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Dementia Joint Commissioning Plan Jill Greenwood & Tracy Ault September 2010

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Central and Eastern Cheshire Primary Care Trust and Cheshire East

Council have developed a joint commissioning plan that looks at

Dementia and the current population together with local service

provision in order to strive to have the right services in the right place

for the right people.

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1. Introduction Page

o Forward

o Setting the Context

What is a commissioning plan?

What is Dementia?

Vision

Financial position

o Executive Summary

2. About us

o CECPCT

o CEC

3. Demographics

o Population and Prevalence

o Equality Impact Assessment

4. Policy Context

o National Dementia Strategy

http://www.dh.gov.uk/en/SocialCare/NationalDementia

Strategy/index.htm

o Equity and Excellence : Liberating the NHS

o Putting People First

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o Mental Capacity Act & Deprivation of Liberty

Safeguards

http://www.nhs.uk/CarersDirect/moneyandlegal/legal/P

ages/MentalCapacityAct.aspx

o NICE Guidelines

http://guidance.nice.org.uk/CG42

o Counting the cost

5. Local developments and Work streams

o DemenShare

http://www.demenshare.com/

o Community Support Centres

o Service User and Carer Influence

Role of LINks

CSED process

Focus groups

o Older Peoples Joint Commissioning Plan

o Care Services Efficiency Delivery (CSED) process

6. Conclusions

o Commissioning Intentions

o Next Steps

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1. Introduction

Forward

1.0 This is a three year Integrated Commissioning Plan (Strategy) for Dementia for

Central and Eastern Cheshire Primary Care Trust (CECPCT) and Cheshire East

Council (CEC).

1.1 The document sets out the commissioning and decommissioning intentions of

CECPCT and CEC for 2010-13 for people who have Dementia and their Carers

within the boundaries of the two organisations.

1.2 It provides a framework to support the provision of flexible, responsive and equitable

services to respond to a broad continuum of health and social needs to support

commissioners to meet national and local key targets.

Setting the context What is a Commissioning Plan? 1.3 A commissioning plan is a formal statement of plans for securing, specifying and

monitoring services to meet people’s needs at a strategic level. It applies to services

provided by the NHS and Local Authority, other public agencies and the private and

voluntary sectors.

1.4 The National Dementia Strategy states in its 14th objective that we need to develop a

joint commissioning strategy for Dementia. It goes on to say that local commissioning

and planning mechanisms need to be established to determine the services needed

for people with Dementia and their carers, and to determine how best to meet these

needs.

1.5 Therefore in line with this objective this is our joint commissioning plan (strategy) and

it is designed to:

o Effect change in the overall configuration of services to meet the needs of the

population of people who have Dementia

o Provide a statement of commitment about the way in which the commissioning

agencies intend to purchase services for the population in the future

o Provide a statement about the values and principles which will underpin all

commissioned services for health and social care

o Determine how we are going to resource the commissioning plan

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o Describe the needs of the relevant population and how these are likely to change in

the future

o Develop a way Forward- A statement about the strengths and limitations of the

current services and what we want more of and less of in the future

o Monitor and review the impact of the strategy upon the range and quality of services

delivered

What is Dementia?

1.6 Dementia is a gradual loss of mental ability, resulting in loss of memory, changes in

personality, and loss of social ability. Dementia is not a normal part of growing old

and most people never develop it.

o Dementia is NOT a normal part of ageing

o There are currently 700,000 people in the UK with Dementia

o Dementia costs the UK economy £17 billion a year

o While the numbers and the costs are daunting, the impact on those with the

illness and on their families is also profound

1.7 Dementia is caused by conditions that damage thinking, memory, reasoning and

language. There are many such conditions, some more common than others

including:

o Diseases and infections or meningitis

o Pressure on the brain, for example from a brain tumour

o Lack of blood and oxygen supply to the brain, for example due to a stroke

o Head injuries

1.8 Dementia is most common in those aged over 60 and becomes more common with

age. Approximately six in 100 people aged over 65 develop Dementia and this rises

to around 20 in 100 people aged 85 or over. It can develop in younger people, but

this is rare, as only around 1 in 1,000 people under 65 are affected.

1.9 There are different types of Dementia but all types of Dementia cause similar

symptoms these include:

o Confusion

o Changes in mood, behaviour and personality

o Loss of memory

o Loss of interest in life

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Vision for Dementia services in Cheshire

1.10 To have one point of contact with a service that listens, is creative, passionate, clear

and simple. People with Dementia and their carers should experience a seamless

journey, from diagnosis through to end of life and beyond to enable continued

support for carers whilst they grieve. Throughout this journey the services delivered

should be specifically tailored to each individual.

Financial position / Economic climate:

1.11 We know resources are very much more restricted than in the previous 10 years and

will remain so for many years to come. Difficult decisions about disinvestment will

have to be made whilst public/patient expectation continues to rise and public

investment slows. New ways of working, improving clinical practice and productivity

will become “the norm” to meet the challenge before us. (QIPP has already outlined

this new way of working for clinicians.)

1.12 Financial sustainability is imperative to our success (Healthcare Community

Sustainability Plan CP1) given our low funding base and high expectation from

patients and public.

1.13 Achieving financial balance (Healthcare Sustainability) has also brought the 10%

challenge message for 2010/11 to all providers and the PCT. This is not a “slash” all

services approach, but a strategic need to deliver efficiencies and rationalisations

that can be achieved quickly.

1.14 Despite the current financial challenges, the PCT has continued to achieve national

and local targets, build good working relationships with two new unitary councils and

develop practice based commissioners and clinical leadership.

1.15 The financial pressures faced by the PCTs are also being experienced by both

partner local authorities, Cheshire East and Cheshire West and Chester. Efficiency

savings will be an inevitable challenge to the councils as they attempt to meet

increasing demand for social care, from an ageing population, within a smaller

financial resource base.

Executive Summary 1.16 1.17 The older population nationally is rising as is the prevalence of Dementia, in

particular within Central and Eastern Cheshire where it appears to be increasing

above the national average of 2.1%. The incidence of Dementia nationally and locally

is set to rise by 48% over the next 15 years and 145% over the next 45 years.

1.18 Currently There are currently 700,000 people in the UK with Dementia, Dementia

costs the UK economy £17 billion a year. While the numbers and the costs are

daunting, the impact on those with the illness and on their families is also profound.

As a result of the recognition of this there have been a number of strategies, policies

and frameworks put in place nationally and locally to support the need to address the

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increasing need to improve Dementia services. Including the National Dementia

Strategy, ‘Putting People First’ Mental Capacity Act, Nice guidelines, counting the

costs etc, details of which are contained in more detail in this document.

1.19 The local response to the NDS was initially to set up a governance structure and

framework, which took the form of a programme board, steering group and four task

and finish groups. There were a number of achievements under this structure which

are detailed later in this document.

1.20 In January 2010 the Care Service Efficiency Delivery Process (CSED) took the

agenda forward by amalgamating the groups into five structured workshops that

developed service specifications based on services that our stakeholders felt, that if

put in place would prevent and / or delay people moving up the pathway into more

intensive higher cost services. These service specs have formed the bases of the

recommendations and commissioning intentions detailed in section 6.

1.21 The intention to create an integrated care pathway resulted in an initial framework

that looks at the services at each level along the Dementia pathway, and how the

service specs influence the journey. It is intended to develop this further into a high

level pathway that will, once complete be appended to this document.

1.22 The Map of Medicine also plays an integral role in the development of Dementia

services, to ensure that we document our approach, services, pathways advice and

support services concisely within the map of medicine that then becomes a source of

information and signposting for our GPs and other professionals, individuals. There is

access to this via the NHS choices website.

1.23 The main recommendations and commissioning intentions include improving and or

providing the following services: respite, Dementia advisers, end of life care, assistive

technology, raising awareness, family based care, training, information, directory of

respite services, and independent befriending services. There has been

amalgamation of some of service specs to enable us reduce duplication.

1.24 To complete this document, there is an action plan appended to this document that

details how the recommendations could be implemented, we do of course have to

consider that the PCT will shortly be handing over responsibility for commissioning

Dementia services to GP Consortia commissioning and the Local Authority. This is

reflected in the action plan.

1.25 It is also important to note that the PCT is currently not coterminous with CEC and

therefore will also work jointly with Cheshire West and Chester Council to ensure that

the citizens both organisations serve are met consistently with both commissioning

plans.

Acknowledgements

There has been a huge amount of work done from publication of the draft National Dementia

Strategy to the present day. From the onset there has been keen interest and dedication

from many sectors of the society from the public and private sector organisations, third

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sector, people with Dementia and their carers and outstanding individuals who have strived

to help with the implementation of the programme along the way. Many people have gone

way beyond what was expected and of course are too many to name individually. But to

everyone who has participated in any way and everyway thank you for your contribution.

2. About Us

Central and Eastern Cheshire Primary Care Trust (CEPCT) 2 .0 Central and Eastern Cheshire Primary Care Trust (PCT) broadly covers the areas of

the former district and borough councils of Vale Royal, Congleton, Crewe and

Nantwich and Macclesfield and now spans two new unitary councils, East Cheshire

and Cheshire West and Chester. It is a diverse area of rural and urban communities

stretching from Disley in the north east (Southern Pennines) throughout the Cheshire

plain to Nantwich in the south west.

2.1 The north east of the district is a commuter belt for Greater Manchester with affluent

towns such as Wilmslow, Alderley Edge and Prestbury. The more rural areas consist

of villages engaged in agriculture which is traditional dairy and orchard. Post

industrial towns such as Macclesfield, Congleton, Northwich, Winsford and Crewe

are regenerating themselves with new industries and employment.

