Purpose of the policy

The Adult Learning Disability Strategy reviews all of the national and local policy expectations, together with the expressed views of local people, staff and other stakeholders in order to:

• Consider how well we are meeting the needs of local people with learning disabilities and their carers;
• Set out the priorities for improvement and development, in order that the Health and Social Care Partnership can ensure the provision of high quality, effective, sustainable services in the future. It is estimated that around 2,500 people with a learning disability live in East Dunbartonshire, using traditional prevalence rates (Dept of Health, 1995).

Many of these individuals will not be in regular contact with specialist health or social care services, but live largely independently or are supported by family. From our own figures we know that 460 adults with a learning disability do receive formal support, ranging from low-level advice and support to extremely intensive round-the-clock care and support with specialist health input.

The Strategy includes a vision: "Working together to deliver better outcomes for people with learning disabilities, and their families and carers" and sets 6 Improvement Themes: 1. To improve the planning for young people with learning disabilities transitioning from childhood to adulthood, with early involvement of parents, carers and the young people themselves; 2. To review and redesign accommodation-based and day support services, to modernise them, provide them locally wherever possible, make them fit for purpose for the people who need them and ensure they are sustainable for the future; 3. To ensure that specialist NHS services for people with learning disabilities are improved and developed in line with the Health Board's improvement programme "A Strategy for the Future"; 4. To continue to embed the principles of personalisation and Self-Directed Support, to encourage choice and independence within a framework that ensures fairness and consistency; 5. To continue to follow the principles and recommendations set out in "Keys to Life", to ensure that the best possible outcomes are being met for people with learning disabilities, their families and carers, within the resources available. 6. To ensure that our resource allocation processes are fair and consistent, and that we maximise efficiencies to secure Best Value for the people we support and the wider community.

Lead Reviewer: Alan Cairns
Please list all participants in carrying out this EQIA: Kelly Gainty (A&CC Support Worker)

Jump to section:

• Impact Assessment
• What is known about the issues for people with protected characteristics in relation to the services or activities affected by the policy?
• Do you expect the policy to have any positive impact on people with protected characteristics?
• Do you expect the policy to have any negative impact on people with protected characteristics?

Impact Assessment

Does the policy explicitly promote equality of opportunity and anti-discrimination and refer to legislative and policy drivers in relation to Equality

