Dr Lisa Wilkins, Consultant in Public Health Medicine

Dementia 2012/13

Dr Lisa Wilkins, Consultant in Public Health Medicine

Jonathan Sutton, Integrated Commissioning Manager

Jan 2013

1  Introduction

The 2012/13 NHS Operating Framework asks Primary Care Trusts to work with their local authorities and publish dementia plans which set out the progress being made locally on the implementation of the National Dementia Strategy. The plan should include details of any local or national CQUIN goals in place.

This joint plan for Oldham Clinical Commissioning Group and Oldham Metropolitan Council, sets out the actions that have been taken to improve the quality of care for people with dementia and the support for their carers in Oldham during 2012 and the actions to be taken in 2013/14.

2  Commissioning Framework

2.1  Health and Wellbeing Strategy

The first Oldham Health and Wellbeing Strategy was published during 2012 and identifies improving the quality of care for people with dementia as a key priority. The other priorities within the Ageing Well theme of the Strategy are also pertinent for people with dementia and include:

·  Improving support for carers

·  Decreasing social isolation for older people

·  Enhancing falls prevention

·  Improving the care of people with long term conditions.

A presentation to the Health and Wellbeing Board in December 2012 summarised the initial findings of the dementia health needs assessment (see section 3 below). The Health and Wellbeing Board endorsed the direction of the dementia programme.

2.2  Dementia Commissioning Group

In April 2012 a Dementia Commissioning Group was established with representation from:

·  Oldham Clinical Commissioning Group (OCCG)

·  Oldham Metropolitan Borough Council (OMBC) Adult Social Care

·  Integrated Commissioning Team

·  Public Health

·  Local Involvement Network

The Group is chaired by Dr Keith Jeffery, OCCG Clinical Director for Mental Health, and reports to the Oldham Integrated Commissioning Partnership (a joint OCCG and OMBC senior management team).

The Dementia Commissioning Group is coordinating the joint OCCG and OMBC dementia programme.

2.3  Vision, objectives and outcomes of the dementia programme

The Integrated Commissioning Partnership agreed the vision, objectives and outcomes for the dementia commissioning programme in August 2012.

Vision

·  To enable people with dementia to receive an early and accurate diagnosis, to receive the information and support they need to make decisions about their life and to lead as full and active life as possible and for their carers to feel well supported.

·  People with dementia will have their individual needs assessed and receive coordinated services, throughout the dementia care pathway, from well trained and skilled practitioners who treat them with dignity and respect.

Objectives

The strategic objectives based on the triple aim principles are:

·  To improve population health – to improve the mental and physical health and well-being of people with dementia and their carers.

·  To improve care provided, and the healthcare experience of individuals – to ensure high quality personalized and coordinated health and social care services are delivered to people with dementia and their carers and that people with dementia are treated with dignity and respect at all times.

·  Value for money – to provide value for money services with a shift in spend away from crisis intervention to enhanced support to prevent crises arising.

Outcomes

The outcomes aimed for by the programme are:

A.  Improve population health / Improve the experience of individuals

1.  People with dementia receive care from staff trained in dementia care and are treated with respect and dignity.

2.  People with suspected dementia receive an early and accurate diagnosis. People newly diagnosed with dementia and/or their carers receive information about their condition, treatment and the support options in their local area

3.  People with dementia have an assessment and an on-going personalized care plan, agreed across health and social care that identifies a named care coordinator and addresses their individual needs.

4.  People with dementia are supported to lead as active a life as possible and to maintain their independence.

5.  People with dementia, while they have capacity, have the opportunity to discuss and make decisions about their future care.

6.  Carers of people with dementia are offered an assessment of emotional, psychological and social needs and are well supported to meet those needs.

7.  Carers of people with dementia have access to a comprehensive range of respite/short-break services.

8.  People with suspected or known dementia using acute and general hospital inpatient services or emergency departments have high quality care and access to a liaison service that specialises in the diagnosis and management of dementia.

9.  Care homes provide high quality care and treat all patients with dementia as individuals and provide a stimulating environment.

10.  People in the later stages of dementia receive well planned and coordinated end of life care so that they die in the place and in the way that they have chosen.

B.  Value for money

1.  To increase focus on patient and carer support and early intervention to prevent costly crises occurring thus decrease avoidable hospital and care home admissions and readmissions.

2.  To enhance support to care homes in the management of inter-current acute illnesses and behaviour that challenges, decreasing the need for hospital admissions for care home residents.

3  Health Needs Assessment and High Level Care Pathway

A Joint Strategic Needs Assessment for dementia commenced in April 2012 and is looking at all stages of the care pathway from early diagnosis to end of life care. Because of the breath and complexity of the care pathway, the needs assessment is being completed in stages.

So far, as well as reviewing the evidence base and national polices for dementia:

·  Over 35 key stakeholders have been interviewed

·  A series of workshops to determine stakeholder views of current services and priorities for improvement have been held that over 100 people attended

·  In collaboration with Age UK Oldham, a number of people with dementia have been interviewed to help us to find out what people with dementia in Oldham think about the services available in Oldham and how dementia is affecting them.

Based upon the national policy review and feedback from the stakeholder interviews and workshops, a high level care pathway (appendix one) has been developed that sets out the types of care a person with dementia may need and the support their carer may require.

The needs assessment will review each of these stages and make recommendations for improvements.

Part one of the needs assessment has been completed and focused on early diagnosis and post diagnostic support. The recommendations have been agreed in full by OCCG and OMBC. A summary of the recommendations is given in box one.

Part two of the needs assessment reported the findings of the Age UK interviews and reinforced the findings of part one.

