DELIVERING THE DEMENTIA HEAT TARGET
HEAT Target
Each NHS Board will achieve agreed improvements in the early diagnosis and management of patients with a
dementia by March 2011.
Delivering the Dementia HEAT target is all about improving access to diagnosis and the provision of early management and support.
Improvements can be categorised under three main headings:
1. Improving the design of the care delivery processes – this is about ensuring a well designed process that eliminates
duplication and unnecessary steps, minimises potential for error, and delivers the right amount of treatment capacity to see the
work without unnecessary waits. Again, this needs to take a whole systems perspective working across the traditional health and
social care boundaries. Changes here should result in an improved experience of using care services.
2. Ensuring the delivery of effective care interventions– this relates to ensuring ICP standards and any other national approved
guidance (ie SIGN) is routinely followed. However, this is not just about improving the clinical standards of care – it is about the
range of care interventions including those delivered by the local authority and voluntary sector services. Changes here should
lead to improved outcomes for people with dementia.
3. Ensuring staff are properly equipped to deliver services – this recognises the importance of applying knowledge and skills
within a values based framework. All improvement work is underpinned by continuous professional development and workforce
planning. There may be a need to develop the skills of existing staff, extend roles, develop new roles and to review the skill mix
within services. Training a wide range of health and social care staff on how to respond effectively to individuals with Dementia will
be key to delivering this HEAT target. Changes here should contribute to both improved outcomes and improved experiences for
those using services.
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The following diagram highlights the key elements of the Dementia Journey that you will need to work on to meet the dementia HEAT
target:
o For design of care delivery processes - the first step is for each Board and their key partners, to understand what their key
system and process design issues are and this document provides advice on how to do this. Over the life of the collaborative we
will collate and share information across the Boards and key partners, to identify where there are common system and process
design issues and what works in terms of redesigning those systems and processes.
o Standards already exist for ensuring we deliver effective care interventions (eg ICP Guidance and SIGN guidelines). At a local
level, collaborative resources can be used to focus on implementing those clinical and care standards that are relevant to the
delivery of the HEAT target. The following diagram shows how ICP Standards and SIGN guidelines relate to this work stream.
Further work will be completed to map other relevant national guidance against the key elements of pathway. In addition, action on
ICP standards 6 and 7 will be of direct relevance to achieving the dementia HEAT target.
o The diagram also highlights some of the key workforce programmes that underpin the delivery of improved services.
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DELIVERING THE DEMENTIA HEAT TARGET
Improve design
of care delivery
processes
Key elements of
Dementia
Pathway that
need to
improve to
deliver HEAT
Target.
Current focus is on diagnosing the key issues with current systems and processes using:
o Pathway Mapping, Value Streaming and Flow Analysis to identify: what adds value, unnecessary steps, duplication,
rework because not done right first time, bottlenecks and hand-offs
o Data Analysis to identify variation and understand when this is justifiable and when it can be reduced
o Demand, Capacity and Queue Theory so understand what the demand is, what the capacity is to respond to it,
opportunities to make more effective use of current capacity, when queues are caused because of the process design
rather than a mismatch between demand and capacity, and where in the process there is a mismatch between demand
and capacity.
