Personal views: Who should care for people with learning disabilities?
Authors: William Sellar
Journal: BMJ (2000)

The medical care of people with learning disabilities in the United Kingdom is largely the responsibility of psychiatrists, for whom it has become a recognised subspecialty. This responsibility has been inherited because, in the past, many people with learning disabilities were condemned to asylums for psychiatric patients as both groups of patients had behaviour that was unaccepted in the wider community and which seemed to be untreatable.


However, although people with learning disability have an increased incidence of psychiatric disorder, most people with mental handicap are now recognised as not having psychiatric illness. So why are they still managed by psychiatrists? 


Many adults with learning disabilities disappear anonymously into the community



Psychiatrists may argue that they are best placed to understand, differentiate, interpret, or treat the altered behaviour of those with learning disability who may find difficulty expressing themselves. Neurotic or challenging behaviour may indicate underlying emotional or physical disorder, or even a psychiatric disorder. Few would deny psychiatrists' skills, but all doctors have an ability to listen to patients and their carers and to examine a patient for disease.

Surveys of mixed groups of patients with learning disabilities show that the majority are multidisabled. For instance, about 30% suffer from visual impairment. But they may also suffer from disabilities of an orthopaedic, neurological, cardiovascular, or hearing nature. So again the question arises—are psychiatrists necessarily the best specialists to offer the care that people with learning disabilities need?

At present children with learning disabilities often pass haphazardly from the hands of developmental paediatricians to community paediatricians and on to general practitioners and psychiatrists with an interest in learning disability. But with the current policy of taking people out of institutions and into community care, many adults with learning disabilities disappear anonymously into the community with little structured follow up. This is partly because not all NHS trusts maintain disability registers and many general practitioners feel inadequately trained to care for people with learning disabilities. Continuous care for these people is clearly not provided at present by psychiatrists. So do we need a new type of specialist?

In Scandinavian countries and in the Netherlands there are general practitioners or specialists in mental handicap. The concept of a general practitioner for the intellectually handicapped might be more appropriate to present day circumstances in the United Kingdom than treating learning disability as a subspecialty of psychiatry. In the Netherlands a specific training is being slowly developed in the area of intellectual handicap, and it already exists in Finland.

You could envisage the development of a vocational training programme in the United Kingdom to address the needs of people with learning disabilities. Such a rotation might include exposure not only to psychiatry but also to developmental paediatrics, general medicine, neurology, cardiology, behavioural science, and (re)habilitative medicine. It might even include attachments in ear, nose, and throat, ophthalmology, and genetics.

Having specifically trained general practitioners to care for people with learning disabilities makes sense, not just because of the numbers of those involved (about 1000 per 100 000 population) but because specific training in learning disability would make more economic sense than the long consultant psychiatric training that is in force at present, some of which may be irrelevant and some of which may be inadequate.

Much of the role of a general practitioner in learning disability would involve coordinating and motivating the multidisciplinary team that would be needed to provide care for multiply disabled people. The team would have to help find appropriate placements for care and education, make appropriate referrals, and find appropriate medical specialists, as well as liaise with mental healthcare and learning disability trusts and social services departments. The team would also have to make sure that people with learning disabilities had equal access to NHS services despite the fact that they might live in a variety of settings, at home, in supervised residences in the community, or in institutions.

The appointment of adequate numbers of learning disability specialists would allow a more integrated approach to the care of people with learning disabilities from childhood, through adulthood, and into old age, and allow a protocol driven approach to improving healthcare provision for this special group of people.