Dementia Workstream
Joint QIPP and JIP initiative
across health and social care
February 2011
Annette Lumb – Workstream Lead
Jill Guild SHA Lead
Dr Richard Prettyman and Professor Rowan Harwood– Clinical Leads
Case for change
•
East Midlands alongside the South West faces the most significant challenge
in England. In 2010 there were 52,836 people living with dementia in the East
Midlands rising to 82,155 in 2025 (55% increase). Direct costs to the NHS
and social care will treble as a result by 2030.
•
Diagnosis is a gateway to appropriate care: Only 37% of people with
dementia are currently diagnosed in the East Midlands and services for
dementia are acknowledged to be underdeveloped in all sectors (community,
specialist MH, care homes, and acute hospitals).
•
As a result too few people access appropriate prevention, early intervention
and intermediate care and too many people with dementia are admitted to
high cost services in hospitals and residential care (up to 1/3 of people in
acute beds and 2/3 of people living in care homes have dementia).
•
Investing in diagnosis, early intervention and improving quality of dementia
care should release savings through reduced admissions to hospitals and
care homes (e.g. £6 million per District General Hospital (DH 2011), 1 year
delay in admission to a care home). Savings realised will need to be
reinvested to deliver quality services in line with rising need.
Variation & Opportunity
Proportion of Dementia Coding in >65 Emergency Admissions (Q1 1011)







-0.85%
0.10%
-0.93%
-0.40%
-1.60%
0.25%
-0.28%
LEGEND
99.8%
Confidence
Interval
20%
18%
16%
3SD CONTROL
LIM ITS
14%
12%
10%
8%
MEAN
6%
4%
Q1 1011
Q4 0910
Q3 0910
Q2 0910
VALUE
UHL
Q1 0910
ULHT
Q4 0809
SFHFT
Q3 0809
NUH
Q2 0809
NGH
Q1 0809
KGHFT
Q4 0708
DHFT
Q3 0708
0%
CRHFT
Q2 0708
2%
Q1 0708
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%

-0.54%
Regional mean
Provider
CRHFT
FY 0708 FY 0809 Q1 0910 Q2 0910 Q3 0910 Q4 0910 FY 0910 Q1 1011
10.37% 11.02% 11.08% 12.00% 11.75% 12.06% 11.73% 11.52%
DHFT
9.55%
KGHFT
10.28% 10.21% 11.12% 11.33% 11.34% 12.37% 11.56% 12.47%
NGH
10.51% 10.93% 11.38% 11.01% 12.20% 12.52% 11.80% 11.59%
NUH
9.36%
SFHFT
12.28% 12.73% 13.60% 15.37% 15.75% 15.05% 14.94% 13.45%
ULHT
9.50%
9.42%
9.60%
10.45% 11.13% 12.25% 10.84% 12.50%
UHL
8.87%
9.66%
9.69%
9.44%
East Midlands
9.85%
10.04% 10.16% 10.49% 10.91% 12.10% 10.93% 11.66%
National
7.15%
10.68%
7.94%
9.30%
6.62%
10.08%
7.98%
9.55%
9.96%
8.20%
9.11%
11.92% 10.23% 11.52%
10.31% 11.73% 10.31% 11.45%
11.65% 11.80% 12.48% 12.99% 12.24% 12.94%
Narrative:
There is variation in the coding of dementia in emergency admissions for the
>65 across the region. The regional average is slightly below that seen
nationally but has been improving in the last 3 years from 9.85% to 11.66%.
Three trusts in the region are coding patients above the national average
whilst DHFT are the only trust significantly below national and their peer
group. The low percentages could be because the coding of dementia is not
relevant to the admission. However early diagnosis in an acute setting will
have an impact on the care and experience a patient receives.
