Dr Nicholas John Consultant Geriatrician RUH Bath

National Dementia National Dementia Strategy Objective 8 Strategy Objective 8 Improved Care in acute Improved Care in acute hospitals-how can we hospitals-how can we achieve this and save achieve this and save

money!?money!?

Dr Nicholas JohnDr Nicholas John

Consultant GeriatricianConsultant Geriatrician

RUH BathRUH Bath

The Scale of the The Scale of the problemproblem• In UK >700,000 people diagnosed with In UK >700,000 people diagnosed with dementiadementia

• In South west 73,000 increasing to In South west 73,000 increasing to 102,000 by 2025(41%102,000 by 2025(41%↑)↑)

• Only 1 in 3 get a diagnosis Only 1 in 3 get a diagnosis EVEREVER• More people retire to the south west More people retire to the south west and their life expectancy is the and their life expectancy is the highest in the countryhighest in the country

• NHS Devon will have the highest number NHS Devon will have the highest number of dementia cases in the country by of dementia cases in the country by 20252025

In HospitalIn Hospital

• ¼ of all beds occupied by patients ¼ of all beds occupied by patients over 65 with dementiaover 65 with dementia

• Higher rates of placement, mortality Higher rates of placement, mortality and morbidity and longer length of and morbidity and longer length of stay for all conditionsstay for all conditions

• Lincs study showed 60% of patients Lincs study showed 60% of patients with dementia in acute beds did not with dementia in acute beds did not need to be thereneed to be there

• NAO suggests these factors cost each NAO suggests these factors cost each acute hospital £6million per yearacute hospital £6million per year

Is Bath special?Is Bath special?

•BaNES and Wiltshire have about 1/3 BaNES and Wiltshire have about 1/3 cases on the QOF dementia and are cases on the QOF dementia and are in bottom 1/3 for “diagnosis gap” in bottom 1/3 for “diagnosis gap” and Cognition enhancer and Cognition enhancer prescription in the country prescription in the country

•122 elderly care patients with 122 elderly care patients with “seasonal” outliers“seasonal” outliers

•MH liaison provided by MH nursesMH liaison provided by MH nurses•7 Community hospitals over 4 PCT’s 7 Community hospitals over 4 PCT’s

The Bath Story so farThe Bath Story so far

• Oct 2007 Bath area conference of Old Age Medicine Oct 2007 Bath area conference of Old Age Medicine and Psychiatry to identify areas for improvementand Psychiatry to identify areas for improvement

• Jun 2008 CSIP case note audit of 34 dementia Jun 2008 CSIP case note audit of 34 dementia patients at RUHpatients at RUH

• July 2008 Multiagency workshop to develop action July 2008 Multiagency workshop to develop action planplan

• Sept 2008 RUH dementia stakeholder group Sept 2008 RUH dementia stakeholder group establishedestablished

• Feb 2009 Trust wide survey of cognitive Feb 2009 Trust wide survey of cognitive impairmentimpairment

• June-July 2009 SW SHA dementia review of BaNES June-July 2009 SW SHA dementia review of BaNES and Wiltshireand Wiltshire

• January 2010 Action Plan agreed to capitalise on January 2010 Action Plan agreed to capitalise on progress so far and attempt to complete progress so far and attempt to complete objectives of NDSobjectives of NDS

Initial case note Initial case note review 2008review 2008•Early information gathering is vitalEarly information gathering is vital

•Environmental factors are contributing Environmental factors are contributing to problemsto problems

•Staff education and awareness lackingStaff education and awareness lacking

•““Medicalisation” of decision makingMedicalisation” of decision making

•No whole system workingNo whole system working

•Risk averse culture to dischargeRisk averse culture to discharge

Cognitive survey 2009Cognitive survey 2009

• 6 Wards with large elderly focus6 Wards with large elderly focus

• 34% had cognitive impairment34% had cognitive impairment

• Average LOS 25.4 days (up to 98 in Average LOS 25.4 days (up to 98 in some cases)some cases)

