On paying doctors to diagnose dementia

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.


Cocoa: Stopping dementia in its tracks (or possibly not)

This morning I heard of a study which had found that drinking hot chocolate regularly could stop older people from developing dementia. The study, run by a team from Harvard, suggests that cocoa improved blood flow to the brain, resulting in better scores on tasks designed to assess memory. I duly had a look at the paper, published in Neurology.

The study was designed to investigate the effect of cocoa on neural coupling, which refers to the relationship between neural activity and cerebral blood flow. Sixty people were included in the study: half were given two cups of high-flavanol (an antioxidant) cocoa each day and the rest were given low-flavanol cocoa. A number of cognitive assessments were carried out, many of which are also used by clinicians in cases where dementia is suspected. The Mini Mental State Examination (MMSE), for example, assesses cognitive functioning in a range of domains, as does the Trail-Making Test. After 30 days of prescribed cocoa-drinking, the cognitive tests were repeated and a significant improvement was observed on one of them (the Trail-Making Test B). There were no differences reported between the groups, i.e. Trails B scores improved regardless of the quantity of flavanol ingested and no other significant improvements were observed in either group.

Like all studies, this one has its limitations. Whilst it’s a positive that the authors split the sample in half and gave them different quantities of flavanol, it’s usually the case that you have an ‘intervention’ group and a ‘control’ group. In this case, you would have had those who took cocoa for 30 days, perhaps splitting them to take different quantities of flavanol, but you would also have had a similar group – matched for age, gender and health – who took no cocoa. They would be your ‘controls’. That way, you can compare scores across all these individuals at baseline and the end of treatment (in this case end of cocoa) and compare them. The advantage of doing this is that you can see if the improvement was associated with the cocoa or if it was simply a spontaneous improvement which was also observed in the control group.

In this study, there was no control group, so it’s difficult to presume that the observed improvement was due to taking cocoa. In any case, an improvement on one test of cognitive function may be interesting, but it won’t necessarily have any real-world impact. The Trail-Making Test assesses a range of functions, but the test is the sort of thing we use clinically, it’s not something you would have much cause to do in daily life. It’s a bit like the Brain Training games which teach you to remember long lists of words – your skills in that domain may improve, but realistically that’s only useful if you want to be able to recite your shopping list verbatim at any moment. I’d be more excited if the improvement had been seen on the MMSE since that is a much more global test of functioning. As it is, this was a small study which didn’t have a control condition and that seriously limits the extent to which we can draw conclusions from the findings. If you’re considering stocking up on the Green and Blacks simply to stave off dementia, I’d think again.