related articles and author guidelines visit our online archive at www. nursing-standard. co. uk and search using the keywords. Aims and intended learning outcomes The aim of this article is to explore the impact of communication on health care for people with learning disabilities. The article discusses how cognition and communication influence interactions between healthcare providers and patients. It also examines how poor communication can contribute to health inequalities that separate people with learning disabilities from the rest of the population.
The article explores communication strategies that can overcome or reduce barriers to effective health care. After reading this article and completing the 58 april 5 :: vol 20 no 30 :: 2006 Time out 1 Based on a figure of 2 per cent of patients having learning disabilities, it is likely that 40 per 2,000 patients registered with GP services are likely to have learning disabilities. How many patients with learning disabilities are you aware of in your practice area? List some of the reasons that might prevent people with learning disabilities from accessing local health services. Health inequalities
Although people with learning disabilities are living longer, the gap that separates the health status of people with learning disabilities and the general population has increased. Cohen (2001) asserted that gross inequalities in health are politically, socially and economically unacceptable. An investigation into health inequalities by the Disability Rights Commission (Nocon 2004) found that people with learning disabilities have: An increased risk of early death compared with the rest of the population; mortality rates are particularly high for those with more severe impairments.
A greater variety of healthcare needs. Many needs that are not met. High rates of unrecognised or poorly managed medical conditions including: hypertension, obesity, heart disease, abdominal pain, respiratory disease, cancer, gastrointestinal disorders, diabetes, chronic urinary tract infections, oral disease, musculoskeletal conditions, osteoporosis, thyroid disease, and visual and hearing impairments.
A briefing paper produced by the NHS Service Delivery and Organisation (SDO) Research and Development Programme (NHS SDO 2004) identified barriers to appropriate and timely BOX 1 Definition of a learning disability A person with learning disabilities has: Significant reduction in the ability to understand new or complex information. Reduced ability to cope independently. Impairment starting in childhood that will have a lasting effect on development. (DH 2001) access to health care within and outside services.
Many people with learning disabilities find that identifying their healthcare needs is a major challenge. Proactive strategies are required to encourage people to access the full range of services that are available. Some people with learning disabilities have said that negative and unhelpful attitudes from healthcare workers have prevented them from seeking medical help (Bristol and District People First 2003). Support and encouragement are required by carers, allies and friends before people with these concerns are ready to engage with services again.
People are more likely to trust service providers when they are convinced that services and practitioners have responded to their needs by improving communication skills and producing information in an accessible format. People with learning disabilities have the same right to access mainstream services as the rest of the population (Department of Health (DH) 2001). However, mainstream services have been slow to develop the capacity and skills to meet their needs.
In the document Valuing People (DH 2001) it was acknowledged that the wider NHS had failed to consider the needs of people with learning disabilities and that overcoming this source of inequality was the most important issue for the NHS to address for this patient BOX 2 Terminology and facts related to learning disabilities ‘Mental handicap’ was a term used to describe people with learning disabilities. It is no longer used in the UK. ‘Mental retardation’ is a term used internationally, however, it is not an accepted term in the UK and some may find this term offensive. Learning difficulty’ is the term used in education to define individuals who have specific learning needs, for example, dyslexia. Some people who are identified as having learning difficulty by education services may also be considered to have a learning disability, but this is not necessarily the case. ‘Mild’, ‘moderate’, ‘severe’ and ‘profound’ are terms to describe different degrees of disability (Figure 1). A person with mild learning disabilities might communicate effectively, learn, live and work with little support.
However, a person with profound learning disabilities will require support with activities of daily living, for example, communication, dressing, feeding, washing and mobility. A diagnosis of ‘mental illness’ is not the same as having a learning disability, but people with learning disabilities may have mental health issues as well. Not everyone with learning disabilities requires a social worker or a community nurse. People with learning disabilities may have multiple diagnoses resulting in complex health needs. People with the most profound physical or sensory impairments do not always have the most profound cognitive impairments.
NURSING STANDARD april 5 :: vol 20 no 30 :: 2006 59 learning zone nursing attitudes group. The briefing paper produced by the NHS SDO (2004) provided key action points for removing barriers and improving access to health care, which included: Using specialist learning disability teams to aid adaptation of mainstream services to meet the needs of patients with learning disabilities. Developing strategies for health education and health checks for people with learning disabilities that promote timely access to health care.
