Common Sense

I see a lot of people with dementia.

I've had a meeting with the local Area Prescribing Committee and our Primary Care Trust and GP representatives and our Trust's medicines management folk.

And would you believe it, everyone agreed on everything.

I can use donepezil, galantamine or rivastigmine for any patient I think would benefit (irrespective of NICE guidance or MMSE scores or specific diagnosis) and GPs will prescribe what I've initiated.

Why's life so easy, this week?!

Comments and complaints

We live in a world where comments and complaints are plentiful. Oddly, I've not had much in the way of complaint. Odd, not because I'm mean and 'orrible with folk, but odd because the nature of my work means I'm often working with folk who don't appreciate the extent that problems are causing (e.g. through their dementia meaning they wander, or financial vulnerability) so I suggest care that they largely see as unnecessary.
Thankfully they indulge me and humour me enough of the time to mean we can try things (despite the fact they don't wholly appreciate why) then there's a tendency to go with the flow when life's easier and better for it, so the support can continue.

Still, it was surprising to receive a rather positive email today. I've been supporting staff with a number of issues of late, I can't help but meddle. Thus, at the risk of blowing what pseudo-anonymity I have, here's an unsolicited email I just received today from my secretary :

"By the way, I omitted to tell you, you are the most wonderful of bosses that I have ever worked for extremely unpretentious and the fact that we have always worked so well together without fuss or hassle!"

Can there be a better way to start the week? My world really is a happy place! :-)

Revalidation

I am behind the times. Jobbing Doctor and Mental Nurse are ahead of the game and already have blogged comprehensively about the scrullious IWGC site that notionally informs folk on a doctor's performance, and the process of formal revalidation as a mechanism to oversee doctors' performance.

Although I've not blogged about the IWGC website I've commented on various blogs. For the record, my thoughts are that Bacon's site is unhelpful. It's not balanced or representative or useful views that enable patients to make informed choices. It's a place to rant and, from a position of anonymity, damage named individuals who can't respond to or explain or give their side of events. I work with families who are abusive to my patients. This month alone, and we're only 3 weeks in to it, has generated 3 referrals to me of patients who are being seriosuly abused by their relatives (with police involvement) and a few others where malign care (but not criminal) is an issue. These patienst are incapacitated and will not comment on web sites about me. The families see me as mean and 'orrible, stopping them having the house/punch bag/money/sex they want. They no doubt see me as meddling and obstructive and unhelpful. They are in a position to be vocal and look to apportion blame, without looking too hard at themselves.

In mental health this issue is particularly relevant. I often do what's unpopular with relatives.

This month I had a family who want their mum bundled in to a care home, the CMHT and I (and their mother) feel she should be managed in her own home. She's given support and she's in her own home, where she's more oriented, and happy. But I'm the nasty doctor who leaves her in her home even though she's getting worse and worse.
I think I've done a good job of patient centred care.
Family could say I don't listen and I do nothing.

This month I had a family who wanted their mum to stay in her house so she wouldn't go in to care and the house wouldn't get sold to pay for it. She was wandering at night, getting lost and wandering around half naked trying to find family at 2.00am. She doesn't live in the sort of area where you want to leave your door open and wander around on a Friday or Saturday night at 2.00am. Risks are unmanageable, she's had, "negative life events," she's lost valuable items, most of her money and is covered in bruises. She's accidentally set things on fire a few times, not attending to risks that her cigarettes pose, including setting her clothes on fire once. She has dementia and is incapacitated with respect to considering her needs, risks and deciding on future care. No donee, no deputy, no LPA, no advance decision. Best Interest meeting is held. Outcome : 24 hour care. Care home found, she's placed, she's happy there.
I think I've done a good job of patient centred care.
Family could say I don't listen and I don't let them care for their own mum and I bundle people in to homes without giving them a chance.

Often in mental health I address what people need. Invariably they're happy with this and oddly I've had no complaints but have had verbal and written compliments recently, but this perplexes me since I'm frequently not doing what they want. And there's the crux. In health care, we address clinical need. This is not always the same as addressing what people want.

My post on Jobbing Doctor's comments summarises my feelings on revalidation :

Appraisal takes me several full days, job planning another full two days, so a week a year of my time is pretty much tied up in this bureaucracy as it is. Also about 2 days of my secretary and about one day of the neighbouring hospital's Medical Director. 2 clerical staff spend 2 full days pulling records of every clinic attendance (and non-attendance), every referral, every admission, calculate length of stay, every home visit, all work done.