Variation & Opportunity
LoS for the Top 3 Dementia Coded Primary Diagnosis (UTI, Pneumonia and
#NOF) in >65 emergency admissions (FY 0910)
LEGEND
99.8%
Confidence
Interval
21
Avg LOS
18
3SD CONTROL
LIM ITS
15
12
9
6
MEAN
3
4
Days Increase when a patient is
coded with dementia
24
0
3
2.5
2
1.5
1
0.5
0
CRHFT
HES
3.5
DHFT
KGH
NGH
NUH
National mean without dementia coding
Provider
CRHFT
DHFT
KGHFT
NGH
NUH
SFHFT
ULHT
UHL
East Midlands
National
SFHFT
ULHT
UHL
National mean with dementia coding
No. of patients
Total number of
Avg LoS without Avg LoS with
with a dementia
patients
dementia coding dementia coding
coding
1495
2443
1489
1101
3299
1753
2982
3765
18327
228312
408
576
356
303
1007
504
723
880
4757
59644
16.05
14.68
16.34
21.61
12.62
11.68
15.51
13.20
15.21
15.71
19.38
17.67
19.26
23.16
13.98
13.56
18.15
15.57
17.59
18.03
CRHFT
VALUE
HES
DHFT
KGH
NGH
NUH
SFHFT
ULHT
UHL
National Days Increase
Narrative:
When comparing LoS for patients with and without dementia coding when
they are admitted for UTI’s, Pneumonia and #NOF most trusts arte operating
around the national averages. NGH have a significantly longer Los in both
scenarios which may require further investigation. NUH have a 1.36 day
difference between the two cohorts of patients which could indicate good
practice that could be shared across the region
Variation & Opportunity
60%
     
LEGEND
3.59% 2.96% -0.97% 3.64% 0.41% 2.78% 1.45% 2.31% 2.31%
3SD CONTROL LIMITS
50%
PEER MIN - MAX
40%
MEAN
1
30%
VALUE
20%
99.8% C.I.
% of dementia patients on a GP QOF
register who have had their care
reviewed in the last 15 months
% of expected dementia population
diagnosed in the GP QOF dementia
register
QOF Indicators (2009/10)
100%

-5.28% -0.46% -0.33% -0.26% 0.71% 3.57% 2.49% 0.83% -0.43%
90%
80%
70%
60%
TREND Q4 vs Q3
Regional mean
National mean
Narrative:
All trusts within the region, with the exception of Derbyshire County, have seen an improvement in the diagnosis of dementia over expected prevalence in the
last year. However with this in mind there is still wide variation between the trusts, 15.41% between the highest and lowest in the region. Looking at the peer
analysis nearly all trusts are within their peer ranges, Lincolnshire are above their maximum peer range whilst LCR are below their minimum peer range.
There is less variation between the trusts in the care review measure . Bassetlaw have seen more of their dementia patients for a care review in the last year
even with the largest decrease from the previous year. Derby City are below their peer minimum peer range for care reviews of their dementia patients.
Variation & Opportunity
Programme Budgeting
Spend per head of population on OMHD (£)
35
30
25
20
15
10
5
0
2008-09
2009-10
Dementia services spend per head of population
2009-10
30
25
20
15
10
5
-
Narrative:
Commissioner level programme budgeting data is published annually to enable commissioners to identify :
• spend over the 23 disease groups and their respective subcategories;
• how, and by how much, their expenditure distribution pattern compares with other commissioners nationally, locally or with similar characteristics
and;
• how their expenditure distribution has changed over time.
Dementia is included within the subcategory of Organic Mental Health Disorders (OMHD) which is part of the Mental Health Disorders category. In addition,
for 2009/10 NHSEM asked PCTs to provide data on spend specifically on dementia services.
In the Organic Mental Health Disorders category, PCT spend per head of population increased for the majority of PCTs from 2008/09 to
2009/10. For expenditure on OMHD and dementia Northants is significantly below the rest of the East Midlands.
Variation & Opportunity
Social Care Data – Recording of Dementia
% of predicted prevalence
CSSR clients 65+ with dementia as a proportion of
predicted dementia prevalence (2009/10)
30%
20%
10%
0%
% predicted
East Midlands
Total
number of Predicted
% of
CSSR clients number of
predicted in
CSSR
recorded people with
contact
with
dementia in
with CSSR
dementia area (65+)
(65+)
9.2%
Derby City
260
2,830
9.9%
Derbys
975
9,800
29.0%
Leic City
755
2,605
4.9%
Leics
390
7,880
1.2%
Lincs
120
10,105
8.1%
Northants
585
7,230
24.3%
Nott City
620
2,555
22.4%
Notts
2,180
9,750
6.4%
Rutland
35
545
5,925
53,300
12.8%
East Midlands
Narrative:
In 2009/10 a total of 5,925 clients aged 65+ years with dementia received services provided or commissioned by Councils with Social Services
Responsibilities (CSSRs) in the East Midlands - representing 12.8% of the estimated number of people with dementia in the region. While not all people aged
65+ with dementia will need or want a CSSR service, the provision of such services to only 1 in 8 of the estimated dementia population appears low.