Families and paid carers have an important role in helping people with learning disabilities to access health care. Some people will need assistance to recognise mental health problems and to identify gradual changes in health. Time out 2 Make a list of the ways that you communicate with patients about their health, for example, through appointments and telephone calls. Take three examples from your list and consider reasons why communication with a person with learning disabilities might be difficult.
Give an example of effective communication between a practitioner and a person with learning disabilities. Policies should address the use of technology to support communication, and the development and dissemination of accessible information. Jones (2003) suggests that managers and commissioners of services should liaise with health, social care and education agencies to ensure consistency in communication policies throughout the lives of people with learning disabilities. Communication can be broadly defined as the exchange of information between a sender and a receiver (Figure 2).
Where a person has learning disabilities they may be communicating with an intention to attract a communication partner and commence a two-way dialogue. However, for some people with profound learning disabilities sending a message might be a response to their body and feelings. Their level of cognition might be such that they are unaware of possible communication partners and of how to take the communication further. This is called pre-intentional communication, in which the individual says or does things without intending to affect those around them.
It is important to remember that everyone communicates and that the role of communicator and communication partner swaps from one person to the other so that a conversation can develop. The challenge for health professionals is to develop skills that enable them to interpret the messages they receive and make the messages they send understandable. Communication is not only about verbal communication; it is also about nonverbal communication, for example, the use of body language, words and pictures. Communication
Recommendations have been made to improve communication and access to health services for people with learning disabilities. Jones (2003) states that services supporting people from birth to older age should develop communication policies. FIGURE 1 Estimated percentage of people with learning disabilities according to level of severity Mild Moderate 12% Severe Profound 80% 7% 1% Augmentative and alternative communication systems Systems of communication, such as sign language, symbols and eye pointing, are known as augmentative and alternative communication systems (AACs).
AACs can be used to enhance or replace customary pathways, such as speech or writing. The use of photographs of everyday objects, picture boards, line drawing and real objects are good ways to enhance communication with people with learning disabilities (American Speech-Language-Hearing Association (ASHA) 2005). You do not need to attend specialist training to be able to use AACs such as these. More formal AACs, such as Makaton (a form of sign language for people who have learning disabilities that uses keywords to enhance understanding), require preparation but learning a basic vocabulary does not require extensive training.
Cognition and communication (Winterhalder 1997) Understanding complex information People with learning disabilities have a reduced ability to NURSING STANDARD 60 april 5 :: vol 20 no 30 :: 2006 understand new or complex information (DH 2001), and those who experience difficulties when processing information may find it hard to learn new skills. Intelligence can be quantified as a figure related to an individual’s IQ. However, it might be more useful to think about intelligence in relation to cognitive processes.
Smith and Mackie (2000) describe cognitive processes as: ‘…the way in which our memories, perceptions, thoughts, emotions and motives guide our understanding of the world and our actions. ’ Intelligence exerts a powerful influence over the ability to process information, the capacity to learn new skills and to adapt knowledge to different situations. Intelligence is an attribute that can guide our understanding of the world, but it is not fixed or static. Teaching and learning strategies can be used to stimulate cognitive processes so that people can approach information, or potentially confusing situations, with more confidence.
Similarly, complicated tasks and information can be broken down into small, simple steps so that people can approach them in stages. Attempting to understand another person’s cognitive processes can help practitioners to develop a more empathetic and person-centred approach to care, and can provide an incentive to develop the teaching and learning strategies that are best suited to the individual needs of patients. Coping independently People with learning disabilities may have a reduced ability to cope independently (DH 2001). Independence is defined according to levels of social functioning.
Assessment of a patient’s strengths and needs in social functioning is a fundamental stage in developing planned care that is familiar to practitioners from all branches of nursing. Making an accurate assessment of social functioning provides valuable information about the range of activities that a person can undertake on his or her own as well as those activities where a person requires support. Some people with learning disabilities may require assistance with tasks such as washing and dressing, and many need help to have their mode of communication understood.
