Re: Effectiveness of dementia follow-up care by memory clinics or general practitioners: randomised controlled trial
Thanks to Dr Meeuwsen and colleagues for their important additions to understanding the dynamics of care for people with dementia and their family carers (1). Their finding that the usual care provided within Dutch General Practice is at least as effective as that provided by secondary care Memory Clinics is encouraging, adding to the accumulating evidence that Primary Care does quite well for its patients and families.
The situation they have explored takes people away from Primary Care for assessment, investigation and diagnosis. Not everyone is willing to cross that divide. The Gnosall model, to which they refer with generosity (2), takes specialist skills which are usually tied into a secondary care clinic out to the front line. They have become part of the Primary Care Team www.gnosallsurgery.co.uk/clinics-and-services.aspx?t=5 . This means that there is no divide for patients or families: people are seen within the Practice for their memory problems just as they are for other symptoms and complications. There is a full (seamless) spectrum of care from identification through assessment, investigation, diagnosis, treatment and on-going support. All components benefit from the local and expert knowledge of the Practice with the added potential of specialist skills and advice. The service has been available for six years. We have outlined a three tier model wherein 90% of all patients might be managed entirely within augmented Primary Care (3).
Our experience is that this can be done in the short term and sustained in the long term. Take up rates are high (our register includes more people than would be predicted by extrapolation from published epidemiology). Satisfaction rates with care are the highest in the county administrative area. The costs associated with the use of other healthcare as reported by the Primary Care Trust (PCT) are extraordinarily low (cost savings by the Practice calculated by the PCT are in excess of £1m on a budget less than £8m). Integrated work with local Social Services and voluntary and informal support is an essential natural ingredient.
Thus we agree with Dr Meeuwsen and colleagues that Primary Care can and does do well for people with dementia. That is not to deny the potential and contribution of specialists and secondary care services, or the scope for improvements. It would be a tragic misreading of matters if their work or that of others, including ourselves, were to be seen to dismiss specialists as only relevant in pursuit of diagnosis.
This is not a question of ‘either/or’ but of togetherness
What we are seeing is appreciation of the strengths of all components of dementia care. We believe their best use will be achieved by closer integration and availability of knowledge and expertise across the time-course of the condition. This includes approaches to reducing risk before the clinical syndrome emerges, living with the condition, dying with the condition and readjustment for families in the ever-after. Integration of care has once again been given high profile on the political agenda in England. A historical reflection on the twists and turns of integration shows the traps of a debate on (re)organising care focused on professional and provider boundaries, rather than on the interests and needs of the public and service users/patients (4). With the developing insights in dementia care about the powerful place of primary care, we have an opportunity to take a better path to deliver integrated care.
(1) Meeuwsen E J et al. Effectiveness of dementia follow-up by memory clinics or general practitioners: randomized controlled trial. BMJ 2012; 344:e3086 doi: 10.1136/bmj.e3086
(2) Greening L et al. Positive thinking on dementia in primary care: Gnosall Memory Clinic. Community Practitioner 2009; 82(5) 20-23
(3) Jolley D, Greaves I, Greaves N and Greening L Three tiers for a comprehensive regional memory service. Journal of Dementia Care 2010; 18 (1) 26-29
(4) Wistow G "Still a fine mess? Local government and the NHS 1962 to 2012", Journal of Integrated Care, 2012; 20(2) 101 – 114
Competing interests: No competing interests