• Only 50% had any diagnosesOnly 50% had any diagnoses

• 14% currently known to MH services14% currently known to MH services

• Only 34% had any test of cognitionOnly 34% had any test of cognition

• Orthopaedic Orthopaedic #NOF proforma had a 90% #NOF proforma had a 90% MTS completion rateMTS completion rate

2009 SHA dementia 2009 SHA dementia reviewreview•Peer reviewPeer review

•Baseline assessmentBaseline assessment

•Good practice highlightedGood practice highlighted

•Deficits identifiedDeficits identified

•Advice re implementation of the Advice re implementation of the NDSNDS

•Action plan developed with Action plan developed with timelinetimeline

SHA review key findingsSHA review key findings

• Chief officers from acute trusts often Chief officers from acute trusts often absentabsent

• User feedback very negative particularly User feedback very negative particularly food and drink, staff awareness and food and drink, staff awareness and frequent movesfrequent moves

• Dementia not a corporate priority and Dementia not a corporate priority and mainly a care of the elderly issuemainly a care of the elderly issue

• Discharge delays due to difficulties with Discharge delays due to difficulties with social services, access to intermediate social services, access to intermediate care, CHC screening and lack of MH inputcare, CHC screening and lack of MH input

• MH Liaison services usually unidisciplinaryMH Liaison services usually unidisciplinary

However….However….

• Many examples of innovative practiceMany examples of innovative practice

• Liaison nurses in Cornwall inreaching into Liaison nurses in Cornwall inreaching into Care Homes to minimise acute transferCare Homes to minimise acute transfer

• ““Life story” booksLife story” books

• Rotation of AHP’s through MH and acute Rotation of AHP’s through MH and acute truststrusts

• Clothing ID system (B&Poole)Clothing ID system (B&Poole)

• Day ward for wanderers in DorchesterDay ward for wanderers in Dorchester

• GP Academy in CornwallGP Academy in Cornwall

Positive practice Positive practice cont.,cont.,• PAINAD scoring system in CornwallPAINAD scoring system in Cornwall• Rehab units with dual trained RGN/RMN Rehab units with dual trained RGN/RMN (Poole)(Poole)

• ““Grab sheets” and “message in a bottle”Grab sheets” and “message in a bottle”• CHC screening and allocation without CHC screening and allocation without panel (B&Poole)panel (B&Poole)

• Dashboard bed management in TorbayDashboard bed management in Torbay• Dementia specific intermediate careDementia specific intermediate care• Bristol MH liaison team Bristol MH liaison team ↓LOS by 3-4 ↓LOS by 3-4 days and saved £1million padays and saved £1million pa

SHA action plan 2009/10SHA action plan 2009/10

• 7 priority areas:7 priority areas:

1.1. Early intervention and diagnosis for Early intervention and diagnosis for allall

2.2. Improved community personal supportImproved community personal support

3.3. Implementing New Deal for carersImplementing New Deal for carers

4.4. Improved care in acute hospitalsImproved care in acute hospitals

5.5. Living well in care homesLiving well in care homes

6.6. Informed and effective work forceInformed and effective work force

7.7. Joint commissioning for dementiaJoint commissioning for dementia

Financial constraintsFinancial constraints

• NAO report Jan 2010NAO report Jan 2010

• NDS implementation cost £1.9 billionNDS implementation cost £1.9 billion

• Funding by efficiency savings only Funding by efficiency savings only £500 million£500 million

• £150 million new money not £150 million new money not ringfenced and no responsibility to ringfenced and no responsibility to show how money spentshow how money spent

• Dementia not in Operating Framework Dementia not in Operating Framework “Vital signs”“Vital signs”

So an impossible task?So an impossible task?

