Friday 27 February 2009


I saw a lady in her 70's for a Mental Health Act 1983 assessment. She was on an acute hospital ward, having been admitted acutely confused. She'd decided to go home, had to look after her dog and kids. Her "kids" are grown up and live far away. Her Consultant Physician thought she shouldn't go home. Although all her investigations were normal she was, "confused and unsafe, please see urgently!"

So I did.

She was, indeed, confused. She believed nurses were poisoning her (because the opiate analgesia for her arthritis, which she was receiving now she was an in-patient but hadn't been taking at home, made her drowsy). They were torturing her, making her confused (because every night they moved the furniture and people around). At night she saw supernatural figures ghosting through the ward, disguised vaguely as people. She thought she was in a prison, but knew she'd done nothing wrong. She thought she was there because nurses had, "made something up" and, "it was in the papers, cruel lies about me."

She was in tears as I spoke to her. Over 40 minutes she spoke of how worthless she was, how nobody cared, which was proper, because she didn't deserve anything. She wanted to leave the prison, because she hadn't done anything wrong. "So why haven't you left yet?"
"Because I deserve to be here."
She felt empty and worthless and unloved. She saw herself as having no value. No wonder her children didn't visit her here, why would they? She didn't want to be there, she wanted to be home, but recognised she had to stay, "locked up" and was just, "waiting to go" now, to fade away and cease to be.

She was slowed down (psychomotor retardation), unexpressive (save for tears, a few times), unreactive, lethargic. She hardly looked up as she spoke, sadly, lamenting her miserable state of torment with stoic acceptance that this was all right and proper, and although unwelcome, was no less than she deserved. Marked dysprosody. She wasn't eating well. She didn't sleep well.

She was clearly depressed. She was unwell. Her medical team had noticed, had started an antidepressant and sought help. She can be helped.

Some patients make no demands, don't want to cause any trouble, don't want to be a nuisance and quietly fade away, putting nobody out. They're easy to ignore, especially when folk are busy. They're silent. Who advocates for them?

She's asked for nothing. I want to give her everything.

Friday 20 February 2009

Old Age Services

Our National Dementia Strategy is a document I've already commented upon this month, but this little gem raised my spirits so has to be shared.

It basically says, right on the last page of the whole strategy (just before the appendicies) that specialist mental health services for older adults should not be dismantled, absorbed into generic "depression" and "schizophrenia" and other "modular" general adult services, but should remain as they are and grow stronger. Hurrah!

You'll find it in chapter 6, page 74, of the full strategy document. In case you don't have it to hand, here it is in full :

"Implementation of this Strategy will need to be part of a broader focus on older people’s mental health services. Strong concerns were raised during the consultation exercise that some localities may be interpreting age equality in mental health services to mean a ‘one size fits all ages’ approach. This generally means using existing working-age adult services to look after older people with functional illness. With reflection, this is much more likely to increase age discrimination than it is to address it. This is because age here is a proxy for a different set of needs and therefore skills. Equivalent quality of care is likely to require enhancing current older people’s mental health teams to have higher levels of functionality in terms of the capacity for assertive outreach, for example. This would benefit those with dementia as well as those older people with functional disorder. The improvement of services for people with dementia must not be used as an excuse for diluting specialist services for older people with other mental health needs."

Thursday 19 February 2009


Chaos is common. Not chaos theory. Or even the rather splendid radio Kaos. Just the haphazard vagaries life throws at us, one and all, that adds change and uncertainty into the best formed plans.

I've been looking after a lady, Christine, for a number of years. Actually, that's an unjust statement, I've not been looking after her, she's a delightfully feisty soul who's more than capable of looking after herself, thank you very kindly. But she's been referred to me on several occasions "for an opinion" by medical colleagues.

She's a lady who can be anxious. Now how to put this charitably; in the past she's had contact with mental health services, in eras when provision of psychiatric care was different from how services are delivered now.