At present the system's pretty excessive, to my mind.

Revalidation will add to the time necessary to collect the data. If a lot of multisource feedback is sought (e.g. from a representative sample of patients) then the time invested necessarily increases further. Then, to gather a portfolio of evidence for good practice, which will be copying and pasting most of my annual appraisal file but will still need additional material that's in other areas such as CPD peer group records and the like.

I won't get paid for doing this revalidation. None of my staff will get paid for supporting this process. The opportunity costs (of erroding clinical time) are, as you suggest, substantial.

A lot of time and money will be invested.

How will it benefit doctors?

How will it benefit patients?

If health management had to be even half as evidence based as health care delivery, my world would be such a better place.

Cured

I received an urgent referral from a GP for a gentleman in his 90's. His GP was worried that he had depression and was seriously ill. I saw him at home with a CPN and his family to unpick why he'd gone to his GP and what the issues currently were.

He said he'd been, "in a dark place," which is why he went on Friday (and not Thursday, or Saturday). It was then, that day, that things, "got too much," and his family whooshed him off to his GP. He didn't want to go, but humoured them and 'fessed up that he wasn't coping.

His wife has always looked after him. She's got dementia, he's now looking after her, all the time. He's declined support (in fact, support's been arranged for him and his wife in the past but after a couple visits he's turned them away from his door, feeling he should be able to do it all himself).

His GP thought the gentleman wasn't coping because he was physically unwell with chronic illness, he was fretting over his wife's physical illnesses, he was caring for his wife all the time (meaning both day and night) so wasn't getting enough uninterrupted sleep/was tired all the time and had unrealistic expectations of how he should be caring for her. He wants, "to be independent," and not rely on others. His GP initiated a SSRI antidepressant at a therapeutic dose.

When I saw him he was cured. This was on day 4 of his antidepressant. He was fine, thank you very much, sorry for troubling you and making you come out. All's well. He thinks his GP is ace and has cured him.

One hour on and it's clear that he had a period where he wasn't coping at the end of the week, but is coping now. All that's changed is that his wife's getting physically better and he's had a better sleep since then. He feels his pills have cured him, "Even though the doctor said they will take 10 days to work."

He declined further support. I found some financial benefits he's not availed himself of that he should, but there wasn't anything I could improve upon. From suicidal and not coping one day to cured and symptom free 4 days on. If that truly is the case, it's miraculous and needs writing up. I rather fear he's not cured. I fear he'll not cope too well in the near future when his wife has her next exacerbation of COPD.

I'm seeing him again and offering ideas. But maybe he's right. Maybe he is cured.

Comment

Comment is free. Well, almost free, now that web space is so cheap. It's certainly cheap when you shamelessly rip off a collegue's postings over the last month just to add a wee point of your own (apologies Jobbing Doctor!). Anyways, there're exciting new initiatives such as this one, although it's incomplete and is generated by a failed doctor.

As doctors we learnt anatomy through dissecting dead people. We spent time as clinicians around dead people, what with learning pathology in weekly post mortem examinations. We learnt about life and death, how to keep folk on the right side of the fence. We read old textbooks, thus learnt the thoughts and ideas of people long dead. Doctors mastery over death. Sweet justice, p'raps, that in a similarly necromantic vein patients can now claim dominion over doctors, when their doctor dies, through being able to comment without challenge on said doctor. Well, the doctor may be challenging it, but as I'm not that adept at necromancy, and speaking with the dead being something the NHS isn't yet investing in, it's essentially comment without redress.

It's this comment without being able to give your side that piques me.

I'm all for patient comment and feedback. My out-patient clinic is a leisurely affair so I'm often sitting in the reception or waiting room and capture what folk are chatting over. I meet with patient representatives twice a month and carer representatives once a month. My Royal College was paid a handsome sum of money to undertake 360 degree appraisal. I listed 30 odd staff I work with, including cleaners, secretaries, nurses, Consultants, anaesthetists, social workers, home care staff, support workers, occupational therapists, CBT practitioners, all sorts. Then I listed 30 consecutive patients I saw. That list went off, I had no say in what happened next. Folk were chosen and sent lengthy questionnaires about me, answers were mailed in sealed envelopes back to the Royal College who collated the information, told me how I came over in loads of domains (ask me about my Emotional Intelligence and I can now tell you!) and critically collated and summarised what my patients think of me. They also gave me a CD with the details. They also compared my results with national averages so I could see how I measured up. At my annual appraisal with the Medical Director in another hospital we went through all these pages, with staff and patient comment being scrutinised and impacting upon my formal annual appraisal (and thus can have impact on my pay).

