A learning difference or disability is a reduction in intellectual ability (GMC, 2024). It causes lifelong difficulty with everyday activities. Different individuals require different levels of support. Individuals with learning disability may also have learning difficulties and mental health problems, but these conditions do not always co-exist. Learning difficulties affect the way someone processes information. They are not related to intelligence but can affect learning and education. People with learning differences can experience higher rates of mental and physical ill-health. The individual's life expectancy is shorter than the average for the population. This is related to access and experience of health care. These patients may experience discrimination affecting their healthcare.

Discrimination arises from staff and organisational attitudes towards patients and judgements about their quality of life. These individuals' care is also at risk of diagnostic overshadowing where a patient's symptoms are attributed to their disability rather than a disease. Many people with learning disabilities may find it harder to use healthcare services, and the investigators want to find out what challenges these individuals face. For example, do these patient have trouble understanding what is being said to them? Are there issues with getting an appointment or understanding the information about their health?

This project focuses on understanding the experiences of people with learning disabilities when they use health services. How easily do can these individuals communicate with their clinician? Are there barriers in accessing care? Do these individuals feel respected and listened to during their appointments? How should healthcare staff be trained to provide better care to these patients? The investigators will be speaking directly to patients with learning disabilities living in Derbyshire. This will be by interviews encouraging the patients to share their thoughts and experiences. The information the investigators gather will help understand these people's experiences of healthcare and how this could be improved. The investigators will also undertake an anonymised survey of medical students on their perceived learning needs regarding individuals with learning differences. This information will be used to develop educational resources for clinical teachers. medical students and staff. Working with the volunteers will better prepare future doctors to provide holistic care for patients with learning differences.

A learning difference or disability is a reduction in intellectual ability. It causes lifelong difficulty with everyday activities. Different individuals require different levels of support. Individuals with learning disability may also have learning difficulties and mental health problems, but they do not always co-exist. Learning difficulties affect the way someone processes information. They are not related to intelligence but can affect learning and education. Examples include dyslexia and attention deficit hyperactivity disorder (ADHD). People with learning differences can experience higher rates of mental and physical ill-health. The life expectancy of individuals with learning difficulties is shorter than the average for the population. This is related to access and experience of health care. Poor quality care severely affects outcomes for these patients, for example during Covid-19. The rate of avoidable death in people with learning disabilities is twice that of the general population. These patients may experience discrimination affecting their healthcare. Diagnostic overshadowing in which new mental and physical symptoms are wrongly attributed to an existing condition or disability are more common in individuals with learning differences and contributes to poorer outcomes.

The lack of training for healthcare staff, both pre- and post-qualification, is recognised as contributing to poor-quality care of patients with learning differences. The UK General Medical Council (GMC) recognises the need to address this in its ethical guidance to doctors. Furthermore, it has developed a learning package to guide practitioners. The GMC recommends staff training which is led by individuals with a learning difference. There is variation in educational interventions for teaching medical students about learning differences. These include classroom-based teaching, simulation with actors, individual placements, home visits and panel discussions. These interventions tend to be teaching about the patient rather than with the patient. Furthermore, study quality is poor with use of non-validated measures making assessments problematic.

Patients are stakeholders and the greatest experts in their own healthcare needs. Leaving no-one behind means listening to all patients, engaging in dialogue and learning to see things from the patient's perspective. This study will examine the co-production of a volunteer-student teaching session to improve the understanding of future doctors of this important area.

Co-production in healthcare planning and delivery is well established including in medical education. The School of Medicine at the University of Nottingham has a long-standing reputation for working in partnership with members of the public. People have contributed to teaching and assessment in innovative ways, and the School has regularly jointly produced publications and co-presented at conferences. Engagement with patients recognises their dignity. It integrates the four ethical pillars - beneficence (do good), non-maleficence (do no harm), autonomy - (self-determination, shared decision-making) and justice (fairness to all).