2.2 Our role is to buy health services for the 450,000 people living in Central and Eastern

Cheshire and to ensure that those people are provided with safe, high quality and

accessible health services

2.3 Our ambition is to work with others to achieve sustainable improvements in health

and wellbeing of the population and to reduce inequalities of health. Some examples

of how we will do this are:

o Make sure older people are supported when needed, maintaining independence

for longer and enjoying good health into an old age

o Develop high quality Primary Care Services

o Develop comprehensive and integrated care pathways

2.4 As part of the World Class Commissioning process, 8 outcome areas were chosen,

plus 2 national areas, to demonstrate how we turn the dial to improve health in key

areas. These areas were selected through a rigorous prioritisation process. Dementia

has been chosen as Outcome 7: Dementia – “Diagnosed earlier, treated better and

independent longer” 60% of expected Dementia sufferers are captured on a practice-

based register and they have an active care plan by 2014 (4077 people).

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2.5 Our approach, described as the Lifecycle of Care, demonstrates how all of us as

citizens will use health services and health care during our lifetime. The PCT seeks

to commission the right services in the right place at the right time to support this

lifecycle of care.

2.6 We have four elements to our vision for health and well-being of our population that

support the Lifecycle of Care. We want to be a high performing PCT that uses public

money well, commissions effectively, has good quality providers of healthcare locally,

and ensures we have plenty of opportunities for people to lead healthy lives locally.

2.7 Currently the PCT commissions the majority of its Mental Health services from

Cheshire and Wirral Partnership Trust. (CWP) CWP provides a range of services for

adult and older people suffering from complex and serious mental health problems.

These services are mostly based in the communities that we serve with access to

local in-patient beds for those clients who need admission to hospital.

2.8 The PCT also commissions services from other non statutory and voluntary agencies

such as the Alzheimer’s Society, Age UK, Mind, and advocacy services from

Citizens’ Advice Bureau.

2.9 Having set the context for the PCT as it stands currently, changes to this are

imminent in the form of the new White Paper ‘Equity and Excellence : Liberating the

NHS’(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPoli

cyAndGuidance/DH_117353) published on the 12th July 2010 which states:

‘The Government upholds the values and principles of the NHS: of a comprehensive

service, available to all, free at the point of use and based on clinical need, not the

ability to pay. ‘‘This is a challenging and far-reaching set of reforms, which will drive

cultural changes in the NHS. We are setting out plans for managing change,

including the transitional roles of strategic health authorities and primary care trusts.

Implementation will happen bottom-up.’ The implications of this will be discussed

later in the commissioning plan under ‘policy context’.

Cheshire East Council (CEC)

2.10 Cheshire East Council came into existence on the 1st of April 2009. It was formed

from the preceding authorities of Congleton Borough Council, Crewe and Nantwich

Borough Council, Macclesfield Borough Council and Cheshire County Council. The

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confirmation of the decision to create a unitary authority was announced in

December 2007.

2.11 Cheshire East is home to the following towns: Congleton, Crewe, Knutsford,

Macclesfield, Middlewich, Nantwich, Poynton, Sandbach and Wilmslow.

Within Cheshire East, Adult Services has moved to a personalisation model which is

providing people with a choice of remaining in their own home and to live as

independently as possible. To support this model we have commissioned Extra Care

Housing schemes in, Crewe, Handforth and Middlewich. We have improved access

to information, provided personalised budgets, increased the use of technology within

peoples own homes and provided a reablement service, to maintain peoples’

independence and enhance the lives of individuals and carers.

2.12 CEC is aware that it needs to consider the demographic changes, the effect of the

personalisation agenda on the current market.

2.13 Cheshire East through the development of local specialist services are in the future,

planning to avoid admissions to acute hospitals and enable people to be discharged

with the right support to regain skills and independence.

Cheshire West and Chester

2.14 It is important to note that some parts of Cheshire are covered by other PCT /

Council footprints i.e. Vale Royal. We will be working closely with our partners in

Cheshire West and Chester to ensure that our commissioning plans compliment one

another and that the citizens of CECPCT footprint are not compromised in those

areas that are not co terminus with Cheshire East Council. Cheshire West and

Chester Dementia Strategy can be accessed via their website.

www.cheshirewestandchester.gov.uk

3. Demographics

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Population and Prevalence

3.0 East Cheshire has a higher than average older age population and it is predicted that

this will continue to rise in an upward trend. Currently there is 17.8% of over 65year

olds compared to the national average of 15.9%.

The percentage of the population in the older age group 85+ is above the national

average of 2.1%.

3.1 The gaps in provision for Dementia care will continue to grow, based on the

population profile. There is estimated to be 4,500 people living with Dementia in East

Cheshire over the age of 65.

o 65% are likely to be women.

o One in five people over 80 has a form of Dementia. One in 20 people over 65 has

a form of Dementia.

o The total number of people with Dementia in the UK is forecast to increase to

940,110 by 2021 and 1,735,087 by 2051, an increase of 38% over the next 15

years and 154% over the next 45 years.

Dementia UK Research Report, Alzheimer’s Society 2007.

http://alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200120&docum

entID=342&pageNumber=1

3.2 Geographical mapping of services appendix

3.3 Extracted data for people with Dementia in Cheshire

Current (2007-2010)

2021 Increase

30-64 65-74 75+ Total

188 1202 7174 8564 12656 48%

Males 2007

30-64 65-74 75+ Total

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111 661 2133 2905

Females

2007

30-64 65-74 75+ Total

77 541 5041 5659

Males 2021

30-64 65-74 75+ Total

120 886 3830 4836

Females

2021

30-64 65-74 75+ Total

83 712 7025 7820

Equality Impact Assessment (Appendix 1)

3.4 A joint assessment has been carried out and shows some interesting data. The

details of the demographics from each authority were collated and demonstrated how

a joint approach benefits the integrated care pathway. Details of the assessment can

be found in appendix 1.

4. Policy context

National Dementia Strategy

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4.0 'Living Well with Dementia - a National Dementia Strategy' is a five year plan. It sets

17 objectives to transform the lives of the 570,000 people living with Dementia in

England under three themes: raising awareness and understanding; early diagnosis

and support and living well with Dementia.

4.1 The first ever National Dementia Strategy is a landmark document that aims to

transform the quality of Dementia care. It sets out initiatives designed to make the

lives of people with Dementia, their carers and families better and more fulfilled.

4.2 Published on 3 February 2009 the National Dementia Strategy will increase

awareness of Dementia, ensure early diagnosis and intervention and radically

improve the quality of care that people with the condition receive.

The three main themes nationally for Dementia support are:

4.3 Improving awareness: Increase public and professional awareness of Dementia

and an informed and effective workforce for people with Dementia

4.4 Early diagnosis and intervention: good quality early diagnosis and intervention for

all; good quality information for those with Dementia and their carers and enabling

continuity of support and advice

4.5 Living well with Dementia: by improving quality of care for people with Dementia

from diagnosis: in general hospitals; home care; respite care/ short breaks; joint

commissioning strategy for Dementia; intermediate care; improved Dementia care in

care homes and improved registration and inspection of care homes.

Non-discrimination

4.6 People with Dementia should not be excluded from any services because of their

diagnosis, age (whether designated too young or too old) or coexisting learning

disabilities.

Valid consent

4.7 Health and social care professionals should always seek valid consent from people

with Dementia. This should entail informing the person of options, and checking that

he or she understands, that there is no coercion and that he or she continues to

consent over time. If the person lacks the capacity to make a decision, the provisions

of the Mental Capacity Act 2005 must be followed.

Carers

4.8 Health and social care managers should ensure that the rights of carers to receive an

assessment of needs as set out in the Carers and Disabled Children Act 2000 and

the Carers (Equal Opportunities) Act 2004 are upheld. Carers of people with

Dementia who experience psychological distress and negative psychological impact

should be offered psychological therapy, including cognitive behavioural therapy,

conducted by a specialist practitioner.

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Coordination and integration of health and social care

4.9 Health and social care managers should coordinate and integrate working across all

agencies involved in the treatment and care of people with Dementia and their

carers, including jointly agreeing written policies and procedures. Joint planning

should include local service users and carers in order to highlight and address

problems specific to each locality.

4.10 Care managers and care coordinators should ensure the coordinated delivery of

health and social care services for people with Dementia. This should involve:

o a combined care plan agreed by health and social services that takes into

account the changing needs of the person with Dementia and his or her

carers

o Assignment of named health and/or social care staff to operate the care plan

o Endorsement of the care plan by the person with Dementia and/or carers

o Formal reviews of the care plan, at a frequency agreed between professionals

involved and the person with Dementia and/or carers and recorded in the

notes

Memory services

4.11 Memory assessment services (which may be provided by a memory assessment

clinic or by Community mental health teams) should be the single point of referral for

all people with a possible diagnosis of Dementia.

Structural imaging for diagnosis (e.g. MRI)

4.12 Structural imaging should be used in the assessment of people with suspected

Dementia to exclude other cerebral pathologies and to help establish the subtype

diagnosis. Magnetic Resonance imaging (MRI) is the preferred modality to assist with

early diagnosis and detect sub cortical vascular changes, although computed

tomography (CT) scanning could be used. Specialist advice should be taken when

interpreting scans in people with learning disabilities.

Behaviour that challenges

4.13 People with Dementia who develop non-cognitive symptoms that cause them

significant distress or who develop behaviour that challenges should be offered an

assessment at an early opportunity to establish the likely factors that may generate,

aggravate or improve such behaviour. The assessment should be comprehensive

and include:

o The person’s physical health

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o Depression

o Possible undetected pain or discomfort

o Side effects of medication

o Individual biography, including religious beliefs and spiritual and cultural

identity

o Psychosocial factors

o Physical environmental factors

o Behavioural and functional analysis conducted by professionals with specific

skills, in Conjunction with carers and care workers.

o Individually tailored care plans that help carers and staff address the

behaviour that challenges should be developed, recorded in the notes and

reviewed regularly. The frequency of the review should be agreed by the

carers and staff involved and written in the notes.

Training

4.14 Health and social care managers should ensure that all staff working with older

people in the Health, social care and voluntary sectors have access to Dementia-

care training (skill development) that is consistent with their roles and responsibilities.

Mental health needs in acute hospitals

4.15 Acute and general hospital trusts should plan and provide services that address the

specific personal and social care needs and the mental and physical health of people

with Dementia who use acute hospital facilities for any reason.

