Characterising inequalities in accessing primary care psychological therapies services for people living with dementia: the example of NHS talking therapies in England.

aimsIn England, psychological therapies provided in primary care are recommended as first-line treatment for people living with mild-to-moderate dementia experiencing depression or anxiety. It is known that people living with dementia experience more barriers to accessing therapy than people without dementia, but such inequalities in terms of rates of access to primary care services are yet to be characterised.

methodsIn this retrospective, observational study of linked electronic healthcare records, the national database of the National Health Service (NHS) Talking Therapies for anxiety and depression programme was used to compare pathways to accessing therapy between 6623 people living with dementia and 4 825 489 without dementia between 2012 and 2019. Outcomes included access to an assessment, to therapy and reasons for discharge. Primary analyses used a propensity-score matched cohort to compare outcomes. Exact matching was used for the NHS service entity.

resultsThe prevalence of dementia in the study cohort was lower than the prevalence of dementia in a representative population, based on an estimation of prevalence in people with mild-to-moderate age over 35 (0.23% in our study vs 3.82% in previous research). Compared to people without dementia, people living with dementia were less likely to access an assessment (odds ratio [OR] = 0.60; 95% confidence interval [CI]: 0.55-0.65), to subsequently receive therapy (OR = 0.67; 95% CI: 0.61-0.73) and more likely to be discharged because services were deemed not suitable before having an assessment (relative rate ratio [RRR] = 4.90; 95% CI: 4.20-5.72) and starting therapy (RRR = 2.74; 95% CI: 2.24-3.35). Female gender, social deprivation, Asian ethnicity and less common dementia subtypes (such as frontotemporal dementia) were also associated with poorer access rates and a higher likelihood of services being deemed not suitable. Involvement of care partners in the referral process was associated with better access rates.

conclusionsPathways to accessing primary care psychological therapy services must be made more accessible for people living with dementia. Better access could be achieved by increasing referrer awareness and training for staff within services to promote access for people living with dementia (especially for groups under-represented in services), better understanding how to involve care partners in the process, as well as when specialist support might be more suited in secondary care. More granularity in the medical coding of rarer dementia diagnoses in electronic health records would also allow for better statistically powered research for these groups.