Steady does it in dementia care

I was pleased to find a reference in the newspaper to important work which confirms that people with dementia who see their own GP regularly do better than those who pass through the hands of a number of doctors and other professionals: Dementia patients who see same GP have better quality of life, study finds | Dementia | The Guardian

The full study is available online Continuity of GP care for patients with dementia: impact on prescribing and the health of patients | British Journal of General Practice (bjgp.org)

It is a fabulous piece of work – conducted by a large and impressively qualified team at Exeter University: It uses record linkage to identify a cohort of 9324 patients with dementia in 2016 and follow them up for up to 12 months – using the Clinical Practice Research Datalink.

The design required the identification of contacts with a General Practitioner rather than another professional in the Practice and this informed measures of continuity of care as: the Usual Provider Index, the Brice-Boxerman Continuity of Care Index and the Sequential Continuity of Care Index. These measures were used to characterise levels of continuity of care divided into quartile – High, high intermediate, low intermediate and lowest.

Adjustments were made for age, gender, deprivation and 14 comorbidities and frailty. Outcomes were represented in terms of the number of medicines prescribed, the number of Potential Inappropriate Prescriptions and the incidence of Adverse Health Outcomes: Death (1827), Emergency Admissions to Hospital, Delirium, Anaemia, Falls, Fragility fracture, Incontinence, Osteoarthritis, Osteoporosis and Pneumonia.

Multiple prescriptions were made to more than 80%, Potential Inappropriate Prescribing in over 75%. Polypharmacy and Potentially Inappropriate Prescribing was seen less often amongst those receiving most regular follow up by one GP.

Deaths were no more common in those with the least continuity of care than those most carefully followed up, but emergency hospital admissions, delirium, and incontinence were less likely amongst those receiving the most intense follow up with one GP.

This is brilliant – it fits with other studies which have found better outcomes for people without dementia who receive consistent follow up by one GP. People with dementia are probably even more at risk of poor outcomes if denied such consistent follow up than those without dementia.

It fits with everything which common sense and what our mothers taught us – and confirms that, whilst it is good to have teams of professionals in primary and secondary care, the central role of the doctor in establishing and sustaining a relationship of trust with the patient and family.

This is a wakeup call to halt the fashionable drift which fragments care between professionals in the name of ‘efficiency’. It is, of course, something demonstrated in the Gnosall Model of Primary Care for People with Dementia.