Dr Jonathan Berry provides advice for improving outcomes when you undertake to increase the number of patients screened for dementia
This year’s dementia Directed Enhanced Service (DES) was designed to help deal with the historically low levels of dementia diagnosis rates by building in financial levers to the GP contract.
The DES promotes a case-finding approach based on a great deal of what we know about comorbidities of dementia, namely that those with vascular risk factors are at much greater risk – in some cases estimated to be over 50% – of dementia. This article aims to guide you through those challenges in five steps.
1 Confront the debate head on
GPs have a role to play in diagnosing and managing dementia and it’s important that GPs are aware of how to explain the condition in order to minimise anxiety after diagnosis and guide people through the stages of the dementia pathway.
The scheme comes as part of a package of changes designed to improve the lives of people with dementia. However, it has sparked significant debate amongst practitioners and policy makers on the question of whether an early diagnosis of dementia is beneficial or desirable.
There will quite rightly continue to be much debate over the best ways to facilitate and incentivise this but GPs undertaking this work can use new diagnoses to justify increased resource being committed to dementia diagnosis and treatment.
2 Assess your patient population and services
There are a number of reasons my practice in Trafford, Greater Manchester, chose to implement the DES.
Firstly, dementia is a problem that GPs are increasingly going to come up against, and as such the DES is incentivising participating GPs for being ahead of the game. Most of the patients we put through the DES and who indicate memory problems will, on having a cognitive assessment, need watchful waiting with a follow-up appointment in around a year. However, one problem with DES is that there is no methodology in the scheme to record this. There is likely to be an intrinsic benefit to having these people on the register in order to react early on when symptoms become more apparent.
Many other patients present at the moderate level of Alzheimer’s and can potentially see benefits from drugs such as donepezil, memantine, rivastigmine and galantamine.
3 Develop templates, and maximise on any potential work savings
The DES is not without its faults. One administrative failing of the scheme is a lack of national coding – a fault on launch which has still not been rectified at the time of writing. We’ve had to develop our own system and will have to spend significant admin time batch changing these codes to the national codes when they are released.
Having agreed to do the scheme, our practice manager needed to develop a recording template with local codes and adapt existing coding for diabetes, ischemic heart disease and stroke to feature dementia.
This enabled us to reach out to patients with co-morbidities which suggested they were at higher risk. Patients with higher vascular risk factors were seen as part of a regular annual review and, if necessary, administered the GPCOG cognitive assessment.
The patients on our register who have risk factors such as Down’s syndrome were approached separately for an appointment with our practice nurses for assessment for dementia though these too were often undertaken as a part of an annual learning disability assessment (another DES).
4 Plan finances as if DES income will vary
The financial incentives attached to the DES are not insignificant. The average size practice would receive £2,587, as an above-average-sized practice we received £3,300. As well as the income the ‘reward’ component of the DES can bring to practice budgets, this set-up money is more than adequate in terms of facilitating manager and nurse time to set up the scheme. Indeed, in our practice the vast majority of assessments have been taken on by nurses and health care assistants with a minimal need for GP attention.
However, the reward element of DES is structured in such a way that fails to respond to individual practice efforts, which may hamper the scheme’s development.
As it stands, the funding is dependent on the response of GPs nationally, with reward being divided by all patients put through the DES in England before being returned to practices – a structural mistake which could stand in the way of individual practice take-up. The obvious side effect of this is that we won’t know what the payment for the next component is due until after the end of the financial year, which can have implications on business planning.
5 Build on your first quarter’s performance
Once you’ve taken on the DES and fully implemented it into your practice, it’s important to reflect and evaluate how well it’s working. My practice has gone further than the national scheme in terms of case finding amongst other at risk groups. For example, we’ve sent out opportunities for memory checks to patients on our register with conditions like learning disabilities and other neurological disorders, which has two benefits. Firstly, we’re able to reach out to patients who wouldn’t have otherwise come forward for a check-up. Secondly, this outreach work has effectively allowed us to plan out our workload and manage time in advance. We completed most of this work before the 2013 flu vaccine season started, so we won’t have to cope with reduced capacity at one of the busiest times of the year.
Dr Jonathan Berry is a GP in Trafford, Greater Manchester, and a member of Alzheimer’s UK’s GP reference group.