This study examines patient-student co-production in the context of educating medical students through collaboration with volunteers who have the lived experience of a learning difference. The collaboration will assess this process from conception to identification of volunteer experience and student learning needs, preparation of resources, delivery of an interactive session working with volunteers and reflection on the strengths and limitations of the educational intervention. The study will assist development of longitudinal resources for supporting students' ability to learn to provide high quality care holistic for individuals with learning differences.

Main research question What are the perspectives of the individual with a learning difference and of medical students on the learning needs and expectations of training of future doctors in healthcare for individuals with learning differences?

Supplementary question Can these begin to be addressed through a volunteer-led teaching and learning dialogue with graduate entry preclinical students?

Data collection methods

Data for the study will be collected using a mixed methods approach and will involve:

1. Initial qualitative interviews with volunteers and carers who have offered to come and speak to patients about their healthcare as individuals with a personal history of learning differences
2. Online survey of baseline learning and self-assessment of learning needs of graduate entry preclinical medical students in the second year of their training
3. Pre- and post-session quantitative evaluation by the students of the delivery of a session on healthcare for individuals with learning differences

Summary of known and potential risks and benefits

The benefits include an increased level and understanding among students and staff of the lived experience of individuals with learning differences. It may also increase confidence and belief among the volunteers and their carers of a willingness of healthcare staff and future doctors in wishing to engage, support and help patients with learning differences.

It will assist students' understanding of communicating sensitively with patients with learning differences around their possible experiences around their learning difference, and their previous experiences of engagement with healthcare services and staff.

It will also enable students to discuss and practice use of communication skills when working with individuals with learning differences (NB: The patients will not be physically examined during the teaching session, but the practicalities of physical examination or of procedures of having, for example, blood tests may form part of the group discussions).

Interviews/ questionnaires or group discussions may include topics that might be sensitive, embarrassing or upsetting either to the volunteers or to students experiencing similar feelings in their own lives or family and friends. It is possible that other disclosures (e.g. previous unprofessional behaviours by healthcare staff) requiring action could occur during the study?

Description of the population to be studied and special considerations

The study population will be 10-15 volunteers and their carers attending to discuss their healthcare experience and up to 120 Year 2 graduate entry medical students. Special considerations will be ensuring all participants are fully informed prior to consent regarding the use of data for analysis and storage. Psychological safety should be provided to participants and compliance with university safeguarding procedures should be in place in the event of participant distress.

Consent

This is a vulnerable group. Possible participants in the study have been identified from volunteers attending to participate in a pilot teaching session to GEM medical students held in September and October 2025. Professor John Frain is the Principal Investigator for the project. The prospective participants are either individuals with a learning difference or their carers. Volunteers will only be admitted to the study if both they and their carers are able to give informed consent.

The volunteers will be invited to either attend a room at the university set aside for the interview or to be interviewed on MS Teams. Some of the participants at the pilot teaching session were from a self-advocacy community group based in the East Midlands, UK. This is not an NHS-related education but is used as a placement for University of Nottingham students in clinical phase. Interviews with volunteers with a personal history of learning differences may take place at this location for the convenience of interviewees.

Interviewers will go through the information leaflet and consent form with both volunteer and carer. Additional time may be required for this, and this will be factored into the time required for the interview. If a volunteer is found not to have capacity to provide informed consent, they will not proceed further in the study.

Carers will also be consented to be key informants during the interview, but they will not be consented to speak on behalf of the patient or to interpret the thoughts of feelings of the volunteers.

Volunteers will be reminded of their right to decline to take part or withdraw without consequence.

Inclusion Criteria:

• Volunteers will be recruited from participants in teaching sessions to GEM medical students held in September and October 2025. This will be using convenience sampling. Up to 120 students currently on the GEM Year 1 preclinical programme at the time of the study will be invited to complete the study.

Exclusion Criteria:

• All who do not meet the inclusion criteria defined above

Individuals with an experience of learning difference based on personal history or a caring role and graduate entry preclinical students at a single institution in the United Kingdom

The participants include vulnerable individuals. Even where data is anonymised, it would be appropriate to request IPD only after the study is completed and they have reflected on their experience of participating in the project and had further opportunity to discuss IPD.