In the introduction to the East Dunbartonshire Adult Learning Disability Strategy 2018-23, it states: "During the 25 years since Community Care was implemented, expectations and aspirations have rightly increased by service users, carers, successive governments and professionals, with ongoing demands for better services, support, choice and control, equality of opportunity and human rights" (p2). The national Learning Disability Strategy is called "Keys to Life". Launched in 2013, it built on the success of the previous strategy called 'The same as you?', which was published in 2000 following a review of services for people with learning disabilities. East Dunbartonshire's HSC Partnership is fully committed to the ambitions and recommendations of Keys to Life and reflects these throughout this strategy. Keys to Life has a central theme of addressing health inequalities that affect people with learning disabilities. Research tells us that people with learning disabilities have some of the poorest health of any group in Scotland14. They are considerably more likely to die at an early age than the general population - on average 20 years before15. Some of the causes of death are potentially preventable, and the main causes of death differ from those of the general population. Whilst the most common causes of death for the Scottish population are cancer, heart disease and strokes, the most common causes of death for people with learning disabilities are respiratory disease, cardiovascular disease (related to congenital heart disease) and different forms of cancer, principally related to gullet, stomach and gall bladder rather than lung, prostate and urinary tract. Many of the causes of learning disabilities may also lead to physical or mental ill health. This means that people with learning disabilities may be more likely to be prescribed multiple drugs due to complex and multiple health needs which, in turn, can sometimes adversely affect health through side effects and drug interactions. In terms of prevention, people with learning disabilities are also less likely to exercise and eat healthily than the general public because they may not always have the knowledge or understanding to make healthy choices, and are reliant on others for support and communication. These issues are often added to by problems accessing the health services they need. What is clear is that some conditions go unrecognised or are recognised at a later stage than would be the case for the general population. Where there is a recognised condition, it may not be monitored as well unless individuals themselves, their carers and professionals proactively do this. Added to which, assumptions are sometimes made that a condition is part of the learning disability and it is not addressed because of this. The way in which service responses are structured does not always help. One example of this is that there is no equivalent of the paediatric service for adults with learning disabilities in the NHS. Instead, responsibility within the community lies principally within primary care. There is no doubt that there is good practice in primary care, but routine exposure to the needs of people with learning disabilities because of the low numbers per average practice makes it harder to build up expertise. Overall these issues contribute to reduced life expectancy, reduced cognitive functioning, reduced quality of life, and disability and pain. As stated above, The Keys to Life has addressing these health inequalities at the core of its strategy and recommendations, with 40 of the 52 recommendations focused on improvements in health service provision and outcomes. The East Dunbartonshire Adult Learning Disability Strategy 2018-23 has at its core the local implementation of The Keys to Life, with one of its Improvement Themes: 5. To continue to follow the principles and recommendations set out in "Keys to Life", to ensure that the best possible outcomes are being met for people with learning disabilities, their families and carers, within the resources available.  In addition, Improvement Themes 4 and 6 focus on the need to ensure fairness and consistency with the allocation and application of resources to people with learning disabilities: 4. To continue to embed the principles of personalisation and Self-Directed Support, to encourage choice and independence within a framework that ensures fairness and consistency. (p22) 6. To ensure that our resource allocation processes are fair and consistent, and that we maximise efficiencies to secure Best Value for the people we support and the wider community. (p22) In the section of the the East Dunbartonshire Adult Learning Disability Strategy 2018-23 called "Context For Change", the document sets out national legislation that underpins national and local policy. Included in this is a section on the Equalities Act (p10): Equality Act 2010 The Equality Act 2010 brings together over 116 separate pieces of legislation into one single Act. Combined, they make up the 2010 Act that provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. The Act simplifies, strengthens and harmonises the current legislation to provide Britain with a discrimination law which protects individuals from unfair treatment and promotes a fair and more equal society. In the "Context for Change" section of the East Dunbartonshire Adult Learning Disability Strategy 2018-23, under Local Policy and Community Planning, the East Dunbartonshire Local Outcome and Improvement Plan (LOIP) 2017-27 is referred to as an overarching business plan for the Partnership against which a number of guiding principles are established, including: Fair and equitable services We will plan and deliver services which account for the different needs of population groups who share a characteristic protected by the Equality Act.  Planning for place We will target resources where they are most needed to reduce disadvantage caused by socio- economic inequality. This is known as using a "Place" approach. The East Dunbartonshire Adult Learning Disability Strategy 2018-23 is designed to explicitly remove discrimination, promote good relations and promote equality of opportunity for this care group with disability, which is a protected characteristic group. The promotion of fairness and consistency can be demonstrated consistently across the Improvement Themes, which is designed to ensure equality of resource allocation and delivery of personal outcomes across all protected characteristics groups 

What is known about the issues for people with protected characteristics in relation to the services or activities affected by the policy?

All
The World Health Organisation (WHO) estimates that learning disability prevalence is about 3% overall in industrialised countries (Mental Retardation 1989). In England, the Department of Health estimates that there are approximately 210,000 people with a severe/profound learning disability, around 3.5 per 1,000, and 1.2 million people with a mild/moderate one, around 25 per 1,000 ('Valuing People' 2001). The then-Scottish Executive's report 'The same as you?' (2000) estimates in Scotland that approximately 20 per 1,000 of the population has a mild/moderate learning disability and 3-4 per 1,000 has a severe/profound one It is estimated that around 2,500 people with a learning disability live in East Dunbartonshire, using traditional prevalence rates (Dept of Health, 1995). Many of these individuals will not be in regular contact with specialist health or social care services, but live largely independently or are supported by family. From our own figures we know that 460 adults with a learning disability do receive formal support, ranging from low-level advice and support to extremely intensive round-the-clock care and support with specialist health input. United Nations Convention on the Rights of Persons with Disabilities and Optional Protocol website requires all service provision to be concerned about the difficult conditions faced by persons with disabilities who are subject to multiple or aggravated forms of discrimination on the basis of race, colour, sex, language, religion, political or other opinion, national, ethnic, indigenous or social origin, property, birth, age or other status. Autism spectrum disorder (ASD) is a lifelong, complex developmental disability that affects how a person communicates, relates, and interacts with/to other people. It also affects how a person makes sense of the world around themselves. ASD broadly refers to a group of disorders. It includes the classical form of autism, as well as closely related disabilities that share many of its core characteristics (for example, Asperger syndrome and Rett's syndrome). All people with ASD have the 'triad of impairments': social interaction difficulties, language impairment, and reduced imagination and restricted activities. It is widely acknowledged that there is a group of people with learning disabilities who have a complex range of difficulties which may include:

• profound learning disabilities
• physical disabilities that limit them in undertaking everyday tasks and often restrict mobility 
• sensory impairment
• complex health needs, i.e. epilepsy or respiratory problems, eating & drinking problems
• challenging behaviour

restricted communication, i.e. pre-verbal though a small number have some spoken or signed language. People with these characteristics are described as having profound and multiple learning disabilities (PMLD) or profound intellectual and multiple disabilities (PIMD). All, however, have the capacity to benefit from good health care and are able in various ways to communicate their satisfaction or otherwise with their quality of life. The causes of PMLD are many and varied. They include genetic disorders, acquired brain injury or brain damage as a result of infection. Causation may be ante-, peri- or post- natal. For many there is no known causation. It is estimated that the prevalence of PMLD in the general population is 0.05 per 1,000. This figure is derived from a survey undertaken in Scotland and would lead to a figure of 2,600 people with PMLD in the country. This is possibly an underestimate and a useful working figure would be 3,000. These numbers will increase with better survival rates, not only in the neonatal period but into childhood and adulthood, due to advances in medical care.
Source: Dept of Health 1995;

Sex
In East Dunbartonshire, 61% of the adults known to the HSCP with a Learning Disability are male. This is almost exactly consistent with the Scottish average, which is 60%. The distribution of sex by age in East Dunbartonshire is also consistent with the national distribution, for example adults over 65 constitute 13% and 8% of all adults with learning disabilities for females and males respectively. The national ratio of males to females is 51% to 49%. The prevalence of learning disability affecting disproportionately more males than females is not fully understood, but has been variously associated with theories including biological vulnerabilities, referral bias and test/diagnosis bias.
Source: Learning Disability Statistics Scotland 2017

Gender Reassignment
The NHS GG&C offer guidance on health needs of transgender people and how to address discrimination against trans people in their Briefing Paper on Gender Reassignment and Transgender people, as well as offering training for NHS staff on the subject of transgender people. The Strategic Plan is fully inclusive to all. Partnership working, inclusive of the Third Sector, is highlighted in various themes within the Plan, and should also impact positively upon transgender people as major research and policy direction around trans people are as yet largely shaped by the Third Sector organisations.

Race
The Learning Disability Statistics Scotland 2017 release reported that of adults known to HSCPs with a learning disability, 88% were recorded as white; 1% as Asian, Asian Scottish or Asian British; 0.01% as Black, Black Scottish or Black British, 0.03% as mixed ethnicity and 10% not recorded or disclosed. Learning Disability Alliance Scotland (2017) in their report: BME People Lose Out Across Scotland suggested that people from Black and Minority Ethnic (BME) communities are less likely to get a service than people from a White Scottish background. While the census shows that that BME people make up 5.2% of the Scottish population, the national database on learning disability, ESAY show only 1.24% of people with learning disabilities are from a BME background. There are some wide regional variations. Many BME communities are well established in Scotland and are likely to have a similar incidence of learning disability in the population. In the report by Trotter R. (2012); 'Over- looked Communities, Over-due Change' published by the Equalities National Council and Scope found many Black and Minority Ethnic (BME)people with disabilities reported that access to services can be compromised by poor translation, inconsistent quality of care and weak links between services and communities. People with disabilities are more likely to live in poverty but BME people with disabilities are disproportionately affected with nearly half living in household poverty. And like all people with disabilities, many of those from black and minority ethnic backgrounds find themselves socially excluded and pushed to the fringes of society.

Disability
Many of the causes of learning disabilities may also lead to physical or mental ill health. This means that people with learning disabilities may be more likely to be prescribed multiple drugs due to complex and multiple health needs which, in turn, can sometimes adversely affect health through side effects and drug interactions. In terms of prevention, people with learning disabilities are also less likely to exercise and eat healthily than the general public because they may not always have the knowledge or understanding to make healthy choices, and are reliant on others for support and communication. These issues are often added to by problems accessing the health services they need. Many people with learning disabilities experience limited verbal communication skills 

