Older Mind Matters

Primary care memory clinics: partnership, collaboration and excitement

This month I am due to start work in the primary care memory clinic at Gnosall Health Centre in Staffordshire, sharing the work with a colleague. This is very exciting - I can’t wait to get started.

As I understand it, the clinic takes place one half day per month in the Health Centre and involves an old age psychiatrist working with a practice based dementia adviser. The GPs identify people to be seen and carry out initial investigations. The dementia adviser carries out an assessment before the person comes to the clinic. The old age psychiatrist has access to all the information in the practice, assesses the referred person in the clinic (or sometimes at home) and talks with them about the diagnosis and treatment plan. Letters are typed in the practice and copied to the person and their carer/s. In this way the expertise of old age psychiatrists is brought directly into primary care, the person with possible dementia avoids becoming a ‘psychiatric patient’, and information is readily shared amongst all those involved.

My colleagues tell me that the diagnosis of dementia in the practice has increased and at the same time the practice has saved a considerable amount of money. They believe that the quality of service provided has improved and this is borne out by feedback from families using the service. It sounds as though everyone gains.

Am I traitor to old age psychiatry when I wonder: why are people still doing memory clinics in secondary care - why isn’t everyone doing this?

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Further information:

If you want to know more this link here will take you to the practice site where you can download information about the clinic. There are several publications about the clinic and you can link here to abstracts in:
Community Practitioner 2009;
the British Journal of General Practice 2010;
the Journal of Dementia Care 2010; and
the Journal of Care Services Management 2011; and a recent rapid response in the British Medical Journal here.


5 comments (Add your own)

1. David Jolley wrote:
Thanks Susan: we are looking forward to having you join the team. All that you say is correct - the Memory clinic – which is really a comprehensive service rather than a limited clinic activity – has been running successfully for 6 years now. A summary of activities and a list of publications is available on the Practice website: www.gnosallsurgery.co.uk/ppg.aspx
There is considerable interest in the model and others are beginning to apply the principles elsewhere. In many ways I welcome this but we are concerned that people may stray away from the essential features we have identified and get into difficulties. We have begun to wonder about applying for a patent or copyright. This would not be with a view to making money, but to ensure maintenance of quality
One of the important spin-offs is our involvement in a training course being organised with colleagues at Bradford University and Newcastle University. This is designed to prepare doctors and others to strengthen their competence and confidence in helping people with memory problems, including dementia, in Primary Care. Your knowledge and experience of teaching and training will be especially helpful in that development

Fri, August 3, 2012 @ 5:08 PM

2. Michael wrote:
As a commissioner of dementia services, I am always on the lookout for better ways of doing things. The Gnosall model is well known and this model has been discussed with other commissioners at various times.

From my point of view and given the stigma attached to dementia, it does seem rather odd in traditional clinics that people are taken from Primary Care to Secondary Care for a diagnosis and then sent back again. I suppose this is historical and also happens within medicine and surgery.

There are existing memory clinics with RCP accreditation and regionally, they will have performed well under the West Midlands Quality Review Service. However, there are criticisms of the traditional model; Perhaps the main one being that people receive a diagnosis (eventually) and then what? What is offered to people other than for some, tablets to hopefully slow the inevitable deterioration? NICE specified what information should be offered to people but we know from feedback that although people with dementia and their carers had received information, they reported that they had not because it was in writing.

In order to avoid the criticisms of established traditional model clinics, does the part time dementia advisor have the time to spend with people in passing on this information, supporting people and signposting them to other supporting agencies? This seems crucial to the success of early diagnosis and intervention.

I applaud the service rarely referring people to secondary mental health services and the question of scans is an interesting one. I see the rate is 1 in 4 but when trying to prompt a 'scan only when needed' approach, clinicians often cite the NICE guidance, which suggest scanning everyone to support diagnosis of sub-types and rule out space occupying lesions.

Have the two roles developed by Staffordshire and Worcester universities for the SHA (Primary Care Liaison Worker and the Dementia Pathway Coordinator role) been incorporated into this pathway?