There is significant variation in the proportion of people with dementia who are recorded as receiving a service by area – from 1.2% in Lincolnshire to 29.0%
in Leicester City. However, this does not necessarily imply that people with dementia in Lincolnshire are less likely to receive a CSSR service. The
apparently low number of people with dementia receiving a service could be due to failure to recognise and/or record the diagnosis correctly.
There is no significant correlation between the % of expected dementia prevalence recorded with dementia on receiving a CSSR service, and the % of the
expected dementia population recorded on GP QOF dementia registers. Two of the areas where a higher % of the estimated number of people with dementia
received a CSSR service (Leicester City and Nottingham City) also had high QOF register completion rates. However, other areas show no relationship e.g.
Lincs has very low CSSR diagnosis rates but average QOF registration rates, and Notts has high CSSR rates but average QOF rates.
Source of data: RAP (Referrals, assessments and packages of care) 2009/10 data available via www.nascis.ic.nhs.uk
Variation & Opportunity
Social Care Data – Service Type Provided
CSSR clients 65+ with dementia - service type provided (2009/10)
80%
70%
60%
50%
40%
30%
20%
10%
0%
CSSR
Community based services
Residential Care
Nursing Care
Derby City
Derbys
Leic City
Leics
Lincs
Northants
Nott City
Notts
Rutland
East Midlands
% receiving
% receiving % receiving
communityresidential nursing
based
care
care
services
65%
63%
58%
45%
75%
55%
69%
47%
71%
55%
25%
29%
42%
55%
33%
54%
31%
39%
43%
39%
27%
10%
12%
14%
8%
14%
13%
14%
0%
13%
Narrative:
Across the East |Midlands, 55% of CSSR clients recorded with a diagnosis of dementia received a community-based service, 39% received residential care
and 13% received nursing care (does not total 100% as some clients received more than one service type).
There is significant variation in the patterns of care provided across the region. A high % of clients in Leicestershire and Northants received residential and/or
nursing care, whereas in Lincolnshire a high % received community-based services. In most areas the % receiving residential care was higher than the %
receiving nursing care, the exception being Derby City where 27% of dementia clients received nursing care compared to only 25% who received residential
care. However, this analysis is subject to the issues described previously regarding completeness of dementia diagnosis recognition and recording.
Analysis of cost data has been undertaken (using PSSEX data), but this was not robust due to variation in practice in apportioning costs between service
types and also inability to identify costs specifically for the dementia cohort (PSSEX data are only available for the 65+) age group and are not diagnosisspecific).
Source of data: RAP (Referrals, assessments and packages of care) 2009/10 data available via www.nascis.ic.nhs.uk
Products achieved
The NHS East Midlands QIP/JIP workstream has:
Product
Status
1. EMPHO East Midlands Dementia Profile, Mapping and analysis of current services, PDF in all
localities (excludes Derbyshire) and action plans
complete
2. Systems Dynamic modelling tool to support commissioning of dementia services (can be
accessed by other regions also)
complete
3. Case study service specifications for memory services
4.
Funded commissioning support across health and social care (Local Dementia Programme
Leads)
5. Case study basic dementia training in care homes (all local authorities participating in project)
6. Integrated workforce plans for dementia (excludes Lincolnshire)
7. Acute hospital dementia coding guidance
In progress
Complete, report in
progress
In progress
In progress
In progress
8. Acute hospital resource pack
In progress
9. Accessible standards – Dementia charter
In progress
10. Updated prescribing guidelines for use of anti psychotics, audit methodology, and behavioural
management guidelines
In progress
11. Social Care Metrics grid
In progress
12 Telecare dementia pilots
In progress
13. East Midlands compendium of good practice
complete
Attachment
Case study / good examples
Derbyshire County Council (working with NHS Derbyshire) opened the first of 8 planned community
care centres in Staveley in 2010. The centre provides services to people with dementia. The centre
aims to provide good quality person centred support and integrated community services that prevents
individuals (or their carers) reaching crisis, needing hospital admission or anti psychotic medication.
