Older Mind Matters

Guest Blog by Michael Hurt: Exocet missiles about to hit dementia services?

I thought it might be useful to comment on the new dementia Directed Enhanced Service (DES) LINK which runs between October 1st 2014 and 31st March 2015. The DES effectively rewards GPs for an increased number of patients diagnosed with dementia and placed, using an appropriate diagnosis code, on their practice dementia list.

I liken this DES to the Exocet missiles used against the British in the Falklands war. You know they are coming but there is very little you can do about it!

There has certainly been some controversy with user groups claiming that the DES is politically motivated since the Prime Minister’s challenges (see the Dementia Challenge) come to an end in March 2015: the national ambition to diagnose 67% of people with dementia has still not been achieved. Paying GPs extra to diagnose a life limiting disease seems to go against the grain - one could argue they should be doing this anyway. The sudden increase in demand may also put pressure on existing support services, which, in some areas, are already lacking. Perhaps of most concern, is that existing shared care protocols, pathways and specialist diagnostic services could be ignored: although GPs are encouraged to diagnose only when they feel confident to do so.

Having said all that, it is not helpful to dwell on the negatives. People generally want to know what is wrong with them, as do their families. Support, treatment, benefits and planning for the future can only be accessed once there is a diagnosis. To support the introduction of the DES, we are putting in place specialist training for all GPs. We are giving them the tools to diagnose if they choose to do so. We are encouraging them to follow existing protocols to rule out reversible causes of memory problems and, whether they make a working diagnosis, code and place people on their practice dementia list or not, still refer all patients for a specialist assessment to confirm the diagnosis.

I note that the DoH has recently written to all councils to inquire how many of their staff have received Dementia Friends training, watched a short video or read a booklet as the Prime Minister’s challenge was for 1,000,000 Dementia Friends by March and there are only 500,000 to date. I will not be cynical and suggest that this has anything to with politics.

The views expressed are my own and not necessarily those of my employer.

Footnote: The diagnosis rate is based on the number of people known to have dementia compared with the number expected to have dementia (based on research figures) in a given area (see link here).

5 comments (Add your own)

1. Dave Jolley wrote:
Thanks – Talk of Exocets always excites me – I remember the addictive fascination of nightly reports from the Falklands War. I think though that people firing Exocets were intent on causing harm to their targets. This initiative is clumsy and vulgar (very unlike the frightening speed and sophistication of the missiles) and claims good intentions.
I object to an approach which seeks to ‘incentivise’ doctors to do something. Highly educated and well informed professionals deserve dignity rather than be treated like donkeys to be bought with a carrot. The saddest learning is that this device is common and established as the way to do things in cancer care and other aspects of healthcare.
Let’s call for a halt, but provide education and better resources for doctors and others to offer to their patients. It is some years since Ian Greaves pointed out that doctors are so well paid that a little extra money is unlikely to influence them greatly. What they want is help to know more, obtain brownie points for their education, and to feel they can do a better job for their patients. The last of these does require resource – in dementia care much of this will be in the social care sector – a sector which is currently being drained rather than nourished. The claim that ‘diagnosis’ leads to better care is hollow and misleading when there are fewer resources to provide the care, frontline staff feel franticly overworked and skilled hands-on care is rewarded with a minimal wage.
Having said all that – We ain’t doing too badly are we!

Wed, November 26, 2014 @ 6:17 PM

2. Susan Mary B wrote:
Thank you both for your thought provoking comments.

Money makes the world go round, but does it make doctors do things differently? What is the job of a doctor in the 21st century? Surely doctors should still be seeing their patients, making diagnoses, and offering appropriate treatment and support. I may be naïve but I thought that’s what we’re paid to do!

It seems to me that this initiative rewards doctors who don’t do their jobs. Don’t make an effort to find out what’s wrong with your patient. If possible don’t even notice that they are developing memory problems. Whatever else you do, don’t try to establish a diagnosis. And don't worry, we’ll pay you extra £££ to do what other GPs have already done because they believe in running a good quality service.

This is more tick-boxing (or maybe box-ticking) I’m afraid. You can't have enough boxes to tick (always room for few more!) and it keeps people out of mischief while they're ticking them. But there’s no point at all in making a diagnosis if it doesn’t lead on to ongoing treatment and support for the patient and their family.

Thu, November 27, 2014 @ 7:33 PM

3. Dave Jolley wrote:
Wonderful stuff. I am caught between being pleased that a Cinderella (people with dementia) is receiving special recognition and, like you, being annoyed about the style and values which the initiative illustrates. This and a conversation last evening bring me back to the need to establish a community of Enemies of the People http://en.wikipedia.org/wiki/An_Enemy_of_the_People
We need a secret place to meet

Tue, December 2, 2014 @ 7:34 AM

4. Michael Hurt wrote:
The response from docors (GPs and others) to the DES is a mixed one. I recently presented for NHS England at a regional event and decided to do a few screens entitled, "Dementia DES: The good, the bad and the ugly."

This is a quote from a UK GP forum on the subject. I used this for the ugly slide:

“what nonsense is this ? more jam tomorrow, maybe, after jumping through a lot of hoops ! a couple of winter deaths in a residential home could put paid to all the extra work you've put in. no thank you - i'd rather do a couple more hgv/psv medicals ! instant payment, no grief, nobody from the "nosey parker brigade" asking for audits etc, and still home in time to watch emerdale !!"

I would be interestd to kow your thoughts on this opinion.

Thu, December 4, 2014 @ 11:05 AM

5. Susan Mary B wrote:
I may be naive, but making a diagnosis of dementia has to have a benefit for the person concerned. It may be that they can have a physical treatment (like an anti-alzheimer drug if they have Alzheimer's disease), or access to some sort of support/ care, or simply that they/ their family are worried and need an explanation for the problems and to understand something about what the future holds so that the person can be helped to live as well as they can with dementia. Making the diagnosis should not be an end - it should be the start of a journey supported by appropriate health and social care.

As to the enemy of the people, I seem to have lost my copy of the play but, as I remember it, the enemy of the people speaks the truth that others prefer to avoid. It's hard to speak the truth when budgets distort assessments of need and limit access to services.

Tue, December 9, 2014 @ 8:02 PM

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