Christine remembers the war. She remembers school children dying young, from infections. She remembers rationing. She remembers the miners strikes and the pit closures affecting her community. She remembers her husband's pneumconiosis and terminal illness, dying breathless and afraid. She remembers the unity and cohesion of her street and the community, resilient and united against "them," whether it was consellors or politicians or whoever. She remembers being a strong, strong woman having to fight time and time again for her and her husband and her childrens' needs to be met.

I find her thoroughly delightful company and have to consciously manage time when I see her, so consultations are clinically purposeful and I don't just while away an afternoon hearing her biographical narrative that's rich and engaging and utterly compelling.

I've had the opportunity (and needed) to read the exhaustive notes that have accrued, from many sources. It took a full afternoon. In the past, when she was challenging authority, she was seen to be paranoid. Neither her medical notes, nor her GP's Lloyd George files, nor her notes from a District General Hospital nor her obstetric records either suggested or documented paranoia. Yet, in the past, her psychiatric records document "challenging behaviour" through her being "confrontational." Her mood was assertive and she'd present time and time again to authorities to "get things done" which, in the 1970's, attracted a diagnosis of hypomania. And of personality disorder. And of anxiety disorder. And of schizophrenia.


Records and professionals support that she's never presented with hallucinations or delusions or thought passivity or formal thought disorder. She's never used drugs or misused alcohol. She's always been cognitively intact, and although not highly educated she's an exceptionally savvy, bright and insightful lady.

Christine's felt breathless, a lot, and has COPD so worries she's going the same way as her husband. Thus, she 'phones her GP and ambulances. A lot. she's comfortable pushing for what she sees as geeting her needs properly heard and attended to. She's 'phoned 17 times in one weekend. Her GP and our local A&E know her well. They invited my input explicitly to see if she's got Munchausens or if she's psychotic, but really through desparation because they're tearing their hair out over her.

She's well. Over the years, whenever I've seen her, she's been well. She feels anxious at times, she's terrible at using a metred dose inhaler so gets little real benefit from her inhalers and latterly has had several courses of antibiotics and steroids. She wants home oxygen but smokes. Her heavy smoking, with her COPD, is something her chest physician has talked through many times but she's adamant she's not going to change. But other than over valued ideas (and commensurate episodic anxiety) around her chest disease (which is understandable, given her husband's course, and that of many friends), she's mentally well. No obsessions. No compulsions. No delusions. No nihilism, no hopelessness, no catastrophic thinking, no depressive cognitions/significant cognitive distortions.

When I was a GP I really struggled with how to manage someone presenting frequently (e.g. several times a day) with a problem that concerned them, but wasn't clinically concerning. I've therefore every sympathy for her GP who's a real saint and far, far more tolerant than I could ever be.

Contriving to say it's a psychiatric problem isn't helpful. Clearly she doesn't have schizophrenia and never has. Her persistant diagnosis of personality disorder really doesn't seem justified, at all. Folk didn't like her behaviour, so labelled it as an illness.

I'm putting this down now, because things have been stable for almost a year, now. I was seeing her at home daily at one point. My psychologist was involved but achieved nothing, so they mutually and affably agreed to part ways. Christine doesn't have faith in what nurses say so my CPN, despite being excellent (and far better than me at the support) wasn't able to be helpful. So I saw her, a lot. Then 3 times a week. Then once a week. Then once a month. Then 4 times a year. Maybe I'll get to every 6 months this year. She 'phones once a week and leaves messages with my secretary that I can attend to (which is part of the plan we've agreed) so any non-urgent symptoms or changes that play on her mind can be shared with me. But all her 'phoning GPs and A&E attendances have stopped, the last contact being June last year.

It's an odd position to be in. I've invested a lot of time, initially, into meeting with her and her Consultant Physician and at her GP surgery with the partners, then seeing her an awful lot, and still seeing her episodically, when she's no psychiatric problem evident what so ever. But I deceive myself that rather than doing this to contain her behaviour and help her GP, I delude myself that I'm supporting her and alleviating distress, so doing something to maintain her mental wellbeing.

The fact that she's a feisty soul who's charmingly good company's irrelevant, surely!

