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Bradford District Care Trust

Based across Bradford, Airedale and Craven, Bradford District Care Trust (BDCT) offers a wide range of health and social care services close to people’s homes. We have been the main provider of mental health and learning disability services since 2002. In 2011 the majority of NHS Bradford and Airedale’s community health service transferred to the Trust. As a consequence, services such as district nursing, health visiting and dental services are now provided by BDCT. We deliver services to a population of approximately 550,000 people. Our vision is to provide the best possible care for the people of Bradford, Airedale and Craven and to be recognised as one of the country’s leading providers of integrated community health care services.

19 October 2016
Yorkshire and Humber
Other, Health, Hospitals and Hospital Trusts
Local Alliances:
Bradford District Dementia Action Alliance, Yorkshire & Humber Dementia Action Alliance

1. Action Plan

1. The National Dementia Declaration lists seven outcomes that the DAA are seeking to achieve for people with dementia and their carers. How would you describe your organisation’s role in delivering better outcomes for people with dementia and their carers?

Triangle of Care & A Call to Action

BDCT is commissioned to provide service to people with dementia and their carers including Memory Assessment and Treatment services, Community Mental Health services, Care Home Liaison services, Acute Liaison services.  These are specialist services that are above and beyond the day to day services provided by District Nurses, Podiatrist and Dental services who deal with many people with various degrees of cognitive problems.  These services are all committed to ensuring that people with dementia and their carers are recognised and provided with access to appropriate services within their locality.  These services all work towards improving outcomes for people in the community and within care homes & acute hospitals.  They promote independence and inclusion, ensuring that capacity is assessed and choice is given as appropriate.  The services are there to support independence and quality of life; signposting on to voluntary sector agencies where appropriate.

BDCT is working with the University & the Bradford Dementia Group on a number of projects to improve outcomes for people with dementia and their carers. And the Trust is committed to being part of the DAA work in the district.

2.  What are the challenges to delivering these outcomes from the perspective of your organisation?

There are an estimated 6,500 people with dementia within the Bradford District area, this is set to increase by 30-35% in the next 15 years.  According to analysis of the Bradford District area carried out in 2008 it is estimated that there were 5,500 people with a diagnosis of dementia in the District and the projected cost of dementia locally is estimated at £130m.  Bradford District Care Trust ( BDCT) is working with partners including commissioners, acute care providers, social care, voluntary and communities around the development of a local Dementia Strategy.

BDCT is committed to reviewing how services are delivered in order to maintain quality, efficiency and effectiveness, with a focus on acute and care home liaison, Learning Disability and Dementia and integrated care working between community matrons and care home liaison.

Further developments are needed around palliative care networks and dementia pathways, as well as improving cultural sensitivity of dementia care for south asian families.

The current service priorities for BDCT are :

  • Early diagnosis and intervention – improving referrals to memory clinics
  • Raising awareness of dementia in people with learning disabilities and developing integrated pathways between mainstream and specialist services.
  • Improving quality of care in acute settings through acute hospital liaison services
  • Living well in care homes – involvement in delirium research in care homes, integrated working in care homes between matrons and care home liaison, continue to build on the work of the care home liaison nurses
  • Reduce anti psychotic prescriptions to people with dementia – ensure that where it is prescribed it’s use is reviewed regularly and is prescribed as part of a therapeutic care plan
  • Continue to work with carers to ensure involvement in assessment and care planning
  • On going work around service user and carer involvement with BDCT
  • Being a member of Bradford Dementia Action Alliance and Yorkshire & Humber Regional Dementia Action Alliance

2. Actions

  • Early Diagnosis

    BDCT is currently commissioned to deliver memory assessment and treatment services within the district.  Work is ongoing with commissioners and acute hospital colleagues  to improve referrals to this service in an attempt to provide early diagnosis.  Work is also being done with individual GP practices to promote early referral and diagnosis.

    There is also ongoing work being undertaken by Learning Disability Services to promote recognition of cognitive changes with formal and informal care providers, so that early diagnosis can be achieved.


