Promoting Health, Supporting Inclusion: Developments in the Nursing and Midwifery Contributions to Improving the Health of People with Intellectual Disabilities in Scotland

Michael Brown, MSc, BSc (Hons), RN, Dip. CMHC, Dip. Prof. Stds. Cert.

Abstract

Public policy within Scotland is directed towards social inclusion and health improvement for all citizens. Since political devolution in Scotland in 1999, there has been a considerable focus on the needs of people with intellectual disabilities. To address the health needs of this group, the government undertook a national nursing review, Promoting Health, Supporting Inclusion, to develop the contribution of all nurses and midwives, both generalist and specialists¹. Intellectual disability nurses have a major contribution to make. A range of actions that focus on health improvement, nurse education, coordination of care, practice development and joint working has been implemented nationally and locally to develop the role of all nurse and midwives.

A significant outcome is the publication of the health needs assessment report, which is one of the recommendations arising from the national nursing review. The health needs assessment report details the differing health patterns of people with intellectual disabilities. The findings have major implications for all aspects of healthcare services since people with intellectual disabilities will be high users; yet significant barriers exist. Nurses and midwives have a significant role in enabling access and improving health.

Support has been given by key national organizations to implement the recommendations within the report, and these have led to a number of significant developments that will enable nurses and midwives to contribute to health improvement for children, adults and older people with intellectual disabilities. Sustaining, maintaining and generalizing the developments beyond the nursing and midwifery professions is one of the challenges for the future.

Keywords: Scottish policy , nursing , health needs , health improvement , education and practice development

INTRODUCTION

The health of the people of Scotland is not good and as a result public policy in Scotland is clearly directed towards health improvement for all citizens². An integral part of the policy framework focuses specifically on people with intellectual disabilities, and recognizes their distinct needs and the actions required to meet them. Nurses and midwives are the largest single group of healthcare professionals, and within Scotland there are nurses with specific preparation to work with children, adults and older people with intellectual disabilities. As a resource, nurses and midwives have a contribution to make in reducing the health inequalities experienced by people with intellectual disabilities, thereby supporting government policy and wider social inclusion.

The contributions required from all nurses and midwives to improve the health and well being of people with intellectual disabilities has been identified following a national nursing review. A number of significant developments are now taking place with the focus of implementation occurring on a national and local basis. The implementation of policy will see the nursing and midwifery resource directed towards health improvement for people with intellectual disabilities in Scotland

IMPLEMENTING POLICY

"Implementation (of policy) must involve a process of interaction between organizations, the members of which may have different values, perspectives and priorities from one another and from those advocating the policy"³

This statement highlights the importance of appreciating and considering the range of issues that impact successful implementation of policy. The care and support of people with intellectual disabilities is a complex issue with many stakeholders, including people with intellectual disabilities, their careers, healthcare services, social care services, education services and many others. All have roles to play. The more stakeholders involved in the implementation process, the more complex the situation becomes and with it the possibility of potential failure despite the best of government intentions related to the conceptualization and framing of the policy⁴. From this, it is apparent that despite the presence of a policy framework, success rests with a sustained focus on implementation and support from stakeholders.

The care and support of people with intellectual disabilities in Scotland has undergone significant change and development in recent years. Policy decisions in intellectual disabilities and other areas are no longer made by the London Westminster Parliament following government devolution in Scotland in 1999. Since then, policy has taken a distinct identity that reflects the needs of the people of Scotland, with areas such as health, social care, housing, education and many others now falling within the purview of the Scottish Parliament. However, some issues remain within the purview of the Westminster Parliament, as is the case in nursing and midwifery legislation and regulation.

SCOTTISH POLICY

The same as you? A review of services for people with learning disabilities was published in Scotland in May 2000 and is the main government policy regarding the care of this group. It sets out the future direction of services for people with intellectual disabilities and estimates there are some 120,000 -150,000 Scottish children, adults and older people with intellectual disabilities within a population of just under 5,000,000^{5, 6}.

The same as you? contains 29 recommendations that seek to improve the lives of people with intellectual disabilities, their families and careers, with a national implementation group established to take forward the recommendations. From a health perspective, a significant recommendation contained within the report is the closure of all long stay institutions for people with intellectual disabilities by 2005. The national closure program is nearing completion and will see all people with intellectual disabilities living in community settings. This policy position needs to be viewed within the context that, in reality, few people with intellectual disabilities were ever resident in long stay institutions; the vast majority have always lived in the community, usually with family members⁷.