Saturday 14 February 2009

Shock news!

You will not be startled to learn the results of the DART-AD trial.

The reason why we've Prescription Only Medicine (POM) is that it's thought to be, ". . . those preparations that are available only on a prescription issued by an appropriate practitioner."

It's the proper stuff. Stuff with risks and benefits. Stuff with real consequences (both good and bad). Rather than Over The Counter (OTC) medicine which anyone can get, over the counter, from a chemist, POM tends to be medication where risks, side effects, treatment emergent adverse events, monitoring, serious interactions or other elements of how the drug works needs careful thought and judgement made.

Hence the legal requirement for not just advice, not just safety netting and input from a manager or a scientist, these proper drugs require, "an appropriate practitioner."

A good turn of phrase, that. "An" suggests one, which pleases me. One GP (not polyclinics and walk in centres). One psychiatrist (not fractured models of a Community one, an Early Intervention one, a Crisis Resolution one, an Inpatient one, a Rehabilitation one etc etc). Optimistic, I know, but having one GP and one Consultant is a model I'm thoroughly wedded to.

"Appropriate" is a handy word, meaning that it's not just a practitioner, it's got to be an appropriate one. The pharmacist in my team's clear on what this means. It means someone who can make valid, rational prescribing decisions. Although, as a pharamcist, there's expertise in the drug's use and interactions, pharmacists don't do out-patient clinics so don't get to see all the consequences of medication used, so don't feel they're experts at prescribing. Sensibly, my pharmacist sees herself as a resource to inform on decisions (and explain medication issues to patients, and manage the governance systems around medicines management), she doesn't see herself as an "appropriate" prescriber.

The word "practitioner" is salient, too. It implies a need for someone in practice, someone practising clinical care. So not just someone who knows a lot about drugs, then. If asked, "Of the last 50 patients you gave advice on medication to, how many had no side effects (and you've documented that), and how many had side effects (which you've documented)?" a "practitioner" should be in a position to answer that, someone just giving advice couldn't. And if that someone's giving prescribing advice but not seeing the consequences of their clinical practice, then I'd suggest they're not "an appropriate practitioner" so should not be issuing prescriptions for Prescription Only Medicine.

Rant over.

POM are medicines that we shouldn't be cavalier with. They're drugs which have real effects, so often need judicious consideration on initiating, continuing, monitoring and withdrawing them.

Which brings me to this study. It's a good study. It's funded by the UK Alzheimer's Research Trust, not a drug company. It's a study that was conducted over an appropriate length of time. Each treatment arm was of a decent size. It's a very relevant research topic.

They looked at folk with Alzheimer's disease, for up to 3 years. They found that patients without antipsychotic medication lived longer than patients with antipsychotic medication. Shock news!

I'm ambivalent about this study, really. On the one hand, it's a well executed bit of credible research that's about a contentious and relevant theme. On the other hand, is it necessary?

In patients with crashing heart failure, with fluid pouring into their lungs, the dread and feeling of drowning, the weakness, then death, life isn't great. Diamorphine can be used to reduce the ghastly symptoms. Diamorphine causes respiratory depression. Stops you breathing. In a patient who's lungs are filling with fluid, reducing their breathing isn't a strategy conducive to a long life. But it's done, rightly, even though life may be shortened, because the clinical condition warrants this palliative care. Is a study necessary to show us that, in heart failure, patients dying without diamorphine live fractionally longer than patients on diamorphine? Probably not. We know diamorphine is a proper drug, a medicine with benefits and side effects that need to be weighed by "an appropriate practitioner."

The DART-AD trial shows us that antipsychotics generate risk in Alzheimer's Disease patients. Although my gut reaction is, "And?!" I do s'pose it's useful to have a well executed study evidencing that what we knew to be the case is actually the case.

So is there anything from this which will change my clinical practice? No. But it's good to know that what I thought (that the drugs were dangerous) is true, and decisions around their use should be very carefully throught through by senior clinicians with expertise in this area.