The centre offers residential beds, intermediate care beds, open access community facilities, and day
opportunities. The centre is used by social care, health and the voluntary sector and the local
community. The sited is adjacent to a school thus providing opportunity for intergenerational work. A
new memory assessment service provided by the mental health trust operates from the centre. The
local authority will be evaluating outcomes of implementing the new model of care.
GPs in Gnosal Staffordshire have led the redesign of memory assessment services based on a pilot in
primary care. For a list size of 7199 in 2006 ( predicted prevalence dementia 60) rising to 8000 in
2009 savings identified against mental health and acute hospital admissions of £400,000 per year.
Diagnosis rates have increased from 6 in 2006 to 38 in 2009 and it is expected that 80% of people
will receive a diagnosis by 2013/14. Time from initial contact to diagnosis was 3 years in 2006 and
was reduced to 4 weeks and in 2009. Only 2 people diagnosed with dementia were admitted to a
hospital or care home in 2009. As a result of the pilot new care pathways and service specifications
have been designed and the service has been re-tendered. The successful provider supporting GPs
to deliver the new model is MAC UK Neurosciences.
Healthcare for London has produced a Dementia Services Guide that includes integrated care
pathways, general hospital care pathways, and commissioning specifications for memory services.
www.healthcareforlondon.nhs.uk/assets/Mental-health/HealthcareforLondon_Dementia-servicesguide.pdf
Securing the benefits
Securing the benefits
Provider
Implement and optimal care pathway in line with
NICE guidance for dementia that
•maximises opportunity to increase capacity
•Includes suite of evidenced based diagnostic tools
•Includes evidence based protocols
•Includes follow-up using the most cost effective
system for 6 month review
System in primary care to link QOF recording and
diagnosis in provider organisations
Commissioner
Agree current activity and cost baseline for
memory services and secure PBR clustering in
order to differentiate dementia patients
Develop outcome focused service specifications
Memory Assessment Redesign
Develop a strategy to increase capacity in line
with increasing prevalence rates e.g. through
re-tender
Agree system to ensure diagnosis is translated
to QOF register
Understand acute sector costs and activity for
dementia, % dementia patients versus non
Appoint a lead clinician, implement a dementia care dementia, Los and relevant costs with and
pathway and protocols, compliance with NICE and without complications. Benchmark between
RCP standards, analyse data on LoS and dementia
providers
Improved quality in Acute care
versus non dementia patients.
Compliance with Quality indicators: Optimal
LoS, NICE Standards, RCP Organisation of
Use coding guidance for dementia to improve
Services Standards
standardisation of coding
Ensure access to liaison and intermediate care/
reablement
Prescribers comply with prescribing guidelines
Audit (use of low dose anti psychotics)
Implement guidelines for managing challenging
Adopt prescribing guidelines
Reduction in anti psychotics prescribed to
Plan to reinvest savings into training and
behaviour
people with dementia
Mental health trust were contracted provide inpsychological interventions to manage
reach into care homes
challenging behaviour
Local authority commissioners specify quality
Identify dementia champion, implement a rolling
standards for dementia in line with NICE
training plan, Implement person centred planning
Improved quality dementia care in care home
standards (awareness training, person centred
including life story work Implement guidelines for
planning, management of challenging
managing challenging behaviour
behaviour. leadership)
Main Regional Contact
Regional Workstream
Executive Sponsors
Mike Shewan, Chief Executive
Derbyshire Mental Health Services NHS Trust
mike.shewan@derbysmhservices.nhs.uk
David Pearson, Director of Adult Social Care and Health
Nottinghamshire County Council
