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Commissioning services for people with dementia: how to get it right

  • Steve Iliffe (a1)
Summary

The current emphasis on improving the quality of dementia services is welcome, but it treats dementia as if it were separable from complex comorbidities, disability and frailty. As a consequence, dementia can overshadow other problems, from heart failure to multisystem failure at the end of life, which may be poorly managed. Three ways in which old age psychiatrists can reconnect dementia with the diseases and disorders of later life are described in this editorial. The first is to improve skills in general practice so that general practitioners (GPs) can take on the bulk of the clinical work of both diagnosis and management of dementia and its comorbidities, while specialists retain complex decision-making and management tasks. The second is for old age psychiatrists to function as consultants to social enterprises run by GPs for the purpose of managing almost all patients with dementia in general practice. The third is for community geriatricians and old age psychiatrists to work together in integrated organisations that take full clinical responsibility for older people with dementia.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Steve Iliffe (s.iliffe@ucl.ac.uk)
Footnotes
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Declaration of interest

S.I. is a member of a locality commissioning board in north-west London and Associate Director of the UK Dementias and Neurodegenerative Diseases Research Network (DENDRON), part of the National Institute for Health Research.

Footnotes
References
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1 Department of Health. Dementia commissioning pack. Department of Health, 2011 (http://www.dh.gov.uk/health/2011/07/dementia-commissioning-pack).
2 Xie, J, Brayne, C, Matthews, FE. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up. BMJ 2008; 336: 258–62.
3 Rait, G, Walters, K, Bottomley, C, Petersen, I, Iliffe, S, Nazareth, I. Survival of people with a clinical diagnosis of dementia in primary care. BMJ 2010; 341: c3584.
4 Connolly, A, Iliffe, S, Gaehl, E, Campbell, S, Drake, R, Morris, J, et al. Quality of care provided to people with dementia: utilisation and quality of the annual dementia review in general practice. Br J Gen Pract 2012; 62: e918.
5 Gambassi, G, Landi, F, Lapane, KL, Sgadari, A, Mor, V, Bernabei, R. Predictors of mortality in patients with Alzheimer's disease living in nursing homes. J Neurol Neurosurg Psychiatry 1999; 67: 5965.
6 Larson, EB, Shadlen, M-F, Wang, L, McCormick, WC, Bowen, JD, Teri, L, et al. Survival after initial diagnosis of Alzheimer's disease. Ann Intern Med 2004; 140: 501–9.
7 Moroney, JT, Bagiella, MS, Tatemichi, TK, Paik, MC, Stern, Y, Desmond, DW. Dementia after stroke increases the risk of long-term stroke recurrence. Neurology 1997; 48: 1317–25.
8 Zekry, D, Herrmann, FOR, Grandjean, R, Meynet, MP, Michel, JP, Gold, G, et al. Demented versus non-demented very old inpatients: the same comorbidities but poorer functional and nutritional status. Age Ageing 2008; 37: 83–9.
9 Rockwood, K, Mitnitski, A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007; 62: 722–7.
10 Boyle, PA, Buchman, AS, Wilson, RS, Leurgans, SE, Bennett, DA. Physical frailty is associated with incident mild cognitive impairment in community-based older persons. J Am Geriatr Soc 2010; 58: 248–55.
11 Sampson, EL, Gould, V, Lee, D, Blanchard, MR. Differences in care received by patients with and without dementia who died during acute hospital admission: a retrospective case note study. Age Ageing 2006; 35: 187–9.
12 Iliffe, S, Wilcock, J. The identification of barriers to the recognition of and response to dementia in primary care using a modified focus group method. Dementia 2005; 4: 7385.
13 Pimouguet, C, Lavaud, T, Dartigues, JF, Helmer, C. Dementia case management effectiveness on health care costs and resource utilization: a systematic review of randomized controlled trials. J Nutr Health Aging 2010; 14: 669–76.
14 Goodman, C, Drennan, V, Davies, S, Massey, H, Gage, H, Scott, C, et al. Nurses as Case Managers in Primary Care: The Contribution to Chronic Disease Management (Project Report). National Institute for Health Research Service, 2010.
15 Gloth, F, Gloth, M. A comparative effectiveness trial between a post-acute care hospitalist model and a community-based physician model of nursing home care. J Am Med Dir Assoc 2011; 12: 384–6.
16 Crotty, M, Halbert, J, Rowett, D, Giles, L, Birks, R, Williams, H, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing 2004; 33: 612–7.
17 Davies, SL, Goodman, C, Burn, F, Victor, C, Dickinson, A, Iliffe, S, et al. A systematic review of integrated working between care homes and health care services. BMC Health Serv Res 2011; 11: 320.
18 Greening, L, Greaves, I, Greaves, N, Jolley, D. Positive thinking on dementia in primary care: Gnosall Memory Clinic. Community Pract 2009; 82: 20–3.
19 Jolley, D, Greaves, I, Clark, M. Memory clinics and primary care: not a question of either/or. BMJ 2012; 344: e4286.
20 European Medical Association. Situation in the member states of the European Union: Netherlands. EMA (http://www.emanet.org/pg-netherlands.cfm).
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Commissioning services for people with dementia: how to get it right