Putting People First

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http://www.dh.gov.uk/en/Publicationsandstatistics/Publicat

ions/PublicationsPolicyAndGuidance/DH_081118

Our health, our care, our say

4.16 In 2005 the Department of Health conducted two consultations, Independence,

Wellbeing and Choice and a listening exercise, ‘Your health, your care, your say.’

Independence, Wellbeing and Choice, the adult social care Green Paper, asked for

views on how social care services could be improved. The listening exercise, ‘Your

health, your care, your say’, allowed the public to speak directly to Ministers, health

professionals, and each other on how improvements could be made to their local

services.

4.17 Nearly 143,000 people contributed their views on what they expected from their local

social care and NHS services. People wanted their local services to:

o understand how they live and support them to lead healthier lives

o help them to live independently if they have ongoing health or social care needs

o be easy to get to and convenient to use

o be nearer to where they live, or easily available in the areas they work.

Mental Capacity Act (MCA) & Deprivation of Liberty

Safeguards (DoLS)

4.18 A persons own preferences for care and treatment are important, and the care team

should support choices wherever possible. The care team will always seek consent

(agreement) about a persons care. They should explain the options available to and

make sure that the individual understands what has been said.

4.19 However, as circumstances change, an individual may no longer be able to make

specific decisions (this is called no longer having ‘capacity’) and they may not be able

to communicate their needs. If this happens, their care team must follow the advice

set out in the Mental Capacity Act 2005 (information about this is available from the

Department of Health; www.dh.gov.uk).

4.20 If someone is worried about being able to make important decisions about their care

in the future, they can make a set of written instructions (called advance decisions

and advance statements) saying what treatments and other help they do and do not

want in the future. These instructions may include a lasting power of attorney and a

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record of their preferred place of care. The care team should discuss these while

they are still able to make decisions and can help them write these instructions.

Deprivation of Liberty Safeguards

4.21 People who suffer from a disorder or disability of the mind, such as Dementia or a

profound learning disability, and who lack the mental capacity to consent to the care

or treatment they need, should be cared for in a way that does not limit their rights or

freedom of action.

4.22 In some cases members of this vulnerable group need to be deprived of their liberty

for treatment or care because this is necessary in their best interests to protect them

from harm.

4.23 The amendments to the Mental Capacity Act 2005 both strengthen the protection of a

very vulnerable group of people, and tackle human rights incompatibilities, by

introducing deprivation of liberty safeguards for people who lack capacity to decide

about their care or treatment, and who are deprived of their liberty to protect them

from harm, but who are not covered by the Mental Health Act 1983 safeguards.

4.24 In line with the provisions of the Mental Capacity Act 2005, anyone who does not

have family or friends who can be consulted will have an Independent Mental

Capacity Advocate (IMCA) instructed to support and represent them during the

assessment process.

NICE Guidelines & The use of anti Psychotics in care

homes The National Institute for Health and Clinical Excellence (NICE) provides guidance, sets

quality standards and manages a national database to improve people’s health and prevent

and treat ill health.

NICE makes recommendations to the NHS on:

o New and existing medicines, treatments and procedures

o Treating and caring for people with specific diseases and conditions.

NICE makes recommendations to the NHS, local authorities and other organisations in the

public, private, voluntary and community sectors on:

o How to improve people’s health and prevent illness and disease.

Using NICE guidance may help commissioners cut costs while at the same time maintaining

and even improving services.

NICE clinical guideline 42 Dementia Key priorities for implementation

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Counting the costs 4.25 The Alzheimer's Society's ‘Counting the Cost: caring for people with Dementia in

general hospitals’ report was published nationally in 2009 and reveals unacceptable

variations in the quality of care for people with Dementia in hospital.

http://alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200149&docum

entID=1199&pageNumber=1

4.26 It reveals people with Dementia often spend longer in hospital than other people

without the condition receiving the same treatment, and nursing staff are ill-equipped

to provide the specialist Dementia care that they need.

4.27 As part of their ‘Putting Care Right campaign’, this report aims to improve the quality

of care for people with Dementia in Britain's hospitals. It calls for nurses to be

empowered with specialist training and for the average amount of time people with

Dementia stay in hospital to be reduced by a week. This could save the NHS over

£80 million per year.

Health and Wellbeing 4.28 Health, Work and Well-being - Caring for our Future is an ambitious strategy put

together by two government departments, the Department of Health and Department

for Work and Pensions, and the Health and Safety Executive to improve the health

and well-being of working age people. It places real responsibility not just in the

hands of Government, but also with employers, individuals, the healthcare profession

and stakeholders.

4.29 The strategy pulls together all the different strands of work going on in this area

within government and is a high-level document, which clearly sets out what action

the government is taking to deliver real change for the health and well-being of

working age people. This strategy is a crucial part of delivering on the Government's

commitment to improving the health and well-being of the working age population;

and will play a significant role in ensuring delivery of the workplace health

commitments outlined in the White Paper Choosing Health.

5. Local developments and Work streams

DemenShare 5.0 DemenShare is an online social media resource for all those who are affected by

Dementia in Eastern Cheshire; it is for those with a diagnosis, carers, families &

friends, professionals or anyone with an interest. Cheshire East Council in

partnership with Central and Eastern Cheshire Primary Care Trust, Age UK and

Opportunity Links were successful with their Bid from the Efficiency and

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Transformation Capital funding from the Improvement and Development Agency

(IDeA). It provides information and support on line by listening to these individuals

and groups. It adapts to current topics and themes to provide a dedicated arena for

those affected by Dementia across Eastern Cheshire to have a voice.

5.1 It is a ‘first’ in the Country and if successful will be rolled out nationally.

5.2 The aim of the site is to reassure, empathize with, engage, acknowledge, inform, and

update people who use the site. The content and community interaction encourages

return visits, nurtures peer support, participation and creation of online and offline

support communities. Content continues to inspire comment to enhance reputation

and bring traffic back to DemenShare.

5.3 DemenShare will target the rural communities of eastern Cheshire it provides

opportunities to encourage Black Minority Ethic (BME) communities to where

appropriate engage in discussion and can in turn facilitate all minority groups to form

their own individual networks.

Dementia cafe 5.4 Cheshire West and Chester Council and NHS Western Cheshire have had initial

discussions with Avantage Housing provider and the Alzheimer’s Society with service

user and representative carers with a view to piloting a Dementia cafe. This would be

a monthly meeting with a drop in facility for a 2-3 hour duration offering activities,

information advice and support. It will be open to anyone with a diagnosis of

Dementia and their carers. It is likely that the Alzheimer’s Society would recruit a

coordinator to run the scheme and will support the volunteers.

It will be based in an Extra Care Housing resource in Winsford called Hazelmere and

will be open to the tenants of this facility as well as the general population.

A Dementia café is being planned for Lincoln House, Crewe and Hollins View,

Macclesfield. There are currently plans for this to happen within Extra Care Housing

in Cheshire East.

Clinical executive workshop 5.5 Cheshire West and Chester Council and NHS Western Cheshire have held a

workshop to raise awareness that the needs of Dementia patients affect nearly every

part of the health economy and that partnership and joined up working is required to

ensure that these patients receive a quality service. The workshop was to support the

implementation of the National Dementia Strategy by focussing on the Local

Enhanced Service and commissioning quality and innovation schemes that can be

put in place for 2011/12.

20

Older People’s Commissioning Plan 5.6 During 2009, a Joint Commissioning group was established to focus on services for

older people. This group is accountable to the Health and Well Being Thematic

Group for Cheshire East within the Local Strategic Partnership arrangements. One of

the requirements of the group is to develop an Ageing Strategy for the local

population. As a first step towards this a one year joint commissioning strategy has

been written by coordinating all the existing joint work streams that relate to older

people. This work has been aligned to the existing outcome framework developed in

Cheshire in 2008 “Every Older Adult Matters”, to link the plan to the areas that relate

to older peoples lives. The full framework can be seen at www.cecpct.nhs.uk.

5.7 A summary of this plan was prepared to share with older people at an engagement

event in Crewe in February 2010. Around 60 members of the public attended the

event, with eight different organisations represented through activities, workshops

and information stands. Feedback from the event was very positive with attendees

appearing to have enjoyed the event, the displays and workshops. Many of the

comments and questions on the day confirmed that the plans are focused on the

right areas, i.e. those areas which are priorities for older people.

End of Life 5.8 ‘How people die remains in the memory of those who live on’ Dame Cicely Saunders

Founder of the Modern Hospice Movement.

5.7 The recent DH Commissioning Guidelines for EOL Dementia estimates that 0.8% of

a population over 65 years of age with Dementia will have End of Life Care Needs.

The current population of Central and Eastern Cheshire is 453,000. CECPCT 2010-

13 Strategy predicts that it will have a demographic that will include 86,800 or 19% of

its population over 65 years old. Based on these figures, we have approximately 694

people with End of Life Care needs each year

5.8 A three year strategy called “Promoting high quality care for all adults at the end of

life” has been developed on behalf of the Adult End of Life and Palliative Care

Strategy Group which operates across Central and Eastern Cheshire. The strategy

group includes stakeholders from health, social care, voluntary sectors and

user/carer representation. The strategy sets out a vision from now to 2012 for End of

Life Care within Central and Eastern Cheshire.

5.9 The strategy aims to strengthen the PCTs commissioned arrangements, responding

to the needs of patients and carers to improve access to high quality care for all

adults approaching the end of life, irrespective of age, gender, ethnicity, religious

belief, disability, sexual orientation, diagnosis or socio-economic deprivation. This

care will be available at the point of need: at home; in a care home; in hospital; in a

hospice; or elsewhere. This is to ensure optimum development is gained to achieve

fully integrated and co-ordinated specialist palliative and End of Life Care services for

our local people.

21

Carers Strategy 5.10 “I know full well that it’s OK for me – this Dementia is harder for the carer than it is for

the person with it!” (A person with Dementia. Focus group report Oct 08 – May 09)

5.11 Alongside the development of a strategy for Dementia, CEC is working in partnership

with CECPCT, carers and other organisations including 3rd sector organisation to

improve services to carers. We recognise the enormous contribution that carers

make to society and to the care of their families and loved ones, as well as the

challenges carers face.

