The results of a pilot memory assessment service showed the value of delivering dementia services within primary care, as Lindsay Hadley and Martin Packwood explain
NHS England estimates that nearly 700,000 people in the UK suffer from dementia. They are supported by over 500,000 people who act as carers, with the overall cost of the disease estimated at £23bn per annum.
The prime minister’s challenge to NHS England is that by 2020 England should be “the best country in the world for dementia care and support for people with dementia, their carers and families to live”.
In East Sussex, with 25 per cent of the population aged 65 or over, the commissioning team for mental health was interested in exploring a more holistic view of care for dementia patients.
In late 2011 the dementia commissioning group made up of representatives from Hastings and Rother Clinical Commissioning Group, Eastbourne, Hailsham and Seaford CCG, High Weald Lewes Havens CCG and East Sussex County Council decided to commission a memory assessment service (MAS).
A decision was made to tender primary care pilots to see which service was delivered most effectively over 18 months. Due to interest from a number of providers a series of pilots was established in 2012 to evaluate models.
Relationships with adult social care and the third sector means the GP can discuss management options in the clinic, and record information in the patients’ electronic care records
One of these involved setting up a MAS run by a consortium of four GP practices in Bexhill.
Memory assessment services diagnose dementia and assess the needs of the patient and carers.
Patients are screened by their own GPs with a simple memory test, appropriate blood tests and a CT scan before referral to the MAS clinic.
The practice nurse carries out detailed assessments before the MAS GP reviews the results, the patient and carer information, medical history and social context and gives the diagnosis to the patient and carer.
Relationships with adult social care and the third sector means the GP can discuss management options in the clinic, and record information in the patients’ electronic care records. Complex cases are passed on to secondary care for specialist management.
As most GPs are not trained or confident in diagnosing dementia, money was freed to commission a post-graduate certificate in dementia with Bradford University’s School of Dementia Studies. This one year, part time course was undertaken by all the GPs running the MAS clinics.
The GPs were mentored by secondary care specialists, and these specialists sat in on some of the clinics, signing off on the GP’s competencies.
Local dementia advisers, trained by the Alzheimer’s Society, see patients and carers after diagnosis, to inform them about local resources and act as ongoing support.
Delivering a dementia diagnostic service with primary care staff provided a less stigmatising, easier to access and familiar service for patients
The MAS GP or nurse will see the patient again around eight weeks later to check adherence to medication and that the appropriate package of care is actually happening.
The patient is discharged back to their registered GP with information on the actioned management plan. GPs and practice nurses are also able to contact the specialist GPs for further advice.
At the end of the pilot, each model of care was evaluated. The service ran for two years and was then tendered. The phase demonstrated that the GP-led MAS model was viable and worked particularly well against many of the pilot criteria:
- GPs and other staff became more familiar with dementia, its diagnosis, and the long term care needs of the patients.
- Many patients in the MAS clinic were seen in the early stages of dementia, indicating that they were being referred early for diagnosis.
- Patients were seen in three to four weeks and typically received diagnosis on their first visit; this compared favourably with other providers.
- Patients were seen in local GP clinics where they felt more comfortable.
- The rate of patients failing to attend clinics was the lowest among participants in the trial.
- Prescribing of drugs was in line with National Institute for Health and Care Excellence guidelines.
- Costs were broadly comparable with other providers.
- Feedback from referring GPs was positive, as was the feedback from secondary care specialists receiving complex cases – these were felt to have been appropriate for referral.
Delivering a dementia diagnostic service with primary care staff provided a less stigmatising, easier to access and familiar service for patients. Feedback from patients and their carers was also positive.
The role of GPs
In delivering the pilot, the MAS GPs had seen the benefits to patients. GPs are close to their patients and their families and are ideally placed to treat the dementia alongside any other co-morbidities.
The care of patients with dementia requires a high degree of flexible and responsive interaction with a variety of local services. GPs and their teams are best placed to understand local provisions and can help co-ordinate a long-term care package.
By placing the MAS within the primary care sector it increases the capability of GPs to provide that essential co-ordination role.
Despite the investment in time and effort required to gain the appropriate skills, the GP consortium felt strongly that the GP-led primary care MAS was the correct option to pursue.
In delivering the pilot, the MAS GPs had seen the benefits to patients. GPs are close to their patients and their families and are ideally placed to treat the dementia alongside any other co-morbidities
They established a limited liability company, Integrated Community Care, and won the competitive procurement process.
It now provides the Memory Assessment Service and co-ordinates dementia care for over 360,000 patients in the Hastings and Rother CCG and Eastbourne, Hailsham and Seaford CCG areas.
Up until September 2015, over 1,500 patients had been diagnosed and discharged, with over 95 per cent of patients receiving their diagnosis within the GP-run MAS, freeing up the secondary care specialists to focus on the small number of more complex cases.
Twelve GPs have gained their postgraduate certificate, with a further three in training, together with two practice nurses and a pharmacist. Eight practice nurses take part in MAS clinics, which take place in 10 practice premises spread across the region.
In addition, an award from the Prime Minister’s Dementia Fund has enabled the specialist GPs and nurses to deliver further training, including structured half days of protected learning time and in-practice workshops for all the local primary care teams to help with learning about dementia.
Driven by the increasing numbers of elderly people, there are many initiatives aimed at moving GPs closer to the heart of dementia diagnosis and care.
However, there are concerns, not least from GPs themselves, about how far primary care can go in taking on the workload of diagnosing and treating the majority of these patients.
The experiences in East Sussex clearly demonstrate that drive and initiative within the primary care sector, combined with a willingness to trial different approaches by healthcare commissioners, can move us closer towards the vision set out in the NHS Five Year Forward View.
Dr Lindsay Hadley is a GP and Memory Assessment Service lead at Hastings and Rother CCG; and Martin Packwood is head of joint strategic commissioning, mental health at East Sussex Commissioning groups
Memory test showed value of keeping it local
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Memory test showed value of keeping it local