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A federated approach to dementia

It is clear there is going to be an ‘elderly care tsunami' over the next decade as the number of patients over 75 grows by a third.

Demographic mapping showed us that the number of people with dementia was set to double. We already spend a third of our budget on older people, and people with dementia are estimated to cost the economy £27,640 a year, whereas long-term conditions such as heart disease and cancer cost us just a few thousand.

We also knew that there are many people with dementia who are undiagnosed. Once diagnosed, 37% go into long-term care. But with early intervention and support, 22% can be prevented from going into institutions.

The National Audit Office reported that length of stay in hospital for people with dementia was 21 days compared with 10 days for people who did not have dementia.

So the potential cost savings from providing a better system seemed huge – both in terms of medical and social care.

Our practice is a member of Stafford and Surrounds CCG. Mid Staffs hospital is in our area, and so we knew elderly patients were not getting good care – and a report from McKinsey pointed to areas where care could be done better.

With all this in mind, five years ago our practice began an anticipatory care pilot for patients with dementia.


What we did

We started by trying to identify, in our practice of 8,000 patients, who might be most at risk of dementia. Using our existing primary care databases we added two screening questions for memory problems, which were put to older patients attending our vascular, stroke, diabetes and heart disease clinics.

Only 5% of patients with dementia have just dementia – most have multiple comorbidities. We also used a BUPA screening tool to identify patients who had been admitted to hospital.

But we still failed to identify as many people as we had hoped, and we were still targeting those who were already ill. So we followed the example of Dr David Beales's Staywell pilot in Cirencester and sent out annual birthday cards to the over-75s with a memory questionnaire.

Five years ago when we started this we only had six people with dementia. We now have 61 – 100% of the expected prevalence for our population.

Once these patients were identified, we had the problem of very long waiting times for referral – so we took the step of putting the whole diagnosis and management pathway into primary care.

We hired an elderly care facilitator, who had previously worked as a volunteer in the third sector and had a lot of experience. She works 14 hours a week and visits the patient for the initial assessment.

At this stage she takes a full history of the person's memory problems, and health and social care needs, and does a set of simple tests – the clock test for dementia, the BASDEC cards for depression and the GPcog test.

This information is added to the GP system and is available when the patient has their first appointment – accompanied by the elderly care facilitator – with our consultant geriatrician, Professor David Jolley, who we have hired to run a clinic.

Professor Jolley sees six patients for £350 a session and has full access to the patients' records so he can give a diagnosis and full care plan – just as a consultant in secondary care would do.

The care plans state the identified need and outcomes expected. It sets out who, what, where and how the service is to be delivered. It covers both health and social care and is linked to appointment diaries.

The patient is referred to social services, Age UK and the pharmacy for a medicines use review.

We engaged a mobile technology software firm, Sero-solutions, to put the care plans, treatment plans, medicines management and personal details on specialised elderly care tablet hardware. The tablet was designed by the phone company Doro and is supported by O2.

The network and tablets are sold directly to the family so they can use them to monitor and performance manage the inputs of the providers.

They are part of a standard network contract when having a Doro device. This set-up allows us to track the activity of the performers and feed this back to the commissioners.

The family can see if and when the carers, doctor or nurses visit and what they have done. We have designed and included a PROMS tool – so that we have continuous performance governance on the care given. This empowers the family, even from a distance, to check up both on the performance of service providers and the wellbeing of their relatives, and facilitates good practice.

The in-house clinics are also used for follow-up, not just for new patients, which is vital.

In our practice we have now expanded this programme to cover all frail elderly.


The federated model

Federations of practices in Stafford and nearby Cannock are now looking at rolling this out across all practices.

For our practice, the initial outlay of £11,400 came from us, but has since been reimbursed by the CCG. The new federation model will allow practices to group together to request such investment.

The federations will bid for resources from a financial pool funded by investment bonds from private providers. The funds enable practices to resource services outside their GP contract, so the federations provide a structure to facilitate the resources coming into primary care.