The review recognizes the significant health needs of children, adults and older people with intellectual disabilities; for many, the needs will be life long. In recognition of the distinct health needs of people with intellectual disabilities, and to ensure that comprehensive specialist care is available across the country, four assessment and treatment healthcare beds per 100,000 have been allotted. In addition, to prevent unnecessary admission, services for people with Autistic Spectrum Disorder are being developed.

THE NURSING AND MIDWIFERY CONTRIBUTIONS IN SCOTLAND

In 2000 Caring for Scotland: The Strategy for Nursing and Midwifery in Scotland was published and outlines the actions required to develop the nursing contribution to improve the health and well being of the people of Scotland⁸. A national implementation group, Facing the Future, has responsibility for overseeing the implementation of the strategy. Broadly, the vision for nurses and midwives seeks to ensure that they contribute to health improvement and healthcare by:

• Realizing their potential for influencing positively the health of the people of Scotland
• Increasing their confidence in contributing to the design and delivery of healthcare
• Maximizing opportunities for exercising autonomy in the provision of patient-centered care
• Striving to protect and secure optimum independence and self-determination for each individual
• Promoting quality care and pursuing excellence in clinical standards.
  (Caring for Scotland 2000:49)⁸

The strategy contains a range of actions, including two with a specific focus on people with intellectual disabilities, which state that:

• The Chief Nursing Officer will implement a review, carried out on a national basis, of the contribution all nurses can make to the care and support of people with intellectual disability, in 2001.
• A report of the review will be produced in 2002.
  (Caring for Scotland 2000:17)⁸

Background to the national nursing review

A national review of the contribution of all nurses and midwives was considered necessary in light of the changing and developing care arrangement for children, adults and older people with intellectual disabilities in Scotland. Historically, the main focus of state-funded healthcare for people with intellectual disabilities was within long stay institutions. Over the last twenty years, there has been a steady move towards community-based multidisciplinary intellectual disability teams, with intellectual disability nurses being at their core⁹.

With the policy focus on reprovisioning of healthcare services for people with intellectual disabilities to community-based services, it was recognized by government, practitioners, people with intellectual disabilities and their careers that there was a clear need to ensure that the contributions from nurses and midwives are directed and utilized appropriately to address health needs. Therefore, the national review focussed on the contribution of all nurses and midwives, irrespective of their area of clinical practice.

Promoting Health, Supporting Inclusion

In 2001 the national nursing review commenced, with the final report, Promoting Health, Supporting Inclusion: The National Review of the Contribution of all Nurses and Midwives to the Care and Support of People with Learning Disabilities being published in 2002 following an extensive and inclusive process . The recommendations sets out the range of actions and developments required from all nurses and midwives - generalist and specialist - to improve the health and well being of children, adults and older people with intellectual disabilities. The report is set within the wider policy context established in The same as you?, in which people with intellectual disabilities are active members of the community and require equal access to all community services, including effective healthcare. This is significant given the increasing evidence of the health inequalities experienced and the barriers faced in accessing and receiving equitable healthcare^{10, 11, 12}.

The national nursing review focus

In order to ensure that the national review was comprehensive, five areas were identified and provided the main focus and structure for the review process:

1. The current nursing and midwifery contributions across the life course
2. The areas of best nursing and midwifery practice
3. The education needs of nurses and midwives
4. The nursing and midwifery contributions required in the future
5. The practice development and research needs of nurses and midwives

 

The report recognizes that nurses and midwives are the largest single group within the healthcare system and, as a result, are in a distinct position to contribute to meeting the healthcare needs of people with intellectual disabilities. To support and enable this, the 24 recommendations arising from the report can be grouped in five broad areas:

1. Health Improvement
2. Coordination of Care
3. Nurse Education
4. Practice Development
5. Joint Working

 

DEVELOPMENTS RESULTING FROM PROMOTING HEALTH, SUPPORTING INCLUSION

1. HEALTH IMPROVEMENT DEVELOPMENTS

Promoting Health, Supporting Inclusion outlines a five-tier model of care as a means to support the conceptualization of the healthcare system in Scotland. An analysis of the nursing and midwifery contributions across the Tiers revealed significant activity from a number of groups of nurses, notably children's nurses, practice nurses, public health nurses and intellectual disability nurses. The Tiers outlined are:

Tier One: Community resources and supports, policy and public health developments

