50 shades

50 shades of drivel in incentivising dementia diagnosis in primary care in England

50 shades

Nobody wants a person waiting unreasonably for a correct diagnosis of dementia.

This discussion is NOT about that.

The now infamous odious scheme from NHS England was designed to give GP surgeries £55 for every patient on their list who has been diagnosed with dementia in the six months up to next March, as part of a drive to get the rate of diagnosis up from about 50% to two-thirds of all those who develop the condition.

Identifying dementia in primary care could minimise the impact of a late intervention; however, it shows high rates of misdiagnosis.

Any misdiagnosis as dementia is of course a disaster professionally.

One of the reasons for problems in primary care may bethe lack of knowledge of adequate cognitive screening instruments.

This is not because it’s the GPs’ “fault”. This is an incredibly specialised area which needs to be done by trained professionals.

Yokomizo, Simon and Bottino (2014) indeed suggested:

“[Screening] Tests such as 6CIT, AMT, GPCOG, Mini-Cog, MIS, MoCA, and STMS seem to be good alternatives to the use of the Mini-Mental State Examination when considering factors such as application time, sensitivity, specificity, and number of studies. However, there is a wide range of tests with different characteristics, therefore it is recommended that the professional gets some expertise in a few number of instruments in order to be able to choose which to use, or use in combination, depending on the setting and the profile of the patient.”

The way in which the policy of incentivised case finding for dementia was introduced is beyond contempt.

The dementia identification scheme was not approved by the BMA GPs committee in negotiations on the 2015/16 GP contract. But this is symbolic of the general arrogant way in which policy seems to be imposed in a ‘there is no alternative’ manner.

In October 2014,  the GPC deputy chair Richard Vautrey said GPs did not need a financial incentive to diagnose dementia, which was something they were already doing, and the investment would be better spent supporting practices to care for these patients.

He said,

“Diagnosis of dementia is important, but chasing government targets is not, particularly if this undermines the doctor-patient relationship, which this proposal could do.”

Historically, the incentivisation of General Practitioners (GPs) to diagnose dementia began in 2011 with updated dementia strategy.

It is now becoming a matter of transparency and integrity that NHS England publishes the official impact assessment which accompanies this policy, and identify clearly where the sources for this policy lie.

Major depressive disorder can present with profound memory problems; it can also present with other symptoms, more traditionally associated with problems in the front of the brain, such as poor planning or apathy.

Major depressive disorder with psychotic features is relatively frequent in patients with greater depressive symptom severity and is associated with a poorer course of illness and greater functional impairment than MDD without psychotic features.

Multiple studies have found that patients with psychotic mood disorders demonstrate significantly poorer cognitive performance in a variety of areas than those with nonpsychotic mood disorders. The Mini Mental State Examination (MMSE) and the Dementia Rating Scale, Second Edition (DRS-2) are widely used to measure cognitive functions in research on MDD with psychotic features.

Wagner and colleagues (2011) reported that:

“the suggested cut-off scores for the MMSE and the DRS-2 in patients with MDD with psychotic features may in some cases produce false-positive indications of dementia.”

A risk of the incentivising scheme is that it potentially undermines the bond of trust between doctors and patients by giving GPs for the first time a financial incentive to diagnose a specific condition.

Whilst certain people who are accountable to boards of trustees or shareholders, GPs are accountable to their patients and to the clinical regulator, the General Medical Council.

Putting it politely, GPs are sitting on quite an explosive matter, and it’s fair to say that existent memory clinics could be better.

It can be difficult to persuade a patient, who is generally apprehensive about the diagnosis, to go to the psychiatric hospital for a memory assessment, especially when post-diagnostic support can be so patchy and poor.

The scheme is a textbook perverse incentive. The initiative is intrinsically unfair because it potentially GP practices with the previously lowest rates of diagnosis the most money.

The policy, more importantly, offends many professional physicians, who have studied medicine, both intellectually and ethically.

Dr Martin Brunet comments:

“We need a Memory Worker in every GP practice; someone who will visit the home within days of a diagnosis, offering flesh-and-blood support to anyone living with dementia. They don’t need to be nurses – though they could call upon their expertise if things get difficult – but they need to have time: time to listen; time to sit; time to visit regularly so that they become a familiar face, a friend even; a travelling companion on the journey called dementia.

These Memory Workers would need to be trained. Get someone like the fabulous dementia campaigner Beth Britton to head this up – hearing her talk for half an hour is enough to inspire anyone to see the person behind the dementia and to recognise the importance of expanding horizons rather than closing them down. We would need thousands of workers, of course, even if each one covered two or three practices. Can we find people to do this work? Of course we can, but it will take time, so we need to start now.”

But a group of GPs (Bell and colleagues, 2015)have further broken rank in an article entitled, “A diagnosis for £55: what is the cost of government initiatives in dementia case finding”

“Not only are we concerned about not reducing the memory gap, but the incentivisation of diagnoses of dementia has the potential to make things worse. The dementia diagnosis rate in Sheffield is higher than most (62%), but this creates more follow-up and support for people with dementia.

This affect waiting lists in the memory clinics, which have increased. A lot of work and resources have been spent to reduce the wait. We investigated the quality of GP referrals to memory clinics. Seventy-six per cent of GP referrals to our memory clinic included cognitive screens. The screens such as the 6CIT have good sensitivity and specificity in distinguishing people with mild to moderate Alzheimer’s disease to health volunteers who responded to an invitation to help in research on dementia. These tools will not have the same sensitivity and specificity if conducted on people who attend GPs with cognitive complaints, as this population will likely include many with functional memory disorder and due to depression. GPs are asked to exclude reversible causes of dementia. Testing of B12 and folate was high, but mood screening was included in only 26%. Depression is a severe debilitating disorder that is treatable. It is also a common comorbidity in people with dementia. We suggest that the financial incentivisation of the diagnosis of dementia may not achieve its targets in reducing the dementia gap, will increase the strain on GPs and Memory clinics, which may adversely affect waiting times and the provision of good-quality post diagnosis care and support for people with dementia and their families.”

The question is: where are the clinical leaders who wish to speak out the problems with this incredibly problematic policy?

References

Bell S, Harkness K, Dickson JM, Blackburn D. A diagnosis for £55: what is the cost of government initiatives in dementia case finding. Age Ageing. 2015 Jan 24. pii: afu205. Citation  here.

Wagner GS, McClintock SM, Rosenquist PB, McCall WV, Kahn DA. Major depressive disorder with psychotic features may lead to misdiagnosis of dementia: a case report and review of the literature. J Psychiatr Pract. 2011 Nov;17(6):432-8. doi: 10.1097/01.pra.0000407968.57475.ab. The citation is here.

Yokomizo JE, Simon SS, Bottino CM. Cognitive screening for dementia in primary care: a systematic review. Int Psychogeriatr. 2014 Nov;26(11):1783-804. doi: 10.1017/S1041610214001082. Epub 2014 Jul 15. Citation here.

 

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