The recent rumpus over GPs being given a financial incentive to diagnose patients with dementia represents an escalation in a battle between the medical profession and the government over the conduct of health care in England.
Practices are being offered £55 for each new case of dementia confirmed over the course of the next six months. The Health Secretary, Jeremy Hunt, has defended the plan, saying that rates of dementia diagnosis are “a national shame”, estimating that around half of the people with the condition are currently without a formal label.
What needs serious debate is the underlying assumption that a diagnosis rate of around 50 per cent must inevitably mean poor practice. It is probable that the figure actually reflects many instances of sound holistic care and that the government’s attempts to influence rates of detection will cause more harm than good.
Any medical diagnosis potentially results in three things: information, treatment and access to care services. If none of these is relevant to an individual patient, attempts to arrive at a diagnosis are pointless; and if the diagnostic process causes distress, it is harmful to undertake it.
There is no simple or precise test for dementia. Patients undergo a battery of blood tests, a brain scan and exhaustive assessments of cognitive function to build an overall picture. The process entails several visits to the outpatients’ department, an experience that can be bewildering. Sometimes a clear answer emerges but many are left with inconclusive results and uncertainty about the future.
So who is the medical profession being bribed to push through this diagnostic mill? Much current “under-diagnosis” involves those with mild cognitive impairment (MCI) who are managing perfectly well within their families and communities. Around half of these people might qualify for a diagnosis of early dementia if formally tested. However, there is currently no cure and few effective treatments. Drugs such as cholinesterase inhibitors can improve cognitive function in some patients with moderate or severe Alzheimer’s disease for around six to 12 months (though they are ineffective in the second-commonest form of the condition, vascular dementia).
Yet a thorough review of the available evidence published by Canadian researchers last year showed no benefit to patients with mild forms of the disease: there is no therapeutic advantage in detecting Alzheimer’s at an early stage. Some people with MCI want to know if they are developing dementia, rather than merely experiencing the normal consequences of ageing. But many prefer to let sleeping dogs lie until or unless they start to experience significant problems.
The other patients currently “under-diagnosed” are those with multiple co-morbidities. Being an age-related condition, dementia frequently occurs in people whose health is already dominated by other serious illnesses. These patients are usually taking a panoply of drugs and adding marginally and only temporarily effective dementia medication is often inappropriate. This group is frequently receiving high levels of care services and pursuing a formal diagnosis of dementia would add little or nothing.
GPs are arch pragmatists, skilled at taking into account all facets of individuals’ situations when formulating decisions with them and their families about their health care. When we have treatments that cure or halt dementia, it will be appropriate to seek out those in the early stages and thresholds for investigating cognitive impairment in patients struggling with other severe ill-health will change. At that point, there will be no need for financial incentives. Doctors will do what they’ve always done: act professionally in the best interests of their patients.
In the ongoing NHS funding squeeze, the incentives being dangled by the government will, inevitably, alter medical behaviour and patients will be pushed through a diagnostic process that will bring many no benefit and may cause harm. The government should stop interfering in medical practice and allow doctors the freedom to exercise their professional judgement once again.
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