This is a robust system of feedback, that's pooled and although information from patients is anonymous (so to this day I've no idea who was asked to comment let alone how folk rated me or who said what) to my mind it's fair. I'd no choice in which patient to select so there's no bias. I'd no notion who was contacted. They had no pressure to say anything good or bad, nobody was looking over their shoulder and everything was collated by a reputable third party. Well, the Royal College of Psychiatrists, which is still vaguely reputable, even if they're changing at a pace measurable in geological epochs, but ho hum that's another issue. From 360 degree appraisal, I find patient feedback is invited and is specific (with a structed questionnaire) and so is fair. I'm happy. If this yielded results which were less than favourable I couldn't challenge them with whoever made them but I could try and offer an account in my formal appraisal for why I felt patients had such an experience. I don't know who's said what, I can't challenge them directly but I've got a voice in it all. This seems sensible and just. I'm happy.

If we want patient feedback, let's use comment and complaint systems that are already in place, but also use mechanisms such as 360 degree appraisal.

Using scrurrilous websites that lack credibility, honesty, authenticity or explanation/just redress is A Bad Thing since it's harmful to doctors and isn't helpful for patients. Let's hope the lawyers can effect change, here.

Duty

Let me take you through a scenario.

A lady with hypertension, diabetes and atrial fibrillation develops dementia and is seen by her GP. Her GP takes a thorough history, speaks with relatives for informant history, undertakes a physical examination then blood tests and excludes acute confusional states. Her relatives are at their wits end because the lady is screaming all the time, thoroughly confused, urinated inappropriately in public at a garden centre last weekend, gets lost so wanders around questing to find something that looks familiar and can't remember to take any tablets.

The GP thinks the lady may have dementia and refers her on to me.

I see her at her home, with a mental health nurse. The nurse and I also take a thorough history and mental state examination and examine relevant things. I go through concentration and attention span, orientation, registration, recall, language, praxis, executive information processing and decision making. Her pulse, which was irregularly irregular. Her shaking (but normal gait) that was almost certainly benign essential tremour. Her eyes, she looked a bit icteric but it was probably the gloom of her room and the colour of her faded curtains. The nurse chats with her about function and changes and how she's feeling she's coping whilst I speak her family in the next room about her dementia.

Explanation, advice, social care input and psychoeducation. CT imaging excludes atrophic changes but confirms vascular dementia.

Family say that home care manage to prompt her to take most of her medication most of the time but she's still wandering across roads and getting lost, fiddling in the kitchen, shouting at people and has no idea of social norms. Because her speech and presentation is well preserved, with vascular damage just compromising a few cognitive domains (particularly frontal lobe function, so judgement and personality are affected), she doesn't present to the general public as ill, she just seems abrasive and frankly delinquent.

An antipsychotic is considered and discussed with family. Risks are explicit and bluntly stated. Perceived benefits are explained with realistic goals thought through. A drug is started. Her behavioural and psychological symptoms of dementia (BPSD) are abolished. No wandering. No fiddling. No urinating inappropriately. No shouting. She is undistressed and happy. Family are happy.

She is reviewed by the nurse and myself over many weeks. The dose of medication if adjusted. Side effects are looked for, but thankfully aren't present. Benefit continues, with abolition of all intrusive symptoms and mitigation of risks. Hurrah.

All problems have been sorted out. She no longer needs the specialist input of a Foundation Trust's mental health team. She's no symptoms, no risks, no problems. All is good. She's discharged back to her GP's care, who's delighted we've sorted everything out.

She's on an antipsychotic. The GP declines to prescribe the antipsychotic. The Area Prescribing Committee have the drug green lighted, so the GP can freely prescribe it. The PCT has no commissioned dementia care service with our Trust to prescribe for these patients, they expect the GPs to prescribe. The patient doesn't get their drugs. The patient has symptoms of BPSD again and it all turns pear shaped. The family complain about the GP. The General Medical Council is notified and the GP is taken to task. The GP's patient had a condition, treatment was started under specialist care, it was evidenced that this drug worked for this patient, risks and benefits were considered with the patient and family, the drug was monitored over time and when the patient was seen to be stable the GP didn't continue this care. Prescribing was rational and appropriate.

The GMC in 2006 published the booklet Good Medical Practice detailing what doctors must and should do. In "Good Clinical Care," section 3 (c) it says the in providing care you must, "provide effective treatments based on the best available evidence."

