NHS England’s National Clinical Director for Dementia and a Devon-based consultant psychiatrist review impressive changes to dementia diagnosis and care in the West Country:

The diagnosis of dementia can be complex and time consuming.

It involves detailed clinical assessment of cognitive, mental and physical health, blood and radiological investigations and carer interviews.

While memory clinics bring together this high level of expertise, they require sufficient capacity for timely access and integration with other services.

Devon is a large county with a population over one million, a high proportion of older people and a significant and increasing prevalence of dementia. In 2012, there were five providers of memory assessment services, 17 referral routes and poor linkage between services. GPs were unclear about clinical pathways, time from referral to diagnosis was often over seven weeks, patients and their families made multiple assessment visits and diagnosis rates were 37% of estimated prevalence.

Consultation with people using the existing services indicated assessment processes were unduly stressful and people felt ‘cast adrift’ afterwards with poor integration with other services such as Older People Mental Health, Dementia Advisors, Memory Cafes and support groups.

Something had to be done.

A pan-Devon partnership project group was established in October 2012 with a number of local partners of whom Devon Partnership NHS Trust was the lead.

Following a review, including patient and carer experiences, four objectives were formed. First, there should be a fully integrated person-centred care pathway. Second, that early diagnosis should be made by a specialist memory clinic, with a clear referral pathway and a person-centred, ‘One Stop’ approach. Third, all GPs should be made able to make a diagnosis in the moderate to later stages of the illness. Fourth, that all patients should have consistent access to evidenced-based interventions wherever they were diagnosed

The redesign process was at all times in consultation with patients and carers, GPs, the voluntary sector and with reference to best practice. Project groups of clinicians from each organisation and locality were set up to design and deliver the new integrated service which was implemented across Devon nine months later.

The new model now delivers:

Support for GPs

• There is now one pathway across Devon for all referrals
• All GPs in Devon have received face-to-face training from GP Dementia Leads on referral criteria and diagnosis and management of dementia
• All referrals are triaged to ensure they meet the referral criteria and to check whether there are other clinical issues, for example depression which need to be addressed before assessment
• All clinic correspondence to patients, carers and GPs has been standardised across the county.

A ‘One Stop’, person-centred service

• The patient or carer chooses an appointment to suit through the Devon Access and Referral Team (DART)
• The patient and/or carer receive a telephone reminder before the appointment and are sent information about the clinic
• Diagnosis is made on one visit to a standardised clinic which are based in the three acute hospitals enabling the multidisciplinary assessment to be a truly ‘one-stop’ appointment with;
  • A CT brain scan at the beginning of the assessment, ‘hot-reported’ to the clinic
  • An assessment of the patient by a psychologist, carer by a nurse
  • A consultant psychiatrist/geriatrician session to discuss the diagnosis, management and care plan
• Patients have dedicated parking at the hospitals to ensure they arrive at the clinic on time and relaxed and to ensure clinic ‘flow’
• A care plan is made with the patient and carer e.g. referring to the dementia advisor service, medication and psycho-social interventions
• To reduce the feeling of being ‘cast adrift’ after the diagnosis there is/are;
  • A ‘clarification and questions’ follow-up appointment by their local Older Peoples Mental Health team
  • A referral to the local Alzheimer’s Society Dementia Advisor (providing support, advice and a point of contact though out the course of the illness)
  • Evidence-based psychosocial education and support (appendix 2). Commissioned as part of the new service
• Continued patient and carer feedback ensures continued development of the service

An integrated, efficient and evidenced-based model of care

• All providers now work in an integrated way along the care pathway and are clear about roles and responsibilities
• Clinical assessment and management is standardised across all clinics and based on best practice guidance eg NICE and existing local and national service models
• The system was designed using ‘lean’ principles and tested before implementation; analysing, testing and eliminating waste in processes eg we successfully introduced Band 4 psychology assistants and Band 5 nurses to replace more expensive staff and developed a ‘lean’ clinic process to maximise flow and capacity.

The main outcomes are: referral to diagnosis time initially reduced from over 50 (but sometimes took many months) to 12 days. (It subsequently stabilised at around 30 days until 2016. Since then, we have been operating at a mean referral to diagnosis time of around 40 days); dementia diagnosis rates have increased by 26%; patient and carer surveys and focus groups show the new person-centred approach, quality of information provided and transparency and openness of staff is highly valued; feedback is being used to further develop the service. The new ‘one-stop shop model’ helps minimise anxiety for the person attending for a very daunting assessment – as a patient who attended the Devon Memory Service said:

“Diagnosis on the day….. it was important because you weren’t kept waiting… we weren’t waiting for a letter, we weren’t waiting for a follow-up appointment, we just got it done with. We valued that very much”

The experience from Devon may be helpful for others who are considering looking at their memory services.

For more details please contact either of us:

• Alistair Burns, National Clinical Director for Dementia, burns@nhs.net
• Colm Owens, Consultant Psychiatrist, Older People’s Mental Health Services, Devon Partnership NHS Trust, colmowens@nhs.net