o PDSA to pilot improvements
Improve public and staff
awareness
Ensure clarity of referral
routes for diagnostic
assessments
Ensure timely diagnostic
assessment
Improve early management
and support
ICP Standards: 2. 5, 38, 39
ICP Standards: 6, 9, 14
ICP Standards: 10, 14, 21
ICP Standards: 11, 13, 16,
17, 21 , 27, 28, 38, 39
Ensuring the
delivery of
effective care
interventions
Best Practice Guidance - SIGN 86
Key National
Workforce
Programmes
relevant to work
Rights, Relationships and Recovery including: The Capability Framework for Mental Health
Nurses, Working with Older People in Scotland
The 10 Essential Shared Capabilities for Mental Health Practice (Scotland)
Changing Lives (Social Work)
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Dementia Pathway – Systems Diagnosis Checklist
This document is aimed at those involved in leading and planning the Mental Health Collaborative (MHC) work. It is provided as a
supportive tool to help those involved in leading and planning the work of the MHC locally to think about how to apply improvement
methodologies to enable the delivery of the Dementia HEAT target. It works on the basis that the first 3-6 months should be on visioning
and diagnosis. Visioning involves defining and describing the ideal systems, processes and pathways of care to fulfil and exceed the
HEAT targets. These ‘ideals’ will be firmly rooted in the best evidence available and complemented by experiential input and insights
from service users, carers and staff. Diagnosis involves comparing current service behaviour with the ideal to establish where changes
need to be made and what these changes might look like in order to achieve the ideal. It also involves understanding your current
processes, what works well and what doesn’t work so well.
As with clinical care – getting the diagnosis right is important as it guides what interventions are taken. If clinicians treat the wrong
problem – chances are the treatment won’t be effective. Likewise – if change programmes are based on an incorrect analysis of the
problem – chances are that the change programme will be ineffective. So it’s worth investing the time up front to get the diagnosis of the
problem right. Visioning is a key part of this– as we need to be clear that we are doing the right things, not just doing the wrong things
more efficiently.
We realise that many Boards (and key partners), have already made significant progress against this target and we are not suggesting
you put on hold any work already in progress. However, the suggestions below may give you some ideas about how to progress this
work further.
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Systems Overview
When looking at changes to one part of the pathway, it’s important to consider the impact on other parts of the system. Otherwise,
services can end up making one part work better but just move the problem elsewhere. For instance, a team might change their referral
criteria and end up effectively reducing the demand on this service, only to find out that requests for services in another part of the
system go up.
The Collaborative promotes looking at whole systems and to do this, services need to have mechanisms in place for discussing potential
changes across different parts of the health and social care system. For the dementia pathway there are key interfaces between all of the
following:
 Primary Care
 Old Age Psychiatry
 Social Work Services and wider local authority services
 People with Dementia and their Carers
 Acute General Medicine
 Care Homes
 Voluntary and Independent sector provider
SYSTEMS OVERVIEW CHECKLIST
Issues
Yes
Yes –
but
needs
refining
No
Priority for
Local
Action?
If priority for
Improvement
action – who
Tools
will take forward
Relevant
and by when
Is there a structure in place for effective
discussion of interface issues between the various
teams responsible for delivering the pathway?
Do you have a system for providing dementia
training across all sectors who come into contact
with individuals with dementia?
Is Advanced Care Planning being promoted locally
and does this include people with a dementia /
cognitive impairment?
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Data Analysis – Assessing Current Performance
The HEAT Target baseline year is the number of patients on the register at the 31st March 2007. A practical start point is therefore
downloading data (from the ISD website - http://www.isdscotland.org/isd/3305.html) on the number of patients on local GP QoF registers
as at 31st March 2007. You can also download data on the registers as at 31st March 2008 and identify those practices who are
managing to increase numbers.
As a first step we recommend all areas compare QoF numbers against those diagnosed with dementia in secondary care, this
presents an opportunity to also cross-check names on lists to establish if any registers are incomplete. Where there is a
difference in names – we recommend you then look at your processes to ensure those who are diagnosed are routinely entered
onto the register.
A helpful step is to compare current (actual) QoF levels with expected UK Dementia prevalence levels for each practice. This will give
you an indication of how many patients have been diagnosed compared to how many (given demographics and national prevalence)
ought to have been diagnosed for each practice.
If there is a Practice, or a number of Practices, with a high % of patients on the register then you could consider comparing this practice
with one at the lower end of detection. Retrospective patient tracking may be helpful in addition to interviews with GPs / Practice visits
in order to compare and contrast knowledge, training, systems and processes.