Learning disability and development Learning disability starts before adulthood, affects people of all ages and has a lasting effect on development (DH 2001). A majority of younger people with learning disabilities are living in the community with their parents or carers. Older people with learning disabilities also live in the community but they may have periods of institutional care. Some people will have frequent contact with health services and others have irregular contact. People with learning disabilities are not a homogeneous group. Their perceptions of nurses, NURSING STANDARD
FIGURE 2 A model for communication Person communicating: we take turns in this role of sender of information. Depending on the person’s cognitive ability, this may be intentional or pre-intentional communication Communication barriers: can be present in the environment as well as being caused by the communicator and communication partner Communication partner: we take turns in this role of the person who receives the information sent, makes sense of it and responds appropriately doctors, health centres, clinics and hospitals will have been shaped by their formative experiences with staff and services.
Providing encouragement for people with learning disabilities to attend health checks and to make use of healthcare services can involve changing their perceptions of health professionals. Some people with learning disabilities have not received the treatment they need because they are reluctant to engage with services where they have had bad experiences in the past. To encourage people with learning disabilities to make effective use of healthcare services throughout their lives, practitioners need to use their communication skills to initiate and maintain positive relationships. Time out 3
Think about the last time you communicated with a person with learning disabilities, or someone who has communication difficulties. Refer to the list you made in Time out 2 about the communication systems you use in your workplace. What are the main barriers to communicating about health with a person who has learning disabilities? How do you remove or reduce barriers to communication? Which environmental factors impede communication? Identify any barriers that you had not previously considered. april 5 :: vol 20 no 30 :: 2006 61 learning zone nursing attitudes Barriers to communication
There are barriers to communication which can be identified in relation to the person with learning disabilities, the health professional and the environment (Box 3). When barriers have been identified, health professionals can start to think about ways of reducing or removing them. Health professionals exchange information by using terminology that reflects their specialised knowledge. Patients and other people who are not involved in the day-to-day delivery of health care BOX 3 Barriers to communication The person with learning disabilities may: Have limited understanding.
Have limited vocabulary or difficulty speaking. Have sensory impairments that limit ability to hear requests or instructions. Have poor understanding of health and healthy living. Be scared of people in uniforms. Be stressed because of illness. Not like new places. Have difficulty waiting and may not understand the concept of time or queuing. Have limited literacy and numeracy skills to read health advice and information, for example, instructions, letters, dosages. Expect contact with nurses to be unpleasant because of previous experiences. The nurse may: Be rushed because of heavy workload.
Have biases and assumptions about people with learning disabilities. Have poor listening and attending skills. Be unable to understand augmentative and alternative communication systems. Have limited knowledge of the individual. Have insufficient time to develop a good relationship with the individual or carer. Not use visual aids to support understanding. Use technical jargon and/or long words. Provide written information without thinking of the patient’s ability to read it. Provide information about the next appointment in a way the patient will not understand or remember.
The environment may: Be crowded. Busy. Uncomfortable. Have strange smells and noises. Bring back bad memories. Have limited physical access, for example, no hoists. Include unhelpful people. Have poor signage, relying on literacy skills and good sensory abilities. Have no area to sit quietly with limited sensory stimulation while waiting. Be filled with machines and instruments that a person with learning disabilities may not understand. may find it difficult to comprehend the terms and ideas they encounter in healthcare settings. They can find it hard to follow advice or instructions.
This could result in patients making inappropriate decisions or exposing themselves to unnecessary risks. For example, patients with learning disabilities who take their own medication may be at risk of overdosing or taking an ineffectual dose, particularly if the route and dosage of a newly prescribed medicine has not been explained clearly and/or recorded in an accessible format. Time out 4 Consider the list of potential barriers to communication and categorise them according to: Barriers that have been addressed for patients with learning disabilities using the services you work in.
Barriers that can be remedied quickly. Barriers that need planning to be reduced or removed. Barriers that require financial investment to be reduced or overcome. Discuss this list with your colleagues. Identify strategies for removing barriers and improving communication. Good practice in communication In South Warwickshire, health passports have been developed for people with learning disabilities (Leamington Spa Today 2005). These provide detailed information about an individual’s health, strengths and needs so that practitioners can provide patient-centred care.