Tuesday 10 February 2009


I know what a medical Consultant does. I've been trained to do the job over many years, I've ongoing appraisal and CPD and Job Planning and meetings that define my role iteratively.

Some roles are clearly medical and Consultant roles. In my corner, elliciting psychopathology and ascribing significance to this, to generate formal diagnosis, is seen as a Consultant Psychiatrist's job. Nurses (especially non-medical prescribers) have to be able to generate a sufficiently robust formulation, but formal diagnosis remains medical. DVLA work and fitness to drive is medical. Assessment of capacity is everyone's business but assessment of testamentary capacity or ability to undertake Lasting Powers of Attorney or fitness to stand trial is seen as medical work (because it's only accepted when done by a medic). Mental Health Act 1983 work is done by doctors (and even within the ammended Act, it's only doctors who can make Assessments and recommend compulsory admission).
We do more. Complex management plans. Case Conferences and Journal Clubs and Clinical Effectiveness. Taking a lead in safeguarding cases, saying How It Is. Expertise in medication, ECT and interventions. Being the one to speak up in court. Teaching of every discipline. Management meetings. We see a lot of patients out of hours (last weekend a Consultant Psychiatrist was called 16 times and drove out and undertook 12 assessments, and had worked 2 other nights in the month, for which she receives the princely sum of £183.50/month for being on-call, i.e. pay of £36.70/night for each night she had to be on-call). I like to know about and input in to every management plan (and at least everyone gets a Consultant Psychiatrist's input then, after a CPN sees them and discusses care with me when they're back in the office and we meet up each afternoon). Audit.

On top of that, we spend a lot of time seeing patients.

Senior clinicians, seeing patients, using their clinical expertise whilst also doing enough management stuff to develop their service as they'd wish. Life as a Consultant Psychiatrist is fairly clear.

In fact, mine is very clear. I share my Job Plan and Appraisal with anyone who's interested. Lots of folk have been curious. Nurses, OT, secretaries, managers. Why not? I'm busy, I do loads, I critique what other people do, it's only fair that we're transparent and folk can see what I do. My folder's a lever arch file full of stats so they can see how many patients I see, what my out-patient activity is, how many home visits I do, how many in-patients I look after, what their length of stay is, what comments (some) and complaints (none, yay!) there've been, what my sickness is (still at 0 days over the last year), everything.

I don't expect everyone to wish to be as open. But I'm surprised at how opaque non-medical Consultants can be.

So, without any rancor, could I pose the question more widely. Rather than existing senior posts, of the non-medical Consultant posts that are high profile (eg the SHA need to agree), what do these posts involve that the non-Consultant posts don't? What is the raison d'etre behind a Nurse Consultant, Physiotherapist Consultant, Occupational Therapist Consultant or Social Work Consultant?

Monday 9 February 2009

Healing Hands

One lady in a care home, with advanced dementia, has a rather feisty disposition. Her daughter's more vehement in her assertions, saying, "She's a vile creature, she's always been evil, really evil!"

As her dementia has progressed, so her frontal lobe function's deteriorated and she's become more disinhibited, her natural demeanour has come to the fore, with any veneer of civility or decorum being long lost, now.

The care home staff describe her as being an active soul. She fills her time to her amusement and satisfaction, "Tormenting other residents with wicked words and abuse," through throwing food she doesn't like from her plate onto the floor, or at carers, grinning as she does so, snatching food from other folks plates if she wants it, saying hurtful things just to get a response, "That's your daughter going, is she? Must be bored with you, what with you saying the same things to her all the time, I expect she's glad to be away."

My nursing colleagues saw her a number of times. I saw her once to establish diagnosis, capacity and exclude a treatable mood disorder.

I use risperidone as a depot medication for a number of folk but I can't think, in the last couple years, of anyone I've prescribed oral risperidone for. My nursing colleague discussed this lady's presentation with me and sought to start a low dose of oral risperidone. She persuaded me it was a reasonable plan to try then review, so we did. She also gave the home advice on how to handle this lady's interesting presentation.