David.pearson@nottscc.gov.uk
Clinical Leads
Professor Rowan Harwood, Consultant Geriatrician
University Hospitals Nottingham
Rowan.Harwood@nuh.nhs.uk
Dr Richard Prettyman, Consultant Psychiatrist,
Leicestershire Partnership NHS Trust
richard.prettyman@leicspart.nhs.uk
Workstream Lead
Annette Lumb, Strategic Relationship and Programme Manager
Department of Health
Annette.lumb@dh.gsi.gov.uk
SHA Lead
Jill Guild Strategic Relationship and Programme Manager
Jill.guild@nhs.net
Nottinghamshire
Local Dementia Programme Lead – Vicky Wright Victoria.Wright@nottspct.nhs.uk
NHS Nottinghamshire and Bassetlaw – Gill Oliver gill.oliver@nottspct.nhs.uk
NHS Bassetlaw – Vicky Wright Victoria.Wright@nottspct.nhs.uk
Nottinghamshire County Council – Jane Cashmore jane.cashmore@nottscc.gov.uk
NHS Nottingham City – Joanne Williams joanne.williams@nottinghamcity.nhs.uk
Nottingham City Council – Rod Madocks rod.madocks@nottinghamcity.gov.uk
Derbyshire
Local Dementia Programme Lead – Ciara Scarf Ciara.Scarff@Derbyshire.gov.uk
NHS Derbyshire - Jane Yeomans Jane.Yeomans@derbyshirecountypct.nhs.uk
Derbyshire County Council - Julie Vollor Julie.Vollor@Derbyshire.gov.uk
NHS Derby City – Ciara Scarf Ciara.Scarff@Derbyshire.gov.uk
Derby City Council – Phil Holmes phil.holmes@derby.gov.uk
Lincolnshire
Local Dementia Programme Lead – Deborah Shepherd
NHS Lincolnshire - Colin Warren colin.warren@lpct.nhs.uk
Lincolnshire County Council – Deborah Shepherd
Deborah.shepherd@lincolnshire.gov.uk
Leicestershire
Local Dementia Programme Lead – Sharon Aitkin Sharon.Aiken@leics.gov.uk
NHS Leicestershire and Rutland – Vanessa Griffiths and Jane Thorpe
vanessa.griffiths@lcr.nhs.uk jane.thorpe@lcrchs.nhs.uk
Leicestershire County Council – Katie Anderson Katie.Anderson@leics.gov.uk
Rutland County Council –Sharon Aitkin Sharon.Aiken@leics.gov.uk
NHS Leicester City – Liz Eastwood liz.eastwood@leicestercity.nhs.uk
Leicester City Council – Bindu Parmar Bindu.Parmar@leicester.gov.uk
Northamptonshire
Local Dementia Programme Lead – Jonathan Ward Langman and Gerry
McMurdie jwardlangman@northamptonshire.gov.uk
GMcMurdie@northamptonshire.gov.uk
NHS Northamptonshire – Catherine O’Rourke
Catherine.O'Rourke@northants.nhs.uk
Northamptonshire County Council – Jonathan Ward Langman
jwardlangman@northamptonshire.gov.uk
Challenges
•
•
•
•
•
•
•
•
•
The need for health and social care organisations to save money
Work stream focuses on improving quality & outcomes
Initial costs required to maximise benefits (invest now, save in future)
Need to implement all recommendations to maximise potential
Benefits are not instant –takes time
Costs and benefits do not fall equally across health and social care
Obtaining credible data for measurable quality benefits and metrics,
and to show variance
Exposure to those with influence that have competing other priorities
The rapidly increasing demand over coming years with anticipated
doubling in need by 2030
Summary & questions
To summarise:
•
Early diagnosis and intervention reduces use of expensive hospital and care home services.
Agree baseline with Mental Health Trusts to scope capacity to redesign Community Mental Health Teams and
identify capacity to deliver new service specification for memory services and early intervention as part of SLA.
Include dementia in reablement plans.
•
Improved quality of care in nursing and care homes can help to reduce use of anti-psychotics and
reduce admissions to hospital
Agreeing model to support nursing and care homes to improve dementia awareness and to manage challenging
behaviour. E.g. access to NHS training monies/ modules and in-reach support from Community Mental Health
Teams
•
Implementation of acute hospital trust Royal College of Psychiatrists guidance, will reduce Length
of Stay
Ensure acute trusts implement coding guidance and RCP quality standards and work with acute trusts to develop
liaison services
•
Reduce use of anti psychotics by2/3
Audit use of low dose of anti psychotics and implement prescribing guidelines alongside improving access to
specialist in-reach and training in the management of challenging behaviour in nursing and care homes