The five big dementia commissioning challenges
Rebecca Norris outlines the five big challenges CCGs face in transforming dementia services.
1. Deciding how much diagnosis work GPs can take on
CCGs face a pressing challenge to improve diagnosis rates, through the introduction of a new NHS Outcomes Framework indicator from April 2013. A figure is yet to be announced, but a diagnosis rate of about 60% is anticipated. As many as half of dementia sufferers are currently unaware of their condition.
The Department of Health will also change the NHS Health Check for 65- to 74-year-olds, so GPs and other health professionals will start to make this group aware of memory clinics and refer those who need assessment.
Prime Minister David Cameron's Challenge on dementia published in March states memory services will also be made available across the country. However, there is growing debate about where responsibility for diagnosis should fall.
Dr Martin Freeman, a GP who sat on the reference group for the DH's Dementia commissioning pack which was published last year, says national guidance ‘still looks to GPs identifying and referring into a memory service'.
While difficult-to-diagnose patients – such as younger people with early-onset dementia – ‘absolutely need a sharp definition', he believes there are a number of patients ‘with quite significant dementia that primary care can be diagnosing'.
Dr Freeman says: ‘We all need to look at our high-risk groups – people with significant vascular disease and with neurological disease such as Parkinson's and MS.'
Dr Nick Cartmell, who works with Dr Freeman as the other regional GP lead on dementia in the South West, adds: ‘Do we need to spend vast sums on expensive memory clinics for people when the diagnosis is pretty clear?'
The debate is sharpened by the shift from block contracts in mental health to payment by results (PbR), which will give commissioners a transparent price for services.
Four of the 21 areas of mental health work drawn up for PbR cover cognitive impairment from low need to high, although national tariffs won't start until 2013 at the earliest.
Tariffs could give CCGs an impetus to shift more assessment work into primary or community care.
Dr Sube Banerjee, co-author of the National dementia strategy published in 2009 and professor of mental health and ageing at King's College London, says memory services can be provided in a variety of ways by different providers: ‘It's not who does it, but what's done. It's more likely to be successful if they're commissioned as a discrete service, rather than as just one of the functions of a general service, but a local CCG might think differently. The most important thing is that they have a source of multidisciplinary skill in making an accurate diagnosis well, and breaking that diagnosis with sensitive communication – which is no small task.'
CCGs looking to revamp or launch services could turn to a £10m fund designed to pump prime memory services, announced by the DH in September 2011.
2. Increasing diagnosis rates
Dr Cartmell cautions that CCGs may find it difficult to drastically raise diagnosis rates: ‘If you look at the latest Alzheimer's Society map of prevalence, it is striking how the further north you go, the higher the recorded prevalence.
‘This is probably due to the well-known increase in vascular risk factors further north. For areas where vascular risk rates are lower, it may be very difficult to reach 60% diagnosis rates even with superb service and proactive case finding.'
Dr Freeman urges CCGs considering GP training needs on dementia detection to look at the EVIDEM-ED model being tested in a randomised controlled trial run by academic GP Dr Steve Iliffe, professor of primary care for older people at University College London.
Final results are due out later this year, but costs for CCGs to consider – in a nutshell – would be for up to three GP trainer-led sessions with doctors and other staff per practice.
Professor Emma Reynish, a consultant physician at NHS Fife, says all healthcare services need to understand that patients often present non-typically: ‘They or their families won't go in and say: "My mother's memory is failing."
‘It will be much more a diagnosis of dementia that comes with what everybody sees as that ageing process – increasing frailty, perhaps starting to fall, or not managing simple tasks. That gradual decline needs to be picked up.'
3. Ensuring care is there following a diagnosis
Dr Freeman says the challenge for primary care is ‘getting ourselves in the position where we believe that identifying and diagnosing dementia early can make a big difference, and that we have support packages to offer when we do – because ethically, to diagnose without doing anything about it would be inappropriate'.
A post-diagnosis community dementia support service could help CCGs not only improve care, but reduce costs of acute hospital and care home admissions, says Dr Cartmell.
