It’s Dementia Awareness Week, which this year aims to encourage people who are worried about dementia to confront their worries by addressing dementia directly and seeking support. Brenda Gannon explains how new research indicates this may not mean increased costs to the NHS.
In the era of health budget Devolution and integrated health and social care services, the efficient allocation of resources for mental health services remain a priority for policy makers, patients, their families and carers.
Public health policy is faced with additional pressures to improve the prevention of disease among the population. Health checks that provide information on prevention, and screening for health conditions are crucial to ensure that long lasting conditions are prevented and treated in a timely manner.
The dementia challenge
The Prime Minister’s Dementia challenge 2020 promotes the introduction of early onset of dementia health checks for all people aged 40 and over. In my view it’s never too early! With current diagnosis of about 850,000 people (2015) and diagnosis rates of around 50-60% this equates to a cost of £26 billion a year (2014) as well as severe quality of life implications for patients, and carers. The challenge is to ensure that increased diagnosis does not lead to over-use of health and social care services in the longer term.
The National Institute for Health and Care Excellence has set a Quality Outcome Framework target of 75 % diagnosis which means that now more people will require services and are entitled to care and treatment. The question remains to be answered – does this lead to more primary care and doctor visits andwill this increase costs to the ever-pressurized health budget?
The answer to this is not easy to obtain, but not impossible. With the increased resources and strategies (e.g. Health Innovation Manchester) to ensure better data are captured for the health and social care sector, we can now tackle such quantitative issues. The methods to apply to these data are less straight –forward, but again not impossible.
Evidence drawn from data
We can first look at the issue of cognitive impairment, which is a marker of onset of dementia (BMJ 2012). Using data from a large European source called SHARE (Survey of Health, Ageing and Retirement in Europe); we found that cognitive impairment may indeed be associated with more visits to the doctor. For example, in a test of word recall – where a person is given a list of ten words and asked to repeat back to the interviewer – the average number of words remembered among a population aged 50+ was 5. Our statistical analysis showed that this is associated with 0.1 more visits to the doctor, on average.
Could it be that these people are simply going to the doctor for other conditions? No, this is not the case. We looked at the impact of other health conditions. The use of primary care services across conditions is interesting in itself. Combined then with the cognitive impairment effect, the higher services users are those with diagnosed heart problems, high blood pressure, diabetes, arthritis and stroke.
By including these conditions into our analysis the effect we found from cognitive impairment, is then the additional or marginal effect, meaning that the resulting use of GP services from those with lower cognition is not overly high. This is good news for the future of dementia prevention information and screening across the population.
Calculating the costs
It could also be argued that our findings are based on secondary data, where the recall of GP services is also affected by cognition. So we modeled this in an advanced statistical model and found the same marginal result, of 0.1 visits per one less word recalled. These new results ill be presented at the International Panel Data Conference 2016.
But why is this important and what does such a proportionate number of visits mean? If one less word remembered leads to additional 0.10 visits, then 10 people could on average incur one visit. So if the prevalence rate of mild cognitive impairment is approx. 5% (Sachdev et al. 2015), then there could be 457,605 visits overall, at a cost of £22.9m annually in the EU28 [£2.5 million annually in UK]. This is not expensive in the long term and if it means many dementia cases can be detected early, the longer-term returns on investment may be massive.
A number of questions emerge from this finding. Could these (relatively low) additional costs be even lower if people were looked after outside primary care for non-medical needs? On the other hand, the little additional cost indicates further investment for early cognitive impairment diagnosis would not be overly expensive to primary care! In economics speak, what are the opportunity costs? In the longer term, could this alleviate cost pressures from later diagnosed dementia? Can early diagnosis really result in delayed onset? There is a need for large epidemiological answers.
Research for efficiency
While we find that there is very little additional use of resources over and above other health conditions, this can imply people with cognitive problems are either already getting sufficient health care, along with any other co-existing conditions or that these people are not optimising resource use, either due to their own decision or due to little uptake so far in any supply incentives.
The remaining question in the European context is, how does this differ across countries and health systems? The main difference we find is across financing structures – implying that demand incentives may be important in countries where patients co-finance their care through out-of–pocket payments or through health insurance.
So how can we use this research to design efficient health care delivery systems? Firstly we need to target this group who use some slight additional resources and see if they can be cared for less expensively in community care. To do this, we need to analyse fully integrated health and social care data (e.g. Electronic Health Records).
The availability of these data in a devolved setting like Greater Manchester is near. The partnerships within Health Innovation Manchester (HInM) are working together to ensure full data capture in health and social care. The advocacy within Dementia United will drive forward the need for integration of data collected from the new Dementia Profile tool. The analysis of such administrative data will provide additional robustness checks to our findings and be used to feed into the design of new service models for health and social care for people with dementia. This way we hope to ensure people, even at the earliest stages of cognitive impairment, are targeted with appropriate interventions and health care, to enhance their quality of life and allow them to live well in the community.
- The University of Manchester together with Manchester Metropolitan University and the University of Salford have recently formed the Greater Manchester Dementia Consortium to promote research and knowledge exchange into dementia. This project shows the importance of linking research with practice across Greater Manchester to more rapidly translate through to patient benefit.