Less than half of the estimated number of people with dementia have a formal diagnosis denying them, and their carers, the emotional, practical and financial support that can follow. The increasing profile of dementia and the current Enhanced Service for Dementia in Primary Care has underscored the opportunities for the identification and detection of people with dementia.
Primary Care is under increasing pressure and with more people with dementia to see and diagnose, innovative ways of linking memory services with primary care are needed. We describe here an innovation in one practice in South Manchester, inspired by the Gnosall model (https://www.ncbi.nlm.nih.gov/pubmed/19480115, now “Memory First”), which may be helpful if colleagues are thinking of developing something similar.
As with many things, it started with a conversation between individuals who get on and who feel that things could be better for a group of patients and their carers. Two things emerged from it: First, an opportunity to pilot a primary care memory clinic with dementia in the Practice and, second, the chance to improve the coding and recording of dementia.
So what actually happens in the primary care memory clinic?
The secret of the clinicis that it is relatively light touch and dominated by governance and bureaucracy. It is owned by the practice. For one session a month, a memory clinic specialist does a clinic in primary care. The assessment is usually scheduled for half an hour with information readily available (a history, GP Cog, blood tests) at the touch of a button.
A brief note is dictated at the practice and appears as an entry on the system under AB’s name (a challenge was dictating a succinct note after 30 years of writing clinic letters – for example an entry does not need to start ….”I saw Mr and Mrs Smith at…..”!.
Patients can be referred to the Memory Clinic and the referral is helped by having an initial assessment (for example a scan can be ordered immediately). A diagnosis can be made there and then and appropriate post diagnostic support provided. Some treatment for symptoms such as depression can be implemented and a review organised at the next practice visit. Home visits are often carried out.
The experience has been universally positive in that people are much more willing to be seen in the practice without recourse to the hospital based clinic and has been welcomed by the local health economy. Earlier and more timely identification of dementia has been facilitated (see the case study). Referrals to the memory clinic have not been changed but more people are seen in primary care and the system has been significantly speeded up.
Colleagues in primary care can extend their skills to support and give them the confidence to make a diagnosis of dementia and a review of some of the patients who have been diagnosed as having dementia showed that many could quite easily and competently been diagnosed in primary care. Memory specialists can gain from seeing a group of patients who have been relatively unfiltered.
Improving the coding can help with the identification of people with dementia which is important on a number of levels. In primary care, the numbers of people on the QOF “register” (in practice, a list generated in the practice as a result of an inquiry for a particular set of codes) determines the annual return in QOF which in turn allows the diagnosis rate to be calculated for each CCG, region and nationally. The benefits include the correct identification of people who have a diagnosis of dementia, facilitating clinical reviews, making sure payments are correct in primary care, informs CCG planning, identifies carers, raising the quality of care provided and allowing local and national planning to take place.
As part of this, a focus was placed on the coding of people with dementia in the practice. There are several other examples of this around the country and we present here our own experience. DJ was made aware of the work by Paul Russell and Sube Banerjee on coding of dementia. Searches of registered patients were compared them our existing dementia register. The reviews involved no clinical contact only assessing information recorded in the patient record.
Prior to carrying out the exercise our dementia register had fifty patients and the exercise resulted in an increase of twenty four patients increasing the register to seventy-four. Without further study it is not possible to be sure if this problem is unique to Dementia but a search for Diabetic drugs did not reveal the same problems with patients not being on the Diabetic register. (For a detailed analysis of the project to improve the dementia register see Improving accuracy of the GP practice Dementia Register in South Manchester)
There are different models where primary care and memory clinic colleagues can work more closely together to achieve better outcomes for patients. This is just one example.
Mrs L, an eighty six year old lady, had a one year history of memory problems which were not causing her any particular concern but her husband and family were very worried as she was not keeping herself as clean as she usually did. She had forgotten the grand children’s birthdays for the first time DJ had spoken to her but she was adamant that she did not have any problems and certainly did not want to go to a Memory Clinic let alone see an old age psychiatrist.
She did, however, agree to see a doctor in the surgery with a special interest in memory problems. She was seen at the surgery by AB within a month of presenting to the surgery. All the blood results were available at the touch of a button in the surgery and a GP Cog had been done.
The history was strongly suggestive of a dementia of the Alzheimer type. After chatting for a few minutes she readily agreed to be seen at the clinic for a CT scan (she had had a bad fall a few months before). She was seen there and the diagnosis was shared with her and her family. She was put in touch with one of the clinic’s dementia advisors and started on donepezil.
It is easy to imagine the scenario that she may have come back, three, six or nine months later still not wanting to see anyone then could have presented in a crisis if she, say, developed a urinary tract or chest infection.
- Doug Jeffrey, Managing Partner, Barlow Medical Practice, Didsbury, Manchester.
- Alistair Burns, National Clinical Director, NHS England. Honorary Consultant Old Age Psychiatrist, Manchester Mental Health and Social Care Trust.