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NHS Greater Huddersfield CCG

NHS Greater Huddersfield CCG is a membership organisation of 39 general practices. Greater Huddersfield, has a population of 245,000 people (an increase of 1.4% since 2010) and is a mix of urban and rural communities. We commission healthcare services on behalf of all people whether they are registered with a GP or not. We know that Dementia is a worsening problem. The highest rate of dementia in those aged over 65 years is in north Huddersfield, followed by south Huddersfield, but variation across Kirklees as a whole is small

8 March 2016
Yorkshire and Humber
Clinical Commissioning Group, Health
Local Alliances:
Kirklees 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?

Our Vision: “Informed by our local population and clinicians, we will drive improvement of healthcare services through leadership, innovation and excellence.”  NHS GHCCG Commissioning Prospectus. (2013/14)

Our vision is for all people with dementia and their carers to be able to continue to 'live life to the full' as described in the Vision for Older People in Kirklees.

To do this we will create an environment where people feel empowered to seek help early, know where to go for help and what services to expect, have access to the care and support that they would benefit from, and are confident that this care is of high quality, where the public and professionals are well informed and where fear and stigma associated with dementia has decreased. Ref: Kirklees Dementia Strategy

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

Our annual budget is £275 million (2013-14) but we have an increasing elderly population (75+); high demand for secondary care services; higher rate of emergency admissions and length of stay compared to other areas; high levels of chronic illness (higher rates of respiratory and chronic heart disease compared to other areas); health inequalities across NHS GHCCG and the financial challenges faced by all of the NHS to do more with less.

Early diagnosis of, and intervention for, dementia are the keys to delaying admission to long term care and to helping people remain independent for longer. Making the diagnosis early means that there is the chance to prevent and plan for future problems and for people to benefit from positive interventions.

Promoting healthy ageing, for example keeping people active and tackling social isolation, is important in delaying the onset and progression of dementia.

Ability to meet increasing demand for the right services at the right time for people with dementia and their families throughout the dementia journey will continue to be a challenge which will require innovative practice and partnership working.

Involving people with dementia and their families in influencing personal choice and design of services and maintaining an active involvement in their community will also provide a challenge.

2. Actions

  • 1. I have personal choice and control or influence over decisions about me

    34 GP practices in Greater Huddersfield CCG are currently engaged in promoting Dementia Friends to all staff within their practice and their progress will be monitored on a half-yearly basis in 2015/16. The Kirklees End of Life Strategy and the Kirklees Dementia Strategy have robust actions identified which are aimed at meeting the needs of individuals with dementia. The community diagnostic pathway has been re-designed to offer a more timely diagnosis of dementia within a community setting closer to home. Personal budgets continue to be promoted to all individuals, including those with dementia
    Being implemented
  • 2. I know that services are designed around me and my needs

    Dementia Friends in GP practice We have introduced a refreshed dementia recognition pathway to improve timely diagnosis of MCI and dementia. The pathway also supports GP to maintain individuals within their communities & deliver quality care in the least restrictive environments 100% of GP practices in Greater Huddersfield CCG are signed up to the Dementia DES. GHCCG will support practices to deliver the Dementia DES, by sharing information & best practice across our practices; we will continue to improve the quality of services. We have agreed a CCG level target for the identification of those with dementia Self care hub – My health tools

  • 3. I have support that helps me live my life

    Kirklees Connect to Support lists all services available in Kirklees including those of interest to individuals with dementia and their carers GHCCG jointly commissions services through Community Partnerships which includes dementia cafes and a wide range of community, wellbeing initiatives delivered across the whole of Kirklees The Self-Care Hub: My Health Tools is a locally commissioned website which offers a number of self-help programmes across 4 main health areas – one of these being dementia. Individuals are able to ‘log on’ and access a wealth of self-help resources and are able to maintain a personal health record on the site.
  • 4. I have the knowledge and know-how to get what I need

    • Gateway to Care offers a single point of access to health and social care services in Kirklees including information and advice regarding benefits. Whether someone is a carer or has dementia themselves, Gateway to Care will help someone find the services they need. • Carers Count is a service commissioned locally to provide information and access to assessments and benefits advice etc. to carers in Kirklees. • 90% of GP practices in Kirklees (34 practices) have at least one staff member who is a Dementia Friend. Practices are being monitored to increase take up of the Dementia Friend initiative. • 90% of GP practices in Kirklees (34 practices) are registered as a Safe Place in Kirklees.
  • 5. I live in an enabling and supportive environment where I feel valued and understood

    • Greater Huddersfield CCG is working towards becoming a Dementia-Friendly Workplace and currently has 17 Dementia Friends. • Greater Huddersfield is working in partnership to create a Carers Charter which will set the standard by which organisations will adhere to become Carer-Friendly • 90% of GP practices in Kirklees (34 practices) have at least one staff member who is a Dementia Friend. Practices are being monitored to increase take up of the Dementia Friend initiative. • 90% of GP practices in Kirklees (34 practices) are registered as a Safe Place in Kirklees.
  • 6. I have a sense of belonging and of being a valued part of family, community and civic life

    • 90% of GP practices in Kirklees (34 practices) are registered as a Safe Place in Kirklees. • As an area, Kirklees constantly monitors the advancements in Assistive technology and considers how these could be used to good effect to help someone with dementia live an independent and fulfilling life • Carers Count is a service commissioned locally to provide information and access to assessments and benefits advice etc. to carers in Kirklees. • CantabMobile is an electronic aid to early diagnosis of dementia and is currently being piloted in Greater Huddersfield CCG member practices
  • 7. I know there is research going on which delivers a better life for me now and hope for the future

    1)PERFECTED WP2: Implementing the optimisation of hospital care delivery to older adults by NHS staff via action research methodology By working collaboratively with clinicians and stakeholders, an action research (plan-do-study-act) approach will be used to generate knowledge to understand how to best implement the intervention (PERFECTED Enhanced Recovery Pathway. As part of PERFECTED’s commitment to Public Patient Involvement, lay researchers will be trained to assist with qualitative research activities, analysis and dissemination. Development 2) At the moment there are two dementia studies ongoing that Greater Huddersfield CCG patients could participate in; AMARANTH and PROTECT (A Longitudinal Study of Cognition in People Over 50 ) both studies are using the CCG member practices as participant identification centres (PIC), so no research activity takes place at the practice but they are offering patients the opportunity to participate by providing information on how to do so when attending routine appointments. AMARANTH is a NIHR CRN portfolio adopted commercial study. The primary objective is to evaluate the effectiveness of AZD3293 in Early Alzheimer’s disease as measured by the Clinical Dementia Rating – Sum of Boxes (CDR-SB) score. PROTECT (A Longitudinal Study of Cognition in People Over 50 )again is a NIHR CRN portfolio study. This study will measure cognition in 5000 adults over 50 over eight years via an online study. 3) Proposed Local work under development; that will be submitted for funding later in 2015/16 :- the YHCS is working with a Professor from the University of Bradford to identify the relevant strengths and weaknesses of different ways of organising memory clinics and allied services to meet the post-diagnostic care and service needs of the diverse UK population, in order to provide recommendations that will support commissioning and provision to meet local needs.