For this patient, the evidence is that the antipsychotic is effective. For a GP not to prescribe is therefore a serious matter for the GMC.

An interesting scenario, eh? And, uniquely, I can't take credit for this vignette. The patient symptoms are from my work this last few weeks but the GP bit was described to me by a lawyer, she saw this as an untenable position for a GP to maintain. Interesting times. Oh, for the record, the lawyer earns more than I do ;-)

Nuisance

I've a lady who I've been seeing for a few years, she's now in her 70's. She has schizophrenia. She's been well for the most part, not needing either regular or frequent review, so we've kept meeting up haphazardly maybe once a year or so when she or her family or her friends or her GP reckon there's merit in doing so.

Last time we met up was a couple months ago, she was well, but wanted to talk about her medication. She was worried. She used to be on more, when she was a lot younger, did we need to increase it? She was well. She had no major problems with her mood, her motivation, her thinking, her memory, her disposition and personality or of her functioning (being motivated and able to do everything she wished to).

She's always been somewhat anxious, as reflected in her worry that she needed more drugs even though she felt all was well. She's sought reassaurance and not unreasonably so. She's had experiences of prolonged paternalistic health and social care so is accustomed to others taking responsibility and telling her how things are. Decades of this has resulted in a lady who, on talking with health or social care staff, is happy to share her 2p worth but then waits for the doctor to Tell Her How It Is.

Her anxiety has been worse of late. I wonder if her contact with me 2 months ago was because she had an awareness that things were changing and she needed more support. But, being a meek and mild and institutionalised wee thing, didn't have the voice to say so and my prejudice against over use of antipsychotics meant I tackled that issue and surveillance of significant symptomatology suggesting relapse but not her ghost of a notion that things weren't quite right.

Her anxiety means she calls her family for support. This is usually once a day and never through the night. Family are unhappy about this, but not so unhappy that they want to stop her 'phoning so much that they act on this. No, family say "she's a nuisance" and want her "sectioned, or something" to "put her away, for her own good."
For her own good. Methinks not.

Much badness.

Lies, damn lies and statistics

As Benjamin Disraeli said there are, "Lies, damn lies and statistics."

This remains true and sadly has been embraced wholesale by politicians. Statistics can be totally accurate, clear and factual. If what you measured is now 34.8% better, things can be shown to be better. The truth, of course, may be different since what you measured may not truly reflect what's really going on.

And that's my beef with statistics. Accurate statistcs are used to infer, support or prove what's in point of fact an inaccurate and untenable position. Statistics may show that quality of life is up 76.8% for patients in my locale but if my patient's dead then no matter how hard I'm told that I'm wrong and, "This year we've done brilliantly, patients' lives have improved 76.8%, your patient is so much better off than they were last year!" I know it's rubbish. For my patient, that individual, the statistics aren't helpful.

Our government have now decided to invest in patient care in hospitals. Hurrah. Dr Crippen will be pleased since the emphasis is to improve care through nursing staff doing more nursing. The NHS Institute of Innovation and Improvement have found that ward nurses spend just 40 per cent of their time on direct patient care. They want to release more nursing time so patients get more care from nurses. Hence their document and the national drive of, "Releasing Time to Care: The Productive Ward." Four sites have piloted this.

Nurses having less time doing paperwork and admin, less time on management, more time with their patients and time to have quality care. Splendid, who can argue with any of this? Laudable proposals are made which can genuinely impact on patient care, for the better, whilst improving the working lives of nursing colleagues. Hurrah!

How much is to be spent of this programme? Why, quite a lot. £50 million. Cooo, that's actually quite a big number, isn't it? Our Secretary of State, Alan Johnson, said in a press release on the 8th May 2008 that the NHS will be investing £50 million in supporting the roll out of the Productive Ward programme. The letter I've had about it is titled, "£50 million to double the time nurses spend on patient care" which is awfully exciting. What can I say, I get excited easily. But really, £50 million national investment to allow nursing colleagues to do more nursing. Fantastic.

One teeny weeny fly in the ointment.

Yet what I read from our SHA is, ". . . we need to demonstrate that £50 million is being invested in implementing the Productive Ward initiative. Schemes may already be in place that count towards the investment target without the requirement to make additional funding of £50 million available." Goes on to say that some PCTs will need to make available additional funding but that, "Any additional funding required should be made available from existing PCT 2008/09 resources."

So, no extra cash at all, then.

