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Improving dementia care: CQUINS and Enhanced Services – Professor Alistair Burns

The national dementia Commissioning for Quality and Innovation (CQUIN) is now in its fourth year and has had a positive and wide ranging impact on the profile of dementia in general hospitals.

The focus on case finding has evolved since the first year of its inception to encompass more emphasis for the support of clinical leadership, the coexistence of delirium (as it is well recognised that the interface between dementia and delirium under the common banner of cognitive impairment is seamless) and the provision of information for carers of people with dementia.

The uptake of the CQUIN has been excellent with the 90 percent target for each of the three stages of the Find, Assess/Investigate and Refer components of the direct clinical aspects of the scheme. There have also been more aspects of the process to changes in the CQUIN, which has also evolved to include, as far as we can, delirium.

This year (2015/16) the CQUIN has been refreshed by extending it to community service providers reflecting the fact that there are people with dementia in these services who could take advantage of the opportunities the CQUIN presents.

The prominence of the care plan reflects the results of the “Cracks in the Pathway” report from the CQC which highlighted aspects of care where people with dementia moved from one part of the health and social care system.

In addition to the existing parts, there is an emphasis on having in place a written care plan on discharge. This is shared with the patient’s GP, ensuring that appropriate dementia/delirium training is available to staff through a locally determined training programme and that the carers of people with dementia and delirium feel adequately supported. Local audit will determine the quality of these. Experience in training and education shared between community providers and general hospitals would be important.

A few months ago, in collaboration with Simon Thacker from Derby Royal Infirmary, we held a meeting to review the CQUIN to reflect views and harness opinion.

The take home messages were:

  • The dementia CQUIN, in general, was welcomed as an initiative to broaden the profile of the disorder in the general hospital, had excited discussions around cognitive impairment and had been a stimulus to improve care.
  • While dementia is a powerful concept, there was a need to capture the profile of delirium, perhaps in a CQUIN, as the two are inextricably linked, in order to deliver optimal care.
  • Looking across health and social care and emphasising quality was regarded as key.

NHS England has also held two web-based presentations on the changes to the CQUIN in April and May, the latter with a focus on community services.

The Directed Enhanced Service (DES) for dementia in primary care is now entering its third year and is distinct from the short term National Enhanced Service (NES) which transiently – October 2014 until the end of March 2015 – incentivised the correct recording of dementia in primary care.

The new DES has expanded the previous groups – people over 60 with cardiovascular disease, long term neurological conditions and people over 50 with learning disability – to include people over 60 who have risk factors for vascular disease, Down’s Syndrome in people over 40, and people over 60 with chronic obstructive pulmonary disease.

This broadens the envelope of people to whom the DES can be applied and gives colleagues in general practice the opportunity, if they so wish, to identify people at risk of dementia, give a diagnosis where clinically appropriate and install post-diagnostic support.

Half the payment for the DES is upfront set up costs with the other 50 percent available for identification of individuals. The list is not proscriptive in any way and any person can be included as part of the enhanced service if felt to be clinically appropriate. The outcomes of the ES should be either a referral for further assessment, provision of an assessment of needs or the instigation of appropriate treatment. There is an emphasis on care planning and the need to provide high quality support for carers. NHS England held a web-based presentation with some examples of good care planning in May.

The profile of dementia is high and the diagnosis rate is improving – concentrating on primary care and hospitals to improve identification of people with dementia. Enhancing care planning and post diagnostic support is a priority and reflected in the CQUIN and enhanced service.

Any observations, comments and suggestions gratefully received at Alistair.burns@nhs.net or @ABurns1907 on Twitter.

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