Just 2 weeks on when she was reviewed, the care home staff say she's cured! All the malicious talk's stopped. She's still swearing like a trooper and nipping and scratching when staff try and help her bathe, but she's no longer biting. At meals and in the lounge she watches everything and grins to herself but can now bite her tongue and remain, if not prosocial, at least asocial rather than being antisocial.

A good result.

Friday 6 February 2009


My normally calm and affable disposition has been perturbed. Why? Because of this (which I chance upon here).

Oh my giddy aunt, where do I begin?

I agree that elderly abuse is common, undetected and poorly addressed. We have a "new" law for this, now. The Mental Capacity Act 2005, section 44 (2), criminalises both ill treatment and willful neglect of incapacitated folk which can result in imprisonment for up to 5 years and a fine. We don't need new laws, we need CSCI and statutory organisations (in health and social care) having strength to highlight this then for it to be addressed.

I can't think of a month, through the last year, where I've not been involved in elderly abuse proceedings. It's commonly seen and flagged up in my corner. Police have a nigh on impossible task of generating evidence "beyond all reasonable doubt" when elderly incapacitated folk are involved. They're honest about this. Last time I was at a High Court for a protection case, the CPS barrister met with me and asked how sure I was about the patient's account, given he had advanced dementia. I explained that the detail could contain erroneous elements but that his account of what grossly trainspired was internally consistent, repeatedly stated with the same content, coherent, fitted with informant and corroborating history/evidence, fitted with the contusions/abrasions and injuries sustained so I saw the minor nuances of flux in his account as inconsequential and that I was 95% sure the account was valid. 95% still left 5% doubt, she said. Not good enough. She met with the judge and it never even went to trial.

Laws alone won't help. We have the laws. We need surveillance, intervention and sanctions if we're to effect change.

Picking on the issue of antipsychotics and running parallels to prescribing this in dementia care as being a criminal act, what?!

Frankly, this just really, really pissed me off. Antipsychotics shouldn't be used first line in dementia care. Or second line. But they can have a place. Babies and bathwater. We don't want to say that there's no patient with dementia who could ever benefit from an antipsychotic. Some experience psychosis. Some benefit from an antipsychotic. Antipsychotic are not placebo. They're proper drugs, with real risks and real side effects. These are serious (eg a 2% increase of a year of having a stroke). Of course, if you're psychotic and tormented and won't live a year, a 98% chance of not having a stroke but getting relief may p'raps have some appeal . . .

Every patient in care homes in my corner gets reviewed. By me. They're not my patients. Most of the time I've not started the medication. But I still believe antipsychotics are such risky drugs and dementia care needs such support that it's worth my time visiting each and every care home in my patch, going through each and every MARS sheet for every resident and ensuring there's rational prescribing for all of them. I see this as good clinical practice. My GPs see this as a useful service, meaning care home patients receive appropriate Consultant Psychiatrist input into their drug regimens without having to refer every care home resident to me. Most of the time I am stopping antipsychotics. Very rarely, I start them. Sometimes I fiddle with the dose. I try and ensure that there's appropriate patient centred care - every patient gets due consideration of the risks, benefits and appropriateness of medication for them, with their history, at that stage in their illness. I would suggest that this is one element of decent clinical care. I do not think that what I am doing is wayward, let alone criminal.

Oft times GPs are called out of hours or at weekends and the "on call" GP has to take a view on how to support a care home with an "unmanageable" patient they don't know, in a care home they don't know, managed by staff they don't know. The GP has no idea on what training the staff have and on what they should be able to manage. GPs try and be helpful. GPs hear care home staff say their resident is battering other folk and "needs medication" so often feel obliged to prescribe. It makes sense for me and my team to then review care.

I have no hospital in-patients at present. This is largely because EMI Nursing Homes accept my patients knowing that nursing staff and I support them, a lot, with frequent visits and use of Continuing Care for 1:1 care so they can adequately staff their units and that use of medication is easily and appropriately reviewed. Use of antipsychotics is a small but important part of care for some patients some of the time. I'm much in favour of acetylcholinesterase inhibitors, I use benzodiazepines, but sometimes, just sometimes, an antipsychotic is appropriate.

