Dementia Screening

Histopathogic image of senile plaques seen in ...

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I wrote up some reflections and thoughts about my time at the Rally and March on Saturday for Community Care and my piece can be read here.

I also wanted to comment about the proposal that the Alzheimer’s Society suggested that everyone over 75 is screened by their GP for dementia. I can see where they are coming from – there certainly needs to be a greater awareness but honestly, I’m not sure if this is the answer.

The idea of the screening is for the GP to offer a type of MMSE (mini mental state examination) test and to have a discussion with a family member/friend in conjunction with this.

Whilst I agree that awareness and early identification of dementias can and must be promoted, I’m not sure that general screening would be of as much use as the Alzheimer’s society do.

I believe it would probably be the people who are more reluctant to go to their doctors who might need the tests the most. There need to be a way of thinking through better targeting of information about dementia and what can be done for people who are diagnosed early in terms of drug therapies and lifestyle changes.

Perhaps if doctors surgeries make contact with people in that age group with whom they have had little contact for months or even years. My concern is the general screening will focus time and resources on those who are  most likely to access the services in any case.

The problem with this is that GPs surgeries are now routinely ‘deregistering’ patients if they don’t attend and don’t send back letters which ask them to confirm their address/registration with a particular surgery. This has frequently been a problem I’ve seen at work as older people who might be more forgetful or just less engaged with responding to correspondence end up without any GP at all.  I expect it happens less in smaller towns and villages where GPs know their patients better but in large cities and inner cities, it is a big problem.

It doesn’t need to be a doctor that carries out the screening tests and conversations either  – perhaps there is scope to use wider ranges of professionals – not to make diagnoses  but to refer for more extensive discussions with doctors. Perhaps you know, even social workers in adult care settings could be involved in identifying some of those people who might be better targeted or leaving information or even adding a few questions about memory and any concerns about it with the people as they call or are requested to call for assistance .

Day centre staff (where they still exist) could have some information to distribute.

General hospitals could also share information and have discussions (this could be a discrete post rather than adding further burdens on currently stressed staff).

It’s useful to look at the prevalence rates for dementia in England and Wales and it is possible to see how it increases after 75 and why this age is the point at which the tests are being proposed. Perhaps even more useful is looking at the incidence figures (new diagnoses) after 75.  It seems that if there is some type of screening it should be repeated at regular intervals rather than a one-off screening at 75.

Maybe it is the way to go. After all, the Alzheimer’s Society has much more expertise in this area than I. I just see so many people whom I know would not go to a doctor’s surgery for a test and I wonder how engaging the process could be.

Often diagnoses are arrived at by family members discussing concerns with GPs in the first place but how to ‘catch’ the diagnosis earlier? Engage those who are likely to see this section of the population and disseminate information.

Information and awareness have to be the key – get the message out that a diagnosis is the start and not the end of help.

I know there was also some discussion about whether someone would want to know if they had a diagnosis of dementia.

Would I want to know if I had a dementia diagnosis? Absolutely and without doubt yes.

I would want to be able to make plans. I would want to be able to benefit from assistance available.

I don’t think general screening is bad. I think there needs to be more thought in how it could be implemented and ultimately, any discussion about dementia on television is a good discussion.

Changes in the NHS – initial thoughts

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I’ll write more about the government proposals to reform the NHS after the Health and SOCIAL CARE Bill is published tomorrow. Oh yes, did anyone pick up that slight subtlety there that it is supposedly covering social care as well as health.. sneakily hidden in.. er.. the title of the bill. You wouldn’t have thought it.

But I shouldn’t be too cynical. That’s just the way that social care has and will roll.

The BBC have a great ‘simple guide’ to the reforms and what they may mean.

Most of my reservations are about the introduction of GP-led commissioning – so I’ll focus on that today.

I know it’s presented as being about more choice and more efficient services – but, as I’ve said before, when the Tories introduced the so-called needs-led agenda of the NHS and Community Care Act in 1990, the talk was about improving efficiency, cutting costs and providing more choice – hmm, those words seem familiar.

What were we left with?

