NHS Devon

Report on the GP education seminar programme

Paper for South West Dementia Partnership. 20th June 2011
Authors / Nick Cartmell, GP Lead for Dementia, NHS Devon and South West Dementia Partnership.
Leah Jones, ST4 GP trainee, Peninsula Deanery
Responsible Director / Jayne Carroll, Jenny Richards
Main aim / To report on the GP education seminar programme as delivered to GP surgeries in South Devon.
Actions taken and planned as a result of the equality impact assessment, with details of action plan with timescales/review dates as applicable
Groups/individuals consulted with as part of the impact assessment
Link to strategic objectives and priorities / National Dementia Strategy 2009
National Outcomes Framework 2010
Options/recommendations / That the programme is extended to cover Exeter and East Devon, and offered to neighbouring Primary Care Trusts within the South West Strategic Health Authority.
Resource implications / Funding for seminar facilitator time and travel will be required. Additional funding for lead GP to undertake administration and data analysis.
Details of residual risk following recommendations /
  1. Lack of uptake by practices
  2. Failure to demonstrate outcome benefit from programme

Any legal implications or links to legislation
Freedom of information including restrictions
Public involvement history / Public involvement at development of local Map of Medicine pathway.
Public involvement with development of EVIDEM project on which this programme is based.
Local carers aware of, and supportive of, programme
Preface
This report explains the methodology and details the currently available outcomes of a locally-delivered GP education seminar programme intended to improve primary care awareness, knowledge, early identification and management of people with dementia and their carers.
It is intended to inform commissioners and educationalists who wish to deliver GP education on dementia matters in an effective format, both in terms of learning and behaviour change and cost implications.

NHS Devon

Report on the GP education seminar programme

Table of contents

Page No.
Assessment sheet
Preface
Table of contents
Section 1 / Introduction...... / 1
Section 2 / Methodology...... / 6
Section 3 / South Devon GP attitudes to dementia...... / 11
Section 4 / Results...... / 15
Section 5 / Discussion...... / 19
Section 6 / Suggestions for programme delivery elsewhere...... / 22
Appendices
Appendix 1 / EVIDEM attitudinal questionnaire
Appendix 2 / National Audit Office knowledge quiz
Appendix 3 / Cost calculator
Appendix 4 / References
Section 1
Introduction

1.Introduction

1.1Dementia is a group of usually progressive neurodegenerative brain disorders characterized by intellectual deterioration and more or less gradual erosion of mental, and later physical, function, leading to disability and death. It is one of the ways in which a person’s social and personal capacities may change, resulting in disability where environmental supports are not adaptable to suit them. The average life expectancy from diagnosis to death at present is 5 years, although with earlier detection this is expected to lengthen.

1.2There are currently approximately 825,000 people in the UK with dementia (Alzheimer’s Society 2007, forecast), and forecasts predict dramatic rises in prevalence, partly due to the increased longevity of the population and partly due to better identification of the disease amongst sufferers. The current prevalence rates in England are around 40-50% of expected prevalence according to age and gender bands, and this is reflected in NHS Devon’s current prevalence of 40% (quarterly QOF register data).

1.3The combination of a rising prevalence and a disease that creates many dependencies for the sufferer means the overall burden of dementia in the UK is enormous, greater than stroke, heart disease and cancer combined. Some of this burden is financial: dementia is estimated to cost the UK £20 billion per annum at present.

1.4In an effort to address this rising challenge the UK government published the National Dementia Strategy in 2009. It details key objectives to improve identification of people with dementia and the care they receive from diagnosis through end of life care to death.

1.5Early diagnosis of dementia is beneficial for the person with dementia and their carer for several reasons:

Reversible causes can be identified and treated in a timely manner

It offers an explanation to people who have noticed a problem

It facilitates planning for future health and social care-related events

More timely access to pharmacological and other interventions and support services (Derksen 2006)

Earlier education of the person with dementia and their carer improves adjustment, reduces crisis situations and may delay care home placement (Brodarty 2003)

Carer identification allows carer-focussed support which may reduce carer stress, manage carer depression in a more timely fashion, and therefore may also delay the need for significant social services interventions

1.6Primary care practitioners play an important role in dementia care through:

Being the first point of contact for many people with health concerns

Identification and assessment of people with memory problems or other cognitive or functional deficits

Providing a route to diagnostic services

Maintaining a dementia register

Undertaking regular reviews of all patients on the register

Overseeing prescribing for patients with dementia, both dementia-specific and other drugs

Managing problems or crises through primary care management or referral to other services

Close links between different members of the primary healthcare team

1.7However, dementia presents a challenge to primary care practitioners because of an ever increasing prevalence, its progressive nature, and its insidious onset (Turner 2004). In addition, many GPs may only diagnose one or two new patients with dementia each year, and have only twelve to fifteen patients with dementia on an average whole time equivalent list. These relatively small numbers may cause a lack of educative exposure to dementia patients and may result in a delay in diagnosis

1.8Whilst the Strategy (2009) is driving forward improvements in a number of areas of dementia care, there remain significant problems with overall delivery from a primary care perspective:

Barriers to earlier diagnosis remain in primary care, where there is still a fear of stigma around the diagnosis; diagnostic uncertainty; a perceived lack of post-diagnosis treatment and support; significant time constraints; financial constraints; and a well-established lack of education and training in dementia and its management, particularly of behavioural problems (Illiffe 2010).