For those practices already displaying a high level of diagnosis (compared to expected prevalence) it may be worthwhile comparing their
performance with practices in other Boards to see if they can further improve their performance. Please consult your Regional Manager
if you need help in identifying practices outside of your region, as this can easily be facilitated at National Learning Events.
We also recommend you look at the QOF information with regards to numbers of those on the register who have had a formal review
after 15 months.
This is not an exhaustive list, it is simply provided as a starting point to help MHC teams think about how improvement tools apply to this
work.
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DATA ANALYSIS CHECKLIST
Issues
Yes
Yes –
but
needs
refining
No
Priority
If priority for
for
action – who
Local will take forward
Action?
and by when
Improvement
Tools
Relevant
Assessing Current Performance - Baseline
Do you know the number of patients on local QoF
registers as at 31st March 2008?
Have you validated your QOF registers against those
known to specialist mental health services?
Have you compared current / actual register numbers
against expected dementia prevalence rates per
practice?
Do practices know where they sit in comparison to
others performance in their Health Board – both in
terms of % on register of expected prevalence and
ongoing % increase?
If you have significant variances between practices –
have you followed a couple of patients through the
individual pathways to identify differences in practice
that might contribute to the different outcomes?
Where there is a difference – have you mapped your
processes from team diagnosing to individual being
entered onto the register to identify where the
process breaks down?
Do you have a system for regularly reporting
progress towards the HEAT target at Board level?
Have you looked at what percentage of those on the
Dementia Register receive the 15 month review by
practice?
Do practices know where they sit in comparison to
Data Analysis
Data Analysis
Data Analysis
Data Analysis
Variance
Process
Mapping
Variance
analysis
Process
Mapping
Data Analysis
Data Analysis
Variance
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DATA ANALYSIS CHECKLIST
others in their Health Board with regards to % of
those on Dementia Register receiving 15 month
review?
Has the QoF register been analysed in terms of
ethnicity and deprivation?
Data Analysis
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Process Analysis
Process Mapping is key for understanding what currently happens and where things break down. It helps to identify what needs to
change. Involving service users and carers in the analysis helps you to understand how it feels to be on the receiving end of our
processes. Understanding care processes from the service user’s perspective is essential for making service user focused
improvements.
All the organisations/teams involved in the pathway should be identified and involved in the process mapping activity. This process
mapping work should already be taking place in all Boards as part of the work to develop a Dementia ICP. The mapping work should
include service user and carers perspectives, in line with the ICP standards (See ICP Process Standard 2). It should also include relevant
social care providers. In addition to the process mapping exercise - it might also help to undertake discovery interviews, feedback
questionnaires, and data sampling in order to fully understand the service user and carers experience.
http://www.scotland.gov.uk/Publications/2006/02/02094408/0
The Mental Health Collaborative team can help facilitate this process mapping exercise and suggest approaches to other diagnostic
work if you’re not sure. Please contact your Regional Manager to discuss further.
But the work doesn’t stop at process mapping – you now need to look at streamlining the pathway and look at the flow through the
pathway. Using value-stream mapping, you can identify:
 those steps in the process that don’t add any value
 bottlenecks in the process where capacity is not sufficient to meet the demand
 unnecessary delays (long waits)
 steps where there are quality issues – ie work has to be redone or sent back to a previous step or where there is confusion
over who is responsible for which aspects of care.
A further question to ask is whether there’s a group/individual that has ownership of the entire care process i.e. is responsible for
ensuring that interface issues between different teams are frequently surfaced and addressed on an ongoing basis. A range of tools
within Lean are available to help with analysing the pathway, and facilitation support is available from the Collaborative Team. The output
of this ‘overview’ investigative work should be clarity on the key issues you need to address locally to simplify and improve the care
process. The Collaborative promotes then using the PDSA approach to make incremental improvements to the process.
The following table helps you to think about applying process mapping to the Dementia workstream. This is not an exhaustive list, it is
simply provided as a starting point to help MHC teams think about how improvement tools apply to this work.
