Saturday, 26 January 2013

Dementia - Beyond Planning

We have just submitted our draft commissioning plans for 13/14. Pages of trajectories, targets, pledges and aspirations. The team have put a huge amount of effort into the document, translated guidance and the new system, and we are now currently consulting with partners and patients.

One of our local and national priorities will be dementia. We have a national target to increase the number of patients diagnosed with dementia, as have all CCGs. Putting the issue of screening aside, is early diagnosis a good thing? Does it matter if treatments aren't effective for all, if a delay in progression is likely to be the best outcome? We are also aiming to reduce antipsychotic prescribing in patients with dementia. It's important to look behind the targets, to talk to patients, to see if what we are doing is likely to make a difference.

So I recently met a group of carers, all with relatives with dementia. They were an inspirational group of people, and it was one of my highlights as a CCG Chair to spend some time with them, realising how they provided mutual support for each other. It was also clear that they shared their frustrations, their anger with the condition and with the care system. There were plenty of tears during the meeting. This was the reason behind the plans.

Clear themes emerged from the discussion.


All used a common word to describe the process of diagnosis. It was a 'battle'. In some cases it took years. The younger the patient, the harder it seemed. Stories were relayed of stressful trips to tertiary centres, to see specialist neurologists, only to be told their loved one's memory was not as good as it used to be. 'I'd told them that, I'd known him for years.' Nearly all had been diagnosed with depression first. 'If he was depressed, it was because he knew what was happening. No one took into account his family history of dementia.'

All agreed that early diagnosis would have been beneficial. But it wasn't just about treatment. It was clear that they valued the mutual support available, the benefit of talking to other carers abut how to cope with difficult behaviour, how to reassure an anxious husband or wife, avoid unnecessary medication. A recognition that their husband wasn't himself, that they were right and that they could explain the diagnosis to people.


After diagnosis what was the most valuable aspect of care? Continuity. There was significant anger at changes to carers, to services that had been changed. Trusting a carer was so important, establishing a routine crucial. Changing times of service offered, the carers involved and worst of all insisting on a move to a different care home had significant effects on patients and their families.


Carers weren't embarrassed by their loved one's behaviour or condition. But they did want understanding and compassion. This included health professionals, carers and the public. There were positive stories about the police, about officers going above and beyond to make sure patients were safe. What would happen if someone forgot to pay and walked out of a shop? This was a cause of some anxiety for some of the carers and patients.

Most said it would have been easier if the diagnosis had been cancer. There would have been a clearer path to diagnosis, more certainty regarding progression, more understanding.

Back to planning

This was the story behind the plans. We have already significantly improved the community memory service and commissioned an excellent outreach team. But we can do more - improving diagnosis accuracy, access to local scans and specialists. But its what we do afterwards that matters most. Focus on continuity, avoiding unnecessary antipsychotics. And listen to carers.

Bassetlaw Dementia Summit is on 5th February, bringing together more than 100 carers, professionals and partners including surgeries, hospitals, voluntary services and emergency services.

Wednesday, 2 January 2013

Opening the Doors

In November 2010 we took an important step as a practice. We opened our doors. We said, 'If you feel you need to see us, come down. If you feel you'd like a telephone call, ring us and we'll ring you back.'

Prior to November 2010 we had a GP on call, with patients phoning for urgent appointments. We would ring them back, usually ask them to come down depending on which GP was on call, and try to manage our workload and their problems. Phone calls and attendances would start at 3pm and finish at 6.30 at the earliest, often with visits in between, and there were extras in each routine clinic. Staff had the difficult job of managing demand amongst doctors, and we could see have up to 60-70 contacts in an afternoon for one GP.

To set some context, we are a large practice with 4 sites and over 27,000 patients. We have over 15,500 patients at our largest site, next to A&E but with high demand and high levels of social and medical morbidities. Over the last decade we had tried models such as nurse practitioner triage, GP telephone triage, minor illness clinics. We had recruited more doctors, more nurses, more reception staff due to a sustained rise in list size. How could we improve access for our patients?

So back to November 2010. The doors opened. Our Urgent Care Service was opened. We are very tight on space but we dedicated 3 clinical rooms to the service, built a separate entrance and allocated a separate waiting room and reception desk for registered patients with urgent, on the day, problems. No phone call needed. We employed nurse practitioners and an additional GP. We opened more routine appointments (no need for extras). We established a GP rota and ensured the Nurses and GPs worked as a team, with reception trained to ensure urgent problems such as chest pain or strokes were screened at the desk. Urgent and elective care was separated and access increased without contractual change or additional payment.

How do we judge if it has been successful? Patients think it is, and satisfaction surveys have been extremely positive. One patient judged the service as 8/10 because they'd 'had to wait 8 minutes', but the service has been extremely popular. We coped with a flu epidemic when we would have struggled, we can adapt the number of GPs and nurses per session as we can predict demand and routine surgeries now start and finish on time. Generally, patients are seen with 20 minutes, sometimes immediately, although at peak times it can be longer. Patients are learning when is best to attend. The doors open from 8.30 to 11.30 and 2.30 to 5.30. If there is a surge in demand GPs can help by seeing additional patients, but it is relatively rare. The 5.30-6.30 period is now relatively quiet.

In the last 12 months we have seen over 24,000 patients in our urgent care service. Most have been appropriate, and we have seen a small but significant reduction in A&E use during the day. Staff are not spending hours on the phone trying to get an urgent appointment for a patient, and visits seem to have reduced. Personally, I feel more confident having 'eyeballed' patients, and telephone calls are now genuinely for problems that can be dealt with on the phone. There are still some teething problems, some inappropriate attendances or days with longer waits, but we are getting there. We may have increased demand, but we provide a better service and we can't ask patients not to go to A&E if we don't provide an alternative.