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GPs set to screen millions more for dementia under ‘significant’ expansion of enhanced service



Exclusive Millions more patients are set to be caught up in the Government’s dementia diagnosis drive, under a major extension of the dementia screening DES that widens the target groups considered to be at high risk for the condition.

Under the new specification for the dementia DES for 2015/16, GPs will be tasked with offering an opportunistic memory assessment to two new groups of patients – those aged over 60 who are at high risk of cardiovascular disease and those over 60 who have been diagnosed with COPD.

The change means millions more patients could be targeted under the scheme, which requires GPs to offer an opportunistic memory assessment to people deemed to be at risk of dementia, and set up advanced care plans for those who go on to be diagnosed with the condition.

GP leaders said the decision to expand the target groups for screening would potentially harm patients, increasing the risk of misdiagnosis and diverting precious resources from patients most at need at a time when GP practices and memory services are already over-stretched.

The DES – titled ‘facilitating timely diagnosis and support for people with dementia’ – was originally imposed in the GP contract of 2013/14 despite high-profile campaigning from leading GP critics to get it dropped because of concerns about over-diagnosis.

Although no formal evaluation of the scheme has been done, NHS England insists it has had a positive impact through improved diagnosis rates, despite reports that it has caused huge waiting times at memory clinics and a huge increase in ‘worried well’ being referred for minor, subjective cognitive problems.

The service specification for 2015/16 has now been revised to expand the groups GPs should screen to include patients ‘over 60 and have a “high-risk” of cardiovascular disease, for instance because of smoking, alcohol consumption or obesity’ and ‘patients who are over 60 with a COPD diagnosis’.

GP critics said the new ‘at-risk’ groups were poorly defined and so could mean millions more being offered the memory assessments – increasing the risk of harm from misdiagnosis.

Dr Martin Brunet, a GP in Surrey and programme director for the Guildford GPVTS, who led a campaign to get the DES scrapped, said this could do more harm than good.

Dr Brunet said: ‘It is disappointing to see they are expanding the number of people to be screened, when the rhetoric from the Department of Health is that we need to change the emphasis from diagnosis more people to supporting more people.

‘The reason why the UK National Screening Committee said “don’t screen” is because of the potential for false positives or misdiagnosis – in other words that it does more harm than good.’

He added it was ‘disappointing’ there is no thorough evaluation of the enhanced service and the impact of it on memory clinics.

‘Why didn’t we have that before it was expanded?,’ he said. ‘And it has been significantly expanded. If you think of all the people aged over 60 who are at increased risk of cardiovascular disease or have COPD, that must run into millions.’

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, said: ‘The pressure to increase the numbers of patients recorded as having dementia is a political rather than medical priority, and the use of the words “case finding” should fool nobody – this is a screening programme which has not been assessed as it should have been by the UK National Screening Committee’

As such, he said, the overall benefits, risks and costs should have been ‘adequately examined’ before an expansion of the programme.

He added: ‘With the limited resources available both in general practice and dementia services, priority has to be given to providing an effective high quality service to those with significant problems.’

A spokesperson for NHS England said: ‘NHS England has issued guidance for GPs to remind them that people with CVD and COPD are at higher risk of having dementia and  should be considered as eligible for a dementia assessment. The guidance is clear that it is the decision of the patients’ GP, using their clinical judgement and personal knowledge of the patient; if they should have the benefit of case finding.’

It follows a change in the way NHS England calculate dementia prevalence, which means that practices will see their dementia diagnoses rates increasing by five percentage points overnight.

Dementia enhanced service specification 2015/16 – ‘at risk’ groups to be offered memory assessment:

  • patients aged 60 or over with cardiovascular disease, stroke, peripheral vascular disease or diabetes
  • patients who are over 60 and have a ‘high-risk’ of CVD, for instance because of smoking, alcohol consumption or obesity
  • patients who are over 60 with a COPD diagnosis
  • patients aged 40 or over with Down’s syndrome
  • other patients aged 50 or over with learning disabilities
  • patients with long-term neurological conditions which have a known neurodegenerative element, for example Parkinson’s disease.

Source: Facilitating timely diagnosis and support for people with dementia – Enhanced Service Specification 2015/16