He carried out an evaluation of dementia support worker roles, published last November, which took an in-depth look at six different services. Costs ranged from £21.43 (Alzheimer's Society adviser) to £1,026 (integrated care) per person with dementia.
The greatest savings, of £300 per person with dementia, were produced by a memory nurse service based at a Cornwall GP practice. The band-six nurse, directly employed by the practice from PBC savings, has increased recorded prevalence, saved around £25,000 in delayed care home admissions, reduced unnecessary prescribing and prevented admissions by educating carers about spotting and managing UTIs.
Dr Cartmell says CCGs should bear in mind that small models like that in Cornwall ‘rely on the enthusiasm of other workers in that geographical location for their success, and applying them to a wider community – where greater barriers to dementia care exist – is more challenging'.
He suggests CCGs consider a two-tier model, with the first tier using high-frequency, low-intensity proactive input, such as an Alzheimer's dementia adviser role, and the second tier comprising low-frequency, high-intensity reactive input, such as existing community practice nurses or an Admiral nurse (specialist mental health nurses supported by Dementia UK).
Dr Cartmell says tier-one advisers can be modified by commissioning ‘added value' to involve them in pre-diagnosis work-up: ‘Another option might be to commission advisers to be advocates for those with dementia and their carers when either going through the diagnostic process or applying for services, support or both.
‘A third option is to co-locate advisers with both primary care complex care teams and community older person's psychiatric nurses to encourage joint working and good communication between team members – whether in health, mental health or social care.'
Dr Freeman adds that ‘we've got to think out of the box about how we spend our money' – carers' education, for example, could delay admission to residential care by 557 days: ‘But in one area, the spend for carers was less than 0.4% [of total spend].'
4. Getting hospitals to make dementia their business too
Last month, CCGs gained a new lever to encourage better hospital management of patients with dementia in the form of the dementia CQUIN. Worth £54m, it will reward hospitals who offer dementia risk assessments to all patients over 75 years of age on admission. The incentive could cut the lengthier stays patients with dementia have compared with non-dementia patients, as well as reduce the numbers discharged directly to a care home.
Professor Reynish says the move is ‘fantastic': ‘That really is bringing things out of the domain of specialist mental health and saying to hospital staff: "This is everybody's responsibility".'
Her own workplace – Victoria Hospital, Kirkcaldy – launched a pilot three years ago to screen for dementia on admission, which has now been rolled out across the health board.
The pilot found nurses doing the screening needed more intensive training than first thought in order to gain ‘a background understanding about what is cognitive impairment, what is delirium and why is functional ability important'.
But it also generated an unanticipated positive response from patients telephoned by the screening nurses.
‘Families were absolutely desperate for some sort of interaction, to be able to tell the hospital system what had been happening at home,' Professor Reynish says.
She adds screening could easily be carried out by other team members, subject to local agreements. And rather than flood mental health memory services with referrals, Professor Reynish believes the screening will prompt a broader response by healthcare professionals to take on more assessment, particularly among geriatricians.
5. Reducing inappropriate prescribing
Two-thirds of antipsychotic prescriptions for the 180,000 patients with dementia on medication each year may be unnecessary, according to an independent review by Professor Banerjee carried out in 2009.
He found this could be contributing to 1,800 excess deaths or 1,620 cerebrovascular events per year, and called for the rate of medication use to be reduced by a third over three years.
To tackle this, the DH's commissioning pack urges commissioners to:
• arrange for a review of all patients
• insert clauses in contracts with providers on reductions, and to ensure they follow NICE/SCIE guidance
• use CQUIN schemes to cut inappropriate prescribing
• publish data on progress to achieve reductions.
Professor Reynish says while this move is welcome, ‘we need to make sure that commissioning of our services has an awareness of the element that [antipsychotics] are the treatment of choice in a number of situations'.
These include acute delirium associated with dementia (where medication review should be carried out every 24 to 72 hours) or psychotic symptoms associated with dementia (requiring review within weeks).
She adds that over time, GPs will gain more confidence in managing dementia and patients will be diagnosed earlier: ‘I don't think people will get to that perilous state where they are needing an antipsychotic, because we will have managed the whole of their dementia better'.
Rebecca Norris is a freelance journalist