4  New initiatives in commenced 2012

4.1  Memory service

In line with the recommendations of part one of the needs assessment a new memory service model is being commissioned that is resulting in approximately £350k of new investment. The new model will:

·  Facilitate the earlier diagnosis of people with dementia, with shorter waiting times for specialist assessment

·  Provide greatly improved post diagnostic support for patients with mild to moderate dementia via an enhanced multi-disciplinary team. Each person with dementia will have a named memory liaison practitioner who will be a central point of contact, advice and support; be offered, with their carer, a structured post diagnosis education programme and an information pack and service guide; peer and carer support groups; support from occupational therapists, psychologists and the voluntary sector to maintain independence and to be able to continue to participate in social activities and community life; training for carers and relatives.

·  More specialist support for primary care and other community health and social care services

In line with the national evidence base, the model will help to reduce / delay the need for more intensive services and prevent crises that precipitate admission to hospital and care homes.

The model will be delivered by a partnership of providers, including Pennine Care NHS Foundation Trust, OMBC, Oldham Carers Centre and a voluntary sector partner working closely with, and supporting, primary care and community services. The model also looks to build on the current role of volunteers and peer support.

Funding for the model has been identified and agreed with a 75% contribution from OCCG and 25% from OMBC.

Service specifications are being prepared and negotiations have commenced with providers.

4.2  Oldham Dementia Partnership

The dementia care pathway is complex and involves a multitude of agencies. While there are significant gaps in the pathway that will require commissioning solutions, the majority of improvements in the quality of care for people with dementia will be dependent upon improving the care that all services offer people with dementia and the practice of individuals within those services.

During the interviews and workshops held with stakeholders for the dementia health needs assessment it was very apparent that:

-  Providers are all making or planning changes to the way they care for people with dementia but there is no coordination of this across the Borough

-  There are a number of issues that would benefit from collective action eg development of competency frameworks, training needs analysis and delivery of staff and carer training, development of a service directory and information packs for carers/patients, enhancing up take of services by BME communities

-  There are a number of carers who actively want to be involved in improving services who have great expertise but no forum to work through/influence

-  Providers and practitioners are eager to work collectively and share their expertise and by coordinating this outcomes would be greater than the sum of individual provider efforts.

An Oldham Dementia Partnership, hosted and supported by Oldham CCG, is being established to:

-  Bring together the expertise and capacity of health, social care, voluntary and independent sector organisations and carers to work collectively on improving the care pathway and individual care received by people with dementia and their carers

-  Provide a route for implementing recommendations of the dementia JSNAs

-  Support the translation of innovation into real changes in practice

-  Ensure that improvements are made in a coordinated way with less duplication of effort and greater combined outcomes.

A part time post has been identified to support the Partnership. Terms of reference have been drafted and will shortly be sent to senior managers of relevant organisations asking for confirmation of commitment, with the anticipation of the first partnership meeting being held in early 2013. Carer representatives and voluntary sector representatives will be sought for the partnership.

4.3  Commissioning for Quality and Innovation (CQUIN)

National CQUINs

In line with the national CQUIN for dementia, Pennine Acute NHS Hospital Trust, the major acute provider for Oldham, is being incentivised to identify patients with dementia and other causes of cognitive impairment. The CQUIN pathway has three parts: Find, Assess and Investigate, Refer (FAIR) (box two).

In 2012/13, the CQUIN applies to patients aged over 75 admitted as an emergency and who stay in hospital for 72 hours or more. However, Pennine Acute have elected to risk assess all patients over the age of 65, in anticipation that the national age threshold is likely to be lowered in the future and on the clinical basis that many patients have onset of dementia before the age of 75 years and that these patients often have the most to gain from earlier diagnosis.

Additional CQUINs for Pennine Acute NHS Trust

In addition to the national dementia CQUIN, a number of Greater Manchester and North East Sector CQUINs relating to dementia care are in place for Pennine Acute Trust for 2012/13. These include:

·  Development and implementation of a dementia action plan

·  Dementia patient experience questionnaire

·  Use of antipsychotics in people with dementia

·  Improving the hospital environment

·  Multidisciplinary care planning and use of Alzheimer’s Society ‘This is me’ booklet

·  Dementia ward champions

·  Root cause analysis of admissions with length of stay greater than planned

·  Enhanced use of volunteers on wards

·  End of life care

In addition to the CQUINs, during 2012 Pennine Acute Trust launched a comprehensive dementia strategy. This also includes a dementia and delirium care pathway and a large scale staff training programme.

Pennine Care NHS Foundation Trust CQUINs

Pennine Care mental health services have been incentivised, via a two year CQUIN, to deliver a new psychiatric liaison service to two sites of the Pennine Acute Trust including the Royal Oldham Hospital. The new service has a strong older persons mental health focus (including dementia) and since commencement in October 2012 has received approximately 100 older persons referrals a month.

4.4  Carers strategy

OCCG and OMBC published a new 3 year joint Carers Strategy in September 2012. The strategy is resulting in £469k of new investment in carers services by OCCG. Many of these generic carers services will benefit the carers of people with dementia. There is also a specific new post to support carers of people with dementia which will be linked to the new memory service model.

4.5  Residential respite care

OMBC reopened a 20 bedded residential respite care centre for people with dementia in April 2012 and has identified additional capital funding to improve its facilities for people with dementia. Various options to utilise this funding are currently being explored.

4.6  Reablement

During 2012, OMBC’s reablement service widened its referral criteria to start providing short term support for people with dementia and their carers, to help people with dementia to remain independent at home.

4.7  Dementia friendly communities

The Alzheimer Society is currently bidding for lottery funding for six dementia friendly community pilots in Greater Manchester. If the bid is successful, Saddleworth will be one of the pilot sites. Learning from the pilot site will be disseminated across Oldham.