• Executive sign-upExecutive sign-up• NHS 2010-15 will be a time of belt tighteningNHS 2010-15 will be a time of belt tightening• PCT payments to acute trusts will change from PCT payments to acute trusts will change from April with emphasis on reducing excess bed April with emphasis on reducing excess bed days in the setting of no increase and some days in the setting of no increase and some reduction in tariffreduction in tariff

• Trust boards need to see tackling dementia Trust boards need to see tackling dementia will reduce bed stays reducing outliers and will reduce bed stays reducing outliers and allowing 18 week RTT targets and 4 hour waits allowing 18 week RTT targets and 4 hour waits to be metto be met

• Dementia steering groups with executive Dementia steering groups with executive presence will facilitate these discussionspresence will facilitate these discussions

How to do itHow to do it

• Information gatheringInformation gathering

• Early cognitive assessment allowing Early cognitive assessment allowing discharge process blocks to be discharge process blocks to be identified earlyidentified early

• Dementia care pathway with cognitive Dementia care pathway with cognitive algorithm (BGS/RCPsych) so every one algorithm (BGS/RCPsych) so every one knows what they are doing-dementia knows what they are doing-dementia website helpfulwebsite helpful

• Carer involvement early Carer involvement early

How to do itHow to do it

•Partnership workingPartnership working•Meet your commissioners!Meet your commissioners!•Consider CQUIN schemes for dementia Consider CQUIN schemes for dementia eg participation in national eg participation in national dementia auditdementia audit

•Clinical involvement in World Class Clinical involvement in World Class Commissioning is key to successCommissioning is key to success

•Identify the outcomes you both want Identify the outcomes you both want and how to achieve them and how to achieve them

How to do itHow to do it

•Patient/carer involvementPatient/carer involvement•National Operating Framework will National Operating Framework will increasingly require evidence of increasingly require evidence of user involvement to reward acute user involvement to reward acute truststrusts

•Patient Experience Tracker is a Patient Experience Tracker is a very powerful toolvery powerful tool

•Use your local voluntary sector-Use your local voluntary sector-they are desperate to be involved they are desperate to be involved moremore

How to do itHow to do it

•Mainstreaming dementia careMainstreaming dementia care•Dementia training needs to be Dementia training needs to be mandatory for all acute trust mandatory for all acute trust staff with records kept of uptake staff with records kept of uptake of trainingof training

•Engagement of non-elderly care Engagement of non-elderly care staff challenging but ward based staff challenging but ward based dementia champions and incentive dementia champions and incentive backed trust dementia chartermarks backed trust dementia chartermarks are one wayare one way

How to do itHow to do it

• Benchmarking and dataBenchmarking and data• National dementia audit starts Mar National dementia audit starts Mar

20102010• DOH dementia portal has some dementia DOH dementia portal has some dementia

metrics available from south coast metrics available from south coast SHASHA

• SHA “must-do’s”SHA “must-do’s”1.1. Clinical dementia leadClinical dementia lead2.2. Care pathway in situ and evaluatedCare pathway in situ and evaluated3.3. OPMH liaison teamsOPMH liaison teams4.4. Training all staff in dementiaTraining all staff in dementia

How to do itHow to do it

• Others locally developed might include:Others locally developed might include:1.1. LOS data for dementia and non dementia LOS data for dementia and non dementia

including subspecialty eg including subspecialty eg #NOF#NOF2.2. Discharge destinationDischarge destination3.3. Anti-psychotic prescriptionsAnti-psychotic prescriptions4.4. Ward movesWard moves5.5. Nutritional assessmentsNutritional assessments6.6. DOLS/MCA/MHA assessmentsDOLS/MCA/MHA assessments7.7. Environmental surveysEnvironmental surveys8.8. Quality of information on wardsQuality of information on wards

SummarySummary

•Don’t despair!Don’t despair!•Make dementia core businessMake dementia core business•Commissioning relationships are Commissioning relationships are of increasing importanceof increasing importance

•User viewpoint will become an User viewpoint will become an important leverimportant lever

•Get it right for dementia and Get it right for dementia and everybody will benefit everybody will benefit