The model enables GPs to integrate this into their infrastructure of premises, computers and patients, without taking on extra work themselves. The schemes can be delivered in the community by willing doctors and can bid for service contracts in competition with other provider trusts.


Lessons learned

Most district general hospitals are failing and overspent. We have to give Stafford Hospital £22m every year for it to remain open, and that is above and beyond the £200m that it receives in payment by results or service level agreements. Yet no politician will consider hospital closure. Despite proven savings (see below) there is therefore no money to run a community system.

If we can reproduce the savings we saw in our practice across the patch, the CCG has said it will move the length-of-stay contract with the hospital from SLA to PBR, which should free more money for the community.

It was initially very stressful trying to solve the problems of capacity in social care, but we got around this through the tablets. We put the family in charge of making sure everyone did what they were supposed to.

In rolling this scheme out more widely, there is an issue of GP morale. We are taking money out of general practice to bail out hospitals and at the same time asking GPs to do more work. We have found it very difficult to get GPs to trust what we are doing – in part because of the view in primary care that nothing can be done for dementia patients.



Our pilots have shown enormous health savings. As a rule of thumb, for every £1 spent we have saved £4.

Here are our costs for 2011:

• elderly care facilitator for 14 hours a week = £6,000

• Professor David Jolley for 12 sessions at £350 each = £4,200

• rent and administrative costs for surgery at £100 per session = £1,200

• total cost = £11,400

In 2011, at our surgery we saw 80 patients  – 19 new and 61 for follow-up. Not one patient needed an inpatient assessment from the mental health trust. This compares with a previous number of inpatient assessments of 280 days.

The patient activity we saved included:

• first attendance outpatient appointments – 19 at £322.12 = £6,121

• follow-up outpatient appointments –

61 at £169.70 = £ 10,351.70

• community contacts – 160 at £151.69

= £ 25,550.40

• old-age mental health inpatient OCBDs – 280 at 324.56 = £90,876

• total saving = £132,899.90

In addition, diagnosis time has dropped from three years to four weeks. Only two patients are in care homes. Patients and carers have reported total satisfaction with the scheme. Only one patient was on antipsychotics, for a period of one month.

There has also been 100% uptake of reminiscence therapy and referral to Age UK to optimise use of benefits. Patients have had other conditions diagnosed as a result of the care planning process.

The CCG tells us in widening this to all frail elderly and looking at the total effect on the mental health budget and acute medicine budget, the total saving we have made this year is £1.5m.


The future

Our pilot for dementia is now being used across the UK and championed by Professor Alistair Burns, the Department of Health's national clinical director for dementia.

In Stafford and Cannock CCGs, if we were to replicate just 10% of the savings we have seen in our practice we would save £5m.

We have solved issues of workforce capacity by making use of recently retired GPs who crystallised their pensions and part-time salaried GPs who could take on extra sessions running dementia clinics.

There is now a course designed and run by three universities – Newcastle, Bradford and Manchester – and validated by the royal colleges to train these individuals to manage dementia in primary care.

The expert patient programme is helping with finding and training the elderly care facilitators. The elder demographic shift is inevitable, but nobody has the courage to do something different. But if we stick with what we are doing, then all we get is the same thing until people die or we go bust.


60-second summary

Initiative: Anticipatory care model for patients with dementia, using practice databases and birthday card memory tests to identify those at risk.

Elderly care facilitators do initial assessments and act as guides through the system. Consultant sessions in primary care develop full care plans, which are then held by the families.

Start-up costs: The annual cost for one 8,000-patient practice is £11.400.

Staffing:In our pilot, one part-time elderly care facilitator plus consultant to run 12 sessions a year.

Savings: A saving of £4 for every £1 spent.

Outcomes: Increase in dementia patients from six to 61. Diagnosis time has fallen from three years to four weeks. Corresponding dramatic drop in need for mental health services and acute medical care, including 280 fewer bed days.


Dr Ian Greaves is a GP at the Gnosall surgery in Stafford. Contact: ian.greaves@nhs.netv