Centrally commissioned services that led to ‘bidding wars’ and reverse auctions so that the company that could provide the service at the lowest cost would ‘win’ the contract. No choice – perhaps less choice as the cheapest options had to be sought regardless of quality.

Why does no-one look to the lessons that should have been learnt from the care sector? I know, there are some wonderful services out there and I don’t want to be dismissive but I feel strongly about the introduction of ‘the market’ to the care sector and I feel equally strongly about the potential failure of ‘the market’ in the health sector.

The US is hardly a glowing example of an efficient and cost-effective health care system after all.

I am not sure I buy into this ‘choice above all’ agenda. Choice is always going to be limited by cost. On a personal level, I live in one of the most deprived areas of the country. I don’t ‘know my GP by his name’. I don’t even necessarily trust the practice.  My current GP practice was ‘taken over’ by the PCT (Primary Care Trust)  for a while because of poor management and a few… financial shenanigans that led to all the doctors in the practice being dismissed. That’s a pretty big deal.

I wonder how a similar scenario would ‘play out’ in the ‘new world’ – where there is no PCT to ‘take over’. But Lansley and Cameron probably haven’t considered those kinds of scenarios. I just hope they remember that we don’t all have local village practices that we’ve been with for years and where everyone knows us and smiles at us in the street.

There are some of us living in very poor areas where some of the chronic health problems that are linked to poverty will very obviously and quite rightly take priority.

So would I get the same treatment for a more minor ailment and a lower priority ‘condition’ as someone in Knightsbridge? I’m not convinced.

Even less convinced because it won’t be my GP who is commissioning – it will be a private company that is hired by my GP. It will likely be the same people who worked in the PCT re-employed by companies like Care UK (a coincidence that they bankrolled Lansley’s private office?).  So it’s likely to be the same people, doing the same job (probably for less money) but for the benefit of shareholders rather than the public purse.

I don’t want to be a grumpy naysayer. I want the NHS to work and to work better.

I am worried though.

I await the publication of the Health and Social Care Bill with trepidation.

I  have reconfiguration fatigue already. The amount of  money my Trust must have spent on change, and more change and even more change and then some more adjustments to that change would probably fund another ward. Or have retained one of the few that have closed.

I want ideas that work. I want a system that works. I am just very sceptical. Perhaps it is up to the government to prove me wrong. I hope I am wrong.

My First Best Interests Assessment

Yesterday I completed my first Best Interests Assessment since the relatively new Deprivation of Liberty Safeguards went live on 1 April 2009.  In brief these assessments grew from the need to clarify the legal position of those who lack capacity when certain restrictive conditions apply which ‘deprive them of their liberty’.

The generally communicated opinion seems to be that rather than the onslaught of assessments from the “live” date of 1 April – there has, instead, been something of a trickle and those who took up the Best Interests Assessments courses to supplement retirement income might be having a few second thoughts now. I’m not wholly convinced by the lack of referrals coming in though and personally expect there to be a slightly higher rate of referral as information trickles out to residential homes – possibly as review processes come around or the CQC (Care Quality Commission) begins to inspect the homes regularly.

Being in a relatively unusual position therefore, of having actually completed a ‘live’ assessment, I thought it would be a useful experience to share.  I don’t intend to look particularly at any of the details of the case that I was presented with but more my responses to the processes.

We are still in the ‘transition’ period. This means that the legal time limits on carrying out the assessments have been extended just for the period of April 2009. So rather than the seven calendar days that I would usually have to complete an assessment, I had the rather more comfortable 21 day limit.  This was particularly useful as the time period fell over the Easter holidays.

I received a telephone call from our DoLs co-ordinator who asked me about my availability to complete an assessment. I agreed to undertake the assessment, not least because after the training course and the written work, I was eager to see how things panned out in practice.

They then sent me copies of the forms that had been completed by the Managing Authority – in this case –  a residential home. There was the request for urgent authorisation of a deprivation of liberty, the request for a standard authorisation of a deprivation of liberty and a comprehensive care plan as well as the request form for a Mental Health Assessor (who has to be doctor).

