Harrogate and Rural District CCG is small, with a population of just under 160,000, but it is challenged by a relatively elderly population and has twice the national average of Elderly Care Home beds.
The result is an estimated prevalence of dementia of 1.7 per cent of the population compared with a national average of 1.3 per cent. Our estimated dementia diagnosis rate in September 2014 was 63.6 per cent and steadily increasing, though this figure has been reduced to 57.5 per cent after a reweighting of estimated prevalence based on our Care Home beds.
Projects have been completed over the last three years to improve the detection, diagnosis and aftercare of people with dementia through a Dementia Collaborative between the CCG, our mental health provider Tees Esk and Wear Valleys NHS Foundation Trust, our local hospital Harrogate District NHS Foundation Trust and North Yorkshire County Council, working with the third Sector, patients and carers and using lean management Rapid Improvement Process Workshops focussed on different parts of the pathway.
Improvements were targeted at areas identified by all the people involved in the work (health and social services staff, third sector representatives, patients and carers) at an initial workshop. The result of the work over the next three years resulted in a general perception of better collaborative working between staff and better morale. There were also measurable positive changes in all aspects of the dementia pathway.
Linked to the National Dementia Strategy Objectives the headline figures were:
- Objective 2: Good quality early diagnosis and intervention for all.
- Organisation of the memory clinic – a reduction in average waiting time for appointments reduced from 74 days to 28 days.
- Diagnosis of dementia in primary care – the referral rate from the target practices increased by 15 per cent.
- Objective 6: Improved community personal support services.
- Domiciliary care – there was a 50 per cent reduction in the time from referral for assessment, for the domiciliary care to start.
- Support for carers of people with dementia – carers grants agreed at the point of assessment, leading to a reduced time for production of the care plan. An information leaflet was produced by a local carers charity and included in a new carers leaflet information pack. A plan to engage with hard-to-reach carers was also developed.
- Objective 8: Improved quality of care for people with dementia in general hospitals.
- First seven days of admission of a person with dementia on a medical assessment ward – better identification of patients with dementia and information collection led to a reduction in average length of stay from 19 to 10.7 days.
- Mental health hospital liaison – 62.5 per cent improvement in time taken from referral to mental health assessment and 100 per cent improvement in awareness of the hospital delirium pathway amongst medical and nursing staff.
- Discharges of patients with complex needs – new information produced for patients and carers to inform about the discharge process. Daily nurse ward rounds introduced, enabling better communication between the hospital and patients/relatives/carer.
- Objective 11: Living well with dementia in care homes.
- Reducing unnecessary admissions of people with dementia from care homes – this focussed on information sharing in the care home and resulted in a 36 per cent reduction in time to find information in a resident’s file and a 50 per cent improvement in the quality of handovers. There was also a substantial reduction in admissions but this is hard to evaluate due to the low numbers involved.
In an effort to create space in the memory clinic for new diagnosis and management of complex problems, a new initiative was developed in 2013. This involved the sharing of follow up of patients on drugs for dementia between the memory clinic and primary care. The existing system required the patient to attend the specialist clinic twice per year for review as per NICE guidelines and in addition attend the GP once per year for a review for the GP to fulfil their own contract. It was recognised that the GP review had no clearly defined purpose and, for patients who were stable on medication, the twice yearly hospital review did not require any specialist input.
It was therefore agreed that the specialist clinic would review stable patients once per year and the GP review them at the six month point between specialist reviews, and feedback the outcome of the review to the consultant.
This resulted in 780 appointments being moved from secondary to primary care, freeing up capacity in the memory clinic.
The GP review was still funded through the GP contract as the annual review, but now had a clear agreed purpose and pathway to resolve any problems detected. The scheme was funded (for the GPs) for the first year as a QOF QIPP reduction in referrals initiative. (We were very grateful to our Area Team in allowing this flexibility).
The first year did generate extra work for GPs as the annual reviews had to be moved to fit with cycle at the memory clinic, but after the first review the only additional work is operating a robust call/recall system and, once a month, sending a list of patients reviewed to the consultant. It is our intention to pay a small sum to GP practices to fund this administrative work as we move to the second year, and the result is that 780 additional appointments are available in secondary care with the only investment being the small payment to our GP practices.