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PROCESS ANALYSIS CHECKLIST
Yes
Improve public and staff awareness
Is awareness and treatment information available to
the general public, patients, carers and professionals.
Is this information regularly updated and targeted?
Is this information accessible by people from different
ethnic backgrounds and those with learning
disabilities?
Routes into Diagnosis/Achieving a Diagnosis
Has the Dementia Pathway been mapped out by those
involved in the service – including those that use the
service and their carers?
Have you mapped your processes for social work to
refer for diagnosis and analysed these to see if they
could be made simpler?
Have you agreed an integrated care pathway (ICP)
through to diagnosis?
Is each team responsible for delivering the pathway
clear on what dementia care they provide and clear
about what information they need from others?
Have you analysed the process maps and identified
duplication, unnecessary steps, missing steps and
work that needs to be redone because note done right
the first time?
Have service users and carers been involved in this
process mapping and identified what adds value from
their perspective?
In particular, have you mapped the process for care
homes to refer for diagnosis where they suspect an
Yes –
but
needs
refining
No
Priority
for
Local
Action?
If priority for
action – who will
take forward
and by when
Improvement
Tools
Relevant
Process
Mapping
Process
Mapping
Process
Mapping
Value
Streaming
Lean
Value
Streaming
Process
Mapping
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PROCESS ANALYSIS CHECKLIST
individual has dementia? Does this process feed
through to registration on the relevant practices
Dementia register?
Do you know where the bottlenecks are in the system?
Early Management and Support
Have you analysed your processes for receiving
support post diagnosis and identified duplication,
unnecessary steps, missing steps and work that needs
to be redone because not done right the first time?
Have service users and carers been involved in this
process mapping and identified what adds value from
their perspective?
Have local discussions taken place regarding the
sharing of GP held information with Secondary Care
colleagues (QoF / Emergency Care Record)?
Have you agreed the post diagnostic support element
of ICP?
Is Advanced Care Planning promoted in Care Homes?
Are Crisis Services available for people with Dementia
during the Out-of-Hours period?
Value
Streaming
Flow Analysis
Process
Mapping
Value
Streaming
Value
Streaming
ICPs
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Understanding Demand and Capacity
Understanding the demand for services is essential – as without this, services cannot effectively plan to meet this demand. However,
they also need to understand the capacity that they have to respond to that demand and whether they are making best use of this. For
instance – if a team has a highly skilled member of staff spending a day booking care plan reviews – this is not making effective use of
their current capacity! An audit across one community mental health area showed that differences in waiting lists between teams where 5
times more to do with what they did with each case (ie differences in number of sessions and duration) than the number of referrals the
teams received.
Matching demand and capacity is important because delays in receiving a timely response can leave people in distress with no support.
Further, delays can lead to an escalation of someone’s illness.
The presence of a waiting list is a sign that demand is not being matched with capacity, it is not necessarily an indication that the demand
exceeds the capacity. It is therefore important to gather information on demand, activity, and capacity and to analyse this in greater
detail to understand profiles, trends and variances and whether additional resources are really needed – or it is a case of redesigning to
make better use of what already exists.
The following table helps you to think about areas you could apply demand and capacity analysis in relation to the Dementia workstream.
Again, it is not an exhaustive list, it is just provided as a starting point to help MHC teams to think about how DCAQ applies to the
Dementia workstream.
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DEMAND, CAPACITY AND QUEUE
Issues
Routes into Diagnosis/Achieving a Diagnosis
Do you know what the projected demand for diagnostic
assessments is?
Do you know what your capacity to provide diagnostic
assessments is?
Early Management and Support
Do you know what your demand for post diagnostic
support is?
Do you know what your capacity to provide post
diagnostic support is?
Have you maximised use of group support, peer
support and self-help, self management?
Yes
Yes –
but
needs
refining
No
If priority for
action – who will
take forward and
by when
Improvement
Tools
Relevant
DCAQ
DCAQ
DCAQ
DCAQ
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