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NHS East Riding of Yorkshire CCG

The East Riding of Yorkshire Clinical Commissioning Group (CCG) covers a large geographical area of approximately 1,000 square miles. This includes rural farming areas, urban areas, developing market towns, picturesque villages in the Wolds, and busy coastal resort towns. East Riding of Yorkshire CCG is made up of 37 local GP practices, The CCG has an annual budget of £350m and is responsible for determining local health priorities, and planning and commissioning hospital, mental health and community health care services for people in the East Riding area The CCG is committed to working in partnership with the East Riding of Yorkshire Council, local NHS Trusts, Alzheimer’s Society and other local organisations and the progress towards achieving the actions in this Dementia Declaration will be overseen by our Older People Mental Health Partnership Board

Updated:
25 February 2015
Location:
Yorkshire and Humber
Sectors:
Clinical Commissioning Group
Local Alliances:
Yorkshire & Humber Dementia Action Alliance, East Riding 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?

The CCG identified improving the identification of dementia and the delivery of effective services to people with dementia and their carers as a key priority

Dementia is a more common problem amongst an older population, although the impact of early onset dementia cannot be underestimated. The East Riding of Yorkshire has a predominance of individuals who are in an older age group and consequently the level of dementia prevalence is higher.

In the East Riding of Yorkshire diagnosis of dementia has historically been low, indicating that there are a number of individuals in the community who are not receiving optimal treatment and support for their condition as well as a high number of informal carers, usually family, who are managing what can be challenging behaviours with minimal external support.

The table below indicates the projected percentage growth in the numbers of individuals with dementia.

ERY CCG table 2

At March 2013, the achieved diagnosis rate was 37.65%. The CCG set the following targets for increasing the diagnosis rate for the following two years

ERY CCG table 1 

At March 2014 the achieved diagnosis rate was 42.0%

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

Our key challenges are:

  • Increasing the rate of diagnosis
  • Increasing public awareness of the benefits of early diagnosis
  • Ensuring wider awareness of sources of support and information for people who have been newly diagnosed and their families and carers
  • Ensuring there is an explicit support pathway for informal carers of people with dementia across different organisations
  • Ensuring there is an explicit care pathway for the management and care of people with dementia across different organisations
  • Ensuring that staff across sectors are appropriately trained in dementia care and deliver person centred care
  • Delivering on all of the National Dementia Strategy objectives whilst prioritising the four key areas of Early Diagnosis, improving the experience of acute hospital care, Living Well in Care Homes and Reducing the use of antipsychotic medication
  • Implementing with the Local Authority our Joint Strategy for the Commissioning of Mental Health Services for Older People 2011-2016

2. Actions

  • Develop a Memory Assessment Pathway which identifies people with potential memory problems, provides sensitive diagnosis, and supports active care planning for patients and carers

    We will

    • Encourage GP practices to offer the nationally commissioned Dementia Directed Enhanced Service, in order to increase the identification of people with memory problems
    • Contract with Acute Hospital trusts to deliver the ‘Dementia CQUIN’  in order to increase the identification of people with memory problems
    • Encourage GP practices to offer a local model of a Mild Cognitive  Impairment Assessment and Review service, to increase identification of people with mild memory problems (which may or may not develop into dementia) and to provide more effective care and support within primary care
    • Support Humber NHS Foundation Trust to develop a Memory Assessment Service to provide sensitive diagnosis and post diagnosis support and guidance
    • Undertake ongoing monitoring of the pathway to ensure its effectiveness or identify areas for improvement

     As a result

    • Most practices in the East Riding (95%) have taken up the dementia DES and so are case finding patients with dementia
    • Half of the practices in the East Riding (covering 46% of the population) will be providing a Mild Cognitive Impairment Assessment and Review service from January 2014.  These patients will be identified and held on a register in primary care and monitored yearly to look for progression to early dementia. This allows a number of patients to have their diagnosis discussed and monitored in primary care without being referred into the full memory service.  This has been worked up in conjunction with the current memory service to help treat patients in practices but also to reduce the waiting times in the memory service proper.  This is a partnership model between the Humber NHS Foundation Trust, general practice and the East Riding CCG.

    Humber NHS Foundation Trust are reconfiguring their services to provide a more effective and efficient memory assessment service

    Status:
    Implementation
  • Ensure patients with dementia have a Personalised Care Plan and effective advance planning and end of life care

    The CCG recognised that individuals with two or more long term conditions have to attend multiple clinics and our intention is to ensure more effective care coordination between disciplines and to offer holistic care. Dementia is included as a long term condition

    We will

    • Encourage GP practices to offer a Personalised Care Plan and regular long term conditions clinics of all people with two or more long term conditions, including dementia
    • Support people with dementia and their carers to consider their preferences and wishes for their on-going care
    • Support people with dementia to consider their end of life care, using information such as the “Living Well” document which provides a structure to the conversations about end of life and a mechanism for documenting  preferences and priorities
    • Continue to implement the locally agreed patient passport to share key information with those individuals involved in delivering care and support to people with dementia. We are aware that there is work designing a national patient passport and we will work with partners to advertise this once it is available
    • Support Humber NHS Foundation Trust in the development of a community initiated butterfly scheme to identify and support people with dementia
    • Support Humber NHS Foundation Trust in its reconfiguration of Older People Community Mental Health Teams (CMHTs) and Neighbourhood Care Teams to ensure the review and treatment of patients’ physical and mental health needs are carried out together

    Support integrated working across health and social care to better identify and support individuals in care homes with early or established dementia

    Status:
    Implementation
  • We will develop integrated commissioning mechanisms between ERY CCG and ERYC to ensure more seamless service provision for people with dementia and their carers

    We have

    • A Joint Strategy for commissioning older people’s mental health services
    • Implementation of this strategy is overseen by a joint older People’s Mental Health Partnership Board
    • A Joint Commissioning Panel responsible for agreeing funding of individual packages of care, whether funded by the local authority of joint funded

     We will

    • As part of the overall Better Care programme between the CCG and the Local Authority we will seek to commission integrated health and social care services
    • Support Humber NHS Foundation Trust in its reconfiguration of Older People Community Mental Health Teams (CMHTs) and Neighbourhood Care Teams to ensure the review and treatment of patients’ physical and mental health needs are carried out together
    • Support the development of integrated access routes into health and social care services through a single point of contact
    • Improve care coordination and case management  to develop a more personalised care approach
    Status:
    Implementation