which impacts on others' ability to understand health needs. Both paid and family carers play an important role in identifying health needs. Many people with more severe learning disabilities rely completely on others to communicate what their health needs are. Children, young people and adults with learning disabilities experience very high rates of obesity. The increased rates of obesity in children with learning disabilities, compared to children who do not have learning disabilities, are already present by the age of three years old. Adults with learning disabilities aged 16-24 experience higher rates of obesity than adults over 50 who do not have learning disabilities. Many children and adults with learning disabilities do not have much opportunity to participate in physical activity. Instead, people with learning disabilities often have sedentary lifestyles. For example, children with learning disabilities spend 85% of each day sitting or lying down and a study in Glasgow found that, on average, adults with learning disabilities walk for around 15 minutes a week. These levels of inactivity cause health problems, such as heart problems or diabetes. One in three people with learning disabilities has unhealthy teeth and gums. This increases to four out of five for adults with Down's syndrome. This may be due to poor diet, poor dental hygiene, co-occurring health conditions and because oral health promotion may not always be accessible to people with learning disabilities. They may also fear dental treatment and, in some cases, will require general anaesthetic in a hospital setting to resolve matters. People with learning disabilities are more likely to have a hearing loss and are 10 times more likely to have a sight loss.

This can have a profound impact on how they are understood and are able to interact with others. Someone with communication difficulties, as someone with learning disabilities may have, might demonstrate challenging behaviours if they are unable to communicate a hidden and undiagnosed sensory loss.

Between 25 and 40% of people with learning disabilities also experience from mental health problems, with higher prevalence than found in those without learning disabilities. The prevalence of dementia is much higher amongst older adults with learning disabilities compared to the general population (Source: Cooper, 1997a), particularly for people with Down's Syndrome (Source: Holland et al., 1998). Prevalence rates for schizophrenia in people with learning disabilities are approximately three times greater than for the general population (Source: Doody et al., 1998). It is widely acknowledged that there is a group of people with learning disabilities who have a complex range of difficulties which may include: • profound learning disabilities • physical disabilities that limit them in undertaking everyday tasks and often restrict mobility • sensory impairment • complex health needs, i.e. epilepsy or respiratory problems, eating & drinking problems • challenging behaviour • restricted communication, i.e. pre-verbal though a small number have some spoken or signed language. People with these characteristics are described as having profound and multiple learning disabilities (PMLD) or profound intellectual and multiple disabilities (PIMD). All, however, have the capacity to benefit from good health care and are able in various ways to communicate their satisfaction or otherwise with their quality of life.
Source: The Keys to Life (Scottish Govt; 2013);

Sexual Orientation
The Lesbian, Gay, Bisexual and Transgender (LGBT) Health and Inclusion Project LGBT Identities and Learning Disabilities (2015) project found that participants reported that there is a lack of support for people with learning disabilities to access support around sex and relationships in general. This can includes misconceptions that all people with learning disabilities are asexual and that sexual urges generally are 'inappropriate'. Furthermore, participants discussed how people with learning disabilities can be infantilised which feeds into the notion that they would not need support around sex and relationships. Participants emphasised that this can be said for people with learning disabilities in general, and that LGBT people then face additional barriers.

Participants identified risk of 'mate crime' and sexual or financial exploitation for people with learning disabilities in night-time venues, including the commercial gay scene. The stigma around learning disabilities can make it hard for people to disclose to LGBT support services that they have additional needs and stigma around LGBT identities can make it difficult to 'come out' to support workers. Participants identified stigma and shame as reasons why LGBT people with learning disabilities may not come out to workers. Participants noted that the first time that people might be asked to consider or disclose their sexual orientation or gender identity may be when completing a monitoring form. This was identified as problematic as there is often not enough time to properly explore what this means.

 Age
The life expectancy of people with learning disabilities has increased over the course of the last 70 years. This is despite the fact that people with learning disabilities are 58 times more likely to die before the age of 50 than the rest of the population (Emerson and Baines 2010). People with learning disabilities face many disadvantages in relation to health (Emerson and Baines 2010, Department of Health 2001). However, better social conditions and access to medicines like antibiotics have meant that more people are surviving beyond childhood and adulthood into older age. For example, people with Down's syndrome have seen a dramatic rise in their life expectancy from seven years in the 1930's to their late 50's today (Holland et al 1998). The number of people with learning disabilities aged over 60, in the UK, is predicted to increase by over a third between 2001 and 2021 (Emerson and Hatton 2008). Recent evidence suggests that older people are one of the fastest growing groups of the learning disabled population (Emerson and Hatton 2011). The most recent predictions suggest that by 2030 the number of adults aged over 70 using services for people with learning disabilities will more than double. Survival rates into older age vary with sex, with national and local statistics demonstrating that adults with learning disabilities age 65+ constitute 13% and 9% of all adults with learning disabilities for females and males respectively (LDSS, 2017). Notwithstanding the increasing longevity of adults with a learning disability, the distribution of age-breakdown still demonstrates a comparatively shorter lifespan. 48% of adults with a learning disability are aged between 18- 34, compared to 22% within the general population. Adults with a learning disability aged 65+ comprise 10% of the population of all adults with a learning disability, compared to 27% of the general population (LDSS, 2017).