5.12 We understand that carers of people with Dementia face particular challenges and

we are working together to support those carers.

5.13 Our carers’ strategy is based on the National Strategy for Carers and information and

feedback about the needs of local carers in Cheshire East.

5.14 The vision identified in the National Strategy is “that carers must be universally

recognised and valued as being fundamental to strong families and stable

communities. Support will be tailored to meet individual needs; enabling carers to

maintain a balance between their caring responsibilities and a life outside of caring,

while enabling the person they support to be a full and equal citizen. Making this a

reality requires changes and attention to issues including breaks, income, information

and advice, the workplace, access to employment, emotional support, the health of

carers, and the specific needs of young carers”.

5.15 Locally carers have told us they would like to see the following improvement as

priorities:-

o Increasing the number of carers identified by GPs and receiving information,

advice and health checks.

o Increasing the number of carers who have an assessment and care plan from

Adult Services.

o Continuing to develop personalised services to support carers, including breaks.

o Continuing to develop staff awareness and training across health and social care.

o Developing commissioning processes and taking into account new

commissioning arrangements in health services.

o Developing the involvement of carers in commissioning services.

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Safeguarding 5.16 Cheshire East is required to provide a Safeguarding Service to protect and prevent

vulnerable adults from significant harm and to promote recovery, well- being, choice

and independence.

5.17 Since April 2009, the commitment to delivering a Safeguarding Service to the citizens

of Cheshire East has continued to grow and develop. The Adult Safeguarding Board

is now established with good senior representation from partner agencies. The sub-

committees are working collaboratively to improve policy and 5.18 training, to raise

public awareness, to make links with hidden communities and to ensure consistency

in practice via quality and audit.

5.19 Moreover, the Dignity in Care Agenda is fundamental to Safeguarding, therefore we

are working in partnership with the PCT and CEC Contract Team to improve the

quality of care in residential and nursing settings across our area.

5.20 The Adult Safeguarding Unit also embraces the Think Family Approach and there are

now links between the Children’s Safeguarding Board and the Adults Safeguarding

Board.

Service user and Carer influence Role of LINk

5.21 LINk is an initiative to give everyone in the community a voice and the opportunity to

improve health and social care services across Cheshire. Anyone can join the LINk,

and it's free. The LINk is an independent organisation that exists to use the

experiences and feedback of the public to help improve health and social care

services for everyone. That means that the more people who get involved, the more

valuable this feedback will be. The LINk is overseen by an elected Committee, and

supported by a 'Host' organisation and contracted by the Council. However, it

belongs to everyone in the county. The PCT and Local Authority are committed to

promoting and using the LINk as a mechanism for involvement and influence of

service users and carers.

CSED

5.22 Following the ‘Care Services Efficiency Delivery’ (CSED) process. This has been

rolled out nationally by the Department of Health in order to look at a way of releasing

resources from existing services for possible reinvestment and the development of

an integrated care pathway.

5.23 In order to do this locally we have held a set of five workshops that have been

exceptionally well attended by people from across the Dementia pathway including

professionals from statutory and non statutory organisations, voluntary agencies and

service users and carers. The workshops took place between January and April

2010.

23

5.24 We looked at where we are now, where we want to be and how we get where we

want to be. This took a great deal of time and work and generated a huge amount of

data, that has been used to develop an integrated care pathway and a set of services

specs that the attendees have developed and has resulted in this commissioning

document. Details of the CSED outcomes can be found later in section 5.

5.25 From an engagement perspective, people with Dementia and their carers have

rigorously engaged with the process in East and West, and work was done in

between workshops in order to ensure full consultation.

Focus groups

5.25 During the CSED process and prior to this when there were a number of task and

finish groups looking at the implementation of the National Dementia Strategy, we

found that engagement with people with Dementia and their carers was often difficult.

5.26 Problems with timings of meetings, length and level of meetings, travel

arrangements, carers’ responsibilities and so on were all barriers to effective

engagement. Therefore the Alzheimer’s Society were commissioned to set up focus

groups that were designed to consult with people with Dementia and their carers.

This was a two way process that resulted in a forum for the PCT to receive feedback

on the Dementia strategy and local implementation, but also for statutory agencies to

pose questions and test out ideas and suggestions. This resulted in a focus group

report, but also due to the success of the groups, they have continued to be

facilitated by the Alzheimer’s society.

Ageing Well Strategy

5.27 CECPCT is working with Cheshire East Council and Cheshire West and Chester

Council on the development of the Ageing Well Strategy, all partners acknowledge

locally that we need to continue this work to meet the needs of our population. There

are two strategies, based on the council boundaries.

5.28 The commissioning intentions to developing and delivering the strategy are to

engage communities in identifying what their needs are and what they as individuals

and communities can offer. The plan is to use an asset based community

development approach and where possible, apply a total place funding model. The

first steps are to work with practice based commissioning consortia and local area

partnerships, using the information from the recently published Public Health Annual

Report 2010 and the joint strategic needs assessment, to agree priorities for the local

aging population.

5.29 The development of the strategy for CEC commenced with a stakeholder event on

the 29th June 2010 with representation from a wide range of partners, including

24

health and council services, the Fire and Police, third sector organisations and carers

and older people. At the stakeholder event, work was undertaken to identify what it is

like ‘to grow old in Cheshire East today’ focussing on the three stages: preparing for

older age (50 – 65 yrs) : living well in later life: and accessing services in the

vulnerable / frail years. The event then considered what we would like to do working

as a partnership to build on the current situation over the next five years.

Ageing Well in West Cheshire

BACKGROUND

1. Previous work has been undertaken to develop a strategic approach to ageing in

western Cheshire. In 2008, the Communities of Cheshire Partnership commissioned the Older People’s Executive Commissioning Group to produce Every Older Adult Matters, an outcomes framework for older people. Performance monitoring and implementation of the framework has not been routinely and systematically monitored and reported. In 2009, the Comprehensive Area Assessment identified the need for the partnership to address issues surrounding the ageing population as a priority.

2. The current financial situation across the public sector together with the rapidly

increasing ageing population presents an opportunity to fundamentally reshape the role of the public sector in improving opportunities for older people in western Cheshire. It provides an opportunity to improve the potential for people to enjoy an active life for longer, enabling organisations to work together more effectively so that they deliver more and cost less and support communities to be more self-reliant. This includes involving older people in assessing their needs and their role as an asset within communities, with skills and expertise to contribute to western Cheshire.

DEVELOPMENT OF THE STRATEGY

A project mandate for the development of an Ageing Well strategy was produced and endorsed by West Cheshire Together Health and Wellbeing Partnership, chaired by Julie Webster, Interim Director of Public Health.

3. Ken Clemens (Age Concern Cheshire) and Gordon Atkinson (Project Support Manger, Adult Social Care and Health) attended CSMT in May 2010 to provide a short presentation, followed by discussion around the need for a whole system Ageing Well Strategy for West Cheshire.

4. Work has been undertaken to map partner's current and future commissioning that

impact on the lives of those aged 50 and over.

5. A full day engagement event was held in July 2010, which provided an opportunity for older adults to contribute to the development of the five emerging themes for the Ageing Strategy:

o Economic wellbeing, - including employment and benefits information

o Health and wellbeing - including physical and emotional wellbeing

25

o Attractive and sustainable environment – including transport, housing and green spaces

o Safe and strong communities – including safeguarding and fear of crime

o Increased choice and positive contributions - including information to allow

effective choices and volunteering opportunities.

6. Key messages from the engagement event were as follows:

o Information is a key factor. In all discussion groups, participants expressed a need for clear, universally accessible and relevant information and communication. A successful strategy and its implementation will address this need.

o People aged 50 and over are not a homogenous group. Rather, they are individuals with differing needs, lifestyles, aspirations, opinions and futures. Within the discussion groups contrary viewpoints were represented and expressed on certain matters, demonstrating this fact (for example, promotion of employment for older people). Services designed to promote ageing well need to embrace this.

o People aged 50 and over have the same expectations and ambitions for wellbeing as anyone else, as was evident in the range of concerns. All services need to be reviewed for “age-proofing”; this population are not an “add on” to society. Services need to be assessed for their relevance to a “whole life journey” rather than designed for particular segments of the population.

o Ageing well will be encouraged by the promotion of intergenerational activities and actions. Ideas included mentoring schemes, skills swap and joint community activities, amongst others. A good ageing well strategy will encompass such ideas and will release the voluntary potential of communities in this and other areas.

o The co-ordination of opportunities and information should happen locally, ideally facilitated by community champions at the local level. This should be supported in a pro-active way by service providers.

o Future strategy to encourage wellbeing must be joined up and collaborative in nature and must promote equality of service and opportunity across the borough. Patchy services (e.g. financial support from advisors) mitigate against equality and are seen as unfair and devaluing of those communities without access to resources.

7. Sub groups of the project team are developing the content for the draft strategy

based on the five themes. The information gathered at the engagement event is now being collated and will be used to influence the shaping of the strategy. This will include a review of evidence on effective ways of working and learning from best practice, including lessons learnt from national projects, for example Partnerships For Older People's Projects

A workshop will be held on 16th November, facilitated by the Department for Work and Pensions and Government Office North West. The workshop is targeted at key

26

partners within the Local Strategic Partnership and key stakeholders including older adults themselves and will be based around a ‘Self Assessment Tool’ used with a number of other local authorities. This event will help us to test our draft strategy on how well we are addressing the opportunities and needs which will arise as a consequence of the changing demographic profile of our ageing population.

8. Davenham Day Centre is currently running the 6 week Carers course which is proving very successful. The Carer groups continue to meet bi-monthly at the Centre. Unfortunately funding has not yet been released to make the adaptations for a specialist unit for people with Dementia, but we are hopeful this will still happen. In relation to training, we trained another 4 Dementia Care Mappers earlier this year, 2 in Vale Royal and they have completed their first map. The Alzheimer's Society has been commissioned to provide a day Dementia refresher training for all Seniors in Building Based and Community. Approximately 96 staff and sessions are now running until January 2011.