Tier Two: Primary care and directly accessed health services

Tier Three: Generic secondary health services accessed via primary care

Tier Four: Specialist locality intellectual disability health services; and

Tier Five: Specialist area and region-wide health services

The model helps to reflect the often complex nature of the healthcare system and the range of health services that, as a result of their layered health needs, people with intellectual disabilities require. The review also considered the health needs of people with intellectual disabilities from the following perspectives:

• Strategic and public health needs - the health improvement actions required to address the needs of all people with intellectual disabilities from a public health perspective
• Everyday health needs - the health needs that all citizens present with and need to be responded to, usually by primary healthcare services (i.e., access to and inclusion in national immunization and screening programs)
• Health needs relating to the learning disability - the needs that result because a person has an intellectual disability (i.e., the range of health needs distinct to people with Down syndrome)
• Complex health needs - the mix of everyday health needs and health needs resulting from the intellectual disability that collectively form 'layered' needs

Health improvement is a priority area for the Scottish government. NHS Health Scotland was formed in 2004 and is Scotland's national health improvement organization. One strand of the work undertaken by NHS Health Scotland is needs assessments, which is aimed at informing, planning and commissioning services in the future. The organization was invited by the government to undertake a needs assessment focussing on the evidence of the health of children, adults and older people with intellectual disabilities to support the development of evidence-based services and care.

The report, People with learning disabilities in Scotland: The health needs assessment report was published in 2004¹³. Based on an extensive review of the evidence base, the report makes clear recommendations for the actions required to ensure that the health needs of people with intellectual disabilities are identified and addressed in the future. The report identified important findings regarding the health disparities and inequalities experienced by this group, with the most significant being their different health profile when compared to the general population. This has implications for healthcare services - both generic and specialist - as people with intellectual disabilities require additional health services and health improvement strategies, in addition to the same ones required by the general population. As a result of their health needs, they will be high users of all aspects of the healthcare system. The Tiered model of care was utilized and developed further within the report to ensure that the full range of healthcare needs were addressed.

The key issues identified within the health needs assessment report include:

• The demographics of the intellectual disability population is changing, with an increase that is expected to continue
• Life expectancy is increasing, with the intellectual disability population aging and more people with complex needs living into older age
• People with intellectual disabilities experience significant health inequalities when compared to the general population and have greater health needs
• Their health profile differs from the general population, therefore so do their health needs and the responses required to address them
• The cause of death differs from the general population, with respiratory and cardiovascular disease being the top ranking causes
• Many health needs are unrecognized and therefore unmet, impacting on life expectancy and quality of life
• Some people with intellectual disabilities would benefit from a targeted health screening program
• People with intellectual disabilities experience significant barriers to accessing healthcare appropriate to their needs
• The cancer pattern differs from the general population, with esophageal, stomach and gall bladder being more prevalent
• Current health improvement policy must take account of the different health profile of people with intellectual disabilities to reduce the health inequality gap, rather than widen it
• People with intellectual disabilities experience institutional discrimination within healthcare systems, despite legislation aimed at eliminating discrimination

The evidence detailed in the health needs assessment report acts as an overview and reference point of the current knowledge base and understanding. This evidence, the Tiered model, and the range of needs (from everyday through to complex) highlight the diverse nature of the health needs of people with intellectual disabilities. Identifying the impact on providing healthcare services for an increasing and aging population also becomes apparent, as does identifying the actions required to address them. Therefore, the need for effective health and social care will be paramount in the future. Local health and social care planners and commissioners need to undertake work across the lifespan that identifies the issues and needs that will impact their services in the future and their ability to respond appropriately.

2. COORDINATION OF CARE DEVELOPMENTS

Quality Improvement

NHS Quality Improvement Scotland is a government-funded organization charged with improving the quality of healthcare of the people of Scotland. This quality improvement agenda covers statutory health service areas across Scotland. A formal visiting and inspection program has been established that centers on quality indicators covering all aspects of the healthcare system¹⁴.

The organization was asked to incorporate the findings of the national nursing review and the health needs assessment within their national intellectual disability quality improvement program, and the Tiered model of care has been used to provide structure and ensure that the full range of health needs are included.

NHS Quality Improvement Scotland is to publish an annual report based on the inspection visits that will provide data of best practice as well as identify areas requiring further development. Over time, this will offer an overview of the progress being made to improve the health and well being of people with intellectual disabilities at local and national levels. Additionally, the program will promote accountability and ensure that the health needs of this group remain a priority within the healthcare system.

