This article published in the London Review of Books by Dr Gavin Francis has generated much discussion:
This BMJ poll asked about the ethics of NHS England’s approach:
Professor June Andrews, “International Dementia expert, consultant, teacher, nurse, writer and researcher” submitted the following response which was published alongside the original article by Dr Francis:
Not surprisingly, the suggestion that GPs should be sued (introducing a stick as well as the carrot of the £55) attracted a lot of responses from GPs. Dr Margaret McCartney, GP in Glasgow, Medical author and regular columnist in the BMJ, replied to Professor Andrews:
Professor Andrews then submitted a fuller reply on Dr McCartney’s blog, which can be read here along with further replies. Professor Andrews appears to have been surprised by the reaction to her forthright suggestion. I have followed the discussions on social media. The responses came from a number of quarters and were largely polite and sought only to better understand the reasoning behind Professor Andrews suggestion.
Professor Andrews final response was: ”Well the mob got me back. Tons of docs against one nurse. All over now. Never bashed you. All I can do is block you all bye bye”
I wonder if Professor Andrews is a step behind the debate. For many years “early diagnosis” went unchallenged and was the basis of both the Scottish Government Dementia HEAT target and Dementia Strategy. Scotland pioneered here and advocated that the rest of the UK should follow.
A number of individuals, including myself, GPs, public health experts, carers and campaigners, advocated that a timely approach was preferable. This was because we understood the potential for harm with a blanket policy based on “early diagnosis”. Following this the Scottish Government changed its approach. In October 2014, I was fortunate to be present when the “Glasgow Declaration” was signed which enshrines a timely approach to the diagnosis of dementia:The Glasgow Declaration from omphalos on Vimeo.
I have always admired Professor Andrews as a gutsy, plain-speaking ‘champion’ for those living with dementia. However I think she made a mistake in targeting GPs in this way and en masse. To advocate litigation, in such a complex area, risks increasing the practice of defensive medicine. The main issue with defensive medicine is that it is not patient-centred and I am sure that this is the very last thing that Professor Andrews would want.
One GP, in reply to Professor Andrews stated in beautifully clear language why this is not a straightforward issue:“Problem is it is impossible to actually diagnose dementia until unable to perform normal tasks. Otherwise only “cognitive impairment” which may not lead to dementia at all.” I have covered this here.
At the height of the enthusiasm for the HEAT target for “early diagnosis of dementia”, I had experience of a GP colleague who I think embodied some of the risks of the approach today advocated by Professor June Andrews.
I was asked by this GP regarding a patient who had evidence of mild cognitive impairment but no evidence of dementia: “Should we not use Alzheimer’s disease as working diagnosis if history indicates it even if [the person] is not at stage of dementia.”
“My question was not whether [this patient] has dementia associated of Alzheimer’s type but rather if [this patient] had Alzheimer’s disease so that we could give appropriate education and support [this patient] and [this patient’s] family and possibly cognitive enhancers at an early stage as per current guidance.”
My reply was as follows: “Regarding the potential for treating [this patient], current pharmacological options are licensed for the ‘treatment of mild to moderate dementia in Alzheimer’s disease.’ The SIGN and NICE guidelines are also for dementia. I have previously sent you the evidence that these drugs do not prevent the development of dementia in any patients. I would also like to reiterate that the provision of support is not dependent on any diagnosis but determined by the needs of any individual patient.”
Although some of this discussion focused around medical issues I agree with Professor Andrews that so many other aspects of care may allow individuals with dementia to live well. However this does not justify the application of a diagnosis before it can be made with reasonable confidence.
The four final slides come from this most helpful paper:
For me, this paper highlights the complex issues involved in the diagnosis of dementia. We now have 50 organisations across Europe who now appreciate this complexity. It has been my experience that my primary care colleagues understood this from the start whereas the specialist leads appeared not to.
To conclude: Professor Andrews’ characterisation of the response of GPs in their approach to the diagnosis of dementia as “Can’t – won’t – no point” is unfair and unhelpful.