Care Services Efficiency Delivery (CSED) process

5.30 CECPCT and CEC in conjunction with the department of health have recently

undertaken a Care Services Efficiency delivery process. It began January 2010 and

extended over 4 month period. The process consisted of a set of 5 workshops with a

wide range of attendees, 50 on average from both statutory and non statutory

services. People with Dementia and their carers were consulted by way of focus

groups commissioned by the PCT and provided by the Alzheimer’s society.

5.31 The workshops looked at where we were, what services were currently available and

where we wanted to be, what services we wanted and valued. The workshops went

on to investigate how we could get where we wanted to be. What could be ceased

changed and or added, the following diagram demonstrates this:

“As is” “To be”

De-commission

Re-commission

AddChange

/ growCease

Commission

LOW

LOW

HIGH

HIG

H

IMPACT

COST

1

2

34

27

5.32 The groups acknowledged how people moved through their pathway, often into more

intensive high cost services, when very likely, if more investment was made in

preventative services, it would prevent them moving through these ‘doorways’ into

more intensive services.

Slide 8

General Population

Cost per patient£ £££ ££££ £££££££

�Home Care

�Crisis Resolution

�Fast Track Therapies

�Time Limited

Intervention

�Sheltered Housing

�Intermediate Care

�Intensive Home Care

�Extra Care Housing

�Nursing Care

�Residential Care

Level 1 Level 2 Level 3 Level 4

Acute Care

Older Peoples ServicesPreventative Services

Low level

Prevention

“Step” decline

This diagram demonstrates the journey through services to typically more intensive / expensive

services.

5.33 Groups then looked at what services could be developed, and or enhanced that

could, if put in place prevent and / or delay the journey through services; these were

scored in order to prioritise them. Those that were considered to be high priority and

easy to implement have been developed into service specifications and form the

basis of our commissioning intentions and recommendations. These are detailed

later in this document.

28

Early

Diagnosis/ Onset

24:17

High Importance

Low importance

Easy

24 Hour Crisis Team

20:

Intermediate

Care

22:16

Improved

Access and Treatment in

A&E 22:15

Improved

Services in General

Hospital 22:14

Access Criteria

20:14 Dementia

Champion/ Adviser

19:9 End of Life

18:10

Family Based Care

16:10 Integrated Training

15:9

Assistive Technology

17:8

Integrated 24 Hour

Helpline

12:11

Raising Awareness AND Support for

carers 16:8

Directory of Respite Services

13:7

Information At GP Surgery

14:5

Independent Befriending

Service

12:5

Respite

22:9

Recreational/ Education

11:7

Improving Leisure Facilities

10:7

Local

Media Campaign

8:5

Advanced Directives

9:5

1

25

1

Integrated Care Pathway

5.34 The care Services Efficiency delivery process also enabled us to start to develop an

integrated care pathway that is detailed in the diagram below.

An integrated care pathway is a documented process that details the journey from

before diagnosis through to end of life and beyond, detailing all of the services from

the statutory and non statutory organisations.

The one we are developing below also integrates our recommendations for each of

the stages along the Dementia journey. It forms the basis of a high level pathway that

will be developed and appended to this document one complete.

29

30

6. Commissioning Intentions and recommendations

Respite breaks

6.0 “All the stress of Dementia is on the carer; the person with Dementia is in their own

world and everything is done for them but we have to carry on with everyday life and

care for them. Who cares for us?”(A care :Focus group report Oct 08 – May 09)

6.1 Another carer from the same report said: ‘if it hadn’t been for the Alzheimer’s Society

she would never have found out about respite being available.’ Her social worker

didn’t tell her it was available, and she said that this could have delayed her mum

going in to permanent care, which would have saved money, and been less stressful

for all concerned.

6.2 Therefore it is apparent that there is a need to rationalise Day services and respite

services, as currently there are a number of service providers that are not being

utilised to their full potential. In order to develop up to date services strategically

placed to meet the needs of our population in a manner that people with Dementia

and their carers say they want.

6.3 Within Cheshire East, consultation is already in progress regarding future provision of

the Community Support Centres. Due to the personalisation agenda it is apparent

that people wish to remain in their own homes as opposed to historical services.

Therefore plans to have a multi purpose centre in the North and South of Cheshire

East. These services will be the ‘hub’ of the community offering tailored programs

that are not necessarily building based. These centres will be beacons of excellence

in line with Government Directives.

It is important to recognise the different lengths of stay and ways in which respite can

be provided for people with Dementia and their carers, these include short stay, ‘one-

call’, outreach, in reach, and family based care. There is a need for respite to be well

marketed with an early booking facility through a one stop shop. Currently within

Cheshire East there are two Community Support Centres supporting people living

with Dementia and their carers. Plans are now in place to progress the temporary

closure of Bexton Court in Knutsford. The service will be transferred to Mountview in

Congleton once extensive refurbishment is completed by 31st December, 2010. In

31

Crewe Lincoln House provides a specialist respite and day care service for people

living with Dementia and their carers.

Dementia adviser

6.4 The role of the Dementia adviser has been well publicised, not least as it is objective

4 of the National Dementia Strategy: Enabling easy access to care, support and

advice following diagnosis. CECPCT and CEC have not been successful to date in

securing funding via bids for this service; despite many areas nationally having

received this funding to set up Demonstration sites for the Department of Health.

6.5 There is a clear role for the Dementia adviser that became increasingly evident

during the CSED work. The role weaves through the Dementia pathway and has a

role in almost every area of that journey.

6.6 Dementia Advisors should be available at point of diagnosis and follow their journey

to give advice and support face to face initially. With a clear job description to ensure

that their role is understood by all. The role provides a named person for each

diagnosed case.

6.7 Recommendation: to develop the role of Dementia Advisor to sit with the 3rd Sector

and provide the above service. It is likely that this will work in Practice Based

Commissioning areas. Resources will need to be sourced for this new service, and

we will continue to work with our partners to secure external funding.

Improve End of life pathway & Advanced Directives

6.8 The NDS states in objective 12 that people with Dementia and their carers need to

be involved in planning end of life care, that recognises the principles outlined in the

Department of Health End of Life Care Strategy. Local work on the end of life

strategy needs to consider Dementia.

6.9 There is increasing evidence to suggest that there is a need for the carer and patient

to have an early discussion on the choice and place of death. It is important to

ensure appropriate symptom and pain management at the right time and multi-

agency teams need to empower carers in all settings. With better end of life planning,

better registration of patients with advanced Dementia on to the Gold Standards

Framework (GSF) of care and earlier discussions with the multi-agency

professionals; it is likely that inappropriate admissions to hospital and inappropriate

treatment will be reduced. Excellent terminal care will keep the patient and carer

needs central, which will reduce complex grieving processes.

6.10 In order to do this we need to:

o Incorporate sensitive discussions around planning for end of life, advance

directives mental capacity, lasting power of attorney etc early in the journey as

32

appropriate to the individual, but should be considered at, or soon after diagnosis.

Information can be given at diagnosis and supported by the Dementia adviser.

o Integrated care pathway will reflect this

o Map of medicine will be adapted to incorporated this

o We will work with our partners to ensure end of life issues are fully addressed in

line with the points above

o Look at specialist palliative care model to assess the feasibility of extending their

numbers / type of role to meet the needs of people with Dementia. This would

require additional resources. Admiral Nurses are currently growing nationally and

are deemed experts in their field of Dementia and may consider developing an

end of life specialist role that includes symptom management and education as

well as psychosocial care. If funding became available, perhaps on a practice

based commissioning basis, then this option could be investigated further

o Care4CE has recently secured funding from St Luke’s Hospice to train specific

staff in advance decision making and communication skills in EOLC and

Dementia. This will be rolled out on a two day training course of up to 20 staff and

delivered by an educational team at St Luke’s

Assistive Technology

6.11 Assistive Technology should be an integral part of the Dementia pathway, available

at all points of an individual's (and carer's) journey.

6.12 The vision is that assistive technology can raise the threshold at which people need a

greater level of support, optimising their independence for as long as possible. E.g.

Memory prompts to enable people to retain a functional independent routine at home,

environmental risk management (fire, flood, gas leak, etc) to enable people to remain

home safely, alerts to carer living in the same property to reduce stress and enable

them to support the cared for person when this is needed.

6.14 Assistive technology mainly in the form of Telecare is currently available to everyone

who is assessed as critical or substantial and comes within our financial criteria. The

use of alerts for carers living in the same property is developing at the moment as the

technology has only just come on stream. This is an area which will be particularly

useful for people with a diagnosis of Dementia. Another area is lifestyle assessment

(e.g. Just Checking system); this is being rolled out across the Cheshire East area

and will have an increasing impact.

6.15 Assistive technology also has a great deal of potential outside of critical and

substantial criteria. Promoting the value of assistive technology to 3rd sector

colleagues and developing expert users is a priority.

6.16 There is value in increasing the profile of assistive technology in prevention designed

to avoid A&E and hospital admissions. We are working on a bid for a large project

33

that will introduce Telehealth into hospitals to facilitate earlier discharge for people

with long term conditions. This should coincide with a similar process for all assistive

technologies.

6.17 There is very limited promotion within the private sector. It is part and parcel of Extra

Care Housing, although there is some potential for further development. In

Reablement there is increasing knowledge and referrals are beginning to come from

staff. This is not the case in the private domiciliary care sector, although

presentations to the providers have been done and information shared with them to

encourage them to see assistive technology as a positive option for people with a

diagnosis of Dementia and others.

Family Based Care

6.18 Number of people with living with Dementia related conditions supported by Family

Based Carers April to August 2010 was 51

6.19 To increase capacity within FBC, possibly increase recruitment of volunteers and

family based care organisers. We need to look at the cost of private respite.

Local Media Campaign / Increase Public Awareness of Dementia

6.20 Citizens of Eastern Cheshire are telling us that they want increased awareness of

what Dementia is, the effect on life and carers, what services are available. This is

also highlighted in the National Strategy Objective 1, improving public and

professional awareness and understanding of Dementia.

We also need to raise awareness of the lifestyle factors that may influence Dementia

in later years. This is because evidence is emerging that a healthy lifestyle can

prevent and reduce the risk of developing specific types of Dementia.

