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A memory clinic v. traditional community mental health team service: comparison of costs and quality

  • Judy Sasha Rubinsztein (a1), Marelna Janse van Rensburg (a2), Zerak Al-Salihy (a1), Deborah Girling (a2), Louise Lafortune (a3), Muralikrishnan Radhakrishnan (a4) and Carol Brayne (a3)...
Abstract
Aims and method

To compare the cost and quality of a memory-clinic-based service (MCS) with a traditional community mental health team (CMHT) service. Using a retrospective case-note review, we studied two groups, each with 33 participants. Consecutive referrals for diagnostic ‘memory’ assessments over 4 months were evaluated. Participants were evaluated for up to 6 months.

Results

The MCS was less costly than the CMHT service but the difference was not statistically significant (mean cost for MCS was £742, mean cost for CMHT service was £807). The MCS offered more multidisciplinary and comprehensive care, including: pre- and post-diagnostic counselling, more systematic screening of blood for reversible causes of dementia, more use of structured assessment instruments in patients/carers, signposting to the third sector as well as more consistent copying of letters to patients/carers.

Clinical implications

An MCS service offered more comprehensive and multidisciplinary service at no extra cost to secondary care.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Judy Rubinsztein (judy.rubinsztein@nsft.nhs.uk)
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Declaration of interest

None.

Footnotes
References
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A memory clinic v. traditional community mental health team service: comparison of costs and quality

  • Judy Sasha Rubinsztein (a1), Marelna Janse van Rensburg (a2), Zerak Al-Salihy (a1), Deborah Girling (a2), Louise Lafortune (a3), Muralikrishnan Radhakrishnan (a4) and Carol Brayne (a3)...
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eLetters

RE: What about effectiveness?

It is good to read of the work of Dr de Silva (1) and his colleagues in South Tyneside. They are seeing people at an impressive hit rate and providing a service which people like. As in Gnosall, the model being used takes advantage of primary care settings. I think the difference is that we provide expertise within primary care, with a view to a potential three tiers (primary/secondary/tertiary) (2), whereas de Silva is describing a secondary tier outreach. The advantage of Gnosall, which has been demonstrated now over nearly nine years, is that continuity of support and integration of care is facilitated and sustained (3, 4). Great stuff though: people are catching on!

References:

1. De Silva P. What about effectiveness? Psychiatric Bulletin February 2015

2. Jolley D, Greaves I, Greaves N and Greening L. Three tiers for a comprehensive regional memory service. Journal of Dementia Care (2010) 18 (1) 26-29

3. Greaves I, Greaves N, Walker E, Greening L, Benbow S and Jolley D. Gnosall primary care memory clinic: Eldercare Facilitator role description and development. Dementia (The International Journal of Social Research and Practice) (2013)12 (5) DOI: 10.1177/1471301213497737

4. Clark M, Moreland N, Greaves I, Greaves N and Jolley D. Putting personalisation and integration into practice in Primary Care. Journal of Integrated Care (2013) 21(3) 105-120.

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Conflict of interest: We are all involved in the Gnosall Memory Service

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What about effectiveness?

Prasanna N. de Silva, Consultant Old Age Psychiatrist
11 February 2015

Both Rubinsztein et al. and Jolly (1, 2) raise differing views on quality, at the expense of comments on effectiveness. For example, themeasure of diagnostic rates across the UK produced by the Alzheimer's society suggest an average rate of 48%, with Norwich at 42.62% and Cambridge at 47.04% (3). The authors of the first paper have not providedresults of the 'Friends and Family' testing, now routinely carried out by most mental health trusts.

In our South of Tyne Memory Protection Service (which has been in existence for 2 years now) the diagnostic rate is 77%. Exhaustive researchto elicit the cause has only come up with two factors: the number of district hospitals serving South of Tyne, and the involvement of the three commissioning CCGs in the design of the service, with all clinics being held in primary care sites (4).

Furthermore, Rubinsztein et al. ignore the impact of 'front loading'Consultant expertise in memory services to improve treatment planning. This includes signposting referrals to treat metabolic and cardiac disease, and to prevent further falls and strokes, all of which have a significant impact on outcome in terms of mortality and ability to remain in the community.

I wonder if there should be a third way: a memory service 'piggybacking' onto day hospitals in District Hospitals, providing a walk-in service. Referrals include those from the other clinics like falls, cardiology, diabetes and Parkinson's Disease. A day hospital has prompt access to phlebotomy, imaging and ECG services. Furthermore, cross referrals to (andlearning from) other clinics within the day hospital is possible.

It is widely assumed that overheads (space, heating, admin and managerial costs) make up 20% of the overall cost; therefore sharing overheads would reduce the overall cost of assessing a patient referred toa memory service. With a memory assessment agreed with radiology, a '2 stop shop' service with a diagnosis is eminently possible. Heady times indeed!

References:

1. Rubinsztein, J.S., van Rensburg, M.J., Al-Salihy, Z et.al. A memory clinic v. traditional community mental health team service: comparison of costs and quality. BJPsych Bulletin (2015) 39, pp6-11

2. Jolly, D. Heads in the sand may leave old age psychiatry looking foolish and vulnerable. BJPsych Bulletin (2015) 39, pp 12-14

3. www.gov.uk/government/news/alzheimer-s-society

4. de Silva, P. What does a good memory service looks like? - improving effectiveness, reducing misdiagnosis.Progress in Neurology and Psychiatry (in press)

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Conflict of interest: None declared

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