Myself and the doctor involved seemed to play telephone tennis for a couple of days, leaving messages for each other at particularly inconvenient moments – until in the end with an awareness of the time limitations, she left me a message saying ‘I’m going to do this assessment tomorrow – are you with me?’  At that point, we were able to make contact and I postponed for a day in order to gather more information but at least we had a day when we could both assess at the same time.

In that period, I called everyone I could find that had had come kind of contact with the person involved – Social Worker/Care Manager, CPN, staff of residential home, GP and most importantly, next of kin.

I requested a couple of extra ‘background’ documents from the social worker and CPN, just to give me a better idea of some of the background history as the signs pointed to someone with very significant cognitive impairment.

On arriving at the residential home, I had a chat with the key worker and a look through the file. When the doctor arrived, we made a quick decision relating to who would complete which forms – I did the age assessment (!), eligibility, no refusals and of course, the Best Interests Assessment and she did the Mental Health Assessment and the Mental Capacity Assessment.

There was an obvious path to take with the way the interview progressed. We had agreed to start with capacity but as it happened, it was more a type of discussion/interview that we both added to but that provided all the necessary answers.

After the interview part, we discussed briefly the recommendations that we were making. She had expected me to hand her a claim form and we commented on the differences with the Mental Health Act Assessment – namely that our role is to make recommendations to the Supervisory Authority rather than to make the immediate decisions.

A couple of thoughts then from the process – the forms didn’t actually take as long to complete as they look like they might. The paperwork is enormous but comparing to my work as an AMHP,  I would say a Mental Health Act Assessment is significantly more time-consuming and involved. Partly this is because with the BIA (Best Interests Assessments) the ‘setting up’ is done by the supervisory body and while there is still a necessity to gather information, there isn’t the same responsibility for engaging doctors, police if necessary, ambulance and hospital bed.  For this assessment, apart from the prior information gathering, I turned up and assessed.

Of course, it has to be considered that the assessment I carried out was fairly clear-cut in that it could have been written up as a model case study in some respects so obviously if decisions are more borderline that is a different matter entirely.

I had some thoughts about the time limit on the authorisation (because I did recommend an authorisation of a deprivation of liberty). I did not go for the full allowable one year but instead a shorter period because I felt it would be useful to reassess the position to see how and if things were progressing. In retrospect, I wonder if this was a slightly arbitrary decision.

It was extremely useful doing the assessment jointly with the Mental Health Assessor – especially as we are still feeling our way around to a certain extent. I think it generally leads to a better experience for the person being assessed as had we visited separately we would have repeated a lot of the same questions.

My slight concern remains that the seven day limit will seem to be a little tight.

I am though, relieved to have finally completed an assessment and seen through the process in action.

An Assessment

I mentioned in passing that I was out at an early morning assessment earlier in the week. I wanted to reflect on some of the issues that arose without mentioning too much of the detail. It was the second attempt to assess as the first visit, Mr A had not been in. That was why we went earlier this time. We knew he was more likely to be in.

This assessment had been troubling me enormously but actually had a fairly satisfactory outcome. I think.  Actually, the real difference made in that assessment was that the GP was present. Although he was reluctant to come to assess because (understandably) he did not want to ruin his therapeutic relationship – it was in fact, exactly that therapeutic relationship which enabled us to try to engage Mr A at home a little longer and see if we couldn’t  avoid a hospital admission.

There was an interesting conversation beforehand though between psychiatrist and GP when GP claimed his therapeutic relationship was crucial and psychiatrist replied snarkily ‘so is mine – psychiatrists also have to build relationships you know’. It was a gem. It was also, for me, a massive lesson in making assumptions before attending but a good one.

But, if there’s one thing my almost-one-year of being an ASW/AMHP has taught me is that assumptions are there to be broken. You plan ahead and outline how you think assessments might go and can never fail to be surprised.


What didn’t help was returning to the office and having a couple of people tell me I’d clearly made the ‘wrong’ decision because I couldn’t possibly not have brought Mr A into hospital – along with a long list of risks which we had previously identified relating to the reasons we had gone ahead with the assessment in the first place.