People with memory problems may not present to primary care for assessment because of their fear of a diagnosis of dementia and the potential stigma that carries.

Once diagnosed, patients may be discharged from secondary care services and left to fend for themselves.

Carers report a lack of information about available supports and this leads to reduced confidence and higher rates of crisis interventions or care home placements, both of which come at a high cost both financially and for the well-being of the patients themselves.

NICE-recommended post-diagnosis interventions, both drug and non-drug, are delivered in a geographically inconsistent way.

1.9Annual surveys by the National Audit Office consistently support a lack of knowledge and training amongst General Practitioners around the diagnosis and management of people with dementia and their carers.

1.10Whilst GPs are required to demonstrate proactive learning at their annual appraisals, this learning is self-directed and many regionally-available update courses focus on more mainstream medical topics.

1.11Where dementia-specific educational events at central locations are provided, attendance can be poor and there is a risk of only those already motivated to improve dementia care attending. Such events may also be viewed as suitable for GPs only, rather than the extended primary healthcare team. In NHS Plymouth, for example, dementia master classes organised by the local older person’s mental health service provider, attracted 38 GPs for the first master class and only 8 at the second.

Research evidence of effective primary care education methods

1.12Although earlier research failed to show significant difference between different models of primary care education, a more recent study showed that decision support software and practice-based workshops significantly increased the detection of dementia (Downs 2006).

1.13The EVIDEM-ED trial is a cluster-randomised controlled trial of an educational intervention to improve dementia detection and management in primary care. This trial is developing and testing an intervention that is customised to the educational needs of individual practices. The educational intervention consists of practice based workshops with a tailored curriculum designed by a multidisciplinary expert group and supplemented by electronic resources (Illiffe 2010).

1.14Based on the interventions that have already been trialled it was felt by the authors of this paper that an educational intervention involving a blended–learning approach, using an e-learning module along with practice-based workshops, linking in with a locally-developed Map of Medicine pathway for Dementia, would be the most likely format to have a positive impact on dementia detection rates, knowledge, skills and attitudes among primary care practitioners.

On-line resources

1.15Map of Medicine is an on-line resource for healthcare workers. It can provide a single point of reference on the identification, diagnosis and management of medical conditions, including both national and local guidelines, referral criteria and patient information. It is presented in a format which is quick and easy to navigate. Although a commercial product, NHS employees have free access via Athens login details and in Devon many GPs have a desktop icon which automatically logs them into the website without the need to remember or enter in their username and password each time.

1.16Another advantage of using Map of Medicine to support primary care teams is that Map pathways are readily updated when there are any changes to local information or patient services, whilst paper-based information will quickly become obsolete.

1.17In addition, the South West Strategic Health Authority commissioned Dr Leah Jones, ST4 GP trainee, to develop an e-learning platform for primary care. This platform draws on existing e-learning programmes developed by NHS clinical knowledge summaries, the BMJ, e-GP learning and the Alzheimer’s Society CD-ROM Dementia: Management in Primary Care.

1.18The new e-learning platform has been developed with Peninsular Medical School and combines learning modules with case studies, on-line quizzes, and background information. Primary care workers receive continuing professional development credits for undertaking various components of the platform and can download certificates to evidence learning for their annual appraisal.

1.19The e-learning platform is linked to a learning node in the local Map of Medicine pathway for easy access, but may also be accessed at

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Section 2
Methodology

2.Methodology

2.1In October 2010 a central scoping event was held in Devon to gather patient, carer and professional input into a Devon-specific dementia care pathway which would form the basis of local Map of Medicine pathways to support clinicians in delivering good quality, consistent care.

2.2In January 2011 Map of Medicine pathways for dementia assessment were published on-line for North Devon, East Devon, Exeter and South Devon. Each pathway is primary care focussed and aims to support GPs and other primary care workers in early identification and assessment of people presenting with memory problems or cognitive decline. It includes guidance and resources to support the ongoing management of people with dementia in the primary care setting, and links to a large number of supportive websites and educational resources.

2.3In parallel with the development of the Map of Medicine pathway, Dr Leah Jones developed a local e-learning platform with assistance from Peninsula Medical School. This platform is now fully functional and there is a link from the Map of Medicine.

2.4Development of the final seminar format was undertaken with invaluable input and constructive feedback from the Peninsula Postgraduate GP Dean Dr Julia Oxenbury.