In order to do this we need to;

6.21 Compose a letter to all schools and colleges asking them to consider a Dementia

module on their curriculum which will include information on Dementia and its effect

on their health and well being and specialist support for children and families. We

could ask them to consider Care4CE’s current training module. Provide a link to

schools and colleges with relevant information on Dementia and their services. This

needs to include entry level in medical/ nurse training.

6.22 Resource centres will have specific information relating to Dementia in their

Statement of Purpose that is shared with all relevant stakeholders from statutory and

non-statutory organisations.

34

6.23 The current road shows delivered on a regular basis by Alzheimer’s Society and Age

UK could be used as an “Information Gateway” about current services and initiatives

within Cheshire e.g. up-to-date one minute guides which will be found on each

organisation’s website.

6.24 There is an opportunity for GP commissioning groups to raise public awareness by

way of Dementia notice boards, Dementia advisors and utilisation of enhanced “Map

of Medicine”.

6.25 Provide a link that contains relevant information for the Occupational Health

Departments of private companies for the benefit of their employees. Companies to

be targeted would need to be subject to a stakeholder analysis to identify them.

6.27 On a regular basis work with communication teams in each organisation to promote

Dementia awareness via social media e.g. radio and television. Explore funding

options for information packs that would be universally available.

o Develop, via a communication plan, an information set for incorporation onto

websites with appropriate links and signposting e.g. CECPCT, CEC, Age

Concern, DemenShare, Alzheimer’s Society and provider websites.

o Link into local media campaign to publicise a user friendly directory for people

associated with Dementia. DemenShare, Yellow pages, Thompson Local, Health

& Wellbeing, Empower card

6.28 Health Improvement Team of Cheshire East in partnership with the PCT will develop

a business case in order to commission a range of suitable lifestyle messages (social

marketing) that could be used with specific groups. CECPCT will also ensure that this

links into the Ageing Well Strategy.

6.29 The Health Improvement Team in partnership with the PCT will develop a range of

social marketing techniques that could be used in order to effectively target different

groups within our community. These then need to be brought together under a

cohesive branding that could then become the overarching presence for Dementia

awareness in our community, both for members of the general public and

professionals. In order to finance this initiative the public health team will provide the

social marketing expertise to develop, coordinate and deliver this, using services

existing funding.

Directory of Respite Services

6.28 During the CSED process there was a clear need to have easy access to respite for

the carer. People were suggesting that they wanted a directory of respite services

through which they could search and book a break of their choice. It was suggested

that having access to respite at short notice could delay and / prevent admissions to

long term care and inappropriate hospital admissions.

35

Integrated 24hr helpline / crisis service

6.29 Work is currently being undertaken by strategic commissioning to provide a

multidisciplinary out of hour’s service. This will provide a more structured 24hr

response that will link into Reablement, intermediate care and crisis response. We

will be expected to ensure Dementia forms a fundamental part of this service, which

is forecast to delay and prevent admissions to hospital and long term care. This

service at present is a Shared Service. By April 2011 Cheshire East will have its own

independent integrated 24 hour helpline/crisis service.

Independent befriending service for Dementia

6.30 An independent befriending service can lead to the reduction in social isolation, delay

or prevent a crisis, support carers to care for longer and promotes the confidence

and maintains the skills of the person with Dementia.

6.31 We propose to do this by increasing the capacity of what we already have that

delivers this service. This is likely to be achieved by raising the awareness and de-

stigmatising Dementia. This could be done by commissioning the third sector to

provide training and awareness sessions to volunteer groups such as the CVS, WI

and faith groups. Once this has occurred we are likely to see an increase in the

number of people who are capable and willing to work with and befriend people with

Dementia.

6.32 The commissioning of Dementia Advisors and Dementia Champions would address

this by working closely with the third sector and the local Community Support Centres

to hold regular sessions on specific days for Dementia advice and support.

6.33 The LILT Teams and Local G.P practices would help facilitate this by signposting.

6.34 A report has been completed by Peter Fletcher Associates but is still in draft that is

linked to Extra Care Housing. Within this report is data that has been collated via

consultation with citizens with regard to personal care and befriending.

o Respondents were asked if they needed help with personal care or were in

need of company or befriending now or were likely to need such support in

the next five years.

o There were 3,591 indications of need for either personal care and / or

befriending.

o Macclesfield had the highest numbers indicating a need for either personal

care and / or befriending.

o The numbers indicating a need for practical help exceed the numbers

needing personal care and this is consistent with the large numbers citing the

maintenance of their home and garden as a primary reason for moving.

36

o This would suggest providing more services designed to help people maintain

their homes and gardens might reduce the demand for extra care housing.

Improving leisure based services for people with Dementia

6.18 Health and Well Being are important aspects of ageing well and will soon be coming

under the remit of Local Authorities. Therefore in consultation with people with

Dementia and their carers there is a need to improve leisure base services for people

with Dementia.

In order to do this we need to;

6.19 Approach libraries to have awareness days, activity sessions or theme sessions.

Cheshire East Council Health improvement services and leisure services can deliver

this. Generic Services need to be at convenient hours of opening to suit its users.

6.20 Although it may not be of benefit to everyone, Cheshire citizens can now use the

Empower Card which is a unique debit card – the first of its kind in the country – that

will enable older people and those with disabilities to lead more independent lives.

The Empower Card is a unique pre-loaded VISA card for individuals across Cheshire

East who receive a personal budget for the costs of their social care. Up until now,

the money was paid as cash in to a bank account, but now people can opt to have

the money loaded on to the Empower debit card. We will work closely with the

Empower team to develop a program that will support people associated with

Dementia. e.g. access to leisure facilities so that people can receive a discount and

where appropriate selected times for admission.

6.21 Use existing services from the health Improvement Team : falls and physical activity

older persons group. This group already exists and has representation from age

concern, Age Uk, all housing associations, acute trust, older peoples representatives

etc.

Access criteria

6.22 During our CSED process it became apparent that people wanted appropriate timely

support and suggested that the access criteria had an impact on this. Although this

strategy cannot influence access criteria directly the steps we can take are;

Provide information on Access Criteria on PCT website, DemenShare, CEC website.

Provide information to:

Public Health Police, Fire and Rescue

LILT Teams D/N’s

Hospital Social Workers Community Matrons

Consultants Practice Managers

37

Carer arranger GP

Acute Hospitals CWP

Intermediate Care

On eligibility Criteria for:

Memory Services D/N’s

Social Workers Community Matrons

Intermediate Care GP

Police, Fire and Rescue Practice Managers

Utilising and developing the Map of Medicine.

Early Diagnosis / Early Onset

6.23 All people with Dementia need to have access to a pathway of care that delivers; a

rapid and competent specialist assessment; an accurate diagnosis sensitively

communicated to the person with Dementia and their carers; and immediate

treatment, care and support following diagnosis. The system needs to have the

capacity to attend to all new cases of Dementia in the area. (NDS objective 2)

In order to do this we need to:

o Investigate if /how we can increase capacity within Memory Service to include

Learning Disabilities. Or increase skills and capacity within existing LD services.

o Investigate how we can improve access to diagnosis

o Look at dedicated memory services in order that there is consistency of third

sector organisations, volunteers and professionals to give advice and support.

o Ensure appropriate screening by GPs prior to referral using tools such as “Map of

Medicine”

o Promotion of:

- Respite in order to reduce the stigma associated with respite and prevent crisis

occurring

- DemenShare

38

- Alzheimer’s Society

- Age Concern

Dementia Advisors/Peer Support to be strategically placed in convenient geographical

areas

o The above can have a presence in other areas

o Skill up the LILT teams to enable them to act in an advisory capacity and sign

post.

Carer Register

6.24 Evidence from carers suggest that they would like GPs to pay more attention to their

needs, as looking after a person with Dementia can often have detrimental effects on

a carers health, although quite often is neglected by the carer.

It is important to ensure that carers have access to services and information that they

may require, such as support from the third sector, benefits advice, social services

and carer assessments. This could be addressed via the GP particularly if we

promote the advantages of the carers register and encourage GPs to use it. We will

ensure that this aspect of the Dementia journey is captured on the Map of Medicine

which GPs use regularly along with information on where to get help.

Housing/community neighbourhood support

6.25 During the CSED process there was an indication that by ensuring that people with

Dementia were appropriately housed, with suitable support such as Telecare,

adaptations, equipment, community support and better communication between

community services, this would prevent or delay admissions to hospital and long term

care. Indeed objective 10 in the NDS states that people with Dementia and their

carers will receive the right housing support, housing related services and Telecare

at the right time. In order to do this we will need to:

o Develop better communication and support services involved in neighbourhood

support. This could include information via leaflet delivered and explained by

police, fire and rescue services and or coordinated by Age Concern, in a strategic

community plan, based on each geographical area.

o We will need to consult with third sector as to how we go about providing

effective community support

o Third sector could potentially develop a forum that involves housing associations,

police, fire, and domiciliary care that meets on a monthly / bimonthly basis to

discuss raise inform and resolve issues relating to neighbourhood support, Local

area partnerships (LSPs) should be considered and link into these as they are

already in existence.

39

Intermediate Care

6.26 Objective 9 of the NDS is to improve intermediate care for people with Dementia.

Intermediate care that is accessible to people with Dementia and that meets their

needs.

Currently there are no dedicated intermediate care beds for people with Dementia,

however there are 101 intermediate care beds that can be used by people with mild

to moderate Dementia. The aspiration for the future is that we will have 15%

dedicated beds supporting people with Dementia at all levels and it is hoped that this

will increase in line with the increase in prevalence over time. It is also imperative

that we utilise our statutory organisations.

Improve services in general hospitals & Improving access and

treatment in A & E

6.27 The National Dementia Strategy objective 8 talks about identifying leadership for

Dementia in general hospitals, defining the care pathway for Dementia there and the

commissioning of specialist liaison older people’s mental health teams to work in

general hospitals. Indeed, local consultation ratifies this and urges us to work with

our partners to improve the quality of care for people with Dementia in general

hospitals.

