We believe there is great potential for GPs to work together with secondary care to improve the care and support of people with dementia. We have been concerned, however, about the proposals from the Department of Health concerning a Direct Enhanced Service (DES) for dementia in the GP contract to be introduced in April 2013. We raised concerns in the British Medical Journal and with the Department of Health, arguing that the proposals amounted to population screening and would do more harm than good.
We were challenged to consider how a DES for dementia could be used to improve the care of patients with dementia, and to come up with positive solutions that we would be able to support, given the confines of what the GP contract can achieve and the limited funds available for the DES (£3000 for an average-sized practice).
Underpinning our thoughts at all times is the over-riding priority that resources should be used to benefit those who most need it, and that any DES should not do any harm. As well as the issue regarding screening we dispute the twin notions that early diagnosis should be the priority in dementia care, and that there is a need to drive up dementia diagnosis rates. We have no issue with the idea that diagnosis rates might rise, but the priority should be to improve care and support for those who have already been identified (and developing excellent care will naturally raise diagnosis rates anyway as patients and their GPs will be more likely to want to benefit from it).
We suggested (on 6 February 2013) the following to the Department of Health:
- GPs, families, carers, social work departments and secondary care colleagues identify patients in need of more support.
- Formal arrangements to share information across the necessary specialities.
- Secondary care colleagues to discuss /meet/review patients and their families as necessary. This can be done at a venue best suiting the patient and her/his family, but the GP surgery could be offered as an ideal venue for non-housebound patients. A DES could partly be used to pay for room use for these clinics.
- All new diagnoses could be reviewed in this clinic within a certain timeframe in order to ensure that appropriate care and support is provided for the patient and their carers. Separate arrangements could be made for patients who are housebound.
- The information gathered is shared between this group with permission and to be reviewed at clinically necessary intervals
- This could take the form of a shared care/patient held record/ plan, whose details are copied to necessary parties.
- The GP takes the lead for care of co-and multi-morbidities coordination with clinical input as clinically required could also conduct physical reviews of these patients at the same time where these are required.
- More proactive systems in place for end of life care.
- More proactive systems in place for helping patients and their carers with issues such as advanced care planning/power of attorney where this is appropriate and wanted by the patient/family.
Were the DES to look something like this, it would have our whole-hearted support.