3. NURSE EDUCATION DEVELOPMENTS

Nursing and Midwifery preparation in the United Kingdom

Within the United Kingdom nursing and midwifery education is university-based and results in Registration with the Nursing and Midwifery Council. All nursing and midwifery programs must comply with the competencies and learning outcomes set out by the Nursing and Midwifery Council and apply across the four counties of the United Kingdom - Scotland, Northern Ireland, Wales and England. Student nurses are required to complete a year-long Common Foundation program, the "CFP." The CFP acts as the building blocks around the core elements of nursing practice, with students studying a range of core subjects such as nursing practice, anatomy and physiology, psychology and sociology.

Following completion of the CFP, students move into a nursing branch-specific program. It is possible within the United Kingdom for the nurse education system to achieve initial nurse registration in four areas of practice - intellectual disabilities, mental health, child health and adult¹⁵. The branch component of the registered nursing programs comprises two years of study and practice focussed on one of the four registration areas. On completion of the program the university makes an academic award, with registration on the relevant part of the nursing register of the Nursing and Midwifery Council¹⁶.

It is at this point that the system within the United Kingdom differs from the majority of countries across the world, where a single Registered Nurse approach allows practice across all clinical areas and care groups by including core education and practice in core areas. Specialization occurs after initial preparation and registration as a nurse¹⁷.

An international dimension to nurse education

As part of the Promoting Health, Supporting Inclusion review, the Scottish government commissioned a report from academics at Monash University, Melbourne, that detailed the changes in nurse education in the 80s in Australia and their impact today on developments in the care and support of people with intellectual disabilities¹⁸. The report highlights the move away from a branch system of nurse education to a comprehensive single Registered Nurse outcome across all States and Territories in Australia. These changes were intended to prepare Registered Nurses with the knowledge and skills to work across all care groups and clinical areas. Implicit within the new education model was the belief that all nurses would be prepared with core skills to work with people with intellectual disabilities; this was part of the rationale for moving away from the branch model. However, in reality, it is the health needs of people with intellectual disabilities and other vulnerable groups that are not addressed within the curriculum.

Today there is a very limited focus on the health needs of people with intellectual disabilities despite clear evidence of their differing, complex health needs and the contributions required from nurses and midwives to improve health across the lifespan. The situation within Australia has been further compounded by a policy decision that regards the care of people with intellectual disabilities as primarily a social care issue. As a result, former intellectual disability health resources and professionals are not found within the healthcare system and have been transferred to social care services. The result is that they no longer practice as healthcare professionals. The situation is further complicated by an absence of a career and education pathway within intellectual disability healthcare. This contrasts with the United States where a Certificate in Developmental Disability Nursing is available for Registered Nurses at a post-qualifying level, thereby supporting the development of nursing practice. However, it is important to note that these developments are not without difficulties and challenges¹⁹.

There are clear messages for the nursing profession in Scotland and the United Kingdom in relation to providing evidence-based nursing practice for some of the most vulnerable and disadvantaged people in society. The changes within Australia support the need to ensure that there are nurses within the wider nursing and midwifery profession that are dedicated to addressing and meeting the health and nursing needs of children, adults and older people with intellectual disabilities. Their contributions will be even more crucial as a result of the increasing and aging intellectual disability population.

Undergraduate nursing programs

Four specific recommendations contained within Promoting Health, Supporting Inclusion relate to the education and development of nurses and midwives. The government established NHS Education for Scotland in 2002 with a directive to advance the knowledge and develop the skills of all healthcare professionals. This organization took forward the education recommendations and published Getting it Right Together which outlines the developments and changes that have occurred in nursing and midwifery education across Scotland²⁰.

As all nurses in the United Kingdom undertake the Common Foundation Program, there is the opportunity to incorporate a focus on the needs of people with intellectual disabilities. To ensure consistency across all universities responsible for nurse education in Scotland, learning materials on the needs of people with intellectual disabilities were commissioned by NHS Education for Scotland and were distributed for inclusion within the Common Foundation program. All students will now be educated and prepared with the core skills to work with this group. Now being implemented, the program's full impact must be formally evaluated to ensure that all student nurses develop an understanding of the needs of people with intellectual disabilities and of their value as citizens who are as entitled to equal access to healthcare as is the general population.

