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Have GPs been 'gaming' the dementia DES?

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Whatever we think about NHS England’s decision to pay GPs for every new diagnosis of dementia, the policy has undeniably had an impact.

Last week, Pulse announced the huge surge in diagnoses since the initiative was introduced in September – nearly 35,000 new cases in five months compared with only 4,600 in the previous five. No doubt, ministers will be congratulating themselves on their success - and if I were interested in bean-counting then I would join them.

But the trouble with ‘bounty’ schemes like the dementia DES is that counting the bounties paid out is only half the story. History is littered with examples where financial incentives created perverse behaviours that only made a bad situation worse - the most famous example being the attempt of British Colonial rulers to rid Delhi of cobras.

The story goes that Delhi was plagued by the snakes at the time, and so a bounty was to be paid for every cobra skin presented to the government. The trouble was that hunting wild cobras was a tiresome and dangerous business, yet the bounty was a lucrative offering.

So some cunning entrepreneurs started to farm the snakes in order to turn a tidy profit. In time, the policy makers discovered they had been outwitted and cancelled the scheme, the market for cobra skins collapsed and cobra farms were closed down – with many of the reptiles simply being released in the process, thus worsening the initial problem.

It’s not only the British who were capable of such misjudgements. In the early 20th century, the colonial French rule placed a bounty on rats to rid the city of Hanoi, Vietnam of the vermin. The rulers only required the rat’s tail to be produced for payment until they discovered many tail-less rats running freely round the city, since the rat catchers had learnt that their trade was most lucrative if they kept the rats alive in order to breed.  

And should you think we are now too civilised or clever to be susceptible to this ‘cobra effect’ there are plenty of 21st century examples, including payments for greenhouse gases and bounties for pig tails in America.

While, I’m not suggesting that GPs are as unscrupulous as the cobra farmers, but there is no way of knowing if doctors have gamed the system.

Does 35,000 extra diagnoses mean 35,000 people with dementia receiving better understanding, care and support?

Or has much of this been just a paper exercise with read codes like ‘memory problems’ changed to dementia at the press of a button?

And how many of these patients even know their diagnosis has been changed?

Given the pressure on memory clinics it’s hard to believe so many patients have been referred, seen and properly diagnosed in so short a time; many of these new diagnoses must have been made in the community. How many patients have been misdiagnosed? We have no way of knowing.

Consider also that someone might have dementia, but the GP knows the memory clinic won’t turn them around before the end of March. What would you do in that situation: tell yourself that’s bad luck that the memory clinic has such a long waiting list in your area, or code them as dementia now, knowing that after the end of March you can always change the code if the specialist diagnoses something else?

I don’t know what I would do - but then again I haven’t signed up to this scheme. Had I joined it, I know that I would resent doing work, only to miss out on payment because of inefficiency elsewhere in the system.

We will never know how many patients have been put off seeing their GP because the scheme undermined the trust they had in their doctor.

Nor will we ever find out how many patients who really needed the support of the memory clinic have been delayed in getting essential help due to clinics being overloaded by referrals from GPs playing the numbers game.

Probably the only things we do know from this whole sorry scheme is that policy makers will always look for a quick fix when there is an election looming, and the human race is destined to relive its mistakes again, and again, and again.

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

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Readers' comments (9)

  • I agree that it is very unlikely that 35000 extra READ coded diagnoses is 35000 extra people assessed and diagnosed in 5 months. I think replacing a READ code of memory problems to dementia as a paper exercise is unethical. The only exception being when the patient has actually been given a formal diagnosis of dementia after formal assessment and the practice simply forgot to replace the memory problem code in the patient 'problem list'. In this situation adding the code is helpful as it ensures these people are invited for dementia reviews and the diagnosis is visible on the problem list. I was pretty surprised that this paper exercise actually yielded a 10% increase in the dementia register in our practice.

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  • qof is unethical but because it has been around for so long we have got use to the game of read coding. the dementia des is an extension of this.

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  • I think most are people who have been previously diagnosed with dementia - but not coded properly having their code corrected.

    I think that is the benefit they were aiming for with this scheme. If they wanted to give people an incentive to diagnose new dementia, they should realise it costs the GP a lot more than 50 pounds.

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  • The Dementia Tsar has said that "doctors are in the driving seat". No mention of patients, often our vulnerable elderly.

    In my considered view, those "in the driving seat" are the politicians fully supported and encouraged by Alzheimer Society.

    In my opinion this is a dark period in policy "improvements" based on a spurious target where dementia risks being further re-defined.

    Dr Brunet is right to be concerned about this. If there is harm as a result of target obsession ...who will be held accountable I wonder?

    Dr Peter J Gordon

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  • There is 'a way of knowing if GPs have gamed the system'........surely you have read the posts on PULSE!

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  • After running a search organised by the CCG we identified 2 patients on donepezil without a code of dementia, which we then duly added. This could at least partly explain the figures. Plus the increased media coverage of dementia and adverts from patient support groups has sent literally dozens of patients into my surgery over the past 12 months complaining of memory problems, and several of these have been diagnosed with dementia too.
    On a separate note Pulse, whilst i do agree it is generally important to allow personal opinion in a blog, surely it is a little irresponsible to publish a colleague joining in with the rampant "GP bashing" in evidence in the media already?

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  • It's well known (to everybody but NHS England, it seems) that the tests for mild cognitive impairment are quite useless in the sense that they produce vast numbers of false positives e.g.
    http://www.dcscience.net/2014/03/10/on-the-hazards-of-significance-testing-part-1-screening/

    It would help if NHS England understood evidence better and were less inclined to tug their collective forelocks when ministers come up with daft ideas.

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  • Harry Longman

    Yah beauty. Go Martin.

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  • A few changes from H/O Dementia to Dementia is hardly gaming, just the wrong codes getting picked up.

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