As part of his on-going, military-styles engagement with the enemy that is dementia, and with great fanfare, Jeremy Hunt has launched a new Government website to name and shame regions of the country over their diagnosis rates for the condition. But I have a problem – and I would like our Health Secretary to help me here; to lend me a portion of his clinical judgement; aid me in the application of scientific scrutiny – because I am not sure if I should be ‘named’ or ‘shamed’.
You see, for the government – with powerful vested interests in the big business that is dementia care whispering in their ear – more is always better and high diagnosis rates can only be a mark of good practice. Keen to do well, it was with the air of a schoolchild being handed back their test results that I checked the statistics for my practice – to find that we have a diagnosis rate of 126.7%! Can more always be better? Is it possible to have too much of a good thing? How can we have diagnosed more people than are out there?
My first instinct was that the figures must be wrong, but Mr Hunt doesn’t get things wrong, surely? Had our diagnosis rate been a woeful 40% I am sure he would have been quick to dismiss my pitiful bleating about misleading figures and declared me to be one of the laggards that he so eloquently derides in his video on the Department of Health website. For the sake of consistency, therefore, we must conclude that the figures are 100% accurate. Binscombe Medical Centre, according to the calculator, should have 86 patients with dementia. The precision of the Government’s calculations is remarkable; not a patient more, not a patient less, 86 it shall be – but we have diagnosed 109. What should I make of these 23 patients that should not exist? Should we conduct an urgent internal review of all our patients with dementia to reassess the validity of their diagnosis? Have we, in our zeal, rank ignorance and need for extra training (GPs always need extra training) been misdiagnosing at a greater rate than anyone else in the country? Should we report ourselves to the GMC? The CQC? The new Chief Inspector of General Practice? Please advise me, Mr Hunt!
Or maybe, just maybe, these diagnosis rates, used to create headlines about ‘Shocking Variations in Diagnosis’, beat up doctors for their lamentably poor performance and focus commissioners away from patients and on to yet another target, are about as reliable as the economic forecasts were in the years before the crash. Maybe we should remember that they are not proven scientific facts, but estimates that are inherently prone to statistical error. Perhaps I could point out that the figures have been derived from studies that are all over 20 years old, and that this data – placed so emphatically on the internet and yet derived from an era when the cyber-world was still the uninhabited domain of computer geeks – has been extrapolated to the present day to give imaginary figures for 2013/14? Might it be worthwhile pointing out that the latest study, bringing the figures up to date and published last year, suggests that there could be over 200,000 fewer people living with dementia in the UK than previously thought, as the incidence has been falling dramatically in the last two decades?
Could I refer to the danger of taking estimates designed for a population of over 60 million, and applying them to a practice population like ours, of under 11,000? How statistical error always increases as sample size decreases, and so to reduce the figures by over a thousand-fold in this way might be expected to bring up the odd anomaly? How the presence or absence of a 40-bedded dementia care home in your practice area might just have a huge impact on your local figures when you are only meant to have 86 patients in the first place?
Of course, Mr Hunt will concede none of these things. After all, to admit for even one second that the figures for one practice could be out by as much as 30 percentage points would fatally undermine his ability to lambast the laggards. So, as he parades these naked figures for all to see, presented with a scientific validity that borders on the absurd, surrounded by the courtiers of Big Pharma and industrial vested interests; as he stands proudly with his Dementia Tsar on one side and the Alzheimer’s Society on the other, it falls to me, and those like me, to shout out from the crowd. As we look around at our patients, and worry about the effect of targets, misdiagnosis and resources directed away from the care that they really need, towards diagnosing more and more, earlier and earlier, all we can do is to try and draw attention to the Emperor’s peculiar attire. No doubt guards will come and bundle us away before we disrupt the proceedings.
Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68