Being paid by outcomes is no new thing in the NHS. In physical health, good outcomes are relatively easy to distinguish. In mental health, it’s more complex. Often, outcomes look at symptoms or daily functioning (often defined as ability to work, travel alone, etc), but these are blunt instruments for complex and often nuanced problems. It’s a fundamental truth that not all health is quantifiable and that not al treatment is quantifiable. It is perhaps as great a truth that the people who decide how health services should be commissioned and run don’t really get that.
Thus it was that I read with horror that GPs are to be paid up to £200 to diagnose dementia. There will be no ‘second opinion’ in this case – no one will verify the diagnosis, but there it will sit, on your medical records, colouring the way you are treated and interacted with for the rest of your life. The government says that this will increase the number of diagnoses of dementia made, which it doubtless will, if it will earn the diagnosers a small fortune. But a diagnosis which is incorrect is worse than useless; it is actively harmful.
Not that I am accusing all GPs of being mercenary. Far from it. Most GPs are dedicated to their patients and, I am pretty sure, have an ethical code which would stop them diagnosing for the sake of it. But some are less scrupulous. I am currently working in learning disabilities. People with learning disabilities tend to have poorer health than the rest of us and, when they become ill, they are more likely to die. Partly, this is because people with an LD often lack the knowledge most people have about the ways their bodies should look or feel and partly it is because they may have trouble communicating it. As such, tumours, abscesses and ulcers can grow and grow without anyone knowing until they become fatal. GPs are paid £100 to do an annual health check for someone with a learning disability – diabetes, breast, prostate and thyroid checks are all par for the course. Yesterday I was told that there are some GPs who have been found to pocket the £100 whilst palming off the health checks to unqualified care home staff. The parallels are clear. The acquisition of money can do terrible things to our sense of professionalism and it takes quite something to resist the lure of it..
But there’s a more fundamental point here. GPs have a breadth of skills and knowledge, but the clue is in the title, they are ‘general’ practitioners. They tend not to diagnose severe and enduring conditions; they, rightly, send you to a specialist. During training, I have spent six months working with older people, diagnosing dementia. I spent six months working in a specialist neuropsychology placement assessing people with stroke, multiple sclerosis, Huntingdon’s chorea, epilepsy, Parkinson’s and so on. Typically, an assessment, a thorough, robust, clinically-defensible assessment would take some four or five hours. With older people, it often takes longer because they fatigue more easily. Writing a report, up to nine pages long, takes hours if it is done well. To be sure, with practice, you can do it more quickly, but there is no substitute for a detailed clinical interview and a well-selected test battery. Neuropsychological assessments show what brain scans can miss and virtually always add real clinical value. That value is then translated into help for the person. I have written reports detailing a dozen recommendations to help the person manage better. It’s time-consuming, but it’s my job and it’s the right way to do it. The wrong way is to have a ten-minute appointment with your GP, be asked some crude questions to estimate your cognitive functioning and receive a diagnosis on the spot.
But, you might say, if the person gets a diagnosis, they will get treatment. Well, perhaps. But if the diagnosis is incorrect I question the point of treatment. And, unfortunately, they blunt truth is that we can’t do a lot for many dementias. There are tablets that work for some people, but they are only prescribed for very specific types of dementia, of which there are many. Thousands of people have dementias which cannot be treated by medication. There are ways to support such people, but a diagnosis is not always helpful and not everyone who has an assessment wants to know the outcome of it. Knowing can affect your ability to drive, your perceived ability to work and retain control of your legal and financial matters. It can make you pitied by your family and friends. It can make you terrified of the future. It cannot be easily undone and the effects cannot be avoided. There is no magic cure and, truth be told, having an assessment, even a good one, is something that people often think about very carefully. Now imagine all those consequences based on a poor assessment and a diagnosis of dubious nature, made in the context of £200 in someone’s back pocket, and think whether you would want your parent to be in that position.