They are used to improve communication across a range of healthcare providers. Having an alert system incorporated into patient notes which provides individual communication needs could be beneficial, especially where staff do not know individual patients. Health practitioners may use and be involved in developing health action plans. These are plans specific to individuals and are developed to meet their access needs. Health action plans are a way of overcoming some of the barriers to high quality health care (DH 2001).
Plans are produced by a group of people including the patient. They encourage the development of a shared understanding about an individual’s health needs. Where training in health action planning has been provided for GP surgeries, improvements have been shown in the health of patients with learning disabilities (Smith et al 2004). There are benefits to having a lead person to deal with learning disability issues. In primary healthcare services, a lead person takes an interest in learning disability issues, collates information, NURSING STANDARD 62 april 5 :: vol 20 no 30 :: 2006 ives support and advice to health staff and develops links with specialist services for people with learning disabilities and other agencies (NHS Executive 1999). Time out 5 Does your organisation have a lead person who is involved in initiatives such as joint communication policies and the development and sharing of accessible health information? If yes, find out how he or she is supporting your team to develop skills in communicating with people who have learning disabilities. If no, how might developing this role benefit your team and improve access to health care for patients with learning disabilities?
To improve communication with people with learning disabilities, more time should be allocated to appointments so that there is more time for them to express themselves and understand any information they have received (DH 1999). This is particularly the case if AACs are being used. Reception staff are often aware of people who have difficulties using services. Supporting these key staff to develop effective communication skills and flexibility can improve access to health services (NHS Executive 1999).
For example, if staff in reception are aware that someone finds it difficult to wait in a queue, they may offer that person the first appointment. Several resources have been developed by trusts to improve communication. Some examples of these include: Hambleton and Richmondshire Primary Care Trust (PCT), in partnership with Mencap, has developed an accessible ‘Choose and Book’ guide for hospital appointments that uses a combination of pictures and words to explain how patients can make choices about hospitals and appointments.
Bristol South West PCT, as part of its ‘Expert Patient Programme’, has developed plans that help prepare people with learning disabilities for a visit to the doctor. The Health Facilitation Team at Gloucestershire Partnership NHS Trust (2004) has produced a ‘traffic light assessment’ that conveys information about individuals on admission to hospital. This ensures that important information is clearly communicated to health professionals. Camden PCT (2005) has used this work to develop an online resource. Although people may appear to have limited communication skills, they should not be ignored.
These patients should be addressed directly and NURSING STANDARD the information they receive should be provided in a simple way without being patronising. Effective communication often depends on how the information is delivered. Practitioners may have to talk to carers, but they should not forget to address the person with learning disabilities. Practitioners should examine their beliefs about people with learning disabilities and avoid making assumptions about an individual’s strengths and needs. This will help to make health assessments more accurate (DH 1999).
It is useful to invite a speaker with learning disabilities to talk to healthcare staff about living with a learning disability and his or her experiences of accessing health services. Time out 6 What beliefs and values do you think society holds about people with learning disabilities? Some examples of negative beliefs and values are that people with learning disabilities: Have a poor quality of life. Have higher pain thresholds. Are dangerous and promiscuous. Will not understand anything. Should not get married or have children. Cannot care for their children. Need institutional care. Cannot work.
Are like children not adults. What are your feelings about these statements? How might the presence of any or all of these beliefs influence the care given to a person with learning disabilities? People with learning disabilities can have additional physical or sensory impairments that should be considered. They are also more likely to have more mental health needs than the general population (DH 2001). Where a patient has additional impairments or health issues these need to be considered during communication. The healthcare environment should be adapted to accommodate people with physical or sensory impairments.
Time out 7 In your work place: Do you have a private area to talk to a person who has a large wheelchair? Do you have rooms where glare is controlled and the environment is suitable for people with limited vision? Do you consider the needs of interpreters/ carers and ensure they fully understand information before they pass it on? april 5 :: vol 20 no 30 :: 2006 63 learning zone nursing attitudes Accessible information Accessible information comes in many forms, such as videos, CDs, DVDs and audiotapes. Pamphlets can be produced with accessible information about the services offered.