Some hospitals may get extra cash from the PCT, some won't. But the PCT doesn't get an extra bean for this, so the "£50 million" is wholly illusory. There is no extra £50 million at all.

Yet, the Secretary of State claims there's "£50 million investment" in this.

Technically, it may be that folk are having to demonstrate that £50 million is being spent on this, but there's no investment at all. It's a meaningless statistic. Worse than that, it's a lie.

Darzi

I've commented on the Jobbing doctor's site, but thought it was worth 'fessing up to it here. I've found something positive within Darzi's review.

It's the emphasis on a "clinically driven" service. Not a politically driven. Not a managerially driven. Not even a patient driven.

Clinically driven. Deliver on that and the world will be a better place.

Physical illness

Dr Crippen got me thinking.

"One of the most dangerous places to get a serious physical illness is in a mental hospital."

No no no, surely not. Our hospital has had no MRSA and no significant hospital aquired infection for years and years. Patients are cared for better than the New York USA model, i.e. staff review and intervene. We've had no assaults on my (old age psychiatry) wards causing physical harm to patients that I can recollect, ever.

Okay, I trained as a GP then did physiciany whatnots and am appointed as a Consultant psychogeriatrician but am also appointed and employed as a Consultant doing physiciany work too. And I work in old age psychiatry, where physical comorbidity is routine and addressing physical health problems is a daily part of my work. So I concede I'm more medical than most psychiatric colleagues.

But even so, aren't all patients having biopsychosocial elements of their presentation addressed? Aren't all elements of physical comorbidity being considered, not simply as good medical care but also as a necessary intervention to address neuropsychiatric sequelae to the physical presentations?

Sadly not.

On reflection, Dr Crippen is quite correct.

I actively look for physical illnesses. I speak with patients and their GP and seek informant history. I find illness. I investigate. I formulate and diagnose. Often, I treat. But, not infrequently, I find something I can't or shouldn't manage myself.

One patient recently had hyperthyroidism. In GP training I worked on an endocrine firm but that was rather some time ago, the world's moved on, I'm not the best placed person to orchestrate optimal care of thyroid dysfunction. Although clinically and biochemically hyperthyroid, our local endocrinologist did not attend the ward, did not see the patient and did not review care. Hmmm.

A lot of drugs I use can affect the heart. It's common to find heart murmurs (i.e. it's not silent between the heart sounds), but most are innocent flow murmurs of no clinical significance. Many years ago I worked on a coronary care unit, fiddled with clever chronotropes and inotropes, but there's no way I'm competent let alone expert at the management of complex cardiac disease nowadays. On finding a murmur and pulse that I thought was significant, then getting appropriate investigations, then referring on to a cardiologist, the patient on my ward wasn't seen. Two weeks through her admission on my ward she went in to high output cardiac failure, my junior doctor 'phoned the Consultant cardiologist, a diuretic was suggested and still my patient wasn't seen. Hmmm.

Dr Crippen has a point.

Even with the best will in the world, with mental health teams having awareness and interest in physical illness, looking for it and treating it, hospital in-patients on mental health wards still get suboptimal care.

Much badness.

Postcodes

Today I was, for the first time in ages, genuinely astonished by two patients.

Not their presentations. Not their diagnosis. Not their comorbid physical illnesses and idiosyncartic polypharmacy. Not their narratives, experiences and lives. I see weird and interesting everyday, it was something unexpected and unusual and wholly incomprehensible that thoroughly disarmed me.

Two elderly patients have moved house and relocated to this patch, purely to get what they think will be better psychiatric care. I could be flattered, instead I have just incredulity and feel perplexed. Good grief, life shouldn't have to be like this for folk! You move your home just to get what you reckon will be better NHS health care!?

Madness.

Drug companies

Have you ever reported a drug rep for breaching ABPI guidelines? I have. I have been more than a little irritated by intrusion in to clinical areas, turning up without appointments to nobble staff, presenting their drugs as fantastic, "because Consultant X down the road uses it loads with really great results."
Recently, although not directly contravening guidelines, I was irked by a rep giving quotes and referenced citations as "evidence" that a drug works when on unpicking this evidence it was from a poster, not a peer reviewed journal publication. Anyone could write a poster, it's not something to influence massive change of practice, yet a drug rep was trying to persuade me otherwise.

Grrr.

But what I do love drug companies for is the drugs. Don't spend time and money trying to push me in to using more of your drug. I'm not paid to spend time with salesmen. My patients and I want better drugs. Spend time and money making better drugs.

