Diagnosing earlier to avoid a crisis later
Victoria Reed and Dr Mark Ward on how a simple screening tool has helped avoid crisis situations
We knew there was a lot of under-diagnosis of dementia because patients were being picked up only at a late stage. Too often this resulted in emergency admissions, when families and carers – struggling alone for a long time without access to the necessary help – could no longer cope.
Earlier diagnosis also means patients can be put on medication at a stage in the disease progression when it could still be effective.
Early support – both social and legal – can be offered for carers and an opportunity created to improve the quality of life of patients with dementia.
Durham Dales locality is made up of 12 GP practices covering 90,000 patients – but approximately 25,000 are in the Teesdale area which is predominantly rural, potentially causing isolation and transport issues that can make services harder to access.
As part of the Department of Health’s integrated care organisation pilot, we had regular meetings with our colleagues in secondary care as well as nursing staff, and it was felt that a standardised screening tool could be easily used to improve early diagnosis and get patients the help they needed before their situation got out of control.
What we did
One of our local consultants recommended the six-item cognitive impairment test, recently endorsed by the RCGP, as an initial screening tool.
The test has been around for many years, but this was not something we routinely used in our practice. It takes about five to 10 minutes to complete and gives GPs a score that determines whether someone needs to be sent for further assessment.
We felt it was a standardised tool that could easily be uploaded onto primary care systems, was simple and easy to use within the context of a routine appointment, and could be used by any healthcare professional.
It required no training and meant that practices were all following the same pathway. It also meant that practice nurses – who might be in a good place to spot memory problems when seeing patients for wound dressing changes and other routine appointments – could use the tool as well as GPs.
This was initially implemented at the Auckland Medical Group before being rolled out to the other 11 practices in the Durham Dales locality.
At the same time, we carried out some publicity to encourage patients and carers to come forward if they were worried about memory problems.
This included leaflets that we handed out at flu clinics and some press coverage in the local newspaper.
We were fortunate that a new specialist memory clinic had been set up at Auckland Park Hospital and they were very keen to improve early diagnosis.
It meant we had guaranteed referral times of four weeks, and in some cases as quickly as two weeks, which was a vital part of the programme.
There would be no point implementing a screening tool if the referral pathway then took months.
To go alongside the screening programme, the CCG put together an information pack with support from a solicitor and the patient reference group at Tees, Esk and Wear Valley NHS Foundation Trust that contained information on Power of Attorney and welfare benefits.
As with the whole early diagnosis programme, there was no specific funding for developing the information pack – the funding we received from the DH for the integrated care organisation pilot was to cover staffing costs.
All of the work we did relied on goodwill and people sharing our enthusiasm to improve things for our patients. There were no specific incentives for GPs to use the screening tool, but we found no problems with buy-in to the scheme.
However, two of the practices decided to use a different memory test that better fitted with the referral pathway they had to a different hospital.
When we rolled out the screening tool to the practices, we assigned it a code so we could monitor when it was being used, how many patients were referred on and how many went on to have a diagnosis.
We had hoped to double the number of patients with a diagnosis of dementia through the use of the screening tool.
At the Auckland Medical Group where the tool was first implemented, the number of people diagnosed with dementia over the 18-month period of the pilot went from 30 to 60.
Across the locality, new diagnoses went from 267 in April 2010 to 346 by March 2011.
One of the most successful aspects was the publicity campaign we implemented alongside the test.
We saw a surge in patients and family members asking about the test after the article appeared in the local press, as well as enquiries to the CCG office either asking about how to get the memory test or just asking for advice.
The leaflets also proved a successful way of getting people to come forward.
The screening test is now used routinely by GPs in Durham Dales, although we are no longer monitoring it.
We are continuing to raise awareness that there are things that can be done to support patients with dementia, and to further drive use of the screening test.
Dementia remains a priority and is one of our strategic commissioning intentions. Of course, once people are diagnosed there need to be appropriate services in place to meet their needs, and we are reviewing our offerings to see if there are any gaps in our services.
Victoria Reed is a project lead for clinical commissioning at Durham Dales Commissioning locality. Dr Mark Ward is a GP at Auckland Medical Group
Initiative: Rollout of a simple six-question memory test to practices within Durham Dales Commissioning locality, alongside a publicity campaign to raise awareness among patients that the screening test was available if they were worried about memory problems. Patients were referred if needed to the local hospital, where a new specialist memory clinic was able to see them within four weeks.
Start-up costs: This was done within a Department of Health integrated care organisation pilot, with no extra funding.
Staffing: The test required no training and could be carried out by GPs or practice nurses.
Outcomes: The publicity campaign was successful, and over a six-month period there was a increase in people diagnosed with dementia.