In the UK there are approximately 700,000 people with dementia. In 30 years, this number is expected to double.
The national cost of dementia is about £17 billion per year and in 30 years this is expected to treble. There are also at least 15,000 people under 65 who have dementia. As a result, the Department of Health has produced a five year strategy to guide modernisation of services for people with dementia and their carers.
After an extensive consultation period involving approximately 50 events involving the Care Services Improvement Partnership and the Alzheimer’s Society, the strategy highlighted three broad domains:
- To provide a strategic quality framework within which local services can deliver quality improvements to dementia services
- To provide guidance and support for health and social care commissioners, strategic health authorities, local authorities, acute hospital trusts, mental health trusts, primary care trusts, independent providers and practice based commissioners in the planning, development and monitoring of services
- To provide a guide to the content of high quality health and social care services for dementia
A corresponding care pathway and 17 objectives were produced as follows:
- Improved public/professional awareness and understanding of dementia
- Good quality early diagnosis and intervention for all
- Good quality information for those with dementia and their carers
- Easy access to care, support and advice following diagnosis
- Structured peer support and learning networks
- Improved community personal support services
- A carers’ strategy for people with dementia
- Improved quality of care for people with dementia in general hospitals
- Improved intermediate care for people with dementia
- Housing support services
- Living well with dementia in care homes
- Improved end of life care for people with dementia
- An informed and effective workforce for people with dementia
- A joint commissioning strategy for dementia
- Improved assessment and regulation of health and care services
- A clear picture of research evidence and needs
- Effective national/ regional support for implementation of the strategy
The national dementia strategy has had £150 million pounds allocated nationally by the DH over two years to support its implementation. This is within the PCT’s baseline allocation for this year and next. The national dementia strategy implementation group has developed similar groups within SHAs to guide its implementation within the local PCT areas.
The SHA implementation groups should be liaising with the local commissioners in PCTs to ensure that the most appropriate services for people with dementia are commissioned in the localities.
Accessing the non-ringfenced budget from the PCTs will be easiest if all stakeholders are in agreement.
Ultimately it is the role of the PCT commissioners to ensure dementia services in their locality are appropriately commissioned. Individuals tasked with this are often enthusiastic at championing the cause of people with dementia, but their experience in dementia services can be limited.
In contrast, provider clinicians have been developing services over many years and, with their daily contact with service users, are often very aware of their needs. They carry with them the baggage of their current services, and often a conservative approach to maintaining the status quo while also being keen on developments. They often find it difficult to countenance a radical change in services due to their personal investment in them.
In NHS North Yorkshire and York, it was decided to perform an exercise to stimulate the thinking among clinicians about dementia services in order to inform local commissioners of the needs of the relevant client group.
We decided to involve all the old age psychiatrists in an exercise whereby they looked at the three principal areas that may affect specialist services: good quality early diagnosis (i.e. enhancing memory services to deal with mild dementia), general hospital care (i.e. hospital old age liaison services) and improved workforce (i.e. enhancing community mental health teams).
There are four local services within the PCT and three of them are part of one provider service, but have developed separately leading to the challenge of providing one system of care for service users.
In order to develop this bottom-up process, the consultants were all asked to provide proposals for the three geographical areas. This challenged the consultants to work together in their localities to look at their current systems.
The results were striking as the proposals for old age liaison psychiatry all suggested the development of hospital mental health teams and the enhancing of community mental health teams was also similar for each locality.
However the development of memory services for people with early dementia was not uniform. This is not because of differing needs of the different localities, but because of the history of the memory services within those localities.
The results were presented to the local management group to develop further and then take to the commissioners. However, as clinicians could not agree on one model for memory services, the managers had to explore the merits of the models. Further work is now being done on this with clinicians to develop a definitive proposal for the commissioners.
Clinicians have skills, knowledge and daily contact with service users and their perspective on the needs of people with dementia is paramount. Involving consultants enhances any proposals in service developments. Clinicians should not passively await involvement in service proposals but should be actively involved from early on. Commissioners need to find ways to hear their views when developing local services.
Andrew Byrne is a specialist registrar and Chris Simpson is a consultant psychiatrist at Friarage Hospital