Written information needs to be in plain language, with short sentences and one subject per sentence. Photographs, drawings, symbols and other visual information can be used to support written information. It is important to keep pages uncluttered on plain backgrounds so that text does not detract from graphics. Letters should be large, 16-18 point type size, and fonts that do not have serifs, such as Arial and Comic Sans, should be used. Graphic text, underlining and italics should be kept to a minimum because they can impede readability. Many trusts are now producing resources to enhance accessibility.
Some of these include: The United Bristol Healthcare NHS Trust has produced a leaflet called ‘You are coming to the Bristol Royal Infirmary about your heart’, TABLE 1 Using terminology that is easy to understand Health issue Common words that are used Epilepsy Investigations EEG (electroencephalogram) Strategies or words that improve understanding Find out more about This word would have to be used, but a photograph of someone having an EEG may help understanding Medicine tablets to help control your epilepsy Having two or more seizures straight after each other or whatever describes status for the individual Taking your medication as we have agreed Things that might make you have a seizure Not being able to have a poo for three days Things you feel in your head and body that make you think you will have a seizure Having a fit or turn, whichever word the person uses which uses pictures and words to introduce some of the staff and explain what happens when patients are admitted to the cardiology department.
The Learning Disability Partnership Board in Surrey has developed ‘The Hospital Communication Book’ that combines words, pictures, signs and symbols. Trafford North and South PCTs have produced a toolkit for people with learning disabilities called ‘Cancer and You’ (Provan 2004). Contact your local Community Learning Disability Team or People First organisation for information about local resources. Simplifying conversation When talking to people with learning disabilities, use approaches similar to those used for written text. Plain language, the use of keywords, short sentences and one subject per sentence should be used. Give people time to process what is being said and to formulate a reply.
Use openended questions to assess a person’s understanding and rephrase the question if necessary, as repeating the same question rarely improves understanding. When information is presented during a consultation it is important to check that the person with learning disabilities has understood it. If there is insufficient time during the initial consultation, it may be necessary to make a further appointment to check what the person has understood and retained. For an individual who processes information slowly this might be essential to ensure an accurate assessment and the effective implementation of a treatment plan. Examples of terms that are easier to understand are presented in Table 1.
Such terms are only beneficial if the person understands them so, for example, ‘constipation’ could be described as ‘not being able to have a poo’, but the health practitioner needs to know whether the person uses this term to describe defecation. Anti-epileptic drugs Status epilepticus Drug compliance Triggers Constipation Aura Time out 8 Think of four common illnesses that are likely to make a person visit your service. Write these in the first column of a table (see Table 1). Identify the language you use when discussing these illnesses and record these words or phrases in column two. These might be medical terms, health terms or long words. Now spend some time identifying words that are easier to understand and record them in the third column. NURSING STANDARD Seizure 64 april 5 :: vol 20 no 30 :: 2006 Conclusion
People with learning disabilities may have communication difficulties that have restricted their access to health care and prevented them from receiving the information required to maintain their health. In addition to learning disability, they are more likely to have complex healthcare needs leading to multiple diagnoses. Steps towards better health for people with learning disabilities can be made by providing encouragement and support to attend regular health screening and reviews, and by developing a range of strategies to improve communication between practitioners and individuals with learning disabilities NS RECOMMENDED RESOURCES British Institute of Learning Disabilities (2001) Factsheet No. 005 Communication. www. bild. org. uk/pdf/factsheets/communication. pdf (Last accessed: March 10 2006. British Institute of Learning Disabilities (2005) Your Good Health (a set of 12 illustrated