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Margaret McCartney: Dementiagate—how politicised pay diverts GPs from working for patients

BMJ 2014; 349 doi: (Published 24 October 2014) Cite this as: BMJ 2014;349:g6446

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The underlying causes of the blundering attempts to promote opportunistic screening in primary care, culminating in the tragic farce of bribing GPs to encourage “early diagnosis” of dementia [1,2], are a diagnostic puzzle. Is it just headline-grabbing politicians, who ignore the potential harms of screening, or victim-manipulating drug companies, who inflate the benefits of early treatment far beyond the evidence [3,4]? Or is it naive specialists looking through their scanners and seeing only “delayed diagnoses”, rather than the uncertainties and risks of false diagnosis in the real world beyond the hospital?
Even if the policy is just a well-meaning but misguided attempt to help dementia sufferers and their families, it sets the stage for a massive betrayal of public trust.
Cognitive testing of patients attending GPs for other reasons may lead to early diagnosis of “mild cognitive impairment”, which has about a 20% risk of progressing to dementia within 5 years [4], with no reliable means of predicting or preventing such progression. Ideally GPs will resist the temptation to improve their “figures” by taking a diagnostic short-cut and leave it to families to judge whether or not this has occurred, from the effect on the person’s daily life. In this ideal world, only one in five will come back, expecting confirmation of the diagnosis to unlock effective treatment and support, but what they will actually get is a prognosis - of inexorable deterioration and annihilation of the person, with death often coming as a final relief. The other 80% will be left to worry.
Medical treatment may slow the rate of memory decline for a short time, but no-one knows whether it will improve overall quality of life or simply prolong the course of a devastating terminal illness. Even the most overstretched care services may be a god-send to families who have struggled without support, but the extra demands made by earlier “diagnosis” will only highlight their limitations. Negative perceptions will not be helped by the knowledge that resources which could have been used for care have been given to GPs for diagnosis.
None of the clinical or economic arguments for early detection can be applied to progressive degenerative conditions without effective means of preventing or arresting the disease process. Until we have something better to offer, every available penny should be spent on providing better dementia care services and training.
1. Kmietowicz Z. Doctors condemn “unethical” £55 payment for every new dementia diagnosis. BMJ 2014;349:g6424.
2. NHS England. Enhanced service specification: dementia identification scheme. 10 Oct 2014.
3. UK National Screening Committee. The UK NSC policy on screening for dementia.
4. Lin JS. O’Connor E. Rossom RC. et al. Screening for Cognitive Impairment in Older
Adults: An evidence update for the U.S. Preventative Services Task Force. Evidence
Synthesis Number 107. AHRQ Publication No. 14-05198-EF-1. Rockville, MD: Agency
for Healthcare Research and Quality; 2013

Competing interests: No competing interests

02 November 2014
David Barer
Consultant Geriatrician / Stroke Physician
Tyne and Wear Stroke Collaboration
Sunderland Royal Hospital, Kayll Rd, Sunderland SR4 7TP