Older Mind Matters

Are memory assessment services doing what it says on the tin?

I recently attended a meeting at the Royal College of General Practitioners, adjacent to Euston Station (a distinct advantage for rail travellers from the north). I was giving a talk on behalf of the Gnosall Memory Clinic Team about our primary care memory clinic (PCMC) model. 

I was impressed by the variation in models of memory assessment service provision across the country. The PCMC at Gnosall involves GPs buying in old age psychiatrists to undertake memory clinics in the health centre. I learned that in Sunderland secondary services buy in GPs with a Special Interest to provide memory clinics, and in the South West there are four different models in use in different CCG patches. Boundaries between primary and secondary care are becoming blurred: people are leaking in both directions.

Someone referred to identifying the ‘right’ model for memory services, and an audience member raised concerns about variations in services. I think we could waste a lot of time arguing about which is the right model, and, it seemed to me, that there are many different ways of running a memory assessment service, but that a core issue is evaluating them to make sure that they do what it says on the tin – ie provide a quality service and meet the needs of people using that service. The National Clinical Director for Dementia had pointed out earlier that, although diagnosis rates need attention, post-diagnostic support is the key (I may be paraphrasing here): in a letter to the BMJ we talked about “a living interactive process, which leads to support for the rest of that person’s life.”

This raises the question of quality in PCMCs: the Memory Services National Accreditation Programme (MSNAP) was cited as a source of possible standards. (see them here). Since these standards have been developed from a secondary care perspective, they would need to be revised for PCMCs, although, curiously, PCMCs might bring advantages in some areas eg:
2.1 “The memory service is accessible to people with memory problems and their carers” – how can a clinic be more accessible than to take place in the health centre that the patient attends for physical health care?
4.2 “Professionals working within the memory service ensure that the person (and their carer, where appropriate) is able to access a range of post-diagnostic supports and interventions” – our Gnosall eldercare facilitator has links to many local sources of support. She acts as key contact in following people up, monitoring any treatment, and providing continuity of care. In secondary care links with local organisations and sources of support are inevitably less developed.

So I offer three main messages from this meeting:
1. memory clinic models are rapidly diversifying;
2. ongoing post-diagnostic support is key – and should continue until death:
3. focussing on (and evaluating) quality is essential to prevent unacceptable service variations.

3 comments (Add your own)

1. Dave Jolley wrote:
Memory Service Models 2014

Thanks for this. It is wonderful to learn of the energy and interest being shown in services for people who have memory problems or similar difficulties in later life.
It will be good if the collection of initiatives brought together for the RCGP meeting can be captured in a summary paper or in some other way made easily available. I do not see problems in diversity, the idea that everyone everywhere should be doing exactly the same seems unnecessarily controlling and unlikely to generate and maintain enthusiasm and creativity. The essential principle of bringing the strengths of specialist and primary care services and professionals together for the benefits of patients and families and to make best use of resources is agreed and surely common to all the models.
I found a power point presentation from Helen Chiu and Edmond Chiu which includes the principles which Tom Arie gave the world for Psychogeriatric Services: Accessible, responsive, individualised, trans-disciplinary, accountable and systemic: www.prcp.org/publications/id_21.pdf
That does not specify ‘seeing people through’, which was another thing Tom insisted we should do – and how right he was in that as in all things.

I would think these attributes might be asked of memory services.
One of the features at Gnosall is that we are catholic in our criteria – If someone in the Practice thinks we might be able to help, we are keen to see them and will do what we can: no exclusion criteria, no ‘triage’, but old fashioned clinical assessment, further investigation as seems necessary, followed by advice and a plan for what’s to be done which is shared with the patient and the family, and all relevant colleagues
Whatever we are able to do has to be understood to be an attempt to make things better in a context where resources are not being made available commensurate with the known and predictable needs www.newstatesman.com/2014/02/why-are-old-dying-their-time

This will never be a perfect world: struggling to make improvements, describing what is done and the benefits and limitations, sharing these with others and keeping open minds – These are elements of hope.
‘Quality’ is not a concept I feel easy with. What’s OK or good for me might be thought of as rough and ready by others and perhaps vice versa

Thanks for the thoughts

Mon, February 24, 2014 @ 8:50 AM

2. Susan M wrote:
I gave another talk about the Gnosall Primary Care Memory Clinic this morning at a conference in Manchester. There were 3 questions/ points which are important to note:

1. about the role of the fire and rescue service which has contact with a lot of vulnerable older people in the community. I know a little about role of Staffordshire Fire and Rescue Service with whom we had contact at the Centre for Ageing & Mental Health, Staffordshire University. See http://www.cfoa.org.uk/14241 for information about the Dementia Pledge.

2. why do we think that the dementia diagnosis rate at Gnosall is running at 100% of the predicted rate? There are many potential reasons we could suggest for this, including the fact that primary care clinics avoid the stigma of attending a secondary care clinic - I suspect this influences referrers as well as families that are referred.

3. Do we see people with a learning disability (LD) who might be developing a dementia for assessment in the clinic at Gnosall. I can't remember seeing anyone with a LD but I can see no reason why they couldn't use the clinic in the same way as anyone else.

Tue, February 25, 2014 @ 12:41 PM

3. Dave Jolley wrote:
The point about the Fire Service is well made and well taken. Both the police and ambulance services have also taken on board the understanding that identifying vulnerable frail older people, including those with dementia, and taking action to make them safer, saves lives and saves money
Discussion of these approaches was impressive at the two open days we organised from Willow Wood Hospice in Tameside
www.willowwood.info/dementia.html

A recent article in the Manchester Evening News: www.manchestereveningnews.co.uk/news/greater-manchester-news/greater-manchester-fire-service-chief-6755813?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+menews+(Manchester+Evening+News+-+RSS+Feed) confirmed that the new systems have been responsible for reducing fires from 27,000 per annum to 12,000 per annum between 2005 and 2012

Such radical changes, which are utterly desirable, have consequences: we do not need so many firemen, fire engines or fire stations. This requires remodelling of services and redistribution of skills

Is it too wild a suggestion to think that widespread implementation of the Gnosall model for memory services will have similar desired effects - which will have secondary consequences which will require flexible redistribution of resources?

I am sure you are correct in saying we will be very happy to see people with Learning Disability who develop symptoms suggestive of dementia. Certainly the clinic has been flexible and inclusive across age-bands and a range of physical and other mental health dimensions

Mon, March 3, 2014 @ 3:14 PM

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