While all nurses and midwives have a responsibility to respond to the health needs of people with learning disabilities, it was recognized that the role of pediatric and learning disability nurses focuses more than other nursing specialities on meeting the needs of people with intellectual disabilities. As a result of this understanding, branch programs were reviewed by NHS Education for Scotland to ensure that they met the recommendations of the national nursing review and would educate and prepare practitioners appropriately for the future. From this work, a national learning disability nursing framework group, comprising representatives from the universities that provide the learning disability branch, was established. The group's framework is due for publication in 2005.

4. PRACTICE DEVELOPMENTS

Life-long learning and professional development are key government policies as well as a requirement of re-registration with the Nursing and Midwifery Council²¹. Recommendation 19 of Promoting Health, Supporting Inclusion asks that Directors of Nursing ensure that the skills and knowledge of intellectual disability nurses are harnessed and used within healthcare service induction programs so that all new appointees to health services have an awareness of the needs of this group. To support this initiative, NHS Education for Scotland is working in partnership with NHS Quality Improvement Scotland to develop the work undertaken for the Common Foundation program, Getting it Right Together, for integration within all local nursing and midwifery induction and continuing professional development programs. This will be a significant resource that will support development and understanding of needs, as previously there were limited opportunities available.

Recommendation 20 of Promoting Health, Supporting Inclusion identified the need for continuing professional development opportunities within the area of intellectual disability practice, particularly for specialist nurses who work with those with the most complex of care needs. A range of post-qualifying education developments have now been commissioned by NHS Education for Scotland with a focus on challenging behaviours, person-centered planning, health promotion, Autistic Spectrum Disorder and complex psychological needs. Education providers have been invited to bid for funding that will see the development and delivery of education material for professionals from health, education, social care and the independent sector. Materials will be developed and delivered in a flexible learning mode, thereby enabling wide access. As these developments are on going, there is a need to ensure that evaluation is integral to the process in order to measure and identify the impact and benefits.

With the implementation of the education recommendations, there is the opportunity to put in place a framework that will support the inclusion of education opportunities for generalist and specialist nurses. While the focus of the national nursing review was on nurses and midwives, the developments are clearly relevant to other healthcare practitioners and those in social care and the independent sector, who all have an important role in improving and meeting the health needs of people with intellectual disabilities. As this work is still in development, it is not possible to determine the impact. NHS Quality Improvement Scotland is to monitor these developments as part of their national intellectual disability inspection program, thereby promoting local accountability.

An important area identified from Promoting Health, Supporting Inclusion was best nursing and midwifery practice in intellectual disabilities across the lifespan. It became apparent there were considerable practice developments taking place, often led by practitioners responding to local need. However, frequently colleagues across the country were unaware of the practice developments taking place. As a result, the Nursing and Midwifery Development Unit within NHS Quality Improvement Scotland undertook a national mapping exercise to identify best practice and developed a database to support the dissemination and sharing of this work. Work is now being taken forward that will see the development and publication of a Best Practice Statement focussing on supporting and improving access to healthcare. This is in recognition of the need to support and develop all healthcare professionals to respond to the needs of people with intellectual disabilities across healthcare settings and enable equal access to care and treatment.

5. JOINT WORKING DEVELOPMENTS

In Scotland developments and changes are taking place within primary care based services, and in health and social care services for the key community care groups - older people, people with mental disabilities, people with physical disabilities and people with intellectual disabilities. The central policy theme is one of partnership between health, social care services and the independent sector. Termed Joint Future, these developments focus on joint resourcing, joint management and joint premises set in the context of a single shared assessment process to support the identification of need and the management of care²².

In addition to the developments supporting joint working between health and social care services, there are major changes in the way primary care services are delivered that will see the establishment of new Community Health Partnerships, 'CHPs'²³. It is the intention of the government that CHPs will develop the roles of primary care teams and support new ways of working with general hospital services and at the community level with social care services, thereby enhancing and improving care.

To support this integration, the government has issued guidance to healthcare services on the inclusion of and development of health services for people with intellectual disabilities²⁴. Such significant policy developments create the opportunity to ensure that health improvement occurs and services respond to and support the needs in an inclusive way. Within these developments there will be new opportunities for nurses and midwives to develop their role in improving the health and well being of people with intellectual disabilities.

The recommendations outlined within Promoting Health, Supporting Inclusion require a range of national and local actions to support their implementation. Others require local action, and to support this, a Scotland-wide Intellectual Disability Senior Nurse Group has been established. This group comprises Senior Nurses - Nurse Consultants, Clinical Nurse Specialists, Nurse Educators and Clinical Service Managers - from all intellectual disability healthcare services across Scotland.