What's being proposed?
Patients without dementia can have antipsychotics.
Patients in their own houses can have antipsychotics.
Patients with dementia can not have antipsychotics.
Patients in care homes can not have antipsychotics.
Erm . . . isn't this blatantly flagrant prejudice?

Politicians offering either "guidance" to clinicians or criminalising clinical care is so so missing the point.

The newspaper goes on to say that the issue is of poor detection by Social Services and poor resourcing (with a predicted £6billion funding gap). Well then, there we are. Use the MCA 2005 if we need legal redress but let's crack on and look at malign care in care homes/institutions, CSCI's role (and teeth), CPS guidance on when to go to trial, training and support for care home staff. Then, critically, look at the lack of resourcing which has generated this system. I'll say it again. We don't need more laws. We need surveillance, intervention and sanctions if we're to effect change.

Thursday 5 February 2009

National Dementia Strategy

Dementia care in the NHS is pretty good.

As Dr Crippen states here, obstacles to good dementia care are not that dementia is poorly diagnosed. Nurses giving information, advice and support to carers, doctors offering information and medical and interventions, this all ticks along pretty well in most areas.

I've issues with "memory clinics" which often aren't (and have evolved solely in to diagnosis and monitoring clinics) but we've had them for over a decade now, they're not new, they undertake a useful role, they need adequate resourcing for the demand (of course) but their role is necessarily narrow. They're a clinic. Only part of dementia care can be undertaken within clinics. But memory clinics are a good thing, usually work well, and deliver results.

It's not all rosy. Several care homes seem addicted to antipsychotics (or rather on foisting them on almost every resident) and there're big misconceptions on what medication can and can't do. I have no "anti-violence" pill, there is no "stop-them-wandering" tablet and we've yet to invent a "stop them being awake all night" tonic (other than the clever gases that our goodly anaesthetic collegues use). The "stop them asking the same thing 27 times" velotab doesn't work. The "anti-swearing" capsules don't exist. Behavioural changes arising in dementia are precisely that - behaviours - they're changes that arise through the illness, they're not an illness themselves and there're no tablets or cures to effortlessly fix them.

There's the rub.

Doctors and nurses do what they can for dementia care. But as Dr Crippen reminds us, what's necessary (as in, truly necessary, rather than merely desirable or a vaguely good idea) is an abundance of hands on practical care.

Continuing Care has improved this, in my corner. If we need 4 calls through the day and a call in the middle of the night, it can now happen. 5 miles away it can't. Why? I work in a deprived area, carers will work doing dementia care, it's a job young people can do and get paid for, without needing lots of exams. Some are bad at it but mostly it's done pretty well. 5 miles away is a much more affluent area. 17 to 19 year old girls don't opt in to dementia care there. Despite Continuing Care funding a patient's needs, the family can't use the cash to pay for someone to deliver care, since nobody's doing the work.

This has nothing to do with doctors and nurses and NHS Secondary Care. It has everything to do with appropriate care in someone's home to assist with simple things, like meals and dressing and bathing and toileting. Although health promotion would see meals and dressing and washing and toileting as "health" and the WHO would define that as part of one's "health" it's more common for us to see what we eat, what we wear, soaking in a bath or when we nip to the loo as part of what we do as part of our "social" routines through our day, rather than thinking of them as tasks done to optomise our "health."

This has fractured dementia care.

There's a twilight that, when sundowning, folk with dementia get lost in. Their needs are evident. Secondary Care's not tasked, resourced, staffed or in a position to deliver this care. Primary Care isn't. Social Care is tasked to, but invariably is not resourced to. There're then arguments around whether the person's needs, such as incontinence, are "health" or "social care" needs. Whilst arguing, nothing gets done.

Enter central bodies, to look at and address this unacceptable state of local affairs where PCTs, Primary Care, Secondary Care, Social Services, voluntary groups and private care do what they wish to do but eschew the shitty jobs.