booklets). www. bild. org. uk/publications/your_very_good_health_details. htm (Last accessed: March 10 2006. ) Communication Matters (updates 2005) What is AAC? www. communicationmatters. org. uk (Last accessed: March 10 2006. ) Communication Matters (updated 2005) How to be a good listener. www. communicationmatters. org. uk (Last accessed: March 10 2006. ) Department of Health. www. dh. gov. uk (Last accessed: March 10 2006. ) Foundation for People with Learning Disabilities (2004) Communication and people with learning disabilities. www. learningdisabilities. org. uk/page. cfm? agecode=ISSICMMT (Last accessed: March 10 2006. ) Foundation for People with Learning Disabilities (2005) Patients with learning disabilities in South Warwickshire have been given a new type of passport to help with their medical appointments. www. learningdisabilities. org. uk/profilenews. cfm? pagecode=ISSICOLN&are acode=ld_communication_news&id=7231 (Last accessed: March 10 2006. ) MENCAP (2003) You and your health: a basic guide to being healthy. www. mencap. org. uk/download/you_and_your_health. pdf (Last accessed: March 10 2006. ) Plymouth Hospitals NHS Trust (2005) Living with cancer. www. learningdisabilitycancer. nhs. uk/ (Last accessed: March 10 2006. ) Time out 9
Complete a SWOT analysis (strengths, weaknesses, opportunities and threats) of your skills and knowledge when communicating with and supporting access to health care for people with learning disabilities. Time out 10 Now that you have completed this article, you might like to consider writing a practice profile. Guidelines are on page 68. References American Speech-LanguageHearing Association (2005) Introduction to Augmentative and Alternative Communication. www. asha. org/public/ speech/disorders/acc_primer. htm (Last accessed: March 9 2006. ) Bristol and District People First (2003) We are People First. (Film) People First, Bristol. Camden PCT (2005) What You Need to Know About Me in Hospital. www. camden. gov. k/ (Last accessed: March 17 2006. ) Cohen J (2001) Countries’ health performance. The Lancet. 358, 9285, 929. Department of Health (1999) Facing the Facts: Services for People with Learning Disabilities: A Policy Impact Study of Social Care and Health Services. The Stationery Office, London. Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the 21st Century. The Stationery Office, London. Emerson E, Hatton C, Felce D, Murphy G (2001) Learning Disabilities: The Fundamental Facts. Foundation for People with Learning Disabilities, London. Gloucestershire Partnership NHS Trust (2004) Traffic light assessment. Unpublished document.
Gloucestershire Partnership NHS Trust, Gloucester. Gravestock S, Bouras N (1997) Emotional disorders. In Holt G, Bouras N (Eds) Mental Health in Learning Disabilities: A Training Pack for Staff Working with People who have a Dual Diagnosis of Mental Health Needs and Learning Disabilities. Second edition. Pavilion Publishing, Brighton, 17-26. Jones J (2003) The Communication Gap. www. learningdisabilities. org. uk /page. cfm? pagecode= FBFMCHTP04 (Last accessed: March 10 2006. ) Leamington Spa Today (2005) Patients with learning disabilities in South Warwickshire have been given a new type of passport to help with their medical appointments. Leamington Spa Today. January 19, 2005.
NHS Executive (1999) Once a Day One or More People with Learning Disabilities are Likely to be in Contact with Your Primary Healthcare Team. How Can You Help Them? Department of Health, Leeds. NHS Service Delivery and Organisation (SDO) Research and Development Programme (2004) Access to Health Care for People with Learning Disabilities. Briefing paper. NHS SDO, London. Nocon A (2004) Background Evidence for the DRC’s Formal Investigation into Health Inequalities Experienced by People with Learning Disabilities or Mental Health Problems. Disability Rights Commission, Stratford upon Avon. Provan K (2004) Cancer and You: Toolkit for Working with People with Learning Disabilities. www. cancerandyou. info/docs/ FullToolkitNov04. pdf (Last accessed: March 9 2006. Smith ER, Mackie DM (2000) Social Psychology. Second edition. Psychology Press, Hove. Smith C, Giraud-Saunders A, McIntosh B (2004) Healthy Lives: Health Action Planning in a Person Centred Way; Including Health in Person Centred Planning. www. valuingpeople. gov. uk/ HealthHealthyLives. htm (Last accessed March 10 2006. ) Winterhalder R (1997) An overview of learning disabilities. In Holt G, Bouras N (Eds) Mental Health in Learning Disabilities: A Training Pack for Staff Working with People who have a Dual Diagnosis of Mental Health Needs and Learning Disabilities. Second edition. Pavilion Publishing, Brighton, 1-6. NURSING STANDARD april 5 :: vol 20 no 30 :: 2006 65