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Cash for diagnoses? Just say no

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The Government wants to bribe us to diagnose more people with dementia – to the tune of £55 per patient in the form of its new dementia DES, so that it can hit its target to raise diagnosis rates.

No-one is against correctly diagnosing dementia, but NHS England have either not considered the ethics of this new policy, or are so blinded by their goal that they don’t deem ethics to be important – either a lack of moral insight, or a failure of moral leadership.

To undertake the DES you would count how many patients with a dementia diagnosis on your register at the end of September, compare this with the number at the end of March and score £55 for every extra patient.

It’s that simple: no questions asked.

The profession can either roll over, take the cash and go back to worrying about all our other problems - or we can stand up to this bullying of the doctor-patient relationship, and tell our masters that this time they have gone too far. And they really have gone too far. NHS England has crossed a line that has not been crossed before.

We are used to being paid for things of course, like asthma reviews and statin prescribing, and we are well aware of the problems this causes – but at least patients can opt out if they don’t like it.

They can refuse to attend a review, decline our offer of a statin or politely take the pill packet and store it unopened in the kitchen cupboard. They cannot opt out of a diagnosis.

The point of making a diagnosis is something the doctor does alone. The patient can contribute, of course, they provide evidence and we certainly want to know what they think, but the moment of judgement is for the doctor and is enormously difficult for the patient to challenge. What we code in the notes really is up to us, which is why there must be absolute trust that the doctor is acting only and solely in the best interests of the patient.

To contaminate this process with a financial payment seriously undermines the doctor-patient relationship in a new and pernicious way.

If we sign up to this DES are we going to explain to our patients the profit we will make from diagnosing them? We would expect an insurance salesman to be transparent about the commission he would make if he sold us a policy – why would doctors be above the need for such transparency?

How will our patients feel if they knew? If you can look them in the eye and explain why you should be paid according to the diagnostic label you apply then go ahead and sign up – I for one could not do that.

And how will you feel about undiagnosing your patients if they’ve been misdiagnosed?

I’ve undiagnosed patients twice in the last year, and had to fight hard for a second opinion in one case when a trainee diagnosed dementia on the basis of an MRI scan alone without really talking to the patient.

Were I signed up it would cost me £55 a time to get these patients correctly diagnosed; might I hesitate if I knew that?

I am not naïve about the financial pressures we are under, but nor am I going to believe that we have no choice but to accept this. To find 10 new cases in the next six months would be some going – and it would only raise £550 in funding from the DES. If it’s money you’re worried about, surely we can afford to have a conscience in this case.

It’s time to say no, time to stand up for the doctor-patient relationship and the trust that it depends upon, and time to boycott this odious scheme, while screaming and shouting about it in the process.

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68. 

Readers' comments (7)

  • Vinci Ho

    (1)I can see people will come up with a criticism ,' we just cannot win with you guys , you moan with or without money anyway!'
    (2) But, always a but, what is the real meaning and motive behind this DES. Yes, if we carry on 'business as usual' , this £55 per patient could be a 'generous ' reward for those new cases we will pick up normally until the end of April next year.
    (3) Bottom line of this government is it believes that dementia is grossly under-diagnosed and wants majority of them diagnosed in the next 6 months.
    (4) In fact , practices will have to show a 'net increase ' in number of new cases before this money will be paid .
    (5) Virtually, this is a screening program with no adequate funding. Bear in mind , one will have to target a population and keep asking whether these patients have a memory problem , at least opportunistically. So 68 years Mr Jones saw me for chest infection , I would ask 'do you think you have concerns with your memory?'
    (6) While you are paid only for positive diagnosis ,£55 per case, Wow, effort and time have been spent on reassuring patients with a negative test result on mental health tests( whichever scale one will use).
    (7) Also , while it matters the most to pick up those with early stage of dementia as they may benefit from cholinesterase inhibitiors/Memantine, one will also pick up a lot of more advanced cases which actually need more input from mental health and social services. Are they properly funded for this extra work? This is where the question of being unethical coming from.
    (8) Once again , this is a ill thought campaign where politicians are running out of time for their political agenda . Another Giant White Elephant , new emperor's clothes.A little bit of money left on the road to pick up with an incoming truck coming towards you!(Copyright of John Glasspool!).
    (9) For those who wants to help these shameless politicians to accomplish this 'mission' , good luck. As I said before , it is only a fine line between politically correct diplomacy and dangerously flawed hypocrisy .

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  • These can be done on a sliding scale. e.g. acute appendicitis=£3. Diagnosis= £ 4.90p.DIY on kitchen table=£ 20. Referral to surgical Registrar=£ 3000.00.
    Anaesthetist=£.2.00.
    Taxis and London shrink=$1000,000.

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  • Great piece Martin, thank you for posting this, I have shared it on my twitter account.

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  • The scheme has the usual problems - too little money and too much bureaucracy.
    But "contaminate the relationship with a financial payment" Seriously? Do you not pursue QOF targets and LESs and DESs? Do you go to work without ever a thought of getting paid?

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  • agree.
    disgraceful extreme insult to the profession.
    just say no..then no and no again a hundred times.
    we do not need such childish demagogic misleading trash schemery but more social care resources..by the way tories have been busily dismantling this and at the same time come up with these evil wastes of public money on non evidence based outrageous ********.
    shame..once again..on them

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  • John Glasspool

    "Just say no". Why don't GPs do this with other things, like unfunded secondary care work dumped on them?

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  • NHS Scotland had a financially incentivised approach to the "early diagnosis" of dementia. This was HEAT Target 4. The target was reached and the Scottish Government were triumphant about this presenting the achievement to Westminster in 2012 (All Party Parliamentary Group)

    NHS Board in Scotland took robust measures to reach the target and thus gain the financial reward. Practice became skewed in many ways to reach the target.

    This target was set by the Scottish Government. The most Senior Official for Mental Health in the Government (Mr Geoff Huggins) stated that the Government had been careful "to take out saboteurs" and that any disagreement by doctors or managers would be dealt with "behind the bike shed".

    Wind on nearly 4 years and it is emerging that elderly patients were mis-diagnosed with "early dementia" as a result of this target. In fact they have static age-related memory loss and not dementia.

    Scotland stands as evidence emerges of the harmful effects of an incentivised target based on "early diagnosis". It is no light matter to make a wrong diagnosis. Ask those mis-diagnosed.

    I personally campaigned across the United Kingdomfor an approach based on a TIMELY approach to diagnosis. This approach was completely rejected by the Scottish Government throughout my "engagement" with them. But CURIOUSLY the Scottish Government are now taking credit for a timely approach to diagnosis. This is quite sickening as Scotland could have offered an important lesson had the Scottish Government been open, honest and shown probity.

    I agree with all those who say that chasing a crude uncertain population target, a target that is politically motivated and has been promoted RELENTLESSLY by the Alzheimer's Society is UNETHICAL.

    This approach risks generating a huge amount of fear. It also risks medicalising too much of ageing such that those living with dementia are further disadvantaged as services get ever more stretched.

    Above all a TARGET like this, an I realise that NHS England call it an “ambition”, ignores complexity and the parabolic distribution of cognition over our life course. Our elder generation deserve far far better.

    Dr Peter J. Gordon
    Psychiatrist for Older Adults
    NHS Scotland

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