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NHS North Kirklees CCG

North Kirklees Clinical Commissioning Group (CCG) looks after the health needs of just over 185,000 people across Dewsbury, Batley, Mirfield, Heckmondwike, Cleckheaton, Birstall, Liversedge and Ravensthorpe. The CCG is made up of a group of GPs who are responsible for the planning and design of local health services.There are a total of 29 GP practices which make up North Kirklees CCG We know that Dementia is a worsening problem and is a priority for the CCG. By 2030 20% of our population will be over 65. For women aged over 65 years, the highest rate was in Birstall & Birkenshaw.

4 December 2014
Yorkshire and Humber
Health, Clinical Commissioning Group
Local Alliances:
Kirklees 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:“Enabling the population of North Kirklees to livelonger, healthier and happier lives.”

NHS NKCCG 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 £218 million (2013/14) North Kirklees has a population of 190,244. The area has the most deprived localities in Kirklees - Dewsbury andBatley - as well as one of the least deprived areas - Mirfield. There is a higher than average South Asianpopulation, with 21% being South Asian. North Kirklees has a range of health inequalities across a range ofconditions, personal behaviours, living and working conditions. Batley and Dewsbury in particular have somesignificant health challenges. Similar to elsewhere, the recently changing economic climate has significantly impacted on both the day to daylives of many residents and the capacity of local services.The growing population, especially the sharp rise predicted in the number of older people; the difficult economicclimate and the local picture of health and wellbeing inequalities give a very challenging context in which toimprove health and wellbeing.

 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

  • Primary Care

    We will improve timely diagnosis of Mild cognitive impairment and dementia.   Our ambition is to achieve a diagnosis rate of at least 67% by March 2015.

    By sharing information across our practices, we will continue to improve the quality of services. We will work with practices, patients and the public to improve their understanding of how to access appropriate services and manage their own care.

  • Care Closer to Home

    This is one of our key transformation work streamswhich will drive change through better integration ofservices between community, social and primary care.The primary aims are to ensure integrated provision ofservices that will promote self-management, earlierinterventions and reduce hospital admissions.People will receive appropriate rehabilitation/re-ablement before assessment for longer term continuing health care.

    Specific areas include: To address the specific short term priority around dementia and reducing hospital admissions and length ofstays for patients with dementia.

  • Medicines management

    We will improve the quality, safety and cost effectiveness of prescribing across the local health economy to make sure that patients gain the maximum benefit from their medicines. We will reduce clinical variation in prescribing practice and improve patients’ understanding of their medicines. We will support self-management of conditions.

    The CCG has elected to work on reducing the volume of low dose antipsychotics prescribed to patients with dementia.

    The CCG has put a requirement for all patients with dementia commenced on a low dose antipsychotic by SWYPFT to have a plan for review and reduction where appropriate within 6-12 weeks of initiation.

    The CCG has provided GP practices with the national guidelines and toolkit on the prescribing and review of patients with low dose antipsychotics.

    GP practices identified as being high prescribers of low dose antipsychotics are being incentivised through the primary care improvement scheme to review patients with dementia prescribed low dose antipsychotics.

  • Effective partnership working

    We will promote strong clinical leadership across member practices and work with local communities partners to develop Dementia Friendly Communities where patients are supported to live well with dementia.

    We will encourage all CCG staff- employees and board members- to become Dementia Friends, and promote this within member practices.