Sigh.  Honestly, I generally love my team but they do like to comment on all the ‘bad’ decisions I make – and even if I had felt Mr A should be in admitted forcibly to hospital (which I didn’t – or at least, I felt we needed to try other things before going down that route) – neither of the doctors would have signed recommendations anyway because we all agreed.

The more stressful decisions come about when you have two signed medical recommendations in hand and then make the decision not to admit. That has almost happened to me – what actually happened is that I had one recommendation and another doctor assessing with me who asked me if I wanted him to write a recommendation or not because it could have gone either way. I told him not to and we didn’t admit.

I get paid more now than most of the people on the same ‘level’ as me at work – namely, all the people who aren’t in senior or management positions. The reason I get paid most is solely because I get additional increments for the AMHP work. I’m also one of the younger members of the team.  These two combined factors don’t always make me the most popular of people.

It can feel very isolating at times. I wanted to come back and discuss the assessment and mull it over. The other AMHP I work with has management responsibilities and also has much much more experience than me, of social work, of work in mental health settings and of ASW/AMHP work. But she was on leave. Anyway, I had three other visits arranged for that day.  Actually, I had four but I cancelled the one which I felt could be postponed.

I probably would have taken today off if I didn’t need to complete the paperwork for a Guardianship renewal. Oh, and apparently I will find out if I’ve been approved as a Best Interests Assessor although it’s likely that I won’t actually find out until Monday as I’m out and about most of the afternoon.  A weekend of two days sometimes just isn’t long enough. I made it to April with my two ‘emergency’ days of annual leave intact! I also realised (and I’m sure all this is related to my general current mental state!) that I haven’t had more than a few long weekends off work for over a year.

At least I have my holiday in July to look forward to! But actually, I’m very very tempted to book myself a week off – even if it is just a ‘stay at home’ week.

Sometimes I think I’m not very good at looking after my own mental health.

Healthcare for Asylum Seekers

I read in The Guardian yesterday that the government is to abolish her plans to tighten regulations that allow asylum seekers to seek free primary care.

To be honest, I was horrified when I heard it had been proposed at all. What kind of society are we to become when we deny very basic health care to those who are extremely likely to be unable to pay for it?

lipo's sojourn lipo’s sojourn@flickr

I am constantly reminded of a woman I was asked to assess a couple of years ago who was admittedly was in a slightly different situation of being a  failed asylum seeker who had run out of appeals. She walked a good five miles to the nearest GP who would treat her – and back again of course – on a weekly basis. She was physically unwell. It certainly concentrated the mind on the importance in general, regarding public health, especially in a crowded city, of treating people who are sick – firstly on a level of humanity and second, just because the spread of infection or someone who is avoiding treatment in primary care will lead to longer and perhaps more widespread difficulties over a longer period.

People, on whatever level they enter the country and whatever the grounds are that decide whether they can or cannot stay, are still people and are still subject, at the very least, to human rights legislation which explicitly ordains a right to life.

The Guardian quotes a spokesman for the BMA (British Medical Association) as saying

‘Our view was always that there had to be more flexibility for GPs. If you are talking about people who can pay, that is one thing, but asylum seekers are unlikely to have the money.’ She said denying primary care could lead to failed asylum seekers later coming to the NHS with ‘more life-threatening and more expensive’ needs: ‘Diabetes may not be an emergency, but if you don’t get any insulin you will end up in a coma and coming to A&E.’

The article goes on to say

Official guidelines state that GPs should not register failed asylum seekers, but they have the discretion to accept them if they wish. Many doctors argue that excluding such people would mean that they were failing in their duty to put patient welfare first.

Good for the doctors who are put into an exceptionally difficult situation by a government that passes out policy documents seemingly on the basis of populist headlines in the ‘Daily Mail‘.

It’s all very well to sit in your comfortable suburban home and grumble about your tax money going to pay the expenses of people who are seeking refuge in this country – but actually thinking of asylum seekers as human beings worthy of dignity and respect rather than numbers and ‘a problem’ might actually make the society that we live in a better and more wholesome place to live in.