An open letter to Simon Stevens, NHS chief executive, and Alistair Burns, national clinical lead for dementia
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6666 (Published 06 November 2014) Cite this as: BMJ 2014;349:g6666
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The writers of this letter are to be commended for a clear, objective protest against a potentially dangerous proposal. The rate of misdiagnosis of the dementias is already so high that it presents an already valid reason for insisting on assessment and diagnosis by only the best trained and most experienced physicians. A few screening tests in the physician's office do not constitute an assessment. The MMSE, clock drawing and other commonly used "tests" are far from diagnostic, indicating only that there is something possibly abnormal but not what that abnormality might be. Unfortunately, this approach to "diagnosis" is likely to continue. In addition, it proposes a violation of the physician/patient relationship which should be, as they state, one of confidence and trust. The money would be better spent on intensive training of physicians and allowing only those so trained to attempt diagnosis of these extremely complex conditions.
Competing interests: No competing interests
Well said.
This scheme has been given a lot of publicity, and has done more to damage the image of doctors than any other issue I can remember. Friends and acquaintances question whether diagnosing dementia is reliable, whether facilities exist to make a diagnosis, whether treatment offers benefit. All valid concerns. They know that support for dementia sufferers and their families is already woefully inadequate. But mostly they are shocked that doctors should be paid piecework for something they assume should be a core duty, and so are wondering whether other procedures that doctors are encouraging them to accept are motivated by financial reward.
Competing interests: No competing interests
I remain confused how Alistair can say with such conviction that an earlier diagnosis will improve outcomes for patients.
"Brief intruments to screen for cognitive impairment can adequately detect dementia, but there is no empirical evidence that screening improves decision making. Whether interventions for patients or their caregivers have a clinically significant effect in persons with earlier detected cognitive impairment is still unclear"
The Conclusion of the authors of a systematic review for the US Preventive Services Task Force Ann Intern Med 2013;159:601-12
Please do not mistake our "first do no harm" moral standing for a lack of understanding of the trauma and blight of dementia
Competing interests: I am also Editor in Chief of the Drug and Therapeutics Bulletin
I thank Martin Brunet (and colleagues) for writing about the National Enhanced Service for Dementia and wish to clarify some factual misunderstandings.
First, dementia is a devastating illness and the Enhanced Service is to support activity aimed to reach the estimated 300,000 people who would benefit from a timely diagnosis and care planning but are currently being denied that. These benefits include: empowering people to make their own choices; access to the right care packages including medication; avoidance of unnecessary emergency care home or hospital admissions; provision of accurate clinical information across health and social care and; advance care planning. The Enhanced Service asks the practices to use the information we can now provide to assess whether they are responding to the level of need estimated within the population for whom they care, by diagnosing and supporting people with dementia and their carers.
Second, the payment is to the practice, not to individual GPs, to support this additional workload.
Third, the incentive scheme is entirely voluntary so those practices that do not wish to avail themselves of the support on offer to develop enhanced identification, timely diagnosis and care planning for this group of vulnerable patients, are free to continue as they see fit. However, they should recognise the national ambition set for dementia diagnosis and post diagnostic support is to help individuals and families deal with this devastating illness.
Dementia is a priority for NHS England and the Enhanced Service is part of a raft of initiatives, including changes to the QOF (from April 2015) to bolster high quality post diagnostic support. We know there is significant variation in diagnostic rates across England. The Enhanced Service is an attempt to capture a nationally consistent approach by offering support to those practices who wish help to increase their diagnosis rate and to afford equity of access, for all people with dementia and their carers, to post diagnostic support.
Yours sincerely
Alistair Burns
National Clinical Director for Dementia
NHS England
Competing interests: Adviser on dementia to NHS England; editor of the International Journal for Geriatric Psychiatry; received contribution towards travel expenses for the launch of Betrinac; received an honorarium from Healthcare Education Services for being on the teaching team of a course on Alzheimer’s disease; is chair of the Data Monitoring and Ethics Committee for Pimavanserin study in AD Psychosis at King’s College London.
The British Ministry of Health has issued the draft Books $ 55 (70 €) to physicians each new diagnosis of Alzheimer's disease or any dementia. The underlying idea is that there would be at least 800,000 undiagnosed patients.
Pay doctors to make diagnoses is a pretty original idea ... My mechanic has been surprised that it has never really asked why he was paid.
