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Thank God they've binned the dementia DES

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‘Do you have any concerns about your memory?’

‘If I say yes, will that sort out your Christmas cashflow?,’ my patient replies, before giving me a knowing half-smile.

I’m relieved that Simon Stevens has stated that there are no plans to extend the dementia DES. I suspect that I’m not the only GP who has avoided opportunistically asking about memory after spotting the headline of the newspaper sitting on the patient’s lap.

The relationship that I have with my patients is crucial. It’s vital that my patients know that I will always aim to act in their best interests because, as corny as it sounds, I care. 

I want them to get timely diagnoses; I want them to access the care they need at the right time. Importantly, I want my patients to trust that this will always be the case. The DES payment system undermines this.

However, GPs should ensure that dementia is recognised and patients and carers can access the care and support they need. We need to strive to slow progression of cognitive impairment and aim to maintain our patients’ good health, wellbeing and independence. To accomplish this, there needs to be identification of all the factors that potentially prevent this. We need to understand why each factor exists and implement means to overcome them. An increased dementia diagnosis target does not achieve this.

A diagnosis doesn’t automatically send health and social care services running in. Many of our health and social care services are buckling under the pressure of looking after those patients already in their care. Without increased investment, we risk diagnosing many people with dementia with the sole consequence of applying a label.

Furthermore, dementia is a complex syndrome without a diagnostic test. It is the most feared illness in people over the age of 55 and patient anxiety can increase the score on the objective tests that we do use. In the quest to drive up the diagnosis rates, we risk causing harm through misdiagnosing those with mild or subjective cognitive impairment.

I ponder the gentleman’s question of whether £55 will sort my Christmas family cash flow. I wish! Admittedly, my patient hasn’t seen the reams of paper required to write the Christmas shopping list, nor the plethora of toys that Father Christmas is storing in our loft.

However, maybe there’s now a clinical need to pursue a memory assessment - beginning with ‘Please can you tell me the year?’

Dr Lisa Harrod-Rothwell is a GP in Essex and former chair of a local CCG.

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Readers' comments (2)

  • Good blog Lisa.

    I agree: thank goodness the dementia DES has been binned.

    I work in Scotland and am an NHS specialist in Dementia - so this incentivised approach has had no remit in my work.

    However, some years ago, Scotland had its own incentivised target for the "early diagnosis" of dementia (HEAT target 4). My concerns stem from this Secondary care target. I found that the target resulted in skewed approaches and changed diagnostic boundaries - such that "early Alzheimer's disease" was considered to be dementia even though the clinical features did not meet necessary diagnostic criteria. Some of these patients have never developed dementia. So they live with "Alzheimer’s" when in fact they do not have it.

    You are right about the heightening of fear. I am of the view that very few people, and especially our elders, will not be aware of dementia. Awareness campaigns have often been reductionist as well as alarming.
    I am of the view that society has lost sight of the parabolic (bell-shaped) distribution of cognition over the life course.

    The potential for mis-diagnosis and indeed over-diagnosis are of equal ethical merit to that of delayed diagnosis.

    My worry is that NHS England has felt "shamed" by Scotland. I say this as Scottish Government have not wasted any breath in telling the rest of the UK that they have done "rather well". There has been an aspect of triumphalism here about Scotland's "success" in reaching the dementia target. Scotland coloured green on the map: and England coloured red.

    Alas, it has been my experience that there have been "casualties" of this target.

    The Scottish approach was based on early diagnosis. I advocated for a timely approach. The Government officials involved wanted nothing to do with a "timely" approach and stated nobody had demonstrated harm from "early diagnosis".

    The senior Government official who oversaw the target and dementia strategy, Geoff Huggins, remonstrated with me after I raised potential harms of early diagnosis. This was at a "Dementia Dialogue" event in December 2012. Geoff Huggins said I was "fretting needlessly" and that we were "not even on the same page"

    Only in the last year have the Scottish Government made a "nuanced" and "subtle" change to a timely approach to the diagnosis of dementia. At a recent European Conference, in a keynote address on “rights”, Geoff Huggins was happy to take credit for “timely diagnosis”. This misrepresentation of the truth was quite galling to witness. This perhaps demonstrates the dangers of politicised targets and the marginalisation of ethics.

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  • Terrified of dementia, most patients are well aware. My memory is crap (early fifties) but it always was. I am in no hurry to dx my dementia. People who may have developed minor cognitive impairment or mild dementia don't necessarily want it rammed down their throats. They will consult if they wish; if they hold capacity they should only be screened with proper informed consent anyway.

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