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Optimising care and support for people with dementia in care homes: The Barbican Consensus – Professor Alistair Burns and James Cross

The Five Year Forward View was published in October 2014 and presented a vision for the NHS including detailed new models of working across health and social care.

The key values of the new care models were local ownership with national support and a major emphasis on clinical engagement and patient involvement. Five models were presented, all of which have varying degrees of relevance to dementia, but in particular the Care Home Vanguards are important – there are six of them (details available on www.england.nhs.uk/vanguards).

The issues being addressed by these Vanguards are wider than care homes and include payment design and pricing, contracts, work force re-design and harnessing technology. They include models of enhanced care with innovative partnerships, use of technology, making the most of local assets, in reach services from outside, flexible in reach services, training and support, redesigned hospital care and, of particular importance, focusing on residents capabilities.

Recent reports suggest that 80% of people in care homes have dementia and there is evidence to suggest that prescription of neuroleptic drugs is higher in this group and that the diagnosis rate, pro rata, might be lower than the general population.

As part of the work programme of the Prime Minister’s Dementia Challenges, NHS England, CQC and Care England convened a meeting (near the Barbican, hence the name) to discuss the issues around dementia in care homes and in particular, the specific theme of improving diagnosis and post diagnosis support.

The organisations present at the meeting were: Skills for Care; Care Quality Commission; Alzheimer’s Society; Care England; Department of Health; National Care Forum; NHS England; Social Care Institute for Excellence; United Kingdom Homecare Association; Four Seasons Health Care.

The Care Quality Commission found in its thematic review of dementia services ‘Cracks in the Pathway that there is more good care than poor care in the care homes and hospitals that their inspectors visited, but that the quality of care for people living with dementia varies greatly.

The report found that it is likely that someone living with dementia will experience poor care at some point while living in a care home or being treated in hospital which is unacceptable and cannot continue. People living with dementia, their families and carers have every right to be treated with respect, dignity and compassion.

Care England’s perspective is that social care and health services should be measured according to the difference they make to the lives of people with dementia. In particular it feels that commissioning should become more personalised and outcome focussed through the use of increased numbers of personal budgets.

NHS England has led a successful programme of work across England to increase the rates of diagnosis for people with dementia as part of the Prime Minister Challenge on Dementia 2012 – 2015.

This work has increased national diagnosis rates so that almost two thirds of people with dementia now have a formal diagnosis. Commentaries on care home care in dementia have been published in my previous blogs:  GPs have a vital care home dementia role and Don’t let care home residents slip through the dementia net.

Earlier this year the Department of Health published ‘The Prime Ministers Challenge on Dementia 2020’ which details the vision for dementia care and support in the future. The document places importance of diagnosis, but also post-diagnosis support and high quality services for people with dementia.

In research, it has been demonstrated the importance of the built environment, the combination of person-centred care training, meaningful activities with social interaction and antipsychotic review is able to reduce antipsychotic use, improve quality of life and reduce mortality in people with dementia, without any worsening of neuropsychiatric symptoms.

The discussion of the meeting was positive and wide ranging. The key themes that were discussed were:

  • The importance of a high quality timely diagnosis of dementia in care homes
  • Personalised health and care services
  • Supporting people with dementia, their families/carers to navigate the available support

The attendees made five observations:

  1. A diagnosis of dementia in residents of care homes, where clinically appropriate, is absolutely essential to ensure high quality post diagnosis support and care planning. All diagnosis should involve, as far as possible, the person with suspected dementia, their family and the care home staff.  The process should follow NICE guidelines.
  2. Care planning is facilitated by that diagnosis. Care plans should be personalised, able to be shared and ideally electronic.  Discussions about End of Life Care planning should be prominent.
  3. Dementia friendly communities have an increasingly important role to play and care homes should become key parts of that community.
  4. Care home staff should have access to education, training and development
  5. Research and spreading of good practice in dementia care should be encouraged.

Care homes are a key area where the quality of life for people with dementia can be improved whether that is by looking at new models of care, improving diagnosis, instigating care planning and enhancing education.

We are interested to hear of novel and innovative examples of where this is being done – please let us know (care of Alistair.burns@nhs.net).

  • Alistair Burns is NHS England’s National Clinical Director for Dementia, NHS England, and James Cross is National lead for Dementia at Skills For Care.

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