In January 2000 the Audit Commission published the report, "Forget Me Not: Mental Health Services for Older People." Over 9 years ago, now. My, we should all be familiar with, inspired by, influenced by, implemented change and have effected change from this document by now, eh?

Elements of the report included :
o "The report emphasises the need for comprehensive assessment"
o "Information and advice should be readily available for carers"
o "Day hospitals are to be used for time-limited assessment and treatment"
o "A person with designated responsibility for early-onset dementia is recommended in all areas"
o "The report recommends that low-referring GPs should be contacted and offered support and training"
o "GPs should refer users and carers to local support groups at an early stage"
o "Effective communication, shared expertise and the need to exchange information are stressed. This might include joint assessments/reviews"
o "Services should be well coordinated and jointly managed services should be considered"

Good assessment, good advice/information, specified responsible clinical leads, work with GPs, good communication, coordinated care.
All simple principles generated 9 years ago.

Another GP laments the comments that GPs need more training. I agree that most GPs are perfectly capable of diagnosing dementia. 2 GPs, in moments of startling honesty, have asked me, "What is dementia?" But by and large, most are pretty clued up. Nurses and I are wont to visit GP surgeries to talk with their nurses, receptionists (the key to good referrals being sent to us) and the doctors so we've opportunity to update GPs on what's relevant. Ongoing training has a place but, like Jobbing Doctor, I don't see it as effecting a tidal wave of change over dementia care. GPs are clever folk, are immersed in high volume work and are easily accessed so, as night follows day, are intimately familiar with dementia care. Formal or further training will improve some pathways of care in some corners, but the changes overall will be modest. Critically, if I were to have a full day training all GPs in my corner, most patients and carers wouldn't see any benefit from this. More training would make small gains for some folk some of the time. Although, I suppose, we've ongoing training already in my patch, all GPs also have formal training already. Touting for more training of GPs is not the best way to improve dementia care.

Training care home staff makes a big difference. Training voluntary groups makes some difference. Training carers going in to poeples' homes makes a big difference.

I'm wary of national strategies. Partly it's me getting all Consultoid, resisting anyone telling me what I should be doing. But I see myself as a sensible soul and when change for the better's suggested, I'm the first in line. Mostly my scepticism is that it's national. How can we have a vision that suits affluent England but also the swathes of deprived communities I work in? That suits urban, tight, inner city service delivery but equally has operational utility in rural areas? The risk of such a strategy is that it's bland, without detail or sincere content, it's a "vision" that has little utility.

On Tuesday this week we were given the report, "Living well with dementia, The National Dementia Strategy," by the Department of Health. Rummage around the bits of it here, if you fancy.

It has 17 Objectives and Outcomes. PCTs will be marked against these. The 7 key priorities are :
o Early intervention and diagnosis for all;
o Improved community personal support services;
o Implementing the New Deal for Carers;
o Improved quality of care for people with dementia in general hospitals;
o Living well with dementia in care homes;
o An informed and effective workforce for people with dementia; and
o A Joint Commissioning strategy for dementia.

I like these. Who couldn't?

Our PCT has already looked at the 17 objectives and outcomes. They reckon what I do, what our service does, what the GPs do and what care homes do already adequately satisfies pretty much all the strategy. Their exercise is now in evidencing this. So, no change or improvement in "social" dementia care, then? It's conceded that this is desirable, but the need to evidence performance in the 17 domains is, of course, "the necessity."

I wonder how this document will be viewed, 9 years on? What beneficial changes will it have effected? At what cost?

The issues around excellent dementia care are neither complicated nor insurmountable. But they're not cheap. Rationing and limiting (health and social) care on financial grounds isn't a politically popular position to maintain, however real it is, and however desirable such an open discourse would be. So, because politicians can't talk about care, because already dementia care costs more than the costs of stroke, cancer and heart disease all put together, we've a "strategy" rather than "solution."

A missed opportunity by the DoH. So it goes.