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NHS Medway Clinical Commissioning Group

Our main role is to plan and buy health services across the Medway towns. With your help and involvement we decide what NHS services are available to residents. We work closely with local public health, social care and voluntary sector partners to make sure the right services are available at the right time. Our CCG is one of 211 in the country and is made up of GPs, other healthcare professionals and experienced commissioners dedicated to making Medway a healthier place to live.

5 January 2017
South East
Clinical Commissioning Group
Local Alliances:
Medway 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?

In the Medway Local Authority area in 2015 there were estimated to be 2,898 people living with dementia, of whom 2,727 were aged over 65 years old. Dementia is a devastating condition for people and their loved ones, and it is estimated that there will be a considerable increase in the number of people living with dementia in Medway in future years, driven largely by the growth in the overall older population. Responding to this challenge is a key priority for Medway Council and Medway CCG.

Key outcomes underpinning the future commissioning of dementia services have been identified in Medway. In Medway, there is an aspiration that, by working with all key partners across the community – including people with dementia and their families – we can co-create:

A place to live that is dementia friendly;A sense of worth and inclusion, in a community that understands;A caring and supportive environment, within which needs are recognised;A commitment to work together to meet people’s needs;A commitment to becoming a community that works together as an alliance to create resilience, rising to the challenge of dementia.

 The proposal is to redesign dementia care pathways in Medway, in order to make better use of existing resources, through better partnership working, and a focus on supporting the whole person within their community. This should lead to less fragmentation and a more positive focus on enabling people with dementia and their families to live well with dementia for longer.

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

Medway CCG is specifically looking at four areas of work concerning dementia support within Medway:

Assessment and DiagnosisPost-diagnostice supportSupport in Care HomesCrisis Support.

It should be noted that support for carers is a key theme throughout each workstream. These programmes of work themselves have complex and multiple relationships with one another and with dementia-specific services. Even in the case of dementia specific provision, current commissioning and provision is currently so fragmented that establishing clear ‘as is’ and ‘to be’ pathways continues to be a complex process.

The key task of identifying the current level of investment in dementia services has proved challenging. Indeed, even if it were possible to disaggregate funding for dementia, there are numerous interdependencies within that resource linked to older people’s mental health more broadly.

Further, it is clear that there is no immediate appetite to fundamentally change the provision for assessment and diagnosis, although there is focused work under way to improve dementia diagnosis locally (within existing resources).  It seems likely that attempting to carve out / disaggregate other aspects of the provision (i.e. those focused on post-diagnostic support), at least in the short to medium term, could have a destabilising effect on the wider system.

The result of this is that there is still no defined funding envelope within which to locate this review, with its current whole system, Medway-wide scope.

2. Actions

  • Improve assessment and diagnosis process

    Four main primary drivers for this action:

    Improve dementia diagnosisStreamline referral processExpedite diagnostic scansReduce the time for patient to be seen between assessments.

    Work to support this action include:

    •Support GPs with review of practice data.

    •Support GPs to code consistently.

    •Work with care homes to identify and assess patients for dementia. 

    •Develop referral form and regularly encourage use.

    •Develop GP advice line Develop electronic referral pathway.

    •Develop Shared Care Protocol to facilitate safe and timely discharge.

    •Improve waiting time for MRI results to inform diagnosis.

    •Embed new referral form as part of dementia pathway.

    Being implemented
  • Improve post diagnostic support

    Four main drivers for this action:

    1. Consistent access to current offer.

    2. Patient-led access to information, advice and guidance.

    3. Support people to live well.

    4. Need to understand capacity and demand.

    Work to achieve this action includes:

    Provide more resource to improve current offer of post-diagnostic support Develop Rainham Dementia Café drop in, engaging with numerous stakeholders within the community Apply for new Dementia Support Worker role Develop post diagnostic pathway out of hospital Improved offer including peer support Ensure person-centred health and care plans for each person Clarify interface with GP Shared Care Protocol

  • To improve patient and staff member experience within care homes

    Four main drivers leading this action:

    Improve assessment and diagnosisProvide appropriate trainingProvide integrated care for residentsEmbed support tools for care home staff use

    Key areas of work to achieve aims:

    •Work with: care home staff, GPs, and KMPT, to identify and assess patients that may have dementia.

    •Encourage use of nationally promoted referral – Dear GP referral tool and Diadem assessment tool.

    •Receive feedback on current training received.

    •Identify champions to undertake higher level training.

    •Identify appropriate training packages and providers.

    •Develop plan for refresher training sessions.

    •Key stakeholders to develop multi-agency approach to care home patients.

    •Develop clear pathway depending on presentation of patient. 

    •Work with care home staff and primary care staff to encourage the use of nationally recommended tools.

    •Provide a communication channel for health professional to raise queries using tool.

    Initial Scoping
  • To develop a crisis pathway accessible all hours

    The provision of out of hours support is an identified gap and is an area that is in early development.

    Four main drivers leading this action:

    1. Clear pathway for patients and carers

    2. Develop support service accessible for those in crisis

    3. Support people to live well

    4. Reduced inappropriate hospital admissions

    Areas of focus to achieve action:

    Work with key stakeholders to establish current capacity and need, and the ideal referral route both in and out of hours. Develop clear triage process to enable safe signposting of patients.Consider all possible options for service provision based on provider and patient feedback. Develop preventative measures to reduce possibility of further crisis experiences. Involve Voluntary Sector in support pathways