In order to do this we need to:

o Ensure that each Acute Trust develops a specific Dementia pathway from

admission to discharge with an emphasis on quality and person centred.

Including opportunities to receive a diagnosis where it is appropriate when

admitted to the acute trusts.

o Develop the contracts with Acute Trusts to include Dementia pathway

- Training: mandatory and refresher according to individual’s posts

- Specialist Dementia pathway to include Police and Ambulance Department

o Both Trusts to be familiar with Gold Standards Framework (GSF) and Liverpool

Care Pathway (LCP). They should have this policy accessible to all including

Police and Ambulance Department. To respect a person’s Advance Decision

where possible, involve Police and Ambulance Department, liaison psychiatry

and hospital social worker.

o Ensure implementation of protected mealtimes. (feeding support / menu selection

/ quiet environments with no medical intervention etc)

40

o Advise Acute Hospitals to consider assistive technology and use specific signage

for someone living with Dementia.

o Involve A&E Department.

o Improve communication with:

- Nursing Homes (potential for in reach), Residential Homes, Respite Centres

- Police

- Liaison Psychiatry

- Dementia Advisors

Improving the Quality of Dementia Pathway in Nursing / Residential

Homes and Day Care

6.28 The National Dementia Strategy objective 6:

o Cheshire East Health Improvement Team in partnership with the PCT will lead a

piece of work that can be delivered potentially by the third sector to develop a

range of appropriate evidence based health and well being activities which can

be used in all of these services. This would include a specific training plan.

o Training to be delivered to all staff appropriate to their post and grade. It will be

done by commissioning this through the statutory or non statutory sector. In order

to fund this in the short term health and well being team will apply for funding via

the Learning Resource Network (LRN).

o In the longer term, we will ensure that training is a requirement documented in

contracts with our service providers.

o Opportunity to look at mental health trust staff working in nursing homes and PCT

staff doing similar work. Such duplication if irradicated could free up capacity in

memory services and develop a high quality review service for nursing homes.

This is being explored currently.

Next Steps

1. Action Plan see appendix

2. We have a massive amount of data including financial that still needs to be collated

in to a financial framework

41

Appendix

Dementia Commissioning plan: Commissioning Intentions and

Recommendations

1.Respite Breaks

Long term aim

Long term aim To provide different lengths of stay and ways in which respite can be provided for people living

with dementia and their carers.

Step How and by whom lead To be

complete by:

date

comments

1.

Ensure there is a

simple, quick and

efficient system to

book respite

Strategic

Commissioning to

ensure this is

embedded in the

contract set down by

the local authority

Jill

Greenwood

Feb 2011

2.

G.P consortia have

relevant information of

how to support carers

to have instant access

to respite support to

prevent a crisis

Ensure all Dementia

Advisors and dementia

champions have this

information readily

Jill

Greenwood

Tracy Ault

March 2011

42

available.

All Health and Well

being centres promote

this information for

their customers and

visitors

Health and Well

being Team Guy

Kilminster

Jill

Greenwood

March 2011

2. Dementia Adviser

Long term aim

Dementia Advisors should be available at point of diagnosis and follow their journey to give advice and support

face to face initially. With a clear job description to ensure that their role is understood by all. The role provides a

named person for each diagnosed case. They will be ideally placed within the third sector but be an integral part

of memory services. The Dementia adviser will play an important role in advising and signposting to all services

and facilitating where necessary. They will be known to GPs, mental health trust, LA and third sector providers.

NB There will need to be additional resources for this role that will potentially make other savings to support

their role along the dementia pathway that could be demonstrated in a business case.

43

Step How and by whom lead To be

complete by:

date

comments

1. Apply for bids.

That may

become available

prior to March

2011 when these

will cease.

PCT and LA commissioners

will liaise with NW colleagues

to ensure awareness of

potential forthcoming bids

and apply.

Tracy Ault

Jill Greenwood

March 2011

2. recommend

for GP

commissioning

consortia

Commissioning plan to go to

commissioning executive in

October 2010 to raise

awareness of this role and for

future consideration

Tracy Ault October

2010

3. develop

business cases to

support the

development of

the dementia

adviser

Business cases will be

developed to support the

role of dementia adviser to

go to GP commissioning

consortia and CEC board /

Cabinet. The business cases

will demonstrate how savings

can be made by

implementation of the role

Tracy Ault

Jill Greenwood

March 2011

44

3. Improve End of Life pathway / advance directives

Long term aim: There is increasing evidence to suggest that there is a need for the carer and patient to have an

early discussion on the choice and place of death. It is important to ensure appropriate symptom and pain

management at the right time and multiagency teams need to empower carers in all settings. With better end of

life planning, better registration of patients with advanced dementia on to the Gold Standards Framework (GSF)

and earlier discussions with the multiagency professionals; it is likely that inappropriate admissions to hospital

and inappropriate treatment will be reduced. Excellent terminal care will keep the patient and carer needs

central, which will reduce complex grieving processes.

Step How and by whom lead To be

complete

by: date

comments

1. Incorporate sensitive

discussions around

planning for end of life,

advance directives

mental capacity, lasting

power of attorney etc

early in the journey as

appropriate to the

individual, but should

be considered at, or

soon after diagnosis.

Information can be

given at diagnosis and

supported by the

dementia adviser.

MT please advise Mark

Theophanous

MT

please

advise

2. Ensure that the

Integrated care

pathway and Map of

Adapt pathways to

ensure end of life needs

are documented

Tracy Ault

care

pathway

Decembe

45

medicine reflect this Jill Greenwood r 2010

MOM

March

2011

3. GP commissioners

could consider the role

of the Admiral Nurse

service or extending

the capacity / role of

the specialist palliative

care model to address

end of life issues for

people with dementia

Commissioning managers

could develop business

cases to support the case

for end of life and how,

by investing in EOL care

resources could be

moved from the acute

and LTC into EOL.

GP

commissioners

March

2012-13

4. Assistive technology

Long term aim: Assistive Technology should be an integral part of the Dementia pathway, available at all points

of an individual's (and carer's) journey.

Step How and by whom lead To be complete

by: date

comments

1.

Lounge within

Lincoln House

Dementia Unit will

be a showcase for

assistive

technologies. As

well as people with

dementia being able

Equipment to be placed

in the lounge in

consultation with

manufacturers.

Support for customers

and carers will initially

be available through

the assistive technology

project manager and

Jill

Greenwood

Jon Wilkie

April 2011

46

to see

The equipment;

carers will be able to

experience the

technology &

consider any

equipment that

would support them

in their role.

project officers

2.

Expert user groups

will be set up in

consultation with

third sector groups

to disseminate

information to

people with

dementia in the

Cheshire East area

Training on assistive

technology to be rolled

out to third sector

groups. Delegates will

be able to nominate

themselves as local

expert users and

receive updates and

support to roll out

training within their

networks.

Jill

Greenwood

Training to be

developed by

February 2011

3.

Dementia Specific

Telecare Pathway to

be developed to

enable people with a

diagnosis access

Telecare at an earlier

stage in their journey

‘Business plan’ to be

developed to establish

value for people with a

diagnosis of dementia.

New guidance training

for social care

professionals to be

developed on the back

of this.

Jill

Greenwood

Business plan to

be agreed

January 2011

5. Family based care

47

Long term aim: To increase capacity within FBC, possibly increase recruitment of volunteers and family based

care organisers.

Step How and by whom lead To be

complete

by: date

comments

1.

To check with

Individual and

Strategic

Commissioning

whether an increase

in dementia referrals

to FBC is anticipated.

If so, quantify the

anticipated increase

and seek an

agreement in principle

to expand the service.

Jill Greenwood

Julie Fogg

March

2011

Cheshire East Council is

going through a period of

transition whereby it is

reviewing it’s current

service structures and

realigning it’s services to

meet the needs of

Cheshire East citizens

2.

Identify and cost out

the additional

resources required to

achieve such an

expansion.

Jill Greenwood

Julie Fogg

March

2011

3.

Obtain the agreement

of IC and SC to

proceed with this,

based on the costs

Jill Greenwood

Julie Fogg

March

2011

48

identified as above

and an agreement

over how the costs

would be met.

6. Local media campaign / Increase Public Awareness of Dementia

Long term aim: Citizens of Eastern Cheshire are telling us that they want increased awareness of what dementia

is the effect on life and carers and what services are available. This is also highlighted in the National Strategy

Objective 1, improving public and professional awareness and understanding of dementia.

Step How and by whom lead To be

complete

by: date

comments

1. Schools and

colleges to consider

a dementia module

on their curriculum

which will include

information on

dementia and its

effect on their health

and well being and

specialist support for

children and families.

Provide a link to

schools and colleges

with relevant

information on

dementia and their

services. This needs

to include entry level

in medical/ nurse

training.

Compose a letter

including a link to

relevant websites; to all

schools and colleges

including nursing /

medical asking them to

consider a dementia

module as described in

step 1.

Jill Greenwood

Tracy Ault

Dec 2010 We are in the process of

seeking advice on how we

will start to integrate

colleges and schools and

have dementia on their

curriculum.

2. Resource centres

will have specific

information relating

Jill Greenwood Dec 2010 All current Resource

Centres that support

people living with

49

to dementia in their

Statement of

Purpose that is

shared with all

relevant

stakeholders from

statutory and non-

statutory

organisations.

dementia have

information to all

stakeholders from statuary

and non statuary

organisations.

3. Up-to-date one

minute guides which

will be found on each

organisation’s

website.

Ensure links are in place

on PCT, CEC, CWAC and

CECH websites to the One

Minute Guide

Tracy Ault

Jill Greenwood

Dec 2010 This is being planned at

present and will link in the

‘Ageing Well strategy’.

4. There is an

opportunity for GP

commissioning

groups to raise

public awareness by

way of dementia

notice boards,

dementia advisors

and utilisation of

enhanced “Map of

Medicine”.

Advice to be sought from

GP commissioning

Colleagues

Commissioning plan and

action plan to go to

commissioning exec

October 2010

Tracy Ault Nov

2010

5. Promote dementia

awareness via social

media e.g. radio and

television.