    2014 - First Quarter Update

    New member

  • Improved quality of care in general hospitals

    Within the Bradford and Airedale district two-thirds of NHS beds are occupied by people aged 65 years or older. Up to 60% of general hospital admissions in this age group will have or will develop a mental disorder during their admission.  We have a  liaison team who are commissioned to provide the following response to these issues:

    Reduce specialist mental health and general hospital admissions for older people with mental health conditions including the specific targeting of those residents in care homes.

    Improve end of life care for older people with mental health conditions.

    Enable more people with mental health problems to be discharged to their own home from hospital


    2014 - First Quarter Update

    New member

  • Living well with dementia in care homes

    Care Home Liaison is delivered as part of the CMHT OP role with the liaison nurse working with specific care homes to manage mental health problems (including delirium, dementia, depression, psychosis etc.).  The nurses provide advice around care planning, reasonable adjustments and liaison with other services, management techniques and training/awareness to staff.  Ongoing work as part of integrated care has also been taking place. 

    Integrated clinical review clinics are taking place, these have evolved from recognition that two parts of the service were engaged in similar work. Mental Health Care Home Liaison is tasked with working alongside Care Homes to prevent unplanned admission to Acute Hospitals were the predominant issue is Behavioural and Psychological symptoms of Dementia, or other mental health issues, and the inappropriate use of antipsychotic medication in the management of such symptoms. South and West Community Matrons, as a pilot scheme are tasked, with managing acute physical health problems in Care Homes, with an aim to prevent unplanned admission into Acute Hospitals.

    Two care homes, identified as frequent refers to the Acute Hospitals, were targeted, to trial a joint review with a Community Matron, Community Mental Health Nurse and senior care staff from the home. Reviews take the form of a ‘ward round’, in which each individual is discussed, and potential issues identified. This provides an opportunity to offer advice and guidance to the care home, on behaviour management strategies, initiate further physical investigation and review medication in a timely and co-ordinated manner.

    Review Clinic take place on a monthly basis, and in the targeted homes, a significant drop in acute referrals to Primary Care service, Community Mental Health team and the acute hospitals is evident. The initiative now includes two more ‘teams’ of Community Matrons and CPNs, working with five care homes in south and west.

    In addition to the Regular review clinics, the ‘teams’ meet together monthly to share practice and discuss issues arising from the review clinics. These meetings also draw on expertise from other disciplines, including Speech and Language, Community Pharmacy, and Dietetics and most recently liaising with BTFT Project Dementia Lead.


    2014 - First Quarter Update

    New member

  • Reducing use of antipsychotic medication

    As part of organisational and national audit, consultants undertake clinical audits of the anti psychotic prescribing for people with dementia.  Where anti psychotic medication is used this should include a robust care plan around why it is used, a timescale for review and be monitored.  Consultants work in line with NICE guidance and BNF/CSM recommendations.  The care home liaison team have had an impact on the use of anti psychotic medication for people in care homes, working with local pharmacists and GPs.


    2014 - First Quarter Update

    New member

  • Improving public and professional awareness

    BDCT is signed up to and committed to supporting the DAA in Bradford District in any way possible.  The Trust have recognised individuals supporting the programme and have offered to provide awareness sessions for businesses and their workers.    As part of the Integrated Care programme the Trust is doing a significant amount of work in local communities and our CMHT OP are included in this work providing support, advice and education to other professionals within the organisation working in the localities.  Regular training sessions are also available for staff within the Trust.


    2014 - First Quarter Update

    New member

  • We are committed to working with carers

    BDCT has signed up to Triangle of Care and A Call to Action.  We work in partnership with people with dementia, their carers, social care, VCS and businesses to ensure that people with dementia receive access to services, assessment, care planning, interventions and involvement in their care. The Trust has a service user and carer involvement forum which meets regularly and feeds into Trust governance structures.   More work is needed on the national drivers.


    2014 - First Quarter Update

    New member