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Herefordshire Clinical Commissioning Group

Herefordshire Clinical Commissioning group is a clinically-led organisation responsible for commissioning most healthcare services in Herefordshire. Our 24 GP practices work in partnership with other health services to ensure quality care and treatment is available. The CCG is made up of 24 GP practices covering a population of 182,798.

8 October 2015
West Midlands
Care, Health, Clinical Commissioning Group, Hospitals and Hospital Trusts, Commissioners Sector
Local Alliances:
Herefordshire 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?

We have a statutory responsibility to effectively commission local health services for people living in Herefordshire. This includes diagnosis, treatments and nursing care across community and acute health services. We work with our Local Authority, NHS and third sector partners, people with dementia and their carers to achieve this. We are working with other statutory bodies, voluntary and community groups to improve the lives of people affected by dementia in our communities. To this end we have contributed to the projects outlined in the Herefordshire Dementia Strategy. Through our work, we will increase the number of people who are supported to live well with dementia; ensure that carers and families receive assistance; and commission quality health services that can meet all of the needs of the person at all stages of the dementia from early diagnosis to end of life. We are committed to listening to the stories of patients and their families and will seek to engage people with dementia and their carers in the development and review of health services. We work with G.P.s to identify people with dementia and then ensure they receive early support, increasing the advice and assistance available post-diagnosis and ensuring this includes a focus on social inclusion and support for carers. We will work with local Dementia Action Alliance and communities to raise awareness of dementia and support our staff to become Dementia Friends.

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

Our rural area has an increasing population of older people, increasing the likelihood of dementia in our communities. Ensuring that services are available across a large rural area with a dispersed population and enabling people to live well with dementia when they live alone are both challenges. In addition we have low diagnosis rates, due to: • Reluctance amongst patients to ask for a diagnosis • Reticence amongst some clinicians to achieve early diagnosis – believing that as dementia cannot be ‘cured’; there is little benefit in seeking a diagnosis. • Capacity issues within secondary care services We are actively addressing all of these challenges as part of the Herefordshire Dementia Implementation Plan.

2. Actions

  • Raise awareness of dementia in Herefordshire

    For patients and the public we want to create information on our website that provides signposting to local advice and support. This is part of encouraging people (and their carers) to visit their GP if they are worried or concerned about their memory, behaviour or personality changes as well as signposting people to sources of support to enable people to live well with dementia and support their carers.

    We are also working with our local memory clinic service with plans to raise awareness amongst Primary Care of the support and interventions locally available for people with dementia and their carers. This will promote early identification and diagnosis by healthcare professionals.

    Initial Scoping
  • To extend the availability of NHS services into care homes for people with dementia

    We will make extra provision for nurses and therapy practitioners to work with care homes to identify and support people with dementia to receive a diagnosis and / or treatment. This will include support for care home staff, advance care plans, challenging behaviour support and end of life.


    2015 - Third Quarter Update

    The care home in-reach team are now commissioned and in place. They are working with care homes to improve identification of people with dementia and to assist Care Homes with their education, awareness and practice. The next CCG Care Home education Day in October will explore dementia practice in detail.

  • To increase post-diagnosis support available to the Herefordshire’ public

    We want to provide one to one and group sessions for people with dementia and their carers as part of the range of support available.  We recognise that having such a service can help at the time of diagnosis to talk through what to do next, and make contact with other people who are experiencing either the same long-term condition or caring for their loved one with dementia. The support will be flexible and can support people as the condition deteriorates through helping with planning for the future or practical assistance.

    We will also provide support through dedicated staff supporting people with dementia and their carers through their journey, helping them navigate the health and care system and linking them in to communities and support agencies, both statutory and voluntary.


    2015 - Third Quarter Update

    The post-diagnosis service is in place - a fantastic partnership between 2gether NHS Foundation Trust and the Alzheimer's Society in Herefordshire. Everyone is offered a care co-ordinator and put in touch with groups and 1-2-1 support. Each identified carer is offered a carers assessment. More intensive support is available when things get more complex with good links to GPs and other sources of support.

  • To run education sessions for primary care staff in Herefordshire

    We will facilitate sessions for GPs and practice nurses to have access to clinical updates from our Dementia Services.


    2015 - Third Quarter Update

    Specific education sessions for GPs have been held, with more planned in 2016.

  • To become Dementia Friends

    As an organisation, we will encourage our staff and those that we work with to receive Dementia Friends training.

  • To implement a new care pathway for dementia in Herefordshire

    To work with NHS services, voluntary and community groups and the local authority to develop a multi-agency care pathway from initial concern to special support, including local guidelines on protocols, prescribing,  support for carers and links with third sector organisations.


    2015 - Third Quarter Update

    We have an agreed care pathway in operation across all agencies in Herefordshire. Our next action is to ensure that we can improve information sharing between agencies; to improve the number of people with a care plan and to publish our evaluation of the care pathway effectiveness.