My last question is about treatment. I presume patients suitable for treatment with acetylcholinesterase inhibitors are prescribed these drugs by the psychiatrist. If the clinics are monthly, what happens when issues with side effects occur after a few days? Do the GPs address these issues? I am interested in this because I have found GPs to be uncomfortable in doing so. Has additional training taken place?

There is no doubt that improved diagnosis, fewer referrals to secondary care and fewer admissions to acute are to be applauded. Informing people of the likely diagnosis ‘on the day’ is brilliant. However, I would like to understand more of how this fits in to the overarching pathway, so that it is not a service in isolation.

I hope you enjoy this new work Professor Benbow.

Wed, August 15, 2012 @ 11:59 AM

3. David Jolley wrote:
Thanks Michael you are as perceptive as ever and your questions provide opportunity for clarification and for me to say something shocking.

The work of the 'part-time' Dementia Advisor: This began as sessional time from the full-time Health Visitor (Lesley Greening) and is now with Elaine Walker who has no formal health or social care qualifications but many years of experience working with Age Concern and an encyclopaedic knowledge of the locality, its people and resources. For all intent and puposes she is an ever-present and she carries the people with dementia, their families and others with devotion, mutual respect and a great deal of success. She continues a voluntary involvement with related charitable work

Scans are done when we believe them to be clinically indicated. Scanning everyone would be unnecessary, expensive, intrusive and an insult to the individual patients and the clinical process. Patients are well known to the Practice, very thoroughly assessed medically and from the perspective of mental health AND they are followed up and followed up: so that if additional signs or symptoms appear which raise the question of further investigation such as a scan or other things - they can and will be done. When scans are requested they are performed quickly and with excellent, timely reporting. Maybe this is in part because the radiologist knows we are asking a serious question rather than using them without thought in a proscribed routine

Pathways - Worcester University and Staffordshire University. Both universities contain some of my very best friends. I have seen some of the work they have produced on this matter. But pathways we (I) do not do - most of our patients have multiple - in excess of six - relevant pathologies. They might be spaghetti junction or a repeated series of 7 ways! In fact they are people - individuals in a setting in time and place and social context. They are all addressed as such, listened to as such and this is the way we go forwards. What can be complicated by fragmentation by referral to several specialist clinics is simplified by person-centred care at source where everything is known about them. We travel the journey with them. Sometimes this is a journey which might have been predicted, but for most it is a unique, individual experience

Side effects from medication or any other unplanned, unforeseen eventuality: First thing is such developments may be dementia-related but may have other causes. Thus it is right that first assessment and review comes from the Primary care team who take action accordingly. Many things are within their competence, when they are not then help is requested. If this relates to dementia or complications of their therapy the alert may go first to Elaine, but I am available at (almost) any time by telephone or email. Contacts to me of this nature have lately averaged between 1-2 per month usually via Elaine, but sometimes directly from a GP or other Primary Care professional or a social service professional or other healthcare professional. On a few occasions direct contact with a patient or family carer is what is required and it is provided

This is not an isolated clinic - it is embedded within Primary care and all the other strengths available locally - social care, voluntary agencies etc and can access other specialist help when needed

Mon, August 20, 2012 @ 5:52 PM

4. Michael wrote:
Hi all,

My apologies, although I have read this a couple of time since, I didn't get around to replying.

Thank you for the clarification, it was most helpful and explains the model very clearly. I don’t think it was too controversial and you make a very good point about pathways. I don’t see them as a patient journey but more of a prompt for staff to use the most appropriate and effective interventions/support/advice as they come into contact with people.

We do have to try hard to fit services around people.

Can I quote you on the scans view please?

Mon, October 1, 2012 @ 9:53 AM

5. David Jolley wrote:
Thanks Michael - It will be good if you quote me on this or any other aspects of this work

I was able to present a summary - 15 minutes plus questions at The Manchester Conference Centre yesterday -
'Dementia - a national crisis' - www.publicserviceevents.co.uk
250 top people in a hot room

They had had a busy morning witha keynote from Alistair Burns and other people with national/international profiles plus 2 x masterclasses

They still had ears to hear our story with gratifying enthusiasm

Crisis? - Well think small and do what you know makes sense

TC

d

Fri, October 5, 2012 @ 5:38 PM

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