National Dementia Strategy Objective 8 Improved Care in acute hospitals-how can we achieve this and save money!?Dr Nicholas John Consultant Geriatrician RUH Bath

The Scale of the problem In UK >700,000 people diagnosed withdementia In South west 73,000 increasing to 102,000 by 2025(41%) Only 1 in 3 get a diagnosis EVER More people retire to the south west and their life expectancy is the highest in the country NHS Devon will have the highest number of dementia cases in the country by 2025

In Hospital of all beds occupied by patients over 65with dementia Higher rates of placement, mortality and morbidity and longer length of stay for all conditions Lincs study showed 60% of patients with dementia in acute beds did not need to be there NAO suggests these factors cost each acute hospital 6million per year

Is Bath special? BaNES and Wiltshire have about 1/3cases on the QOF dementia and are in bottom 1/3 for diagnosis gap and Cognition enhancer prescription in the country 122 elderly care patients with seasonal outliers MH liaison provided by MH nurses 7 Community hospitals over 4 PCTs

The Bath Story so far Oct 2007 Bath area conference of Old Age Medicine and Psychiatry to identify areas for improvement Jun 2008 CSIP case note audit of 34 dementia patients at RUH July 2008 Multiagency workshop to develop action plan Sept 2008 RUH dementia stakeholder group established Feb 2009 Trust wide survey of cognitive impairment June-July 2009 SW SHA dementia review of BaNES and Wiltshire January 2010 Action Plan agreed to capitalise on progress so far and attempt to complete objectives of NDS

Initial case note review 2008 Early information gathering is vital Environmental factors are contributing toproblems Staff education and awareness lacking Medicalisation of decision making No whole system working Risk averse culture to discharge

Cognitive survey 2009 6 Wards with large elderly focus 34% had cognitive impairment Average LOS 25.4 days (up to 98 in some cases) Only 50% had any diagnoses 14% currently known to MH services Only 34% had any test of cognition Orthopaedic #NOF proforma had a 90% MTS completionrate

2009 SHA dementia review Peer review Baseline assessment Good practice highlighted Deficits identified Advice re implementation of the NDS Action plan developed with timeline

SHA review key findings Chief officers from acute trusts often absent User feedback very negative particularly foodand drink, staff awareness and frequent moves Dementia not a corporate priority and mainly a care of the elderly issue Discharge delays due to difficulties with social services, access to intermediate care, CHC screening and lack of MH input MH Liaison services usually unidisciplinary

However. Many examples of innovative practice Liaison nurses in Cornwall inreaching into CareHomes to minimise acute transfer Life story books Rotation of AHPs through MH and acute trusts Clothing ID system (B&Poole) Day ward for wanderers in Dorchester GP Academy in Cornwall

Positive practice cont., PAINAD scoring system in Cornwall Rehab units with dual trained RGN/RMN(Poole) Grab sheets and message in a bottle CHC screening and allocation without panel (B&Poole) Dashboard bed management in Torbay Dementia specific intermediate care Bristol MH liaison team LOS by 3-4 days and saved 1million pa

SHA action plan 2009/10 1. 2. 3. 4. 5. 6. 7.7 priority areas: Early intervention and diagnosis for all Improved community personal support Implementing New Deal for carers Improved care in acute hospitals Living well in care homes Informed and effective work force Joint commissioning for dementia

Financial constraints NAO report Jan 2010 NDS implementation cost 1.9 billion Funding by efficiency savings only 500

million 150 million new money not ringfenced and no responsibility to show how money spent Dementia not in Operating Framework Vital signs

So an impossible task? Executive sign-up NHS 2010-15 will be a time of belt tightening PCT payments to acute trusts will change from

April with emphasis on reducing excess bed days in the setting of no increase and some reduction in tariff Trust boards need to see tackling dementia will reduce bed stays reducing outliers and allowing 18 week RTT targets and 4 hour waits to be met Dementia steering groups with executive presence will facilitate these discussions

How to do it Information gathering Early cognitive assessment allowing

discharge process blocks to be identified early Dementia care pathway with cognitive algorithm (BGS/RCPsych) so every one knows what they are doing-dementia website helpful Carer involvement early

How to do it Partnership working Meet your commissioners! Consider CQUIN schemes for dementia

eg participation in national dementia audit Clinical involvement in World Class Commissioning is key to success Identify the outcomes you both want and how to achieve them

How to do it Patient/carer involvement National Operating Framework will

increasingly require evidence of user involvement to reward acute trusts Patient Experience Tracker is a very powerful tool Use your local voluntary sector-they are desperate to be involved more

How to do it Mainstreaming dementia care Dementia training needs to be mandatory

for all acute trust staff with records kept of uptake of training Engagement of non-elderly care staff challenging but ward based dementia champions and incentive backed trust dementia chartermarks are one way

How to do it 1. 2. 3. 4.Benchmarking and data National dementia audit starts Mar 2010 DOH dementia portal has some dementia metrics available from south coast SHA SHA must-dos Clinical dementia lead Care pathway in situ and evaluated OPMH liaison teams Training all staff in dementia

How to do it Others locally developed might include: 1. LOS data for dementia and non dementia 2. 3. 4. 5. 6. 7. 8.including subspecialty eg #NOF Discharge destination Anti-psychotic prescriptions Ward moves Nutritional assessments DOLS/MCA/MHA assessments Environmental surveys Quality of information on wards

Summary Dont despair! Make dementia core business Commissioning relationships are ofincreasing importance User viewpoint will become an important lever Get it right for dementia and everybody will benefit