When the headlines first broke that GP’s in England are to be paid £55 to diagnose dementia, I have to admit I wasn’t surprised. Improving diagnosis rates has been the number one target since the 2009 National Dementia Strategy, and it came under the microscope again in the 2012 Prime Minister’s Challenge on Dementia. Yet, despite making diagnosis the cornerstone of English dementia policy, diagnosis rates haven’t improved to the desired level.
In policy terms it’s a small step to start offering financial incentives to diagnose, but in human terms it is a massive leap. It puts a value upon a diagnosis of dementia that simply doesn’t exist if the clinician diagnoses another condition. It tarnishes good sound clinical judgement with the promise of payment, and it poses significant ethical and moral dilemmas.
Granted it’s not a huge payment, it is made to the practice rather than the individual GP, it’s optional not mandatory, and it is a relatively short-term scheme that will only last 6 months. Just think about the last part of that sentence though: why is a dementia diagnosis more valuable in the next six months than at any time before or after that? Could it be something to do with targets?
This is where we get into really tricky waters, because you and I and anyone visiting their GP doesn’t see themselves as a target – just a citizen needing the help and advice of their doctor. The doctor/patient relationship is one bound by trust, and like any relationship, if the trust is lost then a breakdown of that relationship becomes inevitable.
Such a breakdown could have many significant and long-lasting consequences, not least that a person may seek to avoid seeing their GP, or any healthcare professional, about other problems that could have serious, possibly even fatal consequences in the future. Every patient needs to be able to trust in their doctor to reach a judgement about their symptoms based on the best available evidence, having availed themselves of all necessary diagnostic tools and tests, and in a holistic way that puts the patient at the centre of a multidisciplinary team.
Even if a GP does all of that, we know that diagnosing dementia isn’t an exact art. There are numerous different types of dementia, each one presenting itself differently, and diagnostic procedures (although greatly advanced) are not completely accurate. There are also other conditions, such as depression and delirium that can look remarkably similar to dementia.
Assuming an accurate diagnosis can be made, for many people there is little, if any, post-diagnostic support. You may be offered some medication, but dementia drugs aren’t suitable for a lot of people (they weren’t suitable for my dad), although it is perhaps very suitable for the manufacturers of these medications that prescribers are going to be paid to diagnose more potential candidates for them.
Of course incentivising GP’s to offer particular services isn’t new, and the argument behind this payment is that it will enable practices to pay for the extra time and work involved in making a diagnosis. But I know that if I went to my GP and I was diagnosed with something that I’d seen headlines telling me they were being paid to diagnose me with, I would be unlikely to trust that diagnosis or that GP.
The money set aside for this payment scheme is £5m, which although it may sound a lot, in terms of overall health service spending it is relatively low. Sadly it doesn’t allow me much creativity to think about how I’d like to spend it if I was the person making the decisions about dementia policy, but with due artistic licence, I’d like to suggest the following:
- Invest in training that enables doctors to do what their profession is meant to do – use sound clinical judgement to make a diagnosis (and be just as confident about not diagnosing something because you aren’t being beaten over the head to steer your diagnosis in a particular direction). The quality of each individual diagnosis should always be more important than the quantity of diagnoses being made.
- Invest in post-diagnostic support. Models of positive support, that genuinely enable people to live well, are vital to tell the public that you can expect to live a good life after a diagnosis. Forget the promised land of cures or life-changing treatments for a moment, if you can’t even offer your patient hope that they can live a life that supports them in the ways that they want to be supported then as a country we are failing big time. Good quality support doesn’t make headlines – it isn’t a major breakthrough in a lab or an eye-catching policy. It is most likely to involve human interaction and specialised social care – the latter of which is expensive in terms of well trained professional personnel, hence why it isn’t invested in.
So instead we focus on diagnosis. The quicker and easier it can be done the happier everyone will be, or will they? I would be the first to argue that anyone who is having troubling symptoms and seeks help should be given every available method of help to accurately uncover what is causing their symptoms. But is a higher diagnosis rate really a mark of a compassionate, supportive society that sets the benchmark for the world in how to care for people with dementia?
I’m not convinced it is. For me the benchmark is in how well each person currently diagnosed with dementia is living, and the confidence anyone with troubling symptoms has about coming forward to find out what is causing their symptoms. I would suggest that adding a financial reward into that diagnostic process will only make the undiagnosed person more sceptical, less likely to come forward and, should they really have dementia, less likely to accept that diagnosis, leading to them potentially experiencing other mental health problems.
I would also suggest that it lays vulnerable older people, especially people in care homes, open to being labelled without a robust diagnostic process, mostly because they could be seen as an easy target, particularly if they don’t have a family to advocate for them. Making a diagnosis of any condition is about integrity, and above all else, putting the person first.
Because after all we are people, not targets.