I wanted to make fun of English tradition to sacrifice, but I find that the English doctors reacted very strongly to this project, as would probably have made my French colleagues. But what do they have those doctors who refuse to easy money?
The reasoning I propose here, can not argue more that is one of an incompetent to make medical diagnoses ...
So let my colleagues unable 800,000 demented run free and without care. I want to say here that if I had one day dementia, I would definitely choose without dementia diagnosis, which seems a priori to be more friendly.
No doctors are not idiots, argue leading experts, guaranteed without conflict of interest, but the diagnosis of pre-dementia is very difficult to do. They are right, this diagnosis is also difficult to do than pre-schizophrenia, pre-hypertension, pre-pre-asthma or diarrhea ...
Since physicians are not fools and the pre-dementia is impossible to diagnose, let's see what we can do ... At this stage of reasoning, there he has someone who wonders what interest the department to create an epidemic of dementia? Regardless, the solution is to rely on the venality of doctors to force this possible diagnosis.
The ministry thought as Peter Desproges Either doctors are idiots and venal and I doubt if even a little, or they are not and I doubt many still.
Maybe the doctors, in a final burst of lucidity realize that € 70, multiplied by one hundred or even two hundred uncertain diagnoses, will never be sufficient to provide training to an understanding of the pre-dementia?
Before such proposals, they have only two honorable solutions, or they require at least ten thousand euros per diagnosis, or they accept their permanent incapacity to make such a diagnosis.
The logic dictating also recognize that they can be themselves with a pre-dementia and unknown risk of being wrong. But in this case, those who have blown this idea Ministry think that cognitive disability doctors is irrelevant, because they could easily take a few euros to make a mark at the bottom of a sheet of pre diagnosis.
Competing interests: No competing interests
Outstanding, principled direct attack on a shameful policy. But let's go further and look at who is behind this. In an interview on Radio 4 Today programme on 23/10/14 about 8:20, Simon Stevens named "the Alzheimer's Society and other patient groups (unnamed)" as supporting the policy. They and Stevens are unelected. Was the elected minister consulted? Alzheimer's clearly have an interest, but do they have backers with further interests?
We need to know from Stevens.
Competing interests: No competing interests
This is a brave letter from the doctors concerned, and it challenges us as GPs to be brave and not to sign up to this foolish scheme which can only benefit a few politicians and perhaps a few drug companies too.
Let us hope that our response, and with luck that of the media, will teach our masters that concocting short term fixes for mainly political goals does not work. Then perhaps we can get down to running our practices without having to dodge the current hail of initiatives that we have to cope with. In recent months we have had to deal with new schemes on admissions reductions, revalidation,online access, to records, boundary changes, the named doctor elderly scheme, friends and family test, weekend working pilots, and preparing for the CQC. If we do not resist this deluge, GPs will increasingly vote with their feet and just leave.
Competing interests: I stand to gain in the short term by recording diagnoses of dementia
Re: An open letter to Simon Stevens, NHS chief executive, and Alistair Burns, national clinical lead for dementia
Dear Sir,
I read the News article BMJ 2014;349:g6614 with interest and would offer some thoughts:
It has been interesting to see and hear on the news the reaction to the £55.00 payment to practices when GP’s make a new diagnosis of dementia. As I am away from clinical practice at the moment I don’t know the details of the contract but the initiative has apparently been to respond to the shortfall in diagnosis compared with expected prevalence. Identifying and treating dementia adequately is as much (or more) about social cohesion and resources as it is about making the Dx. But, if we (GPs) are the block to progressing the plight of dementia patients then we need to address this. I am not averse to short term financial incentives which simply direct our attention to an issue and perhaps facilitate behavioural changes within practices where there is low prevalence.
The argument for withdrawing the fee centres on the dangers of a misdiagnosis and in particular highlights that such a fee undermines the confidence in the doctor-patient relationship. Martin Brunet has led this letter with 50 signatories. It recognises the difficulties in reaching the diagnosis where some subjectivity comes into play. This is honourable but doesn’t address the problem of undiagnosed dementia.
Suggestion:
These are challenging times in Primary Care, increasingly the professional relationship /status is under threat as we become more and more ‘managed’. Why not try to enhance clinical care and service delivery by linking an agreed fee with the satisfactory completion of a validated teaching module on the diagnosis and care of dementia patients. We might then have more confidence in the quality of the diagnoses and begin to affect the outlook.
David Munson GMC 2468468
Competing interests: No competing interests