  • Steve Iliffe (a1)
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Steve Iliffe, Professor of Primary Care for Older People
11 June 2013

In the 'quick and dirty' poll I carried out among psychiatrists in the South West, the least popular option for reconfigured services for people with dementia was the Gnosall model, described in greater detail bySusan Benbow and colleagues. This model inverts the natural world, puttingthe general practitioners (GPs) in charge while fostering 'interactive dialogue', and is surely an example of the more imaginative thinking that David Anderson hopes commissioners will display. Its attractiveness remains to be seen, as it is now at the point where its methods must be picked up from the 'innovator' group which created it, and used by less determined but perhaps more typical 'early adopters'. We shall see whetherthis happens. Since 90% of care homes are outside the public sector (even if they receive enough public funds to be inside the public domain), the second most popular option also fits David Anderson's suggestion about an 'alliance of community geriatrics and old age psychiatry with the independent sector'. This is a difficult option, because it could bring the specialist alliance into conflict with generalists over who is the clinical lead for people with dementia, with an uncertain outcome when clinical commissioning groups are heavily influenced by GPs, and are very aware of the need toreduce costs. Even more imaginative ideas about multiple providers seem tomany to simply replicate the current fragmented system; curing fragmentation of provision by further fragmentation sounds counterintuitive to many, unless the whole process is to be led by consumers under a 'personalisation' agenda. The most popular option was a redrawing of the traditional boundary between specialist and generalist services, with GPs taking more clinical responsibility for continuing support. This is a comfortably low-risk gamble, for specialists at least, because their likely funding scenario islimited growth at best, with budget shrinkage more likely. The question ishow to do it. There are many assumptions that could impede change even in this less challenging option. One is identifying 'knowledge deficit' as the core problem in general practice, as Sudip Sikdar does. This does not fit with the findings of the EVIDEM-ED trial that tailored, workplace-based educational interventions do not change practice, even when policy pressure, consumer demand and incentivisation combine to create a theoretically ideal climate for such change. Low diagnosis rates (based onQuality and Outcomes Framework returns) are exaggerated as a problem by a health service that functions as a target-driven industrial machine, distracting practitioners from the need for timely diagnosis and continuing support for their patients. Any stigma can be 'addressed' as a public health problem (although public health medicine has not been prominent in dementia policy and practice debates) but that does not necessarily change it, whereas dementia prevention strategies are based onsupposition, not evidence of effectiveness. Commissioners are in the difficult (but commonplace) position of having to make investment decisions with poor evidence against a background of competing professional and commercial agendas, while not being able to change the one thing that might be critical - the GP contract. Getting commissioning right for people withdementia will be difficult, so I look forward to carrying out more polls and listening to the debate they provoke.Steve Iliffe is Professor of Primary Care for Older People at the Department of Primary Care and Population Health, University College London, a member of a locality commissioning board in north-west London, and Associate Director of the UK Dementias and Neurodegenerative DiseasesResearch Network (DENDRON), London, UK.

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Conflict of interest: None declared

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Commissioning dementia services

David N Anderson, Consultant Old Age Psychiatrist
15 May 2013

Iliffe (1) makes important points about complex conditions but offers a very limited view of the possibilities for commissioning dementia services.

Any qualified provider broadens the options and there is no reason why the whole system needs to be commissioned from a single provider. In acute hospitals, services may be provided by liaison psychiatry or physicians or both. Liaison psychiatry could extend into the community (2) or intermediate care services. In care homes, where frailty is common, there might be an alliance of community geriatrics and old age psychiatry with the independent sector. Home treatment may include joint health and social care, memory services, and care advisers.

What is crucial is that the whole system has to be commissioned and commissioners see the whole system and bind the component parts together. This point is made in the NICE dementia commissioning guide with reference to dementia clinical networks (3). Networks define a whole system where local providers are clearly identified to meet local need and operate a unified, interactive dialogue, not a care pathway that patients don't follow.

The new commissioning environment creates an exciting opportunity to think more imaginatively and this will be needed to meet the dementia challenge. This has to be more than the 'is it the GP or the specialist?' question.