I was asked to see a lady who was violent.

Visiting her, she wasn't violent. She was climbing up on chairs and shouting out at people through her window because her daughter had been locking her in her house, to try and keep her safe. She wanted to be out.

She felt unhappy because she was such a bad person. She knew this because there were people in her house, listening to her and documenting everything she did. Although she never saw them, she heard them talking about her all the time. They were even there at night time, scrutinising and commenting, day in and day out. "Goodness," she explained, "I must be some really bad person for them to spend so much time on me like this."

Of course, now knowing she was so wicked, it was inappropriate for her to go to church since she was obviously out of grace. "I can't go there, doctor, I'm too bad!" Why, she's evil incarnate, it'd be inexcusable to tread in God's house.
She did everything wrong and made everything bad, so avoided company. She got really, really hungry because she didn't dare go to the shops since she'd then meet people and ruin their lives, too.

Her physical health was good. Her cognition was globally impaired, MMSE was 19/30 recently, at her best. All blood tests were normal. Her CT scan confirmed extensive atrophic changes, consistent with Alzheimer's disease. She has dementia, of moderate severity.

I started her on the antipsychotic aripiprazole four weeks ago. She's cured. No hallucinations at all, now. No negative cognitions, distortions or abnormal beliefs. She's going to church, going shopping and out with friends to bingo twice a week. She doesn't need locking in her house (and in truth never did).

That's why I have a love/hate relationship with drug companies. I have little to do with them (I don't accept anything from them, no biros, no postit notes, no gifts, no evenings out, nothing) but I need their drugs. And, when used correctly, they're fantastic. One lady's now cured of all her hallucinations and delusions, and is cracking on enjoying her life again, through the right antipsychotic. I love my job.

Managers

I was bored, that's my only excuse.

With impish bedevilment a week ago or so I posted on the Mental Nurse site, about why we need nurses. I could have posted here, true, but I wanted to bait more folk. Yes, I really am that childish. Okay, of course it's tongue in cheek, but what came out of it though did pique my interest.

A&E Charge Nurse turned it around from clinicians and asked :
"Having said that that lets imagine 50% of NHS managers [or DoH mandarins] failed to turn up to work tomorrow, how many patients would really suffer ?
Now, lets say 50% of the RMNs did the exactly same thing………well, I’m sure you get my general drift ?"

It's true.

I have no idea if the Executive Directors of our Trust Board are here today, or not. Or have been here this week, or not. When they're on holiday, nothing changes. When mental health nurses or my secretary's away, boy do I notice.

Gets one thinking, eh?

National Dementia Strategy

We now have a consultation document for a National Dementia Strategy.

[ EDIT 06-02-09 : It's now out ]

Have you read it yet? I have. I was incredulous and felt I'd been skipping through to find the good bits and move on past preamble to get to the meat of it so, in my haste, had missed the substance of it. So I read through it all, again.

Good grief, if it wasn't meant to be such a serious document it'd be better than zopiclone.

It's lengthy, it's tedious, it has no substance what so ever. It tells me that our patients and their carers need good dementia care, where ever they may be. Well, thank you, so that is where I've been going wrong all these years.

I can see it's a national strategy and not an operational policy so it's vague and paints broad brushsrokes of themes, but it's so bland it's vacuous and irksome. Hence why it's not actually better than zopiclone, it couldn't send me to sleep (tediously dull though it is) because it irritated me too much. Where are the vaunted standards for Primary Care or Secondary Care or care homes or carer support or PCT engagement of BME or non-statutory organisations' input in to care pathways or content/composition/delivery of acute hospital liaison services or early onset dementia care pathways or . . . or . . . well, anything meaningful?

Okay, it's national, it's can't direct one size fits all for rural settings, urban settings, deprived settings, affluent settings and so on. But heck, there's no clear direction at all.

Worse, CSIP were saying that at present anything has to be delievered largely within existing resources. Improve dementia care but don't spend a bean more. I'm fortunate that dementia care in my corner is pretty decent. We've specialist teams, we've good community teams, we've specialist hospital care, we've sensible social work and PCT partners. Beacon services, speak at national conferences, all good stuff. But it took some time to get it how it is, though, and critically it cost a lot of cash.

The Dementia Care Strategy, without resourcing, is worse than bland and trite mother/apple pie statements. It's unhelpful. It's intimating that there's a strategy, a national one, for better dementia care. There isn't. There's a document that can sit on a shelf gathering dust since there's no investment in to effecting change.