Blood tests for people with severe learning disabilities receiving dental treatment under general anaesthesia

Communication between healthcare professionals

Although letters were sent to the patients' GMP, only 4% responded prior to the day of treatment. There may be a number of reasons for this, including difficulties with postal services leading to failure or delays in delivering letters between settings. Communication by email would be undeniably more efficient, however, there was little use of this facility (1%). A potential reason for this is a reluctance to share information owing to concerns about the security of email facilities between different services. In this evaluation, any email communication was in line with Trust guidance for information governance using secure facilities.

Of family members and carers, 14% attended on the day of treatment with a request from their GMP that they had collected directly. Although positive for this small proportion of patients, overall this was a low response, possibly due to the frequent changes in carers involved in assisting this group.

This emphasizes difficulties previously identified by CIPOLD⁶ regarding the need to improve communication within and between agencies in the care of people with LD. Information sharing between primary and secondary care services undoubtedly contributes to not only improved patient-centred care, but also service efficiencies.¹⁴

Uptake of annual health checks

The implementation of AHC for people with LD has been repeatedly recommended.^5,15 A systematic review has shown that, although there appear to be difficulties in standardization within general medical practice, AHCs are an effective method of detecting unrecognized and potentially treatable health conditions in this group.⁷

The targeting of such services is complicated by the lack of a central register for people with LD. Within a general medical practice, potentially two registers exist for this group:¹⁶

It is the latter group only that will be automatically invited to attend for AHC. However, since every practice does not have an Enhanced Service contractual agreement, and there are many people with LD that are not known to social services, there are potentially many people who could benefit from AHC that are being overlooked.¹⁶

CIPOLD revealed that, although 92% were known to their GMPs, 29% had not received a health check in the previous 12 months, and 12% had never had a health check, despite 97% having one or more long-term or treatable health conditions.⁶ In this evaluation, 56% had not received AHC within 12 months prior to treatment under GA. In the authors' experience, such patients would not be able to cope with several aspects of a health check, even on a domiciliary basis, emphasizing the need for co-ordinated care between services when the opportunity of GA arises.

Blood tests

There are many common health problems among people with LD, including:¹⁷

Such conditions not only increase the risk of further co-morbidities but also complicate their detection. Blood sampling therefore not only forms an important aspect of health screening among people with LD, but also plays a significant role in monitoring,¹⁸ since a large proportion of this group are prescribed medications (eg to control epilepsy¹⁹ or behaviour that challenges²⁰), which can have significant long-term side-effects.

Blood sampling (phlebotomy) is one of the most common invasive procedures in healthcare. Each NHS Trust has its own standard operating procedure guidance; however, they are largely based on those developed by the World Health Organization,²¹ which are summarized in Table 3, along with the practical considerations for people receiving treatment under GA (Figures 1, 2).

In this evaluation, the most common findings were low vitamin D (91%), low haemoglobin (34%) and low iron serum (32%) levels (Table 2). A significant proportion (25%) also had high cholesterol levels. It is accepted that ‘normal ranges’ differ between laboratories and each finding may not warrant immediate medical intervention.

Most of these findings were previously undetected and contributed to new diagnoses. For example, 64% of patients in this evaluation had vitamin D deficiency but family and carers had no previous awareness and the patient had no previous medical input. Of this group, 34% also had a history of epilepsy managed with AEDs. Although ethnicity was not specifically recorded in this evaluation, more than 60% of the local population of Tower Hamlets is from a minority ethnic background,²⁴ and the increased risk of vitamin D deficiency is well known among such groups living in the UK.²⁵ There is evidence of a relationship with AEDs, vitamin D deficiency and bone disease.²⁶ A high prevalence of vitamin D deficiency is not surprising when combining this with limited sun exposure among this group.

In addition, 4% of patients were found to have abnormal thyroid profiles. Down's syndrome is the most common genetic cause of learning disability.³ The RCGPs recognizes increased prevalence of hypothyroidism among this particular group and the complexities that untreated thyroid disease can bring, including a predisposition to obesity and its associated long-term health complications.⁷ Hence, annual blood sampling is particularly important for this group.

Of particular interest, two patients reviewed in this evaluation had severe anaemia, with haemoglobin levels below 6.5g/dL, resulting in urgent referrals to Haematology and readmission for blood transfusion. Although dental treatment provision was uneventful under GA on these occasions, readers are reminded that blood test results were reviewed post-operatively. If noted beforehand, treatment under GA would not have been deemed suitable at that point in time and would have been postponed until the underlying condition had been appropriately managed.

The significant amount of undiagnosed disease among this group will undoubtedly lead to underestimated risks when planning treatment for this group under GA and conscious sedation.

There is clearly considerable patient-centred value in this approach for people with severe LD but, in the interests of long-term sustainability, it is important to compare alternative approaches. Whether blood tests are taken in primary care or secondary care, the costs and resources used will be similar, as outlined in Tables 4 and 5.

Although subsequent costs of sharps and blood disposal have not been included, costs would be similar in between settings. Direct expenses for the usual compliment of blood tests and equipment as recommended by the RCGPs would therefore be £29.53 (including the mean cost of one AED test).

The difference lies in prevention of the expenses and wasted resources brought by failed outcomes in primary care due to anxiety and/or behaviour that challenges among people with severe LD. Taking into consideration the different team members and approaches that can be offered in primary care, Table 6 outlines the potential additional costs that are involved, based on consultation time alone.

In comparison with blood sampling in primary care, blood sampling under GA at the time of dental treatment is a cost-effective way of addressing inequalities in healthcare for this group. This approach may be used more widely by other disciplines providing care for such patients under GA.

The sustainability of a holistic approach can undoubtedly be improved through better communication between primary and secondary healthcare services. An example from this evaluation would be the GMPs responding to the Dental Team and informing them whether blood tests have been conducted recently, as carers attending with patients are often unsure. This would avoid repetition and help to minimize overall expenditure and unnecessary waste of resources.