References:1.Iliffe S; Commissioning services for people with dementia: how to get it right. Psychiatrist 2013; 37: 121-3.

2.Parsonage M, Fossey M, Tutty C. Liaison psychiatry in the modern NHS. Centre for Mental Health, 2002.

3.NICE. Support for commissioning dementia care. National Institute for Health and Clinical Excellent, 2013. http//www.nice.org.uk/usingguidance/commissioningguides/dementia/home.jsp.

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Conflict of interest: None declared

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Dementia commissioning- a missed opportunity

Sudip Sikdar, Clinical Director, Consultant Psychiatrist
15 May 2013

I read Prof Iliffe's article with interest. He finishes the article with a question but does not address a much more important issue in dementia care in this country; he fails to address the issue that although dementia is considered a public health priority by the WHO (1), the commissioning pack does not prioritise dementia.

Less than half of dementia cases continue to remain undiagnosed in the UK (2). Significant resource allocation is needed to address the poor diagnosis rates in the population via public mental health campaigns. This should also address the still prevailing stigma about dementia and highlight the potential prevention strategies.

The Royal College of Psychiatrists and General Practitioners have tried to address this by producing the Joint Commissioning Panel for Public Mental Health (JCPMH) (3); however, most Health and Wellbeing Boards responsible for delivering the public health agenda do not have statutory representations from mental health trusts.

CQUIN (Commissioning for Quality Innovation and Prevention) schemes for 2013-2014 have allocated resources for integrated/collaborative care in dementia but the funding is non-recurrent. The chronic underfunding of old age services to the tune of over approximately £2 billion needs to be addressed. Most consultants working in an Older People's Mental Health Service have a catchment population twice the upper limit suggested by the Royal College of Psychiatrists (4).

GPs need to remain the focal point of coordinating dementia care and need further training in complex care rather than financial incentivisation under the QOF (Quality and Outcomes Framework).

References:1.www.who.int/mental_health/neurology/dementia/en/

2.www.alzheimers.org.uk 3.www.jcpmh.info

4.CR174. Safe patients and high-quality services: a guide to job descriptions and job plans for consultant psychiatrists, Nov 2012

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Conflict of interest: None declared

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Getting it right for people with dementia

Susan Mary Benbow, Consultant Psychiatrist
06 May 2013

Steve Illife's editorial is perceptive, diplomatic and hopefully not too late (1). As he makes clear, dementia is not, for most people, a stand-alone condition. Once established it remains significant in determining quality of life and need for help and support right to the end of an individual's life. Every journey with dementia is unique and will not be constrained bya predictive pathway or tidied into convenient once-and-for-all time phases.

Our model of specialist involvement in Primary Care, which is dismissed as third choice by psychiatrists in the South West, has the advantage of proven sustainability over nearly seven years. The arrangements bring the specialist expertise of psychiatry into the Practice and the Practice retains the clinical responsibility for patients. Many are elderly and carry a number of illnesses for which they attend the Practice: a memory problem is simply one of a spectrum of challenges, and attendance at a Practice clinic is an acceptable addition to the patient's routine. Patients are seen as people with full lives with important social and family involvement. An integrated and collaborative approach achieves rapid access to assessment, diagnosis and care planning, with high satisfaction by all parties and reduced usage of other components of the Mental Health and General Hospital economies (2, 3, 4).

The Gnosall experiment was not intended to remain an isolated enterprise: several visiting teams have taken the essentials of the model and begun similar services elsewhere. We have described a three tier modelwhich foresees the integration of the work in Primary Care within a reorganized district memory service as a component of the Old Age Psychiatry service (5).

We are currently working with commissioners, South Staffordshire and Shropshire Mental Health Trust, and a federation of over 30 primary care outlets that cover 360,000 patients with a view to creating this vision over a wider area.

This is not a pathway to loss of special skills, independence or status, but the logical way to deliver a sensitive, comprehensive, affordable service for every individual and every family with dementia in the context of the UK in the twenty first century.

References

(1) Iliffe S (2013) Commissioning services for people with dementia: how to get it right. The Psychiatrist 37: 121 -123.

(2) Greening L, Greaves I, Greaves N and Jolley D (2009) Positive thinking on dementia in primary care: Gnosall Memory Clinic. Community Practitioner 82(5) 20-23.

(3) Greaves I and Jolley D (2010) National Dementia Strategy: well intentioned, but how well founded and how well directed? British Journal of General Practice 60: 193-198.

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

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

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Conflict of interest: All authors contribute to the work of the Gnosall Memory Service.

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