The problem
As GPs we are often told we don’t know how to look after patients with dementia. We don’t encourage patients to come forward for diagnosis and supposedly we have little understanding of the disease and how it affects patients.
With the ageing population, dementia will be an enormous challenge for both primary and secondary care, threatening to overwhelm services with the burden of care.
Bexhill has one of the oldest populations in Europe and we wanted to make a difference to our patients with dementia and their carers and families. Diagnosis rates were slightly better than the national average but running at around 44% of expected prevalence. As GPs we were familiar with patients with memory problems, repeated consultations, failure to comply with medication and forgotten appointments. Most receptionists could reel off a number of names of patients who were always on the phone with confused stories. However, most did not have a proper diagnosis and were not receiving the help and support that they needed.
Getting started
We set up a memory assessment service within primary care. A memory assessment service (MAS) should be the single point of access for patients who need a co-ordinated package of care tailored to their needs. Primary care is best placed to provide this service. GPs and their teams have an intimate knowledge of the patient and his or her social context. They have often witnessed how the progression of the memory difficulties has impacted on the patient and his family. They have information on the physical health and current medication and they have close links with all the local services and opportunities.
Patients also find GP services accessible and non-stigmatising. Family and carers are often registered in the same practice. Transport is usually not an issue and patients are familiar with the practice team.
However, NICE guidance currently states that in order to make the diagnosis of subtypes of dementia you need to be a clinician with specialist expertise and to initiate the anti dementia drugs you should also have a specialist interest.
What we did
We had to get our GPs trained. Four of us have undertaken a specially commissioned postgraduate certificate in Dementia Studies with Bradford University School of dementia studies. The two modules look at diagnosis and ongoing management of patients with dementia. We have been mentored by secondary care colleagues who have observed us in the clinics on a number of occasions.
Together with two practice nurses, we see patients normally within their own practice. We access their electronic record where we can take account of co-morbidities, medication and specific social circumstances. Patients have had the screening blood and urine tests before we see them and have also had a reported CT scan. The GP takes the history from the patient and carer and can look for supporting information in the patients’ record. The nurse then carries out a full assessment using tools such as the ACE-r and the Lawton activities of daily living. The patient returns to the GP for the giving of the diagnosis and treatment and support options. The dementia advisor is contacted and aims to visit the patient at home within a few days.
Where the diagnosis is more complex and the GP is concerned about behavioural difficulties or more unusual subtypes of dementia, we have the option to refer into a specialist dementia clinic, where the patient is reviewed within a couple of weeks, has any further diagnostic scans and tests and then returns to our service for the appropriate care package to be put in place.
Patients may be seen one or two times more in the memory service so that drugs can be titrated effectively and to make sure that patients and their carers have appropriate support. They are then discharged back to their own GPs with a management plan.
Results
The service has been running for six months now and over. Feedback from patients and carers has been universally good to excellent
The service is funded through monies saved through closure of poorly used day care places and has the support of the local Health Overview Scrutiny committee. Our course has been paid for and the clinics are remunerated for the doctor or nurse’s time. A clinic is normally three new patients and two to three follow-ups that the nurse usually covers.
As a consortium of four practices in Bexhill covering most of the population of the town of 70,000 population, we bid to provide memory assessment services for our patients. We now also cover the neighbouring town of Hastings and rural Rother. The current service is being provided as a pilot with the opportunity to bid for service over a larger area from April 2014. We have already had interest expressed in the course by other GPs in the area.
The future
Our newly-trained GPs have had the opportunity to develop their practices as dementia friendly and to help staff members to understand the condition. An award from the Prime Minister’s Dementia Fund has enabled us to put forward a structured half-day of protected learning time for all the local primary care teams to help with learning about dementia.
Dr Lindsay Hadley is a GP in Bexhill