Educational seminar format

2.5Having identified a blended-learning approach as the preferred model for GP education in NHS Devon, the authors of the EVIDEM-ED research project were consulted for advice on format and kindly supplied resources from the project for use in this model (see appendix 1).

2.6The basic principles of the model are to:

provide an opportunity for open discussion of dementia care issues

benchmark local primary care knowledge and performance against national information

discuss problems with current dementia care in a non-threatening and non-judgemental environment

raise awareness of current dementia-related issues

consider dementia care alongside other chronic disease conditions

gather feedback and ideas on how dementia care might be improved

develop a database of ‘dementia leads’ for future communications

provide local Primary healthcare teams with a tailored Educational Prescription which summarises the content of the seminar and makes suggestions for service improvement and further learning for members of those teams

2.7The model takes the form of individualised primary care education seminars, lasting 1 hour, which are delivered within GP surgeries at a time which suits that primary healthcare team.

2.8All members of the primary healthcare team were explicitly invited to attend since they are all likely to have contact with people with dementia, people with undiagnosed memory problems, or carers.

2.9Each seminar is facilitated by at least one trained general practitioner, but nobody from the secondary care setting: Devon Partnership Trust, the local older persons mental health provider, were informed of the programme but were consciously not invited to participate on advice from the EVIDEM-ED team -the presence of specialists at seminars was felt to risk affecting some of the basic principles of the model.

2.10Additional technical support was provided by the local Right TRaC team, in the form of laptop, data projector and a means of accessing on-line data live. This support was provided within Right TRaC’s existing contract, but as the programme progressed it became apparent that it was very possible for a GP to deliver seminars alone without technical support, using the practices own computers, resulting in cost savings.

2.11Additional resources for the programme were developed fromEVIDEM-ED and National Audit Office (2010) resources (see appendices 1 and 2). Only the National Audit Office multiple choice quiz was required in paper form, one copy per attendee.

2.12The South Devon area within NHS Devon was chosen as the initial target area due to the geographical bases of the principle seminar delivery team members (authors of this paper).

Timetable for seminar delivery

2.13There are several distinct stages in delivering the seminars which were managed and co-ordinated by NHS Devon’s lead GP for dementia:

Invitation is sent to every GP surgery in South Devon via e-mail using NHS Devon’s e-mail database. The invitation is explicitly to all members of the surgery team to attend an in-house dementia seminar.

Positive responses are diarised according to availability of facilitators and the chosen date confirmed with the surgery concerned via e-mail.

A second invitation is sent to any practice which didn’t respond to the first invitation approximately one month later.

One week prior to the seminar the EVIDEM-ED attitudinal questionnaire is sent to the practice, by e-mail, for completion by each attendee prior to the seminar. This communication also gives an opportunity for housekeeping information, such as parking availability, to be gathered for the facilitator.

Delivery of the seminar itself (one hour, in practice).

Four to six weeks after the seminar the practice’s tailored Education Prescription is sent to the identified ‘dementia lead’ by e-mail, together with the National Audit Office quiz for re-completion by attendees of the seminar. Collated quiz answers are requested to be returned to the seminar organiser. Feedback on the seminar is also requested.

Attendance certificates are sent to the surgery’s ‘dementia lead’ for distribution.

Continuing professional development credit allocation

2.14The allocation of continuing professional development (CPD) credits was identified as an additional incentive to primary care staff to attend the seminar and undertake additional study at other times.

2.15Following discussions with the Peninsula Postgraduate Dean it was determined that CPD credits would be allocated as follows:

1 hour’s credit for attendance at the seminar itself

An additional 1 hour’s credit for completion of the pre-seminar attitudinal questionnaire and handing to the seminar facilitator

An additional 1 hour’s credit for subsequent re-completion of the National Audit Office quiz 4 to 6 weeks after the seminar

2.16Therefore a minimum of 1 and a maximum of 3 hours of CPD credits could be awarded to each seminar attendee. The appropriate allocation is detailed on each person’s individual attendance certificate.

2.17The additional credits acknowledged both the extra work required and related reflection.

Outcome measures

2.18The following outcomes measures were identified to allow detailed assessment of the effectiveness of the seminar programme, and available results are provided in Section 4:

Proportion of practices invited who receive the seminar

Attendance at each seminar by primary care professional type

National Audit Office quiz scores, both at the seminar and second attempts 4 to 6 weeks later

Number of times the local Map of Medicine dementia assessment pathway is accessed per month

Number of times the locally developed e-learning resource is accessed per month

Changes to individual practice dementia prevalence rates over time, particularly to assess any difference between pre-seminar and post-seminar prevalence rates

2.19Qualitative information was also collected from attitudinal questionnaires, verbal discussion at each seminar and post-seminar feedback, and a collation of this information is separately given in Section 3.

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Section 3
South Devon GP Attitudes
towards dementia


3.GP Attitudes towards dementia in South Devon

3.1Information was collected using a combination of the EVIDEM-ED attitudinal questionnaire, sent to Practices prior to the seminar, and verbal feedback at the seminar.