Social and Economic Status
he Learning Disability Statistics Scotland 2017 publication collates information on employment opportunities for adults with learning disabilities. These figures include adults with learning disabilities who are known to local authorities from contact in the last 3 years. The figures include 16 and 17 year olds who are not in full-time education. Learning Disability Statistics Scotland changed collection methodology in the current collection to align with that of other national social care datasets. The data reported in this release relate to a single year reporting period from April 2016 to March 2017, compared to the three year reporting period used in previous collections. Employment status is known for 14,085 (68.0%) adults with learning disabilities known to local authorities. Employment status is not recorded for 8,564 (32.0%) adults with learning disabilities known to services. Missing data has not been imputed. Data users should be aware that that the total numbers of adults with learning disabilities known to local authorities in employment and for adults not in employment are likely to be higher. There were 1,219 (13.9%) adults with learning disabilities known to local authorities who were in employment. There were 12,866 (55.5%) adults with learning disabilities known local authorities who were not in employment. The number of adults with employment opportunities, as a percentage of all adults with a learning disability is 13.7%, which is the second highest in Scotland and compares with a national average of 5.3%
Source: Learning Disability Statistics Scotland 2017

 Other marginalised groups (homeless, addictions, asylum seekers/refugees, travellers, ex-offenders
The East Dunbartonshire Adult Learning Disability Strategy 2018-23 is fully inclusive of all marginalised groups. There is no available research or information available specifically in these other areas and their interrelationship with adults with a learning disability. This is a subject for further national and local consideration.

Do you expect the policy to have any positive impact on people with protected characteristics?

General
It is expected that the integration of planning, resource use and service delivery as outlined in the Strategy in the Improvement Themes will have a positive impact on people if the plan recognises the interconnectedness of all protected characteristics and their specific needs.

Sex
It is expected that the integration of planning, resource use and service delivery as outlined in the Strategy in the Improvement Themes will have a positive impact on people if the plan recognises the interconnectedness of all protected characteristics and their specific needs.

Race
Yes, the Strategy will apply to all racial groups and where information is required to be translated or provided in alternative formats it will be provided upon request as is the current Council and NHS Policy 

Disability
Yes, the Improvement Themes are explicitly designed to improve access, fairness, consistency and processes associated with supporting people with disabilities to meet their personal outcomes, in line with the national Learning Disability Strategy and all national legislation and policy, as set out in the document.

Sexual Orientation
It is expected that the integration of planning, resource use and service delivery as outlined in the Strategy in the Improvement Themes will have a positive impact on people if the plan recognises the interconnectedness of all protected characteristics and their specific needs.

Religion and Belief
It is expected that the integration of planning, resource use and service delivery as outlined in the Strategy in the Improvement Themes will have a positive impact on people if the plan recognises the interconnectedness of all protected characteristics and their specific needs.

Age
It is expected that the integration of planning, resource use and service delivery as outlined in the Strategy in the Improvement Themes will have a positive impact on people if the plan recognises the interconnectedness of all protected characteristics and their specific needs.

Marriage and Civil Partnership
It is expected that the integration of planning, resource use and service delivery as outlined in the Strategy in the Improvement Themes will have a positive impact on people if the plan recognises the interconnectedness of all protected characteristics and their specific needs.

Social and Economic Status 
It is expected that the integration of planning, resource use and service delivery as outlined in the Strategy in the Improvement Themes will have a positive impact on people if the plan recognises the interconnectedness of all protected characteristics and their specific needs.

Other marginalised groups (homeless, addictions, asylum seekers/refugees, travellers, ex-offenders
The overarching Strategic Plan will take a locality based approach in order to ensure that needs are met, and that inequalities can be reduced.

Do you expect the policy to have any negative impact on people with protected characteristics?

General
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Sex
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Gender Reassignment 
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Disability
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Sexual Orientation
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Religion and Belief
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Age
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Marriage and Civil Partnership
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Pregnancy and Maternity
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Social and Economic Status
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.

Other marginalised groups (homeless, addictions, asylum seekers/refugees, travellers, ex-offenders
Yes, if the needs of these communities are not recognised in all of the Strategy's consequential improvement actions.