On a regular basis work

with communication

teams in each

organisation.

Explore funding options

for information packs

that would be universally

available.

Jill Greenwood

Tracy Ault

Andrea Brameld

Emma Leigh

On going The launch of DemenShare

website available for all

citizens within Eastern

Cheshire. The launch date

for this project is 14th

October 2010

50

6. Provide a link that

contains relevant

information for the

Occupational Health

Departments of

private companies

for the benefit of

their employees.

Stakeholder analysis to

identify scope of exercise

and relevant

stakeholders.

Write to identified

stakeholders with

information and links to

websites that provide

pertinent information

Ask for feedback on their

intentions

Jill Greenwood

Tracy Ault

Feb 2011 The new G.P Consortia will

have all relevant links to

support people and their

carers associated with

dementia.

7. Develop

information set for

incorporation onto

websites

Develop a

communication plan.

Information for

incorporation onto

websites with

appropriate links and

signposting e.g. CECPCT,

CEC, Age Concern,

DemenShare, Alzheimer’s

Society and provider

websites.

Jill Greenwood

Tracy Ault

Feb 2011 Cheshire East are currently

creating their Information

Pathway, there will be all

relevant links to support

people associated with

dementia

The integrated pathway

for people living with

dementia will sit alongside

the map of medicine that

all G.P’s will have access

to.

51

7. Directory of respite services

Long term aim: access to a range of respite service which are flexible and where necessary can be booked at

short notice

Step How and by

whom

lead To be complete

by: date

comments

1.

Identify current

resources including

private sector and feed

this into the all

information centres

Jill Greenwood

Contracts

department

CECPCT

Jill Greenwood

Rob Walker

February 2011 This information is

available on the Cheshire

east Website and Cheshire

west and Chester website.

2.

publish resource

directory

Jill Greenwood

Contracts

department

Jill Greenwood

Rob Walker

February 2011

52

CECPCT

8. Integrated 24hr helpline / crisis service

Long term aim: provide a multidisciplinary out of hour’s service. This will provide a more structured 24hr

response that will link into Reablement, intermediate care and crisis response.

Step How and by whom lead To be

complete

by: date

comments

1.

The Emergency Duty Team is

being re designed to develop the

service into an Out of Hours

service with a Whole Family

approach. Adult and Children’s

Services are working together to

design a joint approach for the

future of the service.

Work is also being undertaken to

look at further developing this

service which includes other

stakeholders from partner

agencies with a commitment to a

multi agency response for all

services who operate out of

hours services.

The development of home based

solutions where at all possible

will also be integral part of the

service development. This

includes services in terms of Early

Intervention, Prevention and

Reablement.

This is an exciting opportunity to

Lucia Scally

Jacqui Evans

This crisis service is

currently a shared

service and will

become a separate

service with each

council in April; 2011

53

be involved in shaping and

developing services to meet the

needs of service users and their

families.

The Hours of work will be 2pm to

10.30pm Monday to Thursday

and 2pm to 10pm on Friday. This

working pattern enables liaison

with day services to take place

whilst also ensuring staff support

and supervision can be an

integral part of the development

of the service. Quality assurance

and case auditing will also be a

focus of the continuous

improvement and development

of the service.

2.

The Hours of work will be 2pm to

10.30pm Monday to Thursday

and 2pm to 10pm on Friday. This

working pattern enables liaison

with day services to take place

whilst also ensuring staff support

and supervision can be an

integral part of the development

of the service. Quality assurance

and case auditing will also be a

focus of the continuous

improvement and development

of the service

54

9. Independent befriending service for dementia

Long term aim

Step How and by

whom

lead To be complete

by: date

comments

1.

A register for Dementia

champions is being

collated

Jill Greenwood

Tracy Ault

Jill Greenwood

Dec 2010

2.

Training Awareness for

all people associated

with dementia

G.P Consortia to

facilitate signposting

Specialist Support

Centres to promote

dementia awareness

days.

Lisa Burrows

(CEC)

Tracy Ault

Resource

Managers

Jill Greenwood

April 2011

Dec 2010

55

10.Improving leisure based services for people with dementia

Long term aim

To provide specialist activities for people living with dementia in all environments. Develop a referral route for these

individuals so they would have access to appropriate activities tailored to their individual needs

Step How and by

whom

lead To be complete by:

date

comments

1.

Currently there are

limited and un co-

ordinated activities for

people living with

dementia in Nursing and

Residential homes linked

to day care.

Plans now taking place

are:

Health

Improvement

Teams within

CEC which is a

multi agency

group

Donna

Williamson

Emma Leigh

March 2011

56

Mapping existing

programmes

Tailored packages for

each individual will be

set up as part of their

support/care programme

to assist in their health

and well being.

2.

Citizens who are in

receipt of direct

Payments and use the

Empower Card which is a

unique debit card will

enable older people and

those with disabilities to

lead more independent

lives by accessing all

types of specific facilities

at a discounted price

Wynn Spencer

(CEC)

March 2011

11.Access criteria

Long term aim

to provide appropriate and timely support by informing relevant people about Access Criteria

Step How and by

whom

lead To be complete by:

date

comments

1.

Provide information on

Access Criteria on the

PCT website

Jill Greenwood

Tracy Ault

February 2011

57

DemenShare, CEC

website and information

gateway

2.

his information to be

shared with

Police, fire and rescue

teams

Public health

LILT Teams, Hospital

Teams, Consultants,

Practice Managers,

Community Matrons

Utilise the map of

medicine

Provide

information on

Access Criteria

on the PCT

website

DemenShare,

CEC website and

information

gateway

Jill Greenwood

Tracy Ault

February 2011

12.Early diagnosis / Early onset

Long term aim: All people with dementia need to have access to a pathway of care that delivers; a rapid and competent

specialist assessment; an accurate diagnosis sensitively communicated to the person with dementia and their carers;

and immediate treatment, care and support following diagnosis. The system needs to have the capacity to attend to all

new cases of dementia in the area. (NDS objective 2)

Step How and by whom lead To be

complete

by: date

comments

1.

Review early diagnosis

and memory services to

ensure that the

These are the basic

requirements of the

national dementia strategy,

and will be included in

future contracts. Memory

Tracy Ault March

2011

58

pathways to deliver a

rapid competent

specialist assessment,

and accurate diagnoses

sensitively given with

immediate treatment

care and support

following diagnosis.

services should be

discussed regularly at

contract meetings

2.

Develop a service for

people with dementia

with either psychosis or

behavioural problems to

dip in and out of in a

timely way when

needed.

This needs to form a part of

the review of existing

services

Tracy Ault Spring

2011

3.

Develop a service that

reviews people in

nursing homes,

especially on

antipsychotic

medications.

This needs to be done as

part of existing services

Tracy Ault Spring

2011

4.

GP commissioning

consortia to review

pathway and consider

capacity within primary

and secondary care

CWP will work with the

consortia and PCT to

establish any resource,

capacity, and other issues

to ensure that we have a

consistent and high level

approach to early diagnosis

and intervention

Resource issues may relate

to diagnostics and

medication in addition to

GP commissioning

consortia

Tracy Ault

Spring

2011

59

capacity.

Develop the share care

protocol

13. Carer register

Long term aim

G.Ps automatically register a carer which will enable them to seek all relevant support and advice

Step How and by whom lead To be complete

by: date

comments

1.

Ensure G.P Consortia

have access to the map

of medicine

60

2.

More to be added

Work in progress

14. Housing/community neighbourhood support

Long term aim: people with dementia appropriately housed, with suitable support such as Telecare, adaptations,

equipment, community support and better communication between community services

Step How and by whom lead To be complete

by: date

comments

1.

Improve the information

gateway in all

organisations

Communications

Team CEC

Communications

Team CECPCT

Third Sector

Communications

Team

Andrew Arditti (CEC)

2.

The Community strategy

Extra Care Housing to

promote neighbourhood

Support.

Nuala Keegan

(CEC)

Lynn Glendenning

15. Intermediate care

61

Long term aim: improve intermediate care for people with dementia. Intermediate care that is accessible to people with

dementia and that meets their needs.

Step How and by whom lead To be complete

by: date

comments

1.

More to be added

Work in progress

2.

16. Improve services in general hospitals & Improving access and treatment

in A & E

Long term aim: improve the dementia care pathway through acute hospitals

Step How and by whom lead To be complete

by: date

comments

1. Identify dementia

champions in each acute

trust

Work with each trust

to identify senior

members of staff to

drive the dementia

agenda forward

Tracy Ault

Phil Pordes

Bernie Salisbury

December

2010

Work done in MCHT and

progressing well in MDGH

2. Ensure that each

Acute Trust develops a

Work with trusts to

ensure that the

Tracy Ault March 2010 Work done in MCHT and

62

specific dementia

pathway from admission

to discharge with an

emphasis on quality and

person centred.

Including opportunities

to receive a diagnosis

where it is appropriate

when admitted to the

acute trusts.

dementia pathway

through the acute is

addressed

Phil Pordes

Bernie Salisbury

progressing well in MDGH

3. Develop the contracts

with Acute Trusts to

include dementia

pathway

- Training: mandatory

and refresher according

to individual’s posts

- Specialist dementia

pathway to include

Police and Ambulance

Department

Work with the

contracting team to

ensure contracts are

adapted when

possible to include

dementia training and

pathways

Tracy Ault

Jane Walshaw

ongoing Some dementia training

has been included in the

contracts last year, this

needs to be developed

further using CQINs where

possible

5. Both Trusts to be

familiar with Gold

Standards Framework

(GSF) and Liverpool Care

Pathway (LCP). They

should have this policy

accessible to all including

Police and Ambulance

Department. To respect

a person’s Advance

Decision where possible,

involve Police and

Ambulance Department,

liaison psychiatry and

hospital social worker.

63

. Ensure implementation

of protected mealtimes.

Ensure this is done via

pathway work

Tracy Ault

Phil Pordes

Bernie Salisbury

Dec 2010

Work already done in

MCHT and progressing

well in MDGH

7. Advise Acute Hospitals

to consider assistive

technology and use

specific signage for

someone living with

dementia.