The group now meets on a regular basis and has established a work program. The first action undertaken by the group was a mapping exercise of the current local activity supporting the implementation of the recommendations that relate to healthcare service providers. From this it has been possible to identify the areas of progress as well as those where there has been less of a focus and development to date. It is the intention of the group that the map of activity and developments is maintained and updated on a regular basis and that from this priority, areas for development are identified and taken forward. What is apparent from this exercise is the different interpretations of the Promoting Health, Supporting Inclusion recommendations and the prioritization of them. Clearly progress and prioritization need to be set within the context of the local circumstances and priorities; however, as some of the recommendations will require a local lead, there is the possibility that they become 'lost' within the wider changes and developments taking place within healthcare services. The Senior Nurse Group, therefore, has the potential to influence and shape the local implementation of the recommendations.

Additionally, the group can share best practice, enable networking with colleagues, as well as seize the potential opportunity to begin to influence wider policy development and implementation that impacts on the health and well being of people with intellectual disabilities. Therefore, there is the opportunity for the Senior Nurse Group to take a lead role in shaping nursing and midwifery practice and begin to influence and shape wider policy.

DISCUSSION

A WINDOW TO THE FUTURE

Government priorities are evolving and changing and have an impact on the policy process - from the identification of the need for action and change, through to the policy development, and on to implementation. With their changing priorities, there is the possibility that the focus on intellectual disability health may not be sustained.Within Scotland major changes and developments within healthcare services are taking place. People with intellectual disabilities, as citizens, need to have their needs included and taken into account as part of the change process. Therefore, recognition of their distinct and different healthcare needs is crucial in ensuring health improvement takes place. However, while the healthcare developments and changes taking place impact on all citizens, there is a clear danger that people with intellectual disabilities fail to receive the attention and consideration they require, thereby impacting their health and well being in the longer term.

Maintaining a sustained focus and overview of the implementation of the Promoting Health, Supporting Inclusion recommendations are important now and in the future to ensure that the nursing and midwifery contributions to the health improvement of this group are supported and developed. Significant progress has been made across a number of areas since the publication of the review some two years ago, a relatively short period of time from a policy implementation perspective. These developments have in part been possible by recognizing the need for partnership with key stakeholders during the policy development phase, thereby ensuring there is support for the implementation of recommendations.

The recommendations can be grouped into those that have a national focus and those with a local one. The national recommendation have been supported by key organizations - NHS Health Scotland, NHS Quality Improvement Scotland and NHS Education for Scotland - and have resulted in significant developments that have had an impact across the country. This approach builds in accountability for implementation and ensures that the needs of people with intellectual disabilities are integral within their work programs and priorities.

The developments outlined to date relate to nurses and midwives in generalist and specialist roles across the lifespan. This is significant, as they are the largest single group of health professionals and are frequently the first point of contact for people requiring healthcare. Ensuring they have core knowledge and skills on the needs of people with intellectual disabilities is vital. While these developments are clearly necessary, nurses and midwives are but one group of health professionals who come into contact with people with intellectual disabilities. People with intellectual disabilities are found in all areas of the healthcare system and, as a result, it is necessary to ensure that doctors, therapists, administration staff and managers all have an understanding of the core needs of this group.

This is an issue identified and outlined in the health needs assessment report, with recommendations suggesting that the work that has been started with a focus on nurses and midwives be generalized and developed to include all healthcare professionals. As it is now recognized and accepted that people with intellectual disabilities have different and greater health needs than the general population, and with education and practice developments supporting generalists and specialist health professionals, there is also a need to focus on those working in social care, education and the independent sector, and ensure that they have receive core education on the health needs of people with intellectual disabilities and the important role they have in health improvement. This will require a new focus that can build on the positive developments being taken forward by nurses and midwives in Scotland.

CONCLUSION

Government in Scotland has recognized the distinct needs of people with intellectual disabilities as equal citizens and a clear policy framework has been established that supports their inclusion within Scottish society. Nurses and midwives are recognized as having an important contribution to make to this group in addressing their health needs, and the national nursing review has set out the actions required from them. This has ensured that there is a clear framework to support nurses and midwives in Scotland and, since the publication of Promoting Health, Supporting Inclusion in 2002, there has been a range of national and local actions to support implementation. While establishing a clear policy framework is vital, the true challenge rests with full and successful implementation. As part of the policy implementation, on-going evaluation and monitoring is required